Trainingsziele und Risikokategorisierung im Spannungsfeld körperliches Training und Frakturprophylaxe: Ansatzpunkte für individualisierte Trainingsprogramme

Zusammenfassung

Die Definition von relevanten Trainingszielen und deren weitgehend individualisierte Allokation zu Gruppen unterschiedlicher Anforderungen sollte der erste Schritt einer jeden Trainingsstrategie zur optimierten Trainingsplanung und sicheren Trainingsdurchführung sein. Die Festlegung der Trainingsziele im Bereich der Frakturprophylaxe orientiert sich eng an den Frakturdeterminanten „Knochenfestigkeit“, „Sturzhäufigkeit“ und „Sturzimpact“, die für die unterschiedlichen (Fraktur-)Risikokollektive jeweils unterschiedliche Relevanz aufweisen. Für (1) Personen mit erhöhtem Knochenumbau oder mässiggradiger Verringerung (Osteopenie) sowie (2) Personen deutlicher Verringerung der Knochendichte (Osteoporose) ohne Frakturen und ohne relevant erhöhtes Sturzrisiko sind Erhalt/Erhöhung der Knochenfestigkeit das primäre Trainingsziel. Bei (3) Personen mit Osteoporose, ohne einschlägige Frakturen aber mit relevant erhöhtem Sturzrisiko und (4) Personen mit Osteoporose-assoziierten Frakturen und multiplen Sturzrisikofaktoren gewinnen die Trainingsziele „Reduktion der Sturzhäufigkeit“ und „Verbesserung des Sturzablaufes“ zunehmend an Bedeutung. Bei (5) Personen mit multiplen Osteoporose-assoziierten Frakturen, hohem Sturzrisiko und sehr geringer körperlicher Leistungsfähigkeit ist die Bedeutung der Knochenfestigkeit als Trainingsziel vernachlässigbar, nicht zuletzt da die unmittelbare Verordnungsfähigkeit einer pharmakologischen Therapie besteht. Zusammenfassend ist eine individualisierte Zuweisung von Trainingszielen hochrelevant und leistet einen entscheidenden Beitrag zur Erstellung optimierter Trainingsprotokolle zur Frakturprävention.

Abstract

In basic exercise science, defining relevant training aims and their individualized assignment to the specified subject or cohorts is the first step of any training strategy. In the complex area of exercise and fracture prevention, several aspects have to be considered. Whilst pharmaceutic therapy focuses solely on bone, exercise training aims for fracture prevention include all the main determinants (or reasons) of fractures, i. e. “bone strength”, “fall frequency” and “fall-induced impact (on bone)”. However, the relevance of trainings aims covering maintenance or boosting bone strength, reduction of fall frequency and fall-induced impact differs significantly depending on the different cohorts at risk for fractures. In the present work, we differentiate five cohorts classified according to several aspects relating predominately to bone status, fall risk and physical capacity. When allocating the corresponding cohorts to their primary training aim(s), the primary training aim for (1) people with osteopenia and increased bone turnover without increased fall risk and for (2) people with osteoporosis, no fractures and without increased fall risk, is to maintain or increase bone strength. Reducing fall frequency and fall-related impact becomes increasingly relevant for cohorts with (3) people with osteoporosis, no fractures but multiple risk factors for falls and (4) people with vertebral fractures and multiple risk factors for falls. Finally, for (5) people with multiple fractures, high risk of falling and very low physical capacity, the relevance of bone strength as a training aim becomes negligible, partly because the majority of this cohort is provided with a pharmaceutic therapy that focuses on bone. We feel that the early and individualized assignment of training aims facilitates the further training process and represents a crucial aspect in the area of optimized training protocols for fracture prevention.

Schlüsselworte

körperliches Training - Frakturprophylaxe - Trainingsregelung - Trainingsziele - Risikokollektive Fraktur

Key words

Exercise - fracture prevention - training regulation - training aim - type of exercise - cohort of risk for fractures

• Literatur

• 1 RACGP. Osteoporosis prevention, diagnosis and management in postmenopausal women and men over 50 years of age, The Royal Australian College of General Practitioners and Osteoporosis Australia. In: East. Melbourne: 2017
• 2 SIGN. Management of osteoporosis and the prevention of fragility fractures. A national clinical guideline. In: Scottish_Intercollegiate_Guidelines_Network ed. 2020
• 3 Giangregorio LM, McGill S, Wark JD. et al. Too Fit To Fracture: outcomes of a Delphi consensus process on physical activity and exercise recommendations for adults with osteoporosis with or without vertebral fractures. Osteoporos Int 2015; 26: 891-910
• 4 de Souto Barreto P, Rolland Y, Vellas B. et al. Association of Long-term Exercise Training With Risk of Falls, Fractures, Hospitalizations, and Mortality in Older Adults: A Systematic Review and Meta-analysis. JAMA Intern Med 2019; 179: 394-405
• 5 Wang Q, Jiang X, Shen Y. et al. Effectiveness of exercise intervention on fall-related fractures in older adults: a systematic review and meta-analysis of randomized controlled trials. BMC Geriatr 2020; 20: 322
• 6 Hoffmann I, Kohl M, von Stengel S. et al. Exercise and the prevention of major osteoporotic fractures in adults: a systematic review and meta-analysis with special emphasis on intensity progression and study duration. Osteoporos Int 2022; 4: 15-28
• 7 Hoffmann I, Shojaa M, Kohl M. et al. Exercise reduces the number of overall and major osteoporotic fractures in adults. Does supervision make a difference? Systematic review and meta-analysis. JBMR 2022; 37: 2132-2148
• 8 Kemmler W, Haberle L, von Stengel S. Effects of exercise on fracture reduction in older adults : A systematic review and meta-analysis. Osteoporos Int 2013; 24: 1937-1950
• 9 Kemmler W, Weineck J, Hensen J, Lauber D, Kalender WA, Engelke K. Empfehlungen für ein körperliches Training zur Verbesserung der Knochenfestigkeit: Schlussfolgerungen aus Tiermodellen und Untersuchungen an Leistungssportlern. Dtsch Z Sportmed 2003; 54: 306-316
• 10 Weineck J, Kemmler W, Fröhlich M. Trainingsziele, -inhalte, -mittel und -methoden im Sport. In: Güllich A, Krüger M, Hrsg. Bewegung, Training, Leistung und Gesundheit. Berlin, Heidelberg, Germany: Springer; 2020.
• 11 Mohebbi R, Shojaa M, Kohl M. et al Exercise training and bone mineral density in postmenopausal women: An updated systematic review and meta-analysis of intervention studies with emphasis on potential moderators. Osteo Int. 2023 online first.
• 12 Sherrington C, Michaleff ZA, Fairhall N. et al. Exercise to prevent falls in older adults: an updated systematic review and meta-analysis. Br J Sports Med 2017; 51: 1750-1758
• 13 Groen BE, Weerdesteyn V, Duysens J. Martial arts fall techniques decrease the impact forces at the hip during sideways falling. J Biomech 2007; 40: 458-462 S0021-9290(06)00004-2 [pii]
• 14 Weineck J. Optimales Training. Erlangen: Spitta-Verlag; 2019
• 15 Turner CH. Exercise as a therapy for osteoporosis: the drunk and the street lamp, revisited. Bone 1998; 23: 83-85
• 16 Jarvinen TL, Sievanen H, Khan KM. et al Shifting the focus in fracture prevention from osteoporosis to falls. BMJ 2008; 336: 124-126 336/7636/124 [pii]
• 17 Kanis JA, Johnell O, Oden A. et al. FRAX and the assessment of fracture probability in men and women from the UK. Osteoporos Int 2008; 19: 385-397
• 18 Parkkari J, Kannus P, Palvanen M. et al. Majority of hip fractures occur as a result of a fall and impact on the greater trochanter of the femur: a prospective controlled hip fracture study with 206 consecutive patients. Calcif Tissue Int 1999; 65: 183-187
• 19 Costa AG, Wyman A, Siris ES. et al. When, where and how osteoporosis-associated fractures occur: an analysis from the Global Longitudinal Study of Osteoporosis in Women (GLOW). PLoS One 2013; 8: e83306
• 20 Sambrook PN, Cameron ID, Chen JS. et al. Influence of fall related factors and bone strength on fracture risk in the frail elderly. Osteoporos Int 2007; 18: 603-610
• 21 Freitas SS, Barrett-Connor E, Ensrud KE. et al. Rate and circumstances of clinical vertebral fractures in older men. Osteoporos Int 2008; 19: 615-623
• 22 Rubenstein LZ, Josephson KR. The epidemiology of falls and syncope. Clin Geriatr Med 2002; 18: 141-158
• 23 Kannus P. Preventing osteoporosis, falls, and fractures among elderly people. Promotion of lifelong physical activity is essential. Bmj 1999; 318: 205-206
• 24 Matkovic V, Jelic T, Wardlaw G. et al. Timing of peak bonemass in Caucasian females and its implications for the prevention of osteoporosis. J Clin Invest 1994; 93: 799-808
• 25 Okano H, Mizunuma H, Soda M. et al. The long-term effect of menopause on postmenopausal bone loss in Japanese women: results from a prospective study. J Bone Miner Res 1998; 13: 303-309
• 26 Nohara T, Kamei T, Ohta A. Accelerated decrease in Bone Mineral Density in women aged 52-57 years. Tohoku J Exp Med 2006; 210: 341-347
• 27 Ensrud KE, Palermo L, Black DM. et al. Hip bone loss increases with advancing age. J Bone Miner Res 1994; 9: S153
• 28 Montero-Odasso M, van der Velde N, Martin FC. et al. World guidelines for falls prevention and management for older adults: a global initiative. Age Ageing 2022; 51
• 29 Kemmler W, Stengel V. The Role of Exercise on Fracture Reduction and Bone Strengthening. In: Zoladz J, Hrsg. Muscle and Exercise Physiology. London: Academic Press; 2019: 433-448
• 30 WHO. Assessment of osteoporotic fracture risk and its application to screening for postmenopausal osteoporosis. In:. Geneva: World Health Organization; 1994. WHO technical report series No. 843
• 31 DVO. Prophylaxe, Diagnostik und Therapie der OSTEOPOROSE bei postmenopausalen Frauen und bei Männern. Stuttgart: Schattauer; 2017
• 32 Jansen CP, Gross M, Kramer-Gmeiner F. et al. Empfehlungspapier für das körperliche Gruppentraining zur Sturzprävention bei älteren, zu Hause lebenden Menschen. Aktualisierung des Empfehlungspapiers der Bundesinitiative Sturzprävention von 2009. Z Gerontol Geriat 2021; 54: 229-239