Balneotherapy in postmenopausal osteoporosis Alev Ay,MD Uludag University Atatürk Balneotherapy and Rehabilitation Center, Bursa, Turkey Balneotherapy in postmenopausal osteoporosis Alev Ay,MD Uludag University Atatürk Balneotherapy and Rehabilitation Center, Bursa, Turkey

Thermal water analysis in Atatürk Balneotherapy and Rehabilitation Center Filed Analysis: T ( 0 C)LF(uS)pH0 2 (mg/l)m (mol/l)-p (mmol/l) Laboratory analysis: Anionsmg/lmval/l HCO Cl F-F SO Total Cationsmg/lmval/l Ca Mg Na K+K Li Total

Osteoporosis due to estrogen deficiency in postmenopausal women is a significant health problem with a prevalence of 30-50% and the prevalence of vertebral and hip fracture is rising as a consequence. The role of regular exercise in the maintenance of good health is receiving more attention currently than in the past.

Tsukahara N, Toda A, Goto J et al Cross-sectional and longitudinal studies on the effect of water exercise in controlling bone loss in Japanese postmenopausal women. J Nutr Sci Vitaminol 1994;40:37-47 * cross-sectional, longitudinal study * Study duration: weeks * study groups: veterans group (35 weeks aquatic exercise, N=27), newcomers (39 weeks aquatic exercise, N=40), non-exercisers (N=30). * exercise design: walking, jumping and light calisthenics in warm (28-29°C) water. the exercise activity: 10 min warm-up, 20 min of aerobic exercise and deep breathing, 10 min of swimming, 5 min cool-down =40 min/day and once a week..

Results: The rate of change in the BMD (Z scores) of the lumbar spine was %/year in the non-exercisers, +1.55%/year in the Veterans and +2.16%/year in the Newcomers. The subjects’ general avareness of health and fitness in daily life was enhanced after starting the water exercise program. Conclusion: The least the BMD, the much percent changes in BMD Z scores were observed in the exercise groups. Consistently participating in water exercise is an important factor in preventing bone loss and moreover, promote health and improve daily life.

Ay A, Yurtkuran M Evaluation of hormonal response and ultrasonic changes in the heel bone by aquatic exercise in sedentary postmenopausal women Am J Phys Med Rehabil 2003;82:942-9 Design. randomized controlled study duration: 6 months 41 postmenopausal sedentary women (Patient selection: T scores of BUA; a variable of QUS). mean age: 54,8±6 2 groups: aquatic exercise (n=21), control (n=20) groups exercise frequency: 3 times a week and 40 minutes a day standardized dietary program and 1000mg elementary calcium/day were given to all of the subjects ultrasonic and hormonal evaluation (GH, IGF-1, CT, PTH) was done before and after the 6 months training study..

Aquatic exercise (in 29°-30° C water) In the 1st week, aquatic exercisers did 5 minutes warm-up (walking slowly and breathing) 10 minutes aerobic exercise (walking fast, jumping and swaying in the water) 5 minutes cool-down (walking slowly and breathing) 5 minutes stretching to iliopsoas, hamstrings, quadriceps, gastrocnemius, pectoral muscles and dorsal extensors (outside the pool). aerobic exercise was gradually increased to 25 minutes (total duration of exercise in one session was 40 minutes/day at the end of the 1st month).

Results. In the exercise group, there were 36%, 75% and 54% increases in the serum levels of IGF-1, GH and CT respectively. In addition, 31% decrease was found in the serum levels of PTH In the control group, serum levels of GH decreased by 61% but there were no statistically sigificant changes in other variables. T scores of BUA and SOS increased by 19% and 63% in the exercise group There were statistically significant differences between the control and the aquatic exercise groups for the 6 months percent of changes in all the variables.

Conclusion: * The major finding was the significant increase of the ultrasonic scores and growth factors in response to an aquatic exercise regimen. * The osteogenic response to exercise was also followed by an increase in GH and IGF-1; the potent cell mitogens, that might exert a systemic effect on bone density. * Aquatic exercise was determined to be effective to make an anabolic effect on the bone of the postmenopausal sedentary subjects.

Ay A, Yurtkuran M. Influence of aquatic and weight bearing exercises on QUS variables in postmenopausal women. Am J Phys Med Rehabil 2005;84:52-61 randomized controlled study duration: 6 months 62 postmenopausal sedentary women (Patient selection: T scores of BUA; a variable of QUS). mean age of the subjects: 54,1±7 3 groups: aquatic exercise (n=21), weight bearing exercise (n=21) control (n=20) groups exercise frequency: 3 times a week and 40 minutes a day standardized dietary program and 1000mg elementary calcium/day were given to all of the subjects

Exercise design: aquatic exercise (29°-30° C water) In the 1st week, aquatic exercisers did 5 minutes warm-up (walking slowly and breathing) 10 minutes aerobic exercise (walking fast, jumping and swaying in the water) 5 minutes cool-down (walking slowly and breathing) 5 minutes stretching to iliopsoas, hamstrings, quadriceps, gastrocnemius, pectoral muscles and dorsal extensors (outside the pool). In the 2nd week, aerobic exercise was prolonged to 15 minutes. In the 4th and the following weeks, aerobic exercise was 25 minutes and total duration of exercise in one session was 40 minutes. weight bearing exercise The exercise regimen was the same (warm-up,walking, jumping, swaying outside the pool, cool-down and stretching)

Results: *Calcaneal BUA increased in aquatic exercise (G1) and weight bearing exercise (G2) groups by 3.1% and 4.2% respectively. There was a non-significant decrease in BUA by 1.3% in the control (G3) group. *SOS did not change significantly in any of the groups. *There were no statistically significant differences between the exercise groups for BUA and SOS amplitudes. *The percent changes in the exercise groups were statistically significant when compared with the control group for BUA and SOS amplitudes. Comparison of the groups by percentage of changes in BUA and SOS G1 G2 G3 G1-G2 G1-G3 G2-G3 (MV±SD) (MV±SD) (MV±SD) BUA,% 3.1*± * ± ±0.49 NS p<0.01 p<0.01 SOS, % 0.4± ± ±0.5 NS p<0.05 p<0.05

Conclusion: It is generally accepted that the exercise to be effective in preventing bone loss, it must be weight-bearing in nature to generate enough mechanical strain for ambulatory, healthy postmenopausal women. Cross-sectional evidence from other investigators remains inconclusive as to whether muscular contraction independent of weight-bearing impact forces is capable of producing an increase in bone mass. Our present evidence shows that aquatic and weight bearing exercises both can increase calcaneal BUA amplitude.

Comments about the three interventions-1 * Regular aerobic exercise as aquatic or weight bearing exercises, 40 min/day and 2-3 times/week may be exerting a very local effect on the highly stressed parts of the skeleton or making a systemic effect mediated by increased GH secretion, which in turn increases the production of İGF_1 or both of them. *Even though aquatic exercise can be considered a kind of nonloading exercise, it increased calcaneal BUA and lumbar & femur BMD of the healthy postmenopausal subjects. Viscosity of the water acts as friction or resistance when walking fast in the water. An isokinetic exercise model is created in which the load and the velocity is constant for the whole range of motion.

Comments about three interventions-2 The critical point is to increase the quantity of physical activity level to an unusual state *These findings showed that exercise causing repeated mechanical loading in the long bones, outside the normal physiologic range, produces significant increases in bone quality and quantity assessment variables. The critical point is to increase the quantity of physical activity level to an unusual state for osteogenic stimulus, independent of the kind of exercise performed. Aquatic exercise is a suitable means by which the aged and nonswimmers can move their arms and legs easily and freely, without burdening the joints with moderate physical exertion. It combines the stimuli of minimal mechanical impact on the spine with intermittent contractions of the back muscles. It would therefore be sensible to offer to postmenopausal women to increase their physical activity by means of aquatic exercise