the flight of the flamingo

Alan Cook DC

EasyWebCE - The Flight of the Flamingo

A man’s legs must be long enough to reach the ground.

~ Abraham Lincoln         


Some things in life are free. A simple-to-perform exercise contributes to skeletal health, specifically at the proximal femur, and reduces fall events and fractures.

Osteoporosis is a disease where decreased bone strength, mass, and quality significantly increase the risk for fractures. Bringing this closer to home, consider the following:

  • In Australia, 2.2 million people are affected by osteoporosis.(1) Of these, approximately 11% of men and 27% of women aged 60 years or more are osteoporotic. For this same age group, 42% of men and 51% of women are osteopenic.(2)
  • There are 20,000 hip fractures per year in Australia (an increase of 40% per decade).(1)
  • In New Zealand, there were an estimated 84,000 osteoporotic fractures (2007) with 60% of those occurring in women.(3)
  • New Zealand estimates suggest that both the number of osteoporotic fractures and the cost of healthcare associated with osteoporosis will increase by over 30% between 2007-2020.(3)

Approximately one half of the adult patient population will experience one or more fractures due to osteoporosis in their lifetime.(4,5) Rather than immediately jumping to treatment, recall that the underlying reasons for osteoporosis are numerous. Different causes require different treatments. A partial list of risk factors includes: female, smoker, excessive alcohol, high protein diet, family history of osteoporosis, early menopause, or a history of previous fractures. Also, an enormous percentage of the worldwide population is vitamin D insufficient or deficient.(6-10)

A partial list of diseases that can cause osteoporosis include: amenorrhea, malnutrition, Cushing’s disease, diabetes, hypogonadism, hyperparathyroidism, hyperthyroidism, and multiple myeloma.

Prescription medications that are associated with bone demineralization, and thus cause or contribute to osteoporosis, are: aromatase inhibitors, antiepileptic drugs, antiretroviral drugs, depo-provera, and corticosteroids.

There are many adults that are not taking the above bone demineralizing drugs nor have any of the above listed diseases. Yet many have, or will have, osteoporosis.

This article would quickly turn into a book length if all aspects of osteoporosis were discussed; bone density tests, laboratory studies, vitamins, mineral, other natural compounds, medications, exercise, etc. There is one item that can be profound that rarely gets the deserved press.

Unipedal standing is a balance exercise performed with open eyes and standing on each leg for one minute, three times per day.(11) Unipedal standing (aka dynamic flamingo therapy) helps to reduce falls(12), increase bone mineral(13,14), and may prevent fractures(11-15).

Vigorous weight bearing exercise has a protective and anabolic effect on bone especially in the pre and early adult years. High force activities (e.g. volleyball, weight lifting, sprinting) may not be an option for the elderly. Unipedal standing was calculated to increase the stress at the femoral neck by a factor of 2.75 as compared with standing on two legs. Two minutes (one minute on each leg) of unipedal standing is equivalent to 53 minutes of walking.(15)

Unipedal standing appears to yield the greatest benefits in the elderly as is noted with increases in femoral neck and total hip bone mineral density, better balance, and fewer falls. Each of these is associated with a lower risk for hip fracture.

The results of unipedal standing have a positive impact on osteoporosis and fracture prevention however, treatment never needs to be limited to this exercise. Expanding the exercise program to include tai chi(16) and muscle strengthening(17) also contribute to fracture reduction.

Osteoporosis is a multifactorial disease necessitating a spectrum of treatments. The various choices of exercises are one aspect of an overall management plan. Unipedal standing for 6 minutes per day provides genuine benefits as a contribution to osteoporosis treatment. This is a low risk, inexpensive, and easily learned treatment.


Alan Cook DC has been in practice since 1989, emphasizing osteoporosis. He is currently working with EasyWebCE providing Continuing Professional Development in a web-based video format.





  1. Sambrook PN, Seeman E, Phillips SR, Ebeling PR (2002) Preventing osteoporosis: outcomes of the Australian Fracture Prevention Summit. Med J Aust 176 Suppl:S1.
  2. Nguyen TV and Eisman JA (1999) Risk factors for low bone mass in elderly men. In: ES Orwoll (ed) Osteoporosis in Men. Academic Press, San Diego, p 335.
  3. Osteoporosis New Zealand Inc. (2007) The Burden of Osteoporosis in New Zealand: 2007-2020. (www.bones.org.nz)
  4. Bikle DD. Vitamin D metabolism, mechanism of action, and clinical applications. Chem Biol. 2014;21(3):319-329. 
  5. Holick M: High prevalence of vitamin D inadequacy and implications for health. Mayo Clinic Proc 2006, 81:353–373
  6. Allain TJ, Dhesi J. Hypovitaminosis D in older adults. Gerontology. 2003;49(5):273-278.
  7. O’Malley G, Mulkerrin E. Vitamin D insufficiency: a common and treatable problem in the Irish population. Ir J Med Sci. 2011;180:7-13.
  8. Arunabh S, Pollack S, Yeh J, Aloia JF. Body fat content and 25-hydroxyvitamin D levels in healthy women. J Clin Endocrinol Metab. 2003;88:157-61.
  9. Bandeira F, Griz L, Dreyer P, Eufrazino C, Bandeira C, Freese E. Vitamin D deficiency: a global perspective. Arq Bras Endocrinol Metabol. 2006 Aug;50(4):640-6.
  10. Aranow C. Vitamin D and the immune system. J Investig Med. 2011;59(6):881-886.
  11. Sakamoto K, Nakamura T, Hagino H, 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. Journal of Orthopaedic Science 2006;11:467-72.
  12. Sakamoto K, Endo N, Harada A, et. al. Why not use your own body weight to prevent falls? A randomized, controlled trial of balance therapy to prevent falls and fractures for elderly people who can stand on one leg for ≤15 s. Journal of Orthopaedic Science 2013; 18: 110-120.
  13. Sakai A, Oshege T, Zenke Y, et. al. Unipedal standing exercise and hip bone mineral density in postmenopausal women: a randomized controlled trial. J Bone Mineral Metab 2009; 28:42
  14. Sakamoto K, Nagai T, Murakami J. Does a One-minute Unipedal-standing Balance Exercise with Eyes Open Three Times Daily Increase Bone Mineral Density? A Randomized Controlled Trial. Showa University Journal of Medical Sciences 2010; 22
  15. Sakamoto K. Effects of unipedal standing balance exercise on the prevention of falls and hip fracture. Clinical Calcium 2006;16:2027-32.
  16. Maciaszek J, Osinski W, Szeklicki R, Stemplewski R. Am J Chinese Medicine 2007;35: 1-9.
  17. Iwamoto J. Exercise and Fall Prevention. Osteoporosis in Orthopedics 2019: 221-34.