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Why Flamingoes don’t get Osteoporosis
December 1, 2008
Jacob Schor, ND, FABNO
There is a new therapy to treat osteoporosis that may decrease the odds of fracturing a femur as one gets older. Recall the movie, Karate Kid, from 1984 and download from your rusty memory banks the image of the kid, balancing one footed on a log at the beach, seagulls flying overhead. Now imagine an older person in a nursing home, slowly moving about with the aid of a walker doing an imitation of the Karate Kid. What you’ve got is Dynamic Flamingo Therapy, the invention of researcher, K. Sakamoto, from Tokyo, Japan. This must be the least expensive, least intrusive and lowest technological intervention ever described in the medical literature for preventing hip fractures.
Hillel, a famous rabbi who lived in Jerusalem during the time of King Herod, was asked if he could summarize the Torah while standing on one foot. His famous reply made on one foot was,
"That which is hateful to you, do not do to your fellow. That is the whole Torah; the rest is the explanation. Now go and learn." (Talmud: Shabbat 31a.)
This article is not about Hillel’s ‘golden rule’ but rather on his method of standing. “Unipedal Standing” is the scientific term for standing on one foot. Daily minute long intervals may be a useful intervention to prevent falls and hip fractures in the elderly
Back in the October 2006, writing in the Journal of Orthopedic Science, Sakamoto described the effect of what he called ‘unipedal standing’ on the frequency of falls and hip fractures in an elderly population. His “unipedal standing balance exercise’ was simple. Stand on each leg for a minute with your eyes open three times a day. If you need to, hang onto something so you don’t tip over.
In this first experiment, Sakamoto recruited subjects, averaging about 82 years old, and randomized them, some to serve as controls and some to ‘exercise.’ Falls and hip fractures for a six-month period were counted. Data was collected for 315 unipedal standers and 212 control subjects that presumably rarely stood on one foot.
The 315 subjects in the exercise group recorded 118 falls in the six-month test period. The 212 control subjects recorded 121 falls. There was one hip fracture in each group. The difference in number of falls was statistically significant but not the number of fractures as there weren’t enough to generate accurate statistics. 
Sakamoto calculated that unipedal standing increases the weight load on the femoral head by a factor of 2.75 over standing on two legs.
Bone density and bone strength is improved by mild stress to the bone. That’s why we make all the fuss on weight bearing exercise. By Sakamoto’s calculations, standing on one foot for a minute would have an effect on bone density equivalent to walking 53 minutes. 
Repeating his exercise three times a day would be equivalent to taking three almost hour long walks a day. For older people who are not that mobile, unipedal standing is an interesting option. It improves balance enough that it decreases spontaneous falls by about a third. It also strains the bone, in theory strengthening it and decreasing the chance of fracture if the person does fall.
A new paper was recently published that lends greater weight to unipedal standing, only, the treatment has been renamed. No longer is standing on one foot called ‘Unipedal Standing,’ now it is “Dynamic Flamingo Therapy.”
The paper was published in the November 2008 issue of Clinical Calcium by Sakamoto, author of the 2006 paper. Sakamoto describes a group of women doing his exercise for a period of ten years. Starting in 1993, he recruited 86 women to do his flamingo exercise, the same standing on one foot at a time for a minute three times a day.
The women were tested regularly to evaluate bone density. At the start of the program, the average age was just under 68. Sakamoto summarizes the results as the percentage of participants showing increased bone mineral density (BMD) compared to their initial levels when they enrolled in the study.
After three months 63% of the study participants had increased bone density. This isn’t as exciting as it sounds. Recall there is a seasonal variation in bone density, increasing over the summer months as production of vitamin D increases with greater sun exposure. But after 6 months 41% still had denser bones than when they started; after one year the number increased to 58%. This is exciting. There was a drop at the three year mark, down to 32%. This increased after five years back to 54%. Most striking though is that one third of the women still had increased bone density compared to their initial scan ten years after starting to perform the exercise. 
There was no control group but increasing bone density as a woman ages from 68 to 78 is clearly unexpected. None of the women who continued the exercises fractured a hip during the ten year period. This also stands out. A study looking at Swiss women during about the same time period concluded that for women, “…incidence of hip fractures was 455 (95% CI: 439–471) per 100,000 person-years in women….” 
If we use these numbers (readily admitting Japanese and Swiss women are not comparable), we would estimate that about 4 of Sakamoto’s women should have fractured a hip during the study rather than none.
Granted this isn’t as large a study as one would want to make definitive predictions. Yet the results are congruent with expectations generated from the earlier papers and Unipedal Standing or Flamingo Therapy appears protective against hip fractures in older populations. It also fits snugly into our preferred things best described as, “It’s not going to hurt and might help.” In other words, you’ve got little to lose and perhaps much to gain.
For people too frail for rigorous workouts or even walking, this therapy still offers an alternative ‘exercise.’ Even for those of us who do exercise routinely, a few minutes on one foot may still provide added advantage
Karate Kid photo:
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 Sakamoto K, et al. Effects of unipedal standing balance exercise on the prevention of falls and hip fracture among clinically defined high-risk elderly individuals: a randomized controlled trial. Orthop Sci. 2006 Oct;11(5):467-72.
 Sakamoto K. [Effects of unipedal standing balance exercise on the prevention of falls and hip fracture]. Clin Calcium. 2006 Dec;16(12):2027-32.
 Sakamoto K. [Dynamic flamingo therapy]. Clin Calcium. 2008 Nov;18(11):1594-9.
[Article in Japanese]
 Chevalley T, et al. Incidence of hip fracture over a 10-year period (1991–2000): Reversal of a secular trend. Bone, Volume 40, Issue 5, Pages 1284 - 1289