1 Copyright © 2012 by ASME Proceedings of the ASME 2012 International Mechanical Engineering Congress & Exposition IMECE2012 November 9-15, 2012 ,… [600210]

1 Copyright © 2012 by ASME Proceedings of the ASME 2012 International Mechanical Engineering Congress & Exposition
IMECE2012
November 9-15, 2012 , Houston, Texas , USA
IMECE2
012-86748

BENEFIC EFFECT OF CONSERVATIVE TREATMENTS ON PATIENTS DIAGNOSED WITH
OSTEOPOROSIS

Petru A. Pop Liviu Lazar Florin M. Marcu
O
radea University Oradea University Oradea University
1 University Str., 410087 1 Un iversity Str., 410087 1 University Str., 410087
Oradea, Romania Oradea, Romania Oradea, Romania
[anonimizat] [anonimizat] [anonimizat]

ABSTRACT
Osteoporosis (OP) represents the most common metabolic
bone disease, characterized by the shrinkage in bone mass and
the destruction of bone quality, thus conferring a higher risk
for micro-fractures and injuries. The goal of treatment in OP is
to grow-up the bone mineral density of the skeleton and to
increase resorption of formed bone, due to improving the
quality life of patients . The methods are diverse, such as
medications, conservative measures, weight reduction,
physical and occupational therapy, mechanical support devices
and surgery. This paper presents a balneal-conservative
treatment of patients diagnosed with OP from Rehabilitation
Clinical Hospital of Felix Spa. The treatment is complex and
involves balneal- physical-kinetic therapy or balneal-physical-
kinetic recovery treatment, which must be periodical repeated
every six months to obtain good results. The study has been
applied to two separate groups of patients with OP between
2009 -2011. The first group of 100 subjects, presented clinical
symptomatology, as pain of variable types like backaches,
fragility fractures or deformation of bone shape that resulted
from fractures or alterations of weakens bones. A second
group of 80 subjects, received the balneal-rehabilitation
treatment combined, or not with physical exercises. DEXA
and SF-36 scores, using statistical analysis, performed the
evaluation of OP treatment . The results of experiment
emphasized the efficiency of balneal-rehabilitation treatment
applied patients with OP. The future research will be focused
upon the implementation of vibration therapy with balneal-
conservative treatment on patients with osteoporosis and
osteoarthritis to reduce the therapy time and improving the
quality life of patients.

KEYWORDS
Balneal-Conservative Therapy, Bone Mineral Density,
Osteoporosis, Quality Life INTRODUCTION
A disease with major health problem and great social
impact on millions of people from the entire world is the
osteoporosis. The main cause of osteoporosis is the aging,
followed by the obesity, diabetes, gout, inactivity and other
hormone disorders. Generally, more than 40% of women and
25% of men about 50 years of age and older will have an
osteoporosis-related fracture in their lifetime [9, 11] .
Osteoporosis (OP) is a systemic skeleton disease,
characterized by a low bone mass and micro-architectural
deterioration of bone tissue with consecutive increasing of
fragile bones and susceptibility of fractures [3-11, 17-22]. This
tissue suffers in physiological conditions a constant
remodeling to keep a natural balance between forming and
resorption in the bone tissue. After the third decade of life, the
resorption exceeds bone forming and leads to osteopathy or, in
severe conditions to osteoporosis (Fig.1) .

a. b.
Figure 1: a-Interior of healthy bone; b-Interior of porous bone to
osteoporosis [21]

Practically, when an imbalance between osteoblastic and
osteoclastic activity occurs, skeletal problems arose . Risk
factors to develop OP and resulting fractures, as advanced
ages, family history, rheumatoid arthritis, low calcium intake,

2 Copyright © 2012 by ASME physical inactivity, and low body weight can lead to this
condition. In addition, a poor bone mineral density may cause
bone fragility and high fracture risk, usually located along the
lumbar spine (Fig.2), hip, fist, tibia and humerus.

Figure 2: Evolution in time of OP, located at lumbar spine [22]

The fracture risk depends on the patient falls, impact force
of falls and bone strength. In the absence of any fracture, the
osteoporosis is asymptomatic, so the osteoporosis fractures are
responsible for occurrence of pains, disabilities, lost labor
capacity and reducing of quality life.
Preventive measures of OP include [9, 17 , 21, 22]:
– A balanced diet rich in Ca and vitamin D
– Maintenance of a healthy body weight
– Beneficial weight-bearing exercise minimum 20 min
everyday
– Avoid tobacco and excess of alcohol consumption
– Fall prevention
– Careful medication usage and seeking alternative, if
possible.
Some symptoms and signs can develop the suspicions
about the presence of OP [9-13, 19- 21], such as:
– Decreasing height with collapse vertebrae
– Back pain, usually in lower thoracic and lumbar areas
– Development of kyphosis or curvature of the upper back
– Suspicion of vitamin D deficiency
– Fracture occurring with minimal trauma
– Low body weight with more than 1% per year at the
elderly.
Bone mineral density (BMD) represents the main value
for the evaluation of OP that is calculated by using reference
values for healthy young white women who are 20 to 29 years
of age and are expressed in standard deviation (SD) units and
reported as a T-score [5, 21, 22]:
o Normal bone density : T-score ≥1 SD below the
young adult reference mean
o Osteopenia : T-score between 1 and 2.5 SD below the
young adult reference mean
o Osteoporosis : T-score ≤2.5 SD below the young
adult reference mean.
In addition, Z-scores should be used in premenopausal
women, men younger than 50 years, and children, adjusted to
ethnicity or race.
OP evaluation on BMD indexes can be produced by using
several diagnostic techniques [9, 19], such as:
– Dual-energy x-ray absorptiometry (DEXA) – Ultrasound
– Radionuclide absorptiometry
– Computed tomography (CT);
– Magnetic resonance imaging (MRI); used especial ly for
assessing the risk of fracture.
OP therapy and treatments are diverse and include
osteoporosis medications, rehabilitation options, and
alternative therapies. The management of OP is focus ed on
slowing and stopping bone loss or creating new bone. First-
line therapy represents diet supplementation and regular
weight-bearing exercise, both of them can be begun before
adult age.
Conservative treatments and non-conventional treatments
produce good results in OP therapy, as electro-therapy,
magneto-therapy, electro-magneto-therapy, ultrasound ’s
therapy, hydrokinetic therapy, balneal-rehabilitation therapy,
acupuncture, and others.
A new treatment used in osteoporosis, osteoarthritis and
recovery neurological-motor performance of sportsmen is
whole-body vibration method (WBV) by using a vibration
platform [1 ]. This therapy is an alternative or adjunctive
intervention, which has the role in preventing and treating
osteoporosis. The authors had some research in WBV [15, 16 ]
that is yet an early stage, applied only on Wistar rats.
In this paper, we present two studies of balneal-
rehabilitation treatment applied to patients with OP from
Recovery Clinical Hospital of Felix Spa during of 2009-2011.

CONSERVATIVE TREATMENT OF OP
The conservative treatment used for patients diagnosed
with OP from Recovery Clinical Hospital of Felix Spa
involves balneal-physical-kinetic therapy (BPKT) or balneal-
physical-kinetic recovery treatment (BPKRT). These
treatments consist in complex and multiple therapies, as
analgesics and symptomatic anti-inflammatory, background
medication, electrotherapy, thermotherapy, kinetotherapy, and
massage during a period of 14 days. The treatments must be
repeated periodical ly every six months to obtain good results.
The paper presents two studies of cases applied the
patients diagnosed with OP by BPKRT. DEXA and SF-36
scores make the evaluation of subjects, by using SPSS
Statistic v17 Program. Parameter averages, as well as
frequency intervals, standard deviations, statistic significance
tests were calculated by using the Student method (T test) and
2.

A. Clinic-Statistic Study of OP
This first study presents a group of 100 subjects
diagnosed with OP by DEXA and hospitalized at
Rehabilitation Clinical Hospital from Felix Spa in 2009-2011.
The study refers only to patients with a present clinical
symptomatology, meaning pain of variable types like
backaches, fragility fractures or deformities of bone shape that
result from fractures or alternations of weaken bones.
At the distribution of patients with OP on sex, a net
preponderance of the female gender (86% vs. 14%) can be
remark ed (Fig.3). The report of female/male was of 6.1/1
(p<0.001).

3 Copyright © 2012 by ASME
Figure 3: Diagram of patients with OP on sex

Another distribution of subjects was made according to
their residences (town-village) because it is known that the
people from rural areas have low medical access to treatment
as urban area. From Fig.4, it can be seen a predominance
value from urban locations (p<0.05) as than rural ones, both in
male and female.

Figure 4: Diagram of patients with OP on residence

The analysis of patients with OP subjected on balneal-
recovery treatment was made on age groups (Fig.5).

Figure 5 : Distribution of patients with OP on age groups Analyzing the diagram’s distribution of patients with OP
according to age from Fig.5 it can be remarked a prevalence
peak among subjects of male gender around the ages of 46- 50
years, while in subjects of female gender, the peak is recorded
at ages of 51- 55 years. This can be explained by the
occurrence of menopause at women around the age of 50
years (p<0.02), and by the neurological deficiencies of male
subjects under 50 years who are impaired in the wheelchair.
The evaluation of subjects with OP was made by DEXA
using T-score, presented in Fig.6.

Figure 6 : Diagram of T-score for patients with OP used DEXA

Analyzing the values of T-score at DEXA from Fig.6, we
can observe that at female subjects in range of – 3.5 to – 4.5,
the size in percentage is almost three times greater than at
male subjects (p<0.001).
An important factor in OP analysis is the risk factor on
fractures. The result of fragility factures of subjects with OP is
presented in Fig.7.

Figure 7: Diagram of the risk factor on patients with OP

From Fig.7, we can be observed that over 31% of female
subjects with OP present a risk factor vs. 7.1% of male
subjects.
The results of this study emphasize that the
symptomatology of osteoporosis along with pain and even
cases of fragility fractures is more evident and frequent at
female subjects than at male subjects. In addition, this study
shows that the osteoporosis is more visible in the early
postmenopausal period.
14%
86% Male Female
0 10 20 30 40 50 60 57.1
42.9 58.1
41.9
Male
Female [%]
Urban Rural
0 10 20 30 40 50
14.3 42.9
14.3 14.3
7.1 7.1 3.5 11.6 37.2
22.1
12.8 12.8 Male
Female [%]
>45 46-50 51-55 56-60 61-65 <65 [years]
0 20 40 60 80 100 85.7
14.3
0 54.7
39.5
5.8 Male
Female [%]
-2.5(÷)-3.4 -3.5(÷)-4.5 <-4.5 [T-score]
0 10 20 30 40
7.1 31.4 [%]
Male Female

4 Copyright © 2012 by ASME B. Effects of Physical Exercises in OP
A second study presents a group of 80 subjects diagnosed
with OP that received the same complex baln eal-recovery
treatment (BPKRT) at Recovery Clinical Hospital of Felix Spa
in 2009-2011. From this total it was only half of them that did
daily physical exercises, in parallel with BKPRT, during the
12 months.
Exercise therapy can be considered a key symptomatic
and supportive treatment for OP, being more effective in
improving or maintaining function. Exercise, also increase s
muscle strength, coordination and balance, and decreases the
likelihood of falls in the elderly . Some positions of physical
exercises specific to OP treatment are presented in Fig. 8.

Figure 8: Positions used in physical exercises for OP patients [2]

The acceptance criteria for the study were the positive
diagnosis of OP patients’ acceptance , the absence of contra-
indication for BPFKT and psychical diseases.
The OP patients were been randomized in two lots: 1st Lot
(n=40) is a reference lot that followed BPKRT in combination
with physical exercises everyday for 12 months, and 2nd Lot
(n=40) is a control lot that followed only BPKRT. DEXA and SF-36 scores make the evaluation of subjects,
by using SPSS Statistic v17 Program. The results of trial are
presented in Tab.1 for SF- 36 and in Tab.2 for BMD scores,
respectively. In addition, their evolutions in the diagrams from
Fig. 9 to Fig. 14 are presented.

Table 1: SF-36 score for patients with osteoporosis
SF-36
Score Reference Lot
(n=40 )
Initial 6 Months 12 Months
Nr.. % Nr. % Nr.. %
40-50 6 15.0 5 12.5 3 7.5
50-60 8 20.0 6 15.0 5 13.5
60-70 17 42.5 19 47.5 20 50.0
70-80 9 22.5 10 25.0 12 30.0
Mean
±SD
62.3±4.3
63,54,4
65,35,1
Control Lot
(n=40 )
40-50 5 12.5 4 10.0 4 10.0
50-60 7 17.5 6 15.0 5 12.5
60-70 19 47.5 21 52.5 22 55.0
70-80 9 22.5 9 22.5 9 22.5
Mean
±SD
63,04,4
63,84,6
64,04,5

Figure 9: Evolution of SF-36 score for patients with OP at initial
time

Figure 10: Evolution of SF-36 score for patients with OP after 6
months

0 10 20 30 40 50
15 20 42.5
22.5
12.5 17.5 47.5
22.5 SF-36 Score at Initial Time
Reference Lot
Control Lot [%]
40-50
50-60 60-70 70-80 [SF-36 Score]
0 10 20 30 40 50 60
12.5 15 47.5
25
10 15 52.5
22.5 SF-36 Score after 6 Months
Reference Lot
Control Lot
40-50 50-60 60-70 70-80 [%]
[SF-36 Score]

5 Copyright © 2012 by ASME
Figure 11: Evolution of SF-36 score for OP patients after 12 months

Figure 12: Evolution of mean values of SF-36 score for OP patients

Analyzing the results obtain ed with Quality Life
Assessment it can be seen that in both lots there is a
progressive rise of SF-36 scores from initial time to 12 months
of treatment, with significant values for Reference Lot of
subjects that indicates the main role of exercises in improving
the quality life of patients with OP. In this sense, we can
remark a rising of SF-36 score at (60-70) points for 6 subjects
of Reference Lot vs. only of 3 subjects of Control Lot.
Similar ly, at (70-80) points the improving is for 3 subjects of
Reference Lot vs. nobody of Control Lot.
Moreover, for a fine assessing, we can calculate the
sensibility of change expressed by Effect-size (ES) due to a
medium rise of quality life of Reference Lot from one stage to
another (see Figs. 9 to 12). Therefore, for Reference Lot, the
values are ES=0.30 at 6 months and ES=0.41 at 12 mont hs,
while for Control Lot this rise is minimum, as ES=0.18 at 6
months and ES=0.05 at 12 months. By comparing these values
with initial time, it can be seen that the value of Reference Lot
has a good rise with ES=0.71, and a small rise for Control Lot
with ES=0.23.
Table 2: BMD index for patients with osteoporosis
BMD
Index Reference Lot Control Lot
Initial 12months Initial 12months
Nr. % Nr. % Nr. % Nr. %
-2.5(÷)-3.4 28 70 27 67.5 26 65 24 60
-3.5(÷)4.5 9 22.5 10 25 12 30 14 35
<-4.5 3 7.5 3 7.5 2 5 2 5
Figure 13: Diagram of BMD- index for OP patients at initial time

Figure 14: Diagram of BMD- index for OP patients after 12 months

From analyzing the subjects ’ lots from BMD-index, it can
be seen that in both lots, we did not find significant
differences. Although, these differences are low (p>0.05) it
can also be remark ed a reduction of BMD index for one case
in Reference Lot (2.5%) as two cases in Control Lot (5%).
This aspect demonstrates that physical exercises do not have a
real effect in evolution of BMD only in minimization of loss
bones.
Table 3: Fractures’ frequency for patients with osteoporosis
6 Months 12 Months Total
Nr. % Nr. % Nr. %
Reference Lot 2 5.0 1 2.5 3 7.5
Control Lot 3 7.5 3 7.5 6 15.0

Figure 15: Evolution of fractures frequencies for patients with OP
0 20 40 60
7.5 12.5 50
30
10 12.5 55
22.5 SF-36 Score after 12 Months
Reference Lot
Control Lot [%]
40-50 50-60 60-70 70-80
[SF-36 Score]
60 61 62 63 64 65 66
62.3 63.5 65.3
63 63.8 64 Mean Values of SF -36 Score
Reference Lot
Control Data
Initial 6 Months 12 Months [%]
0 20 40 60 80 70
22.5
7.5 65
30
5 BMD Index at Initial Time
Reference Lot
Control Lot [
-2.5(÷)-3.4 -3.5(÷)-4.5 <-4.5 [BMD Index]
0 20 40 60 80 67.5
25
7.5 60
35
5 BMD Index after 12 Months
Reference Lot
Control Lot
-2.5(÷)-3.4 -3.5(÷)-4.5 <-4.5
[BMD Index] [%]
0 5 10 15
5
2.5 7.5 7.5 7.5 15 Risk Factor of OP Patients
Reference Lot
Control Lot [%]
6 Months 12 Months Total

6 Copyright © 2012 by ASME Comparative evaluation of osteoporosis fractures ’
frequencies (Fig.15) show a reduction for Reference Lot from
6 months to 12 months twice time vs. Control Lot (5% vs.
2.5%), similar per total from 15% to 7.5% (p<0.01).
In the conclusion of this trial, it can be emphasized that
application of physical exercises in combination with BFKRT
showed a real improvement in treatment of patients with OP.
The exercises adequate to osteoporosis proved to be efficient
to the patients, as:
– Decreasing the frequencies of osteoporosis fractures as
amelioration of muscle mass, equilibrium and coordination;
– Amelioration of quality life of patients;
– Keeping the mobility and easier development of daily
activities.
For the elderly, the exercises have a low effect in
stimulation of osteogenous because the activity of osteoblasts
forming at this life period is lower.
CONCLUSIONS
This paper has presented two studies of cases about the
efficient application of balneal-conservative therapy to
patients diagnosed with osteoporosis. The evaluation of trial s
performed with SF-36 and BMD scores by using statistical
analysis.
The first trial was a clinic-statistic study of OP with a
present clinical symtomatology, which has shown that pain
and cases of fragility fractures are more evident and frequent
in female patients. Moreover, the results emphasized the
appearance of OP in the early postmenopausal period.
A second trial was a successful implementation of
exercise therapy with balneal-conservative treatment applied
to patients diagnosed with OP. The treatment results
underlined that by applying adequate exercises to patients with
OP led to amelioration of quality life, reducing of OP
fractures ’ frequency and improving the mobility, equilibrium
and daily activities. Unfortunately, the efficiency of exercises
with the elderly is lower because the resorption exceeds bone
forming of bone tissue in this life period.
The future interest of our research team is the
implementation of vibration therapy with balneal-conservative
treatment on patients with OP to reduce the therapy time and
improve the quality life of patients. Now, the vibration trial is
in initial phase and was been applied with success only on
Wistar rats, and we are waiting for the acceptance proof from
Romanian Healthy Minister to be applied to patients.
NOMENCLATURE
BPKRT Balneal Physic Kinetic Recovery Treatment
BPKT Balneal Physical Kinetic Therapy
DEXA Dual-Energy X-ray Absorptiometry
BMD Bone Mineral Density
MRI Magnetic Resonance Imaging
WBV Whole-B ody Vibration
SF-36 Quality Life Assessment
CT Computed Tomography
ES Effect Size
OP Osteoporosis
ACKNOWLEDGEMENT
The authors would like to thank Clinical Eurorad from Oradea
for DEXA tests, and medical team from Rehabilitation
Clinical Hospital from Felix Spa for supporting of balneal-
rehabilitation trial on OP subjects.
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