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Presented by Mushi Harush,2005Aquatic exercise trainer specialistMA.Haifa University. Wingate Institute

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The women in the experimental group who participate in the seven-month physical activity program in water will evince no decline in bone density; they might also register an increase in bone density. If there is nevertheless a decline, it will be less than for the control group.

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ParticipantsExperimental group This group included 25 postmenopausal women aged 50 to 65 who met the following criteria:They no longer have their monthly cycle (menses)

They do not engage in organized physical activity in any official setting

They do not suffer from osteoporosis, that is, their baseline bone density is higher than 55% of mean bone density for the normal population of this age.

They do not suffer from one of the following medical problems which may affect their bone density: thyroid gland problems, blood pressure problems, and diabetes.

They do not take any of the following medications (which affect bones): Matrix, B complor, Betoptic, Arimidex, Cosamin, Bondormine, Glucosamine, Chondroitin, Tarivite, Normalol,, Vascace, Activelle, Normiten, Lipidal, Ocsaar, Simvastatin, Narvasc, Aspirin.

They do not smoke.

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Control group

The control group consisted of 10 women the same age as those in the experimental group who met the same criteria as the experimental group.The following table presents a comparison of variables between women in the experimental group and women in the control group:

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Table 1: Comparison of data for the experimental group and control group

Variable Experimental group

Control group t- test Level of significanc

e

MeanS.D

Mean /S.D

Mean /S.D

t(29) Sig

Age in years 54.90 /4.45

56.0 /3.49

706.- N.S

BMIKg / m²

29.55 /5.45

28.16 /5.31

686. N.S

Age at cessation of menses - years

49.57 /6.16

49.63 /2.41

032.- N.S

No. of years after menses cessation

5.32 /6.07

5.95 /4.18

305.- N.S

Height in cm 159.75 /8.29

158.54 /7.94

035. N.S

Weight in kg 74.25 /12.64

69.0 /16.52

1.02 N.S

According to the data in Table 1, there were no significant differences between the two groups in any of the variables.

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Physical measurements before commencing physical activity – for all the women in the experimental group

Height

Weight using an electronic scale

Bone density measurement by means of DEXA in the following body areas: Vertebrae L1-L4 Vertebrae L2-L4 Femoral neck of the dominant and non-dominant legs

Measurements were: bone density in the vertebra – BMD (g/cm2), z-score,t-score, and mineral content of vertebra BMC (grams)

Measurement of bone density by means of Sunlight Omnisense (QUS) in the following parts of the body: Distal radius of dominant and non-dominant arms

Midshaft tibia of dominant and non-dominant legsMeasurements were: SOS – speed of sound in meters per second (m/sec), t- score, and z-score.

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The training program commenced in May 2003 and concluded at the end of November 2003, for a total of seven months. The experimental group worked regularly on Monday Wednesday and Thursday eveningswith the same instructor (the researcher) throughout the period,. The loads applied on the bones were increased gradually. The water in the pool used for the study was warmed to 32 degrees C.Celsius, and all activity was conducted at chest level. The sessions were conducted with strict adherence to safety principles and to AEA and American College of Sports Medicine guidelines for working with elderly women (ACSM, 2000).

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WeekNumber of repetitions of each exercise

Auxiliary equipment for activity

1-2 10-12 Without equipment, use of water resistance only, varying lever length, surface area and movement speed

3-4 10-12 Equipment that adds resistance to drag, pool wall and gloves

5-6 12-15 Weights to strengthen upper body with maximal resistance and work to strengthen abdominal muscles.Strengthening lower body through water resistance, using noodles

7-8 15-20 Aquafines and noodles, pool wall, weights

9-12 15-20 Various equipment for circuit training

13-17 15-30 Variety of equipment to create different stimuli with gradual and varying load on bones. Drills such as circuit training at stations and interval training at varying degrees of difficulty

17-28 20-30 Activity time remains the same, but exercise intensity increases by adding more power, speed, increasing surface area, more frontal resistance, lever length, movements to help and resist direction of movement

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Warm-up: 7-10 minutesThis was intended to allow the body to adapt to water temperature. This part of the session included movements with short levers that gradually became long levers. Stretches performed at this stage were always at normal range of movement and included the neck, chest, deltoid, lower-back, quadriceps, pelvic, hamstring and gastrocnemius muscles.

Aerobic set: 20 minutesThe aim of this part of the session was mainly to improve participants‘ general aerobic ability and not bone density, although it contributed to the latter as well. Reasonable aerobic capacity was essential for participants to withstand the training load required in other parts of the program intended especially to improve bone density. Participants were directed to work at a load equivalent to the feeling of effort registering 12-16 on the Borg Scale. Furthermore, throughout the lesson emphasis was placed on proper posture.

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Strengthening muscles and loading the bones: 20 minutesThis segment worked on specific muscle groups in order to improve their strength and endurance, while raising the resistance load on bones and muscles. The activities of this segment utilized four movement patterns: compression, twisting, stretching/extension, bending, and combinations of the four. Each exercise was repeated 16 to 32 times, in accordance with ACSM guidelines (2000).

Cool down and stretches: 10 minutesThe duration of this part of the session depended on air and water temperature. It included static and dynamic stretches to maintain body heat and to promote proper posture, flexibility and relaxation.

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Exercises to improve range of movement and flexibility

Exercises to improve posture, and to strengthen abdominal,

upper and lower back, chest and leg muscles with an emphasis

on ankle-related muscles in order to prevent falls.

Exercises to strengthen muscles and load bones –

isotonic and isometric exercises integrating the four movement patterns (compression, stretching, bending, and twisting).

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Equipment used in the training programThis study utilized equipment by Thera-Band (United States) developed mainly to increase resistance to movement in water.

Aquafines Cuffs – a wing-shaped aid attachable to arms and legs that increases resistance to limb movement in water. It was used mainly in work on the ankle area to increase intensity of effort by the following muscles: Hamstrings, vastus lateralis, vastus medialis, quadriceps, gluteals, abductors and adductors.

Hand Bars – an apparatus in the shape of a hand weight, with bar and two foamy sponge "weights." The aid increases buoyancy and creates water resistance to movements that try to push the bars towards the floor of the pool. It increases resistance for arm muscles and the upper part of the body.Noodles – buoyant, water-resistant sponges 1.6m long and 6cm in diameter. They are used mainly to strengthen the upper part of the body: chest, abdominal and back muscles (pectorals, rhomboids/trapezius, stabilizing trunk muscles, external and internal obliques).Pool wall – used to increase stability, strengthen muscles and increase flexibility.

Gloves – rubber-lined gloves covered with waterproof cloth. The gloves are used to reduce gaps between fingers and thus increasing hand surface area and water resistance.

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Within two weeks after completing the seven months of water training, the same type of bone density tests were conducted on the experimental group as before the sessions.

The control group underwent only DEXA tests, seven months after the initial test.

Instruments

Electronic scale

Ultrasound: Omnisense (Sunlight, model 8000S)

DEXA: Luna model DPXIQ # 4941

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Data were examined by means of two-way 2x2 repeated measures (ANOVA repeated measures) with group as the independent variable (between group factor).

Participating in this study were 35 women, mean age 55.45 years (SD=3.97), of them 25 women in the experimental group (54.9±4.45) and 10 women in the control group (56±3.49). During the training period five women dropped out of the experimental group so that only 20 women completed the study. Baseline data for the women in the study, as presented in Table 1, indicated no significant differences in age, BMI, age of menstrual cessation, number of years after last menses, and height between the experimental and control groups.

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Table 3 presents the findings for the DEXA test, comparing the experimental and control groups for the following variables:

BMD: Bone density measured in grams per square centimeter

T-score: Number of standard deviations of BMD values for the participant from the mean value for a 25 year old woman

Z-score: Number of standard deviations of BMD values for the participant from the mean value for a women her age

BMC: Mineral content of bone, measured in grams

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Table 3: Results of DEXA tests for vertebrae L2-L4

Variable Pre Post F(1,27)Sig

F(1,27)Sig

F(1,27)Sig

Mean S.D. Mean S.D. Time Group Time*Group

BMD(g/cm2)

ExperControl

1.111.11

.157

.2331.121.08

.165

.215.199N.S.

0.120N.S.

9.25P<.01

t-score ExperControl

-.67-.72

1.331.95

-.59-.96

1.391.80

2.17N.S.

0.122N.S.

9.41P<.01

z-score ExperControl

.005

.0471.701.36

0.84-.154

1.441.52

1.01N.S.

0.029N.S.

5.35P<.05

BMC(grams)

ExperControl

45.1345.95

7.7712.55

45.3844.13

7.5712.10

4.61P<.05

0.003N.S.

7.99P<.01

According to the findings, the Time factor by itself (differences between pre and post) appears to have had a significant effect only on the BMC variable. In the other dimensions no significant pre and post differences were found. On the other hand, the interaction of Time*Group was found to be significant for each of the measures. Figures 1-4 detail the interactions for each of the variables. These figures indicate the positive effect of the treatment and the general trend of bone density maintenance or increase in the experimental group, and a downward trend in bone density for the control group.

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1.06

1.07

1.08

1.09

1.1

1.11

1.12

1.13

Pre post

exper.

control

BM

D (

gr/

cm

2)

Figure 1: BMD values pre and post treatment in the experimental and control groups for vertebrae L2-L4

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-1.2

-1

-0.8

-0.6

-0.4

-0.2

0

exper.

control

pre post

t-sc

ore

BM

D

Figure 2: t-score values for BMD pre and post treatment for the experimental and control groups for vertebrae L2-L4

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-0.2

-0.15

-0.1

-0.05

0

0.05

0.1

exper.

control

pre post

z-sc

ore

BM

D

Figure 3: z-score values for BMD pre and post treatment in the experimental and control groups for vertebrae L2-L4

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43

43.5

44

44.5

45

45.5

46

46.5

exper.

control

BM

C (

gra

ms

)

pre post

Figure 4: BMC values pre and post treatment for the experimental and control groups for vertebrae L2-L4

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DEXA test findings for vertebrae L1-L4Table 4 presents the DEXA test findings and a comparison between the experimental and control groups

for the variables BMD, t-score and z-score and BMC., Table 4: Results of DEXA test for vertebrae L1-L4

Variable Pre Post F(1,27)Sig

F(1,27)Sig

F(1,27)Sig

Mean S.D. Mean S.D. Time Group Time*Group

BMD(g/cm2)

ExperControl

1.091.08

0.140.22

1.091.06

0.150.20

2.47N.S.

0.081N.S.

11.01P<.01

t-score ExperControl

-.737-.770

1.231.84

-.658-.978

1.311.70

2.41N.S.

0.096N.S.

11.92P<.01

z-score ExperControl

-.084.020

1.291.58

0.00-.189

1.361.42

1.60N.S.

0.006N.S.

8.84P<.01

BMC(grams)

ExperControl

56.3957.68

9.5115.58

56.7455.67

9.4414.86

3.62N.S.

0.001N.S.

7.25P<.05

It appears that no significant differences were found for the Time factor or the Group factor, as there are no pre and post treatment differences between the experimental and control groups. On the other hand, there is a significant interaction, that is, the combination of Treatment and Group indicates a significant difference in Group behavior. The interactions in Figures 5-8 illustrate the positive effect of the treatment and testify to the general trend towards maintenance or improvement of bone density in the Experimental group and a trend towards declining bone density for the control group.

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1.04

1.05

1.06

1.07

1.08

1.09

1.1

Pre post

exper.

control

BM

D (

g/c

m2 )

Figure 5: BMD values pre and post treatment for the experimental and control groups for vertebrae L1-L4

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-1.2

-1

-0.8

-0.6

-0.4

-0.2

0

exper.

control

pre post

t-s

co

re B

MD

Figure 6: t-score values for BMD pre and post treatment for the experimental and control groups for vertebrae L1-L4

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-0.2

-0.15

-0.1

-0.05

0

0.05

exper.

control

pre post

z-sc

ore

BM

D

Figure 7: z-score values for BMD pre and post treatment for the experimental and control groups for vertebrae L1-L4

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54.5

55

55.5

56

56.5

57

57.5

58

Pre post

exper.

control

BM

C (

gram

s)

Figure 8: BMC values pre and post treatment for the experimental and control groups for vertebrae L1-L4

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Table 5 presents the findings of the DEXA tests and a comparison of the experimental and control groups for the following variables:

Total BMD right: mean bone density in right femoral neck (g/cm2)

Total BMD left: mean bone density in left femoral neck (g/cm2)

Total BMC right: mean mineral content of right femoral neck (gr)

Total BMC left: mean mineral content of left femoral neck (gr)

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TestPre Post F(1,27)

SigF(1,27)

SigF(1,27)

Sig

Mean S.D. Mean S.D. Time Group Time*Group

Total BMD right(g/cm2)

ExperControl

.998

.9750.1220.095

1.00.952

0.1270.114

1.69N.S.

0.43N.S.

4.14N.S.

Total BMD left(g/cm2)

ExperControl

1.00.937

0.110.12

1.00.942

0.110.11

0.20N.S.

1.08N.S.

0.20N.S.

Total BMC right (grams)

ExperControl

31.7931.73

5.293.72

32.4630.40

5.344.85

0.35N.S.

0.25N.S.

8.08P<.01

Total BMC left (grams)

ExperControl

31.7828.66

5.385.23

32.0129.20

5.695.30

0.96N.S.

1.15N.S.

0.161N.S.

Table 5: Results of DEXA test for femoral neck, right and left legs

Two-way ANOVAs with repeated measures reveal no significant differences between the groups before and after treatment. Significant interaction was found only for BMC in the right leg, and it is presented in Figure 9.

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29

29.5

30

30.5

31

31.5

32

32.5

33

Pre post

exper.

control

tota

l BM

C (

gram

s)

Figure 9: Total BMC values for right femoral neck pre and post treatment in the experimental and control groupsFrom this figure it can be seen that the women in the experimental group exhibited a trend towards improved bone density. Among the women in the control group there is a trend towards declining bone density. This interaction was found to be significant statistically.

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Table 6 presents the findings of the QUS test for the experimental group with a comparison of bone density pre and post treatment for the following variables:

t-score: the number of standard deviations of SOS (speed of sound) values in bone density of the participant from the mean for a 25 year old woman

z-score: the number of standard deviations of SOS (speed of sound) values in bone density of the participant from the mean value of a woman the participant's age.

The variables were measured in values of speed of the returning wave in meters per second (m/sec) in the following sites:

Raddom: proximal radius of the dominant arm

Radnon: proximal radius of the non-dominant arm

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QUS test Table 6: Pre and post study QUS test findings for the proximal radius of dominant and non-dominant arms of women in the experimental group

Type of testPre Post F(1,14)

Sig

Mean S.D. Mean S.D. Time

Raddom Exper 4058.73 135.44 4092.27 105.55 2.008 N.S.

Raddom t-score Exper -1.125 1.38 -.783 1.07 2.00 N.S.

Raddom z-score Exper .464 1.41 -.281 .93 3.73 N.S.

Radnon Exper 4093.36 90.22 4081.0 83.94 .624 N.S.

Radnon t-score Exper -.772 .920 -.898 .856 .624 N.S.

Radnon z-score Exper .464 1.41 -.281 .93 3.73 N.S.

It can be seen that no significant changes were observed in the ultrasound test between the commencement and the conclusion of the program.

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Summary of studies of water exercise and bone density

Researcher Harush Yurtkuran Bravo Tsukahara Goldstein

Year of publication

Unpublished 2003 1997 1994 1994

Country Israel Turkey Canada Japan Israel

Duration 7 months 6 months 12 months 36 months 5 months

Frequency of training sessions

3 times per week

3 times per week 3 times per week 1 time per week 3 times per week

Duration of session

60 minutes 40 minutes 60 minutes 45 minutes 45 minutes

Structure of session

10 min warm-up 20 min aerobic activity20 min muscle strengthening, 10 min cool-down

Week 1: 5 min warm-up, 10 min aerobics, 5 min relaxation ex, 5 min stretches outside pool. Week 2: aerobics 15 min, Week 3: 20 min; Week 4 to end: 25 min. Other elements remained unchanged

10 min warm-up (flexibility & stretching ex), 40 min jumps in intervals and muscle strengthening ex. 10 min cool-down including relaxation ex., stretches, balance & coordination

10 min warm-up 20 min aerobic activity and deep breathing10 min swimming5 min cool-down

10 min warm-up 25 min strength training 10 min cool-down and stretches

Measurement tools

DEXAQUS

QUS DEXA DEXA Compton scattering method

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Researcher Harush Yurtkuran Bravo Tsukahara Goldstein

Areas of measurement

1.Vertebrae L1-L42.Vertebrae L2-L43.Femoral neck (both legs)4.Proximal radius5.Midshaft tibia

Heel bone Vertebrae L2-L4Femoral neck one leg( right)

Vertebrae L1-L4

Distal radius

Participants 35 postmenopausal women 41 postmenopausal women

77 postmenopausal women

65 postmenopausal women

50 post menopausal women

Findings 1.Vertebrae: significant interaction between Time & Group factors in all four measures: BMD, BMC, t-score, z-score.2.Bone density in femoral neck: significant interaction between Time & Group only for BMC and right leg (p<0.01)3.No significant changes in bone density in radius and tibia

Increase of 19% and 63% in t-scores of broadband ultrasound attenuation and speed of sound, respectively; decrease in control group

1. Significant decline of 1 % in vertebral bone density2. No change in femoral neck bone density

1. Veteran exercisers showed mean increase of 1.55% in bone density; novice exercisers showed mean increase of 2.16%; control group showed mean decrease of 0.92%.2. For the two active groups, there was not correlation to number of years since cessation of menses

1.Significant increase of 1% in bone density in water group over baseline.2.No significant change in the land-based group

Conclusions Regular water exercise a number of hours per week may help maintain bone density

Water exercise was found to effectively create an anabolic effect on postmenopausal women's bones

No positive effect of water exercise was found on the skeletal system

Regular water exercise is an important component in preventing bone density loss

Weight-loading activity using water resistance is effective in treating loss of bone density

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Research problems

1. Too small a sample2. No SOS data for control group

1. Small sample2. Too short a research period3. Activity sessions were only 40 minutes. 4. Bone density measurement in only one site

1.Instructors were lifeguards not water exercise instructors2.Lack of bone stimulus variety 3.No auxiliary aids used to heighten resistance

1.Sessions were 45 minutes instead of 602.10 min of each lesson were devoted to swimming. Hard to know whether the physical activity or the swimming or both affected bone density3.Additional physical activity (outside study) was not neutralized4.No special equipment was used in the water

1.Additional physical activity was not neutralized2.Bone density was measured at only one site

Researcher Harush Yurtkuran Bravo Tsukahara Goldstein

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1. water exercise allows the option of creating the types of loads that have a positive effect on bone density

2. This study provides support for the idea that non-body-weight-bearing physical activity can stimulate bone density,

Gross and colleagues(2004) assumed that integrating rest periods between loading cycles might reproduce the maximal flow effect and thus significantly increase the potential for rebuilding bone and enhancing its density

3. water exercise as performed in the present study provided the required hiatuses between loads and thereby allowed the vertebrae to respond positively.

.

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5.the effect of water exercise on bone density of the femoral neck

in the present study, a significant interaction was found between the Time variable and the Group variable only for BMC and only in the right leg (p<0.01). The meaning of this finding is that the training program increased bone density in the femoral neck of the right leg only in the experimental group, in contrast to a decline among women in the control group who did not engage in physical activity at all. At the same time, it should be emphasized that the other measures (BMD, t-score and z-score) did not register a positive effect for the treatment and no interaction was found.

A possible explanation for the increase in bone density only in the right femoral neck may be attributable to the fact that the right leg is dominant for most people. As seen earlier, the professional literature offers evidence of higher bone density in the dominant side among athletes (basketball, soccer, squash, baseball and badminton players), because of their greater and more correct use of that limb (Bailey et al., 1996)

study, required symmetric, equal work by both legs which was supposed to affect bone density in both equally. Perhaps the natural tendency of the dominant leg to work harder explains the greater effect of physical activity on its bone density.

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6. The effect of water exercise on bone density of the proximal radius and of the midshaft tibia

in the present study, no significant pre- post-differences in bone density were found using the Sunlight Omnisense apparatus among women in the experimental groupThese findings are consistent with the study hypothesis that among women in the experimental group there would be no decline in bone density, and the findings reinforce the conclusion that water exercise contributes to maintaining bone density.

The effect of water exercise on bone density of the tibia and the radius was tested only for the experimental group, and without data on the control group it is difficult to draw clear conclusions about possible effects of the treatment on the experimental group

At the same time, and even though no differences were observed in bone density of the proximal radius and the midshaft tibia, it was possible to identify in both of them an increase in density of the dominant limb in contrast to the non-dominant limbThis increase might actually signal a rise in bone density but this is only supposition as the change was not significant.