Content uploaded by Alsayed Abd Elhameed Shanb
Author content
All content in this area was uploaded by Alsayed Abd Elhameed Shanb on Jan 22, 2015
Content may be subject to copyright.
THE EFFECT OF MAGNETIC THERAPY AND ACTIVE
EXERCISE ON BONE MINERAL DENSITY IN ELDERLY
WOMEN WITH OSTEOPOROSIS
Al-Sayed A. Shanb
,
†
, Enas F. Youssef
‡
,
§
,
††
, Mohamed G. El-Barkouky
¶
,
Rasha M. Kamal
||
and Ahmed M. Tawfick
Physical Therapy Department
College of Applied Medical Sciences
University of Dammam, KSA
†
Department of Physical Therapy for Cardiopulmonary
Disorders and Geriatrics
Faculty of Physical Therapy, Cairo University
‡
Physical Therapy Department
College of Applied Medical Sciences
University of Dammam, KSA
§
Department of Physical Therapy for Musculoskeletal Disorder and Its Surgery
Faculty of Physical Therapy, Cairo University
¶
Orthopedic Surgery Department, Alhelal Hospital, Cairo University
||
Department of Diagnostic Radiology-Faculty of Medicine, Cairo University
Agouza Rehabilitation Hospital, Cairo
††
drefyoussef@hotmail.com
Accepted 10 June 2012
Published 27 July 2012
ABSTRACT
Purpose: To evaluate the effect of pulsed electro-magnetic therapy and exercise training on bone
mineral density (BMD) in elderly women with osteoporosis. Material and Methods: A total of
30 elderly women with osteoporosis aged from 60 to 70 years old were randomly divided into two
groups: A magnetic group consisting of 15 women who received pulsed electro-magnetic therapy at a
frequency of 33 Hz and an intensity of 50 gauss for 50 min per session and an exercise group consisting
of 15 women who practiced active exercises that included treadmill walking and selected exercises for
Journal of Musculoskeletal Research, Vol. 15, No. 3 (2012) 1250016 (9 pages)
© World Scientific Publishing Company
DOI: 10.1142/S0218957712500169
1250016-1
hip and back muscles for 50 min per session. Both interventions were applied for three sessions/week
for three months at a physical therapy clinic. Dual-energy X-ray absorptiometry was used to measure
the BMD of the neck of the femur and the lumbar spine (L3-L5) before and after intervention. Results:
Statistical analysis revealed that the BMD of the neck of the femur and the lumbar spine significantly
increased in the two groups without a significant difference between them. Conclusion: Pulsed
electro-magnetic therapy and exercises can increase BMD at the neck of the femur and the lumbar
spine in elderly women. Physical therapists could apply pulsed electro-magnetic therapy or exercise
training to increase BMD in elderly women.
Keywords: Osteoporosis; Pulsed magnetic field; Treadmill walking; Aerobic exercise.
INTRODUCTION
Osteoporosis is a serious and common condition
in which bones become thin, brittle and easy to
break, even with mild stresses such as bending
over or forced coughing.
10
It is called a silent
disease as it develops gradually and progresses
without symptoms until the fracture occurs.
38
Fractures that result from osteoporosis are the
major cause of morbidity in elderly individuals
and place a huge financial burden on health ser-
vices. Osteoporosis dramatically increases with
advancing age.
22
Many risk factors have been
found for osteoporosis, including menopause,
prolonged cortisone therapy, low calcium intake,
smoking, alcohol intake and lack of physical
activity.
3
Hormone replacement is the most widely pre-
scribed pharmacotherapy used for the treatment
of osteoporosis.
10,16
However, calcium, vitamin D,
exercise training and smoking cessation are con-
sidered to be the primary preventive measures for
osteoporosis and consequent fractures and ade-
quate intake of calcium and vitamin D should be
emphasized as cornerstones for the prevention
and effective treatment of osteoporosis.
10,13,14,16,17
There is an agreement in the literature that
physical activities improve muscle mass and
strengthen the bone.
2,5,23,37
Active exercises have
significant osteogenic effects on bone structure,
even during youth and periods of skeletal growth,
and they can, for example, reduce fracture risk in
later decades.
6,18,39
Active exercises serve to
encourage calcium absorption in bone as a result of
increased blood flow, which aids the deposition of
vital nutrients and minerals such as calcium from
general circulation in compressed sites.
6,17,21
Weight-bearing bones are maximally affected by
gravitational forces and repetitive muscular
actions during weight-bearing exercises, e.g. run-
ning and walking.
29
It has been reported that
the bone mass of physically active individuals is
significantly higher than their nonactive counter-
parts and that muscular contraction during
strengthening exercises and gravitational forces
create piezoelectric forces that affect bone
remodeling.
23,31,37
Accordingly, active exercises are one of the
most important methods to prevent bone loss
and to help maintain bone mineral density
(BMD).
23,31
In addition they enhance aerobic
capacity as well as increase muscle strength and
flexibility, and improve posture and balance
performance.
2,4,21
The positive associations
between exercise and bone mass means that it is
recommendable that people engage in active
exercise programs to reduce the incidence of
osteoporotic fractures and the rate of morbidity
and/or mortality.
2,39
Brisk walking is suggested
to be an ideal and simple form of active exercise,
especially for osteoporotic postmenopausal
women. Treadmill exercises, a useful form of
walking and weight-bearing exercises, are low
A.-S. A Shanb et al.
1250016-2
impact aerobic workouts and are suitable for the
majority of elderly patients.
12,39
Recently the application of magnetic therapy
during physical therapy has shown promise in the
treatment of different disorders, e.g. osteoarthritis,
and other conditions via, for example, healing
bone and ulcers and relieving pain.
9,20,28,35
A
magnetic field always exists when there is an
electrical current flow and it can penetrate
through highly resistant structures such as bone.
9
Exposure to pulsed electro-magnetic fields
(PEMFs) increases BMD in animals and humans
who are prone to osteoporosis.
11,28
Li-qun et al.
25
concluded that low-frequency PEMFs may
increase BMD and enhance bone cell formation in
secondary osteoporosis.
25
In a recent systematic review and meta-
analysis, it was postulated that there is still a
need for further well-designed randomized con-
trolled trials to quantify the effect of exercise on
bone strength and its structural determinants.
31
At the same time magnetic therapy has become a
therapeutic modality due to its positive osteo-
blastic effects. Furthermore, a large number of the
elderly cannot practice exercises as a result of
associated advanced complications and bed
recumbence, increasing the potential usefulness
of magnetic therapy.
Based on the related literature the aim of this
study was to evaluate the effect of active exercises
on BMD and to determine if magnetic therapy
can be considered an alternative therapeutic
modality to improve BMD and retard osteopo-
rosis progression.
METHODOLOGY
Study approval
The approval of this study was given by the in-
stitutional review board before starting patient
assessment and treatment.
Subjects
A total of 30 elderly women participated in this
study. Their ages ranged from 60 to 70 years old.
They were randomly selected from elderly nurs-
ing homes in Cairo with the following inclusion
criteria: A T-score of 2:5, with oral calcium
supplementation (1000 mg/day), alendronate
sodium (one 70 mg tablet/week) and vitamin D
(400 IU/day) and a Berge balance scale score of at
least 41 was used to select patients with a suffi-
cient balance performance (low fall risk) to enable
them to perform the exercises.
27,30
Subjects were
excluded from the study if they had advanced
musculoskeletal problems, unstable cardiopul-
monary conditions, or were receiving hormone
replacement therapy or any medications that in-
terfere with balance. All participants were in-
formed that collected data would be submitted
for publication and they signed an informed
consent form before their participation.
Instrumentation
(A) Evaluative Instrumentation: Dual-energy
X-ray absorptiometry (DEXA; GE Medical
Systems, USA), a bone densitometer, was
used to measure the BMD at the neck of the
femur and the lumbar spine (L3-L5) in each
patient of the two groups before and after
the treatment programs.
(B) Therapeutic Instrumentation:
(1) ASA magnetic field (Automatic PMT
Quattro PRO. ), which consists of an
appliance, motorized bed and solenoids.
It is provided with 1 couch with a 80 cm
diameter manually sliding solenoid and
two FLEXA applicators with vibrating
effect. The appliance is capable of gen-
erating PEMFs with a pulse repetition
frequency up to 100 Hz and an intensity
of 85 gauss.
Magnetic Therapy and Exercise for Osteoporosis
1250016-3
(2) Electronic treadmill (En Tred with a
computerized speed detector and heart
rate monitor to determine pulse rate
during walking exercises and support
bars for safety. It is with 1.0 to 4.0 HP
AC Motorized Treadmill with Taiwan
Alatech Controller, HRC, Healing, MP3
and USB Function. Zhejiang Outdo Fit-
ness Manufacturing Co. Ltd
(3) Wall bars were used to perform specific
exercise training from a standing position.
Assessment procedure
DEXA was used to measure the BMD of the neck
of the femur and the lumbar spine (L3-L5) for
every patient before and after the treatment
programs.
1,26
Treatment procedure
Magnetic group: A total of 15 patients received low
frequency and low-intensity pulsed magnetic
therapy. The magnetic device was applied to each
patient from a comfortable supine lying position.
After connection of the appliance to a power sup-
ply, the solenoid was adjusted over the affected
parts of the body (lumbar spine and hip regions).
Magnetic therapy was applied with a frequency of
33 Hz and intensity of 50 gauss for 50 min in each
session, three times per week for three months.
11,25
Exercise group: A total of 15 patients practiced
the exercise training program (treadmill and aer-
obic exercises) for 50 min, three times per week for
three months. This program consisted of a walking
exercise on the treadmill (20 min) in addition to
selected aerobic exercises for hip and lumbar
muscles (25 min) with a rest period (5 min) be-
tween the treadmill and aerobic exercises.
4,23,38
(A) Walking exercise: Each patient was asked to
walk with normal breathing for 20 min on
the treadmill at zero inclination, three times
per week for three months. The treadmill
was stopped if there was any symptom that
limited the exercise such as fatigue, balance
disturbance, excessive sweating, breathless-
ness, chest pain or leg cramps. Walking ex-
ercise included:
(i) Warm up phase: Each patient was asked
to walk for 5 min on the treadmill at the
lowest speed.
(ii) Stimulus Phase: Each patient was asked
to walk for 10 min on the treadmill at a
greater intensity (from 40% to 60% of the
pre-determined individualized maximal
heart rate) or according to patient toler-
ance. The intensity was increased only
by increasing the speed of the treadmill
in a horizontal position.
(iii) Cool down phase: Each patient was
asked to walk for 5 min on the treadmill
at the lowest speed.
(B) Hip and lumbar muscle exercises
40
: Each
patient practiced these exercises for 25 min
every session, three times per week for three
months. A sustained 5 s muscle contraction
for each exercise was followed by 10 s of
relaxation. Each exercise was repeated
10 times for both the lower limbs and back
and each patient took 30 s rests between each
type of exercise.
(i) Hip extensor exercise from a comfort-
able standing position: Each patient
stood facing the wall bars with one foot
distance between both her feet, firmly
grasped the wall bars at chest level,
extended the right lower limb backward
as far as possible and maintained this
position for a few seconds before relax-
ing. Each patient did the same exercise
for the left hip.
(ii) Hip abductor exercise from a comfort-
able standing position: Each patient was
A.-S. A Shanb et al.
1250016-4
asked to abduct her right lower limb
sideways as much as possible and to
maintain this position for a few seconds,
before returned to the starting position
and relaxing. Each patient did the same
exercise for the left hip.
(iii) Hip abductor exercise from a comfort-
able left side lying position with flexed
left knee: Each patient was asked to raise
up her right lower limb, held straight, as
high as she could and to maintain this
position for a few seconds before
returning to the starting position. Each
patient did the same exercise for the left
hip from the right side lying position.
(iv) Back exercise from crook lying position:
With both feet rested on a plinth, each
patient was asked to raise her waist as
high as she could to make a bridge and
to maintain this position for a few sec-
onds before returning to the starting
position and relaxing.
(v) Back exercise from sitting position: From
a sitting position on a comfortable chair
with a pillow behind her back, each
patient was asked to push backward
against the pillow and to maintain this
position for a few seconds before
returning to the starting position and
relaxing.
STATISTICAL ANALYSIS
The collected data were analyzed using SPSS
(Version 16.0). A paired t-test was used to com-
pare the mean T-score values of the neck of the
femur and the lumbar spine before and after in-
tervention within each group. An independent
t-test was used to compare the mean T-score
values of the neck of the femur and the lumbar
spine before (pre-test) and after treatment (post-
test) between both groups. Statistical significance
was determined at a p-value <0:05 and confi-
dence interval of 0.95.
RESULTS
A paired t-test was used to determine the sig-
nificance of changes in the T-score, which repre-
sents the BMD, of the neck of the femur and the
lumbar spine before and after intervention in
both the magnetic therapy and exercise training
groups. Analysis showed a significant increase in
the T-score after exposure to both magnetic
therapy (p<0:05; Table 1) and the exercise
training program (p<0:05; Table 2).
However, comparison between the two groups
using an independent t-test showed that there
were non significant differences (p>0:05) be-
tween the T-score of the neck of the femur
(Table 3) and the lumbar spine (Table 4) of the
magnetic and exercise groups before and after
intervention.
Table 1 The Mean Values of the T-Score
Pre and Post Treatment in Magnetic Group.
Variables Neck of Femur Lumbar Spine
Pre Post Pre Post
Mean 2.78 2:32.83 2:47
SD 0.67 0.5 0.48 0.39
T-value 3.67 4.23
p-value 0.002* 0.00*
Table 2 The Mean Values of the T-Score Pre
and Post Treatment of the Exercise Group.
Variables Neck of Femur Lumbar Spine
Pre Post Pre Post
Mean 2:74 2:31 2:69 2:44
SD 0.46 0.47 0.57 0.33
T-value 5.67 2.63
p-value 0.00* 0.01*
Magnetic Therapy and Exercise for Osteoporosis
1250016-5
DISCUSSION
In the current study, BMD was evaluated by
DEXA with the finding that the mean T-score
values of the neck of the femur and the lumbar
spine (L3-L5) of elderly women significantly in-
creased after magnetic therapy. These results are
supported by previous experimental studies
performed in rats, where it was found that elec-
tromagnetic fields of low intensity and frequency
significantly suppresses trabecular bone loss and
restores trabecular bone structure in bilateral
ovariectomized rats and that PEMF stimulation
for eight weeks enhances BMD in rats with disuse
osteoporosis.
7,34
The improvements in bone metabolism due to
magnetic therapy can be explained by a number
of mechanisms. It stimulates osteogenesis by si-
multaneously increasing osteoblastic activity and
decreasing osteoclast formation, thereby shifting
the metabolic process towards bone osteogene-
sis.
7,15,28,37
It also enhances fibrocartilage turn-
over to bone cells and increasing ionic calcium
channels.
28
In addition, it increases blood supply
at the site of application, which is considered to
improve bone healing.
25
Furthermore it has an
inhibitory effect on the resorption phase of
wound healing that leads to early callus forma-
tion.
35
Many authors consider magnetic therapy
to be of an interesting physical modality because
it has many advantages. For example, it is a
noninvasive, easy, safe and focused method of
treatment for the concerned site in the body.
15,25
It also can save many elderly people from un-
dergoing surgery and it is being suggested that
magnetic therapy be the first line of treatment for
osteoporosis.
11
However, in contrast to our results, some
authors found that treatment with magnetic
therapy did not cause a significant increase in
BMD.
15
The variability in these results may be
due to a number of differences between the two
studies: First, the mean age of their sample was
more advanced (>75 years old) than in the cur-
rent study (60 to 70 years old). Secondly, mag-
netic therapy in their study was not used in
conjunction with sufficient calcium and vitamin
D supplementation, while in our study all
patients received one alendronate tablet of
70 mg/week, oral calcium (1000 mg/day) and
vitamin D (400 IU/day) during the entire treat-
ment period. Thirdly, there was a difference be-
tween the magnetic therapy parameters that was
100 Hz vs 33 Hz in this study).
15
Many other
studies have shown that BMD is higher after 34
months of magnetic therapy
11,25
and the benefits
of three months of PEMFs were previously
proved in a randomized controlled trial.
19
It has
been suggested recently that standardization of
frequency, intensity and session time of magnetic
therapy is required, as parameter differences are
considered to be one of the limitations of mag-
netic therapy.
11
The second finding is that the BMD of the neck
of the femur and the lumbar spine of the elderly
Table 3 The Mean Values of the T-Score at the Neck of
Femur Pre and Post Treatment in Both Groups.
Variables Group A Group B Group A Group B
Pre Pre Post Post
Mean 2:78 2:74 2:32:31
SD 0.67 0.46 0.5 0.47
T-value 0.22 0.18
p-value 0.83†0.86†
Table 4 The Mean Values of the T-Score at Lumbar
Spine of Both Groups.
Variables Group A Group B Group A Group B
Pre Pre Post Post
Mean 2:83 2:69 2:47 2:44
SD 0.48 0.57 0.39 0.33
T-value 0.83 0.3
p-value 0.41†0.76†
A.-S. A Shanb et al.
1250016-6
women was also improved by an exercise pro-
gram. This improvement has also been shown
previously.
12,37
A program of weight-bearing
training and aerobic and balance exercises
undergone by elderly women for 12 months
improved bone density as well as muscle strength
and walking ability.
12
Another study found that
elderly women who exercise regularly have 30%
denser bones than similar individuals who do not
exercise.
37
Many explanations for the benefits of weight-
bearing exercises can be found in the literature.
For example, the mechanical loads of weight-
bearing activities are transmitted to the skeleton
by muscle pull and gravitational forces where the
bone cells selectively respond to different me-
chanical stresses to increase or decrease BMD.
31,32
In addition the bone tissue responds to dynamic,
rather than static, loading as dynamic loading
creates fluid movement in the bone network,
which in turn generates shear stresses on the
plasma membranes of osteocytes and osteo-
blasts.
39
There is agreement in the literature that
exercises not only improve BMD but also increase
muscle strength, flexibility, postural stability,
balance and reduces risk of falling.
5,21,32,40
Resistance training and weight-bearing aerobic
exercises are recommended for osteoporosis
treatment by some investigators.
32,40
These exer-
cises are the main components of our exercise
program. Treadmill walking was used in the
current study because it is the best known way to
prevent bone loss in the elderly.
38
Walking adds
the stress required to the hip joint and lumbar
spine to build bone density in a natural way and
thus increases BMD in lumbar vertebrae and the
neck of femurs.
24,38
In addition the specific
strengthening exercises can retard and even re-
verse bone loss in healthy postmenopausal
women.
33
Therefore, in the current study active
exercises of hip and back were used to obtain
maximum benefits.
12,39
The exercise program in our study was applied
three times per week and maintained for 50 min
to influence BMD, a training regime whose effi-
cacy is supported by the literature.
32,38
While
there is controversy regarding the total duration
of the exercise program in the literature, some
authors recommend 12 months of training.
12,38
Others practiced eight months of specific exercise
on postmenopausal women to increase the BMD
of the lumbar spine,
15
while in another study a
combined aerobic and anaerobic exercise regime
was applied in overweight postmenopausal
women for 12 weeks.
36
Furthermore, in more
recent studies, Chang et al.
8
applied treadmill
exercise for 36 weeks on ovariectomized rats
8
and
Westcott et al.
40
applied strength and aerobic
workouts for 36 weeks on subjects that ranged in
age from 39 to 82 years. Consequently we se-
lected three months (12 weeks), as previously
used,
36
because intervention in the present study
included, for one group, magnetic therapy, for
which three months has previously been shown
to be an efficient duration of exposure.
11,20,25
The third finding of the current study is that
no significant difference was found in the BMD
of the neck of the femur or the lumbar spine
between the magnetic and exercise groups. As far
as we know, no clinical study has compared these
two types of intervention. Consequently it is
recommended that more clinical studies with
larger sample sizes and longer treatment periods
are conducted in order to better compare both
interventions.
CONCLUSION
Either magnetic therapy or an exercise program
can increase BMD in elderly osteoporotic women.
Magnetic therapy could be used for the treatment
of osteoporosis in elderly women who cannot
undergo exercise training as a result of common
associated chronic complications of the elderly.
Magnetic Therapy and Exercise for Osteoporosis
1250016-7
Limitations of this study
(1) A small number of patients were included in
the study (only 30 female elderly subjects in
total).
(2) The period of observation for both treatment
groups was three months, which may be
short to quantify significant changes between
both treatment in T-score. So it would be
preferable to do follow-up at longer times for
the involved subjects.
References
1. Andreoli A, Scalzo G, Masala S. Tarantino U, Guglielmi
G. Body composition assessment by dual-energy x-ray
absorptiometry (DEXA). Radiol Med 3(5): 6574, 2009.
2. Ashe MC, Khan KM. Exercise prescription. J Am Acad
Orthop Surg 12(1): 2127, 2004.
3. Baltas CS, Bolanika AP, Raptou PD, Tournis S. Clinical
practice guidelines proposed by Hellenic foundations of
osteoporosis. J Musculoskelet Neuronal Interact 5(4):
388392, 2005.
4. Brentano MA, Cadore EL, Da Silva EM, Ambrosini AB,
Coertjens M, Petkowicz R et al. Physiological adapta-
tions to strength and circuit training in postmenopausal
women with bone loss. J Strength Cond Res 22(6):
18161825, 2008.
5. Burr J, Shephard R, Cornish S, Vatanparast H, Chilibeck
P. Arthritis, osteoporosis, and low back pain: Evidence-
based clinical risk assessment for physical activity and
exercise clearance. Can Fam Physician 58:5966, 2012.
6. Burrows M. Exercise and bone mineral accrual in chil-
dren and adolescents. J Sports Sci Med 6: 305312, 2007.
7. Chang K, Chang WH. Pulsed electromagnetic fields
prevent osteoporosis in an ovariectomized female rat
model: a prostaglandin E2-associated process. Bioelec-
tromagnetics 24(3): 189198, 2003.
8. Chang TK, Huang CH, Huang H, Chen HC, Cheng CK.
The influence of long-term treadmill exercise on bone
mass and articular cartilage in ovariectomized rats
cartilage in ovariectomized rats. BMC Musculoskelet
Disord 11: 185, 2010.
9. Crowe MJ, Sun ZP, Battocletti JH, Macias MY, Pintar
FA, Maiman DJ. Exposure to pulsed magnetic fields
enhances motor recovery in cats after spinal cord injury.
Spine 28(24): 26602666, 2003.
10. Deepa K, Stephanie AF. Medical management of oste-
oporosis. Am J Manag Care 10: 445455, 2004.
11. Devi AM, Le-Hua YU. Pulsed electromagnetic field
therapy for osteoporosis. J Chin Clin Med 5(4): 226230,
2010.
12. Englund U, Littbrand H, Sondell A, Pettersson U, Bucht
G. A 1-year combined weight-bearing training program
is beneficial for bone mineral density and neuromus-
cular function in older women. Osteoporos Int 16:
11171123, 2005.
13. Francis KL, Matthews BL, Van Mechelen W, Bennell
KL, Osborne RH. Effectiveness of a community-based
osteoporosis education and self- management course.
Osteoporos Int 5: 123130, 2009.
14. Gammage KL, Francoeur C, Mack DE, Klentrou P.
Osteoporosis health beliefs and knowledge in college
students: The role of dietary restraint. Eat Behav 10(1):
6567, 2009.
15. Giordano N, Battisti E, Geraci S, Fortunato M, Santa-
croce C, Rigato M et al. Effect of electromagnetic fields
on bone mineral density and biochemical markers of
bone turnover in osteoporosis. A single-blind, ran-
domized pilot study. Curr Ther Res Clin Exp 62:
187193, 2001.
16. Going S, Lohman T, Houtkooper L, Metcalfe L, Flint-
Wagner H, Blew R, et al. Effects of exercise on bone
mineral density in calcium-replete postmenopausal
women with and without hormone replacement thera-
py. Osteoporos Int 14: 637643, 2003.
17. Granney A, Guyatt GH, Griffith L, Wells G, Tugwell P,
Rosen C et al. IX: Summary of meta-analyses of thera-
pies for postmenopausal osteoporosis. Endocr Rev 23(4):
570578, 2002.
18. Hind K, Truscott JG, Conway SP. Exercise during
childhood and adolescence. J Cyst Fibros 7(4): 270276,
2008.
19. Huang S, Meng P, Cai HW. Effect of pulsed electro-
magnetic fields combination with estrogen on post-
menopausal osteoporosis. Chin J Clin Rehabil (Chin) 7:
13991400, 2003.
20. Jacobson JI, Gorman R, Yamenashi WS, Saxena BB,
Clayton L. Low amplitude extremely low frequency
magnetic field for the treatment of osteoarthritic knees.
Altern Ther Health Med 7(5): 5469, 2001.
21. Jessup JV, Home C, Vishen RK, Wheeler D. Effect of
exercise on bone density balance, and self efficacy in
older women. Biol Res Nurs 6: 182190, 2003.
22. Joseph R, Tucci V. Importance of early diagnosis and
treatment of osteoporosis to prevent fractures. Am J
Manag Care 12: s181s190, 2006.
23. Kerr D, Ackland T, Maslen B, Morton A, Prince R.
Resistance training over 2 years increases bone mass in
calcium-replete postmenopausal women. J Bone Miner
Res 16(1): 175181, 2001.
A.-S. A Shanb et al.
1250016-8
24. Lin JT, Lane JM. Non-pharmacologic management of
osteoporosis to minimize fracture risk. Nat Clin Pract
Rheumatol 4(1): 2025, 2008.
25. Li-qun H, Hong-Chen HE, Cheng-qi HE, Chen Jian C,
Lin Y. Review article. Clinical update of pulsed elec-
tromagnetic fields on osteoporosis. Chin Med J 121(20):
20952099, 2008.
26. Long TF, Guglielmi G, van Kuij C, De Serio A, Genant
HK. Measurement of bone mineral density at the spine
and proximal femur by volumetric quantitative com-
puted tomography and dual-energy X-ray absorptiom-
etry in elderly women with and without vertebral
fractures. Bone 30(1): 247250, 2002.
27. Mancini M, Horak FB. The relevance of clinical balance
assessment tools to differentiate balance deficits. Eur J
Phys Rehabil Med 46(2): 239248, 2010.
28. Markov MS, Colbert AP. Magnetic and electromagnetic
field therapy. J Back Musculoskelet Rehabil 15:1729,
2001.
29. Marwaha RK, Tandon N, Shivaprasad C, Kanwar R,
Mani K, Aggarwal R et al . Peak bone mineral density of
physically active healthy Indian men with adequate
nutrition and no known current constraints to bone
mineralization. J Clin Densitom 12(3): 314321, 2009.
30. Neuls PD, Clark TL, Van H, Nicole C, Proctor B, Joy E,
et al. Usefulness of the Berg balance scale to predict falls
in the elderly. J Geriatr Phys Ther 34(1): 310, 2011.
31. Nikander R, Sievänen H, Heinonen A, Daly RM,
Uusi-Rasi K, Kannus P. Targeted exercise against oste-
oporosis: A systematic review and meta-analysis for
optimizing bone strength throughout life. BMC Med
8: 47, 2010.
32. Papaioannou A, Morin S, Cheung AM, Atkinson S,
Brown JP, Feldman S et al. 2010 clinical practice
guidelines for the diagnosis and management of oste-
oporosis in Canada: Summary Can Med Assoc J 23(11):
182190, 2010.
33. Roush K. Prevention and treatment of osteoporosis in
postmenopausal women: A review. Am J Nurs 111(8):
2635, 2011.
34. Shen WW, Zhao JH. Pulsed electromagnetic field
stimulation affects bone mineral density and local factor
production of rats with disuse osteoporosis. Bioelec-
tromagnetics 31(2): 113119, 2010.
35. Shupak NM. Therapeutic uses of pulsed magnetic field
exposure: A review. Radio Sci Bull 307(12): 930, 2003.
36. Svendsen OL, Hassager C, Christiansen C. Effect of an
energy-restrictive diet, with or without exercise, on lean
tissue mass, resting metabolic rate, cardiovascular risk
factors, and bone in overweight postmenopausal
women. Am J Med 95(2): 131140, 1993.
37. Swezey RL, Swezey A, Adams J. Progressive resistive
exercises for osteoporosis. Arch Phys Med Rehabil
3: 319323, 2000.
38. Todd A, Robinson R. Osteoporosis and exercise. Post-
grad Med J 79: 320323, 2003.
39. Turner CH, Robling AG. Exercises for improving bone
strength. Br J Sports Med 39: 188189, 2005.
40. Westcott W, Varghese J, DiNubile N, Moynihan N,
Loud R, Whitehead S, Brothers S, Giordano J, Morse S,
Madigan MA, Blum K. Exercise and nutrition more ef-
fective than exercise alone for increasing lean weight
and reducing resting blood pressure. J Econ Perspect
14(4): 120133, 2011.
Magnetic Therapy and Exercise for Osteoporosis
1250016-9
