To Predict Mortality, You Need a Leg to Stand On

Adam Marcus

June 21, 2022

Storks everywhere, rejoice. A new study shows that the ability to stand on one leg for at least 10 seconds is strongly linked to the risk of death over the next 7 years.

According to the findings, people in middle age and older who couldn't perform the 10-second standing test were nearly four times as likely to die of any cause ― heart attacks, strokes, cancer, and more ― in the coming years than those who could, well, stand the test of time.

Claudio Gil Araújo, MD, PhD, research director of the Exercise Medicine Clinic-CLINIMEX in Rio de Janeiro, Brazil, who led the study, called the results "awesome!"

"As a physician who has worked with cardiac patients for over four decades, I was very impressed in finding out that, for those between 51 and 75 years of age, it is riskier for survival to not complete the 10-second one-leg standing test than to have been diagnosed as having coronary artery disease or in being hypertensive" or having abnormal cholesterol, Araújo told Medscape Medical News.

The findings appear today in the British Journal of Sports Medicine.

Researchers have known for at least a half century that balance and mortality are connected. One reason is falls: Worldwide, nearly 700,000 people each year die as a result of a fall, according to the World Health Organization, and more than 37 million falls annually require medical attention. But as the new study indicates, falls aren't the only problem.

Araújo and his colleagues have been working on ways to improve balance and strength as people age. In addition to the one-legged standing test, they have previously shown that the ability to rise from a sitting position on the floor is also a strong predictor of longevity.

For the new study, the researchers assessed 1702 people in Brazil (68% men) aged 51–75 years who had been participating in an ongoing exercise study that began there in 1994.

Three Tries to Succeed

Starting in 2008, the team introduced the standing test, which involves balancing on one leg and placing the other foot at the back weight-bearing limb for support. People get three tries to maintain that posture for at least 10 seconds.

Not surprisingly, the ability to perform the test dropped with age. Although 20% of people in the study overall were unable to stand on one leg for 10 seconds, that figure rose to about 70% for those aged 76–80 years, and nearly 90% for those aged 81–85, according to the researchers. Of the two dozen 85-year-olds in the study, only two were able to complete the standing test, Araújo told Medscape.

At roughly age 70, half of people could not complete the 10-second test.

Over an average of 7 years of follow-up, 17.5% of people who could not manage the 10-second stand had died, compared with 4.5% of those who could last that long, the study found.

After accounting for age and many other risk factors, such as diabetes, body mass index, and a history of heart disease, people who were unable to complete the standing test were 84% more likely to die from any cause over the study period than their peers with better one-legged static balance (95% CI: 1.23 – 2.78; P < .001).

The researchers said their study was limited by its lack of diversity ― all the participants were relatively affluent Brazilians ― and the inability to control for a history of falls and physical activity. But they said the size of the cohort, the long follow-up period, and their use of sophistical statistical methods helped mitigate the shortcomings.

Although low aerobic fitness is a marker of poor health, much less attention has been paid to nonaerobic fitness ― things like balance, flexibility, and muscle strength and power, Araújo said.

"We are accumulating evidence that these three components of nonaerobic physical fitness are potentially relevant for good health and even more relevant for survival in older subjects," Araújo said. Poor nonaerobic fitness, which is normally but not always associated with a sedentary lifestyle, "is the background of most cases of frailty, and being frail is strongly associated with a poor quality of life, less physical activity and exercise, and so on. It's a bad circle."

Araújo's group has been using the standing test in their clinic for more than a dozen years and have seen gains in their patients, he said. "Patients are often unaware that they are unable to sustain 10 seconds standing one legged. After this simple evaluation, they are much more prone to engage in balance training," he said.

For now, the researchers don't have data to show that improving static balance or performance on the standing test can affect survival ― a "quite attractive" possibility, he added. But balance can be substantially improved through training.

"After only a few sessions, an improvement can be perceived, and this influences quality of life," Araújo said. "And this is exactly what we do with the patients that we evaluated and for those that are attending our medically supervised exercise program."

George A. Kuchel, MD CM, FRCP, professor and Travelers Chair in Geriatrics and Gerontology at the University of Connecticut, Farmington, called the research "well done" and said the results "make perfect sense, since we have known for a long time that muscle strength is an important determinant of health, independence, and survival."

Identifying frail patients quickly, simply, and reliably in the clinical setting is a pressing need, Kuchel, director of the UConn Center on Aging, told Medscape. The 10-second test "has considerable appeal" for this purpose, he said.

This could be ― or rather should be ― of great interest to all busy clinicians who see older adults in primary care or consultative capacities.  Dr George Kuchel

"This could be ― or rather should be ― of great interest to all busy clinicians who see older adults in primary care or consultative capacities," Kuchel added. "I hate to be nihilistic as regards what is possible in the context of really busy clinical practices, but even the minute or so that this takes to do may very well be too much for busy clinicians to do."

Araújo and Kuchel reported no relevant financial relationships.

Br J Sports Med. Published online June 21, 2022. Abstract

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