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Effects of motor physical therapy on bone mineralization in premature

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DOI: 10.1038/jp.2008.60 · Source: PubMed

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 Journal of Perinatology (2008) 28, 624–631
r 2008 Nature Publishing Group All rights reserved. 0743-8346/08 $30
www.nature.com/jp
ORIGINAL ARTICLE
Effects of motor physical therapy on bone mineralization in
premature infants: a randomized controlled study
CM Vignochi1, E Miura2 and LH Canani3
1
Department of Physiotherapy, Federal University of Rio Grande do Sul, Graduate Studies in Universidade Luterana do Brasil, Porto
Alegre, RS, Brasil; 2Graduate Studies at the College of Medicine, Department of Neonatology, Federal University of Rio Grande do Sul and
the Federal Foundation of Medical Sciences of Porto Alegre, Porto Alegre, RS, Brasil and 3Bachelor’s and Graduate Studies at the College of
Medicine, Department of Endocrinology, Federal University of Rio Grande do Sul, Endocrinology Service, Porto Alegre, RS, Brasil
Objective: To study the effect of physical therapy on bone mineralization,
weight gain and growth in preterm infants.
Method: After fulfilling the inclusion criteria, preterm infants were
matched for gestational age and birth weight and then randomly assigned
to the physiotherapy group (PG, n ¼ 15) and control group (CG,
n ¼ 14). The PG received motor physical therapy for 15 min daily,
5 times per week until hospital discharge. Bone mineralization was
measured by total body dual energy X-ray beam absorptiometry (DEXA) at
the onset and end of the study. Statistical analysis was realized by ANCOVA
and linear correlation tests.
Result: The physical therapy group (PG) presented greater body weight
gain per day (27.4±2.4 vs 21.01±4.4 g, P<0.001) and length
(1.3±0.3 vs 0.8±0.2 cm week1, P<0.001) than did the control group
(CG). Body composition values verified by DEXA were greater for the PG.
The mean gain in bone mineral content (BMC) (mg) was greater in the
PG (434±247.5 vs 8.9±11.4, P<0.001), as was the mean bone
mineral density (BMD) gain (mg cm2) (8.4±5.6 vs 3.1±5.5,
P<0.001). The gain in bone area (BA,cm2) was 10.3±5 in the PG vs 1.5
±2 in the CG (P<0.001). The gain in lean mass (LM) (g) in the PG
was also greater than in the CG (271.1±21.4 vs 109.1±1.0, P<0.009).
The fat mass (g) was similar between the groups (P ¼ 0.432).
Conclusion: These results showed that physiotherapy in preterm infants
produced greater gains in growth, body weight, BMC, BMD, BA and LM.
Journal of Perinatology (2008) 28, 624–631; doi:10.1038/jp.2008.60;
published online 17 July 2008
Keywords: osteopenia; prematurity; physical therapy
Correspondence: Professor CM Vignochi, Department of physiotherapy, Graduate Studies in
Medical Sciences: Pediatrics, UFRGS, Av Rubem Berta 1690, Sapucaia do Sul, RS 93218-350,
Brazil.
E-mail: carinemv@yahoo.com.br
Received 29 October 2007; revised 24 March 2008; accepted 14 April 2008; published online
17 July 2008
Introduction
Metabolic bone disease or osteopenia in prematurity occurs in more
than 30% of suckling infants weighing 1500 g or less at birth and
in 50% of those who weigh less than 1000 g. The classic signs of
rickets, such as epiphyseal dysplasia and skeletal bone deformities,
become clinically evident between 2 and 4 months of age.
Additionally, the fracture frequency can reach 70%, especially in
extreme cases involving sickly preterm infants.1–4
The prolonged period of hospitalization of premature infants
without physical stimulation may contribute to bone
demineralization and can lead to changes in bone development
and growth.5–9 These alterations in bone development produce a
reduction in both growth velocity and height, with a higher
frequency of scoliosis, leg curvature and cranial deformities.10–17
Some researchers have recently suggested that 5 min per day,
5 times per week for 4 weeks of passive exercises with soft
compressions result in increased bone mineral density (BMD) in
very low birth weight premature infants.18–21 This prospective
randomized controlled clinical assay was carried out with the
objective of evaluating the effects of a motor physical therapy
protocol, 15 min per day, 5 days per week, on bone mineralization
in very low birth weight preterm infants.
Methods
A controlled randomized clinical assay, stratified by gestational age
and birth weight, was realized from June to December 2006 at the
Neonatal Intensive Care Unit at the Hospital de Clı́nicas de Porto
Alegre. Patients who met the inclusion criteria were randomized
into the physical therapy (PG) and control (CG) groups, by means
of drawing closed envelopes containing the code for one of the
groups.
The sample included 15 premature infants in the PG and 14 in
the CG, giving a total of 29 patients. Bone mineral content (BMC)
was the variable used to estimate the sample number, as it is
considered the most exact measurement evaluated by dual energy

X-ray beam absorptiometry (DEXA) in preterm newborns. A mean
of 10 mg cm1 difference between the groups, with a standard
deviation of 10 mg cm1 was used, based on the study by Moyer-
Milleur (2000). Considering a 0.05 significance level and power
equal to 80%, an n of 16 patients per group was determined. Upon
reaching 29 patients, the study was interrupted, as a significant
difference in the BMC value already existed between the groups.
Inclusion criteria
Premature infants in the Intensive Care Unit, with a gestational
age between 26 and 34 weeks and birth weight less than 1600 g, in
stable condition, presenting an appropriate size for gestational age
and favorable evolution, that is, presenting no associated diseases
besides prematurity and not requiring oxygen or mechanical
ventilation at the onset or during the protocol, whose parents
provided a term of written informed consent.
Exclusion criteria
Premature infants diagnosed with serious periventricular
hemorrhaging (degrees 3 and 4); serious sepsis and use of
medications (diuretics and corticosteroids). After matching for
gestational age and birth weight, the infants were randomly
assigned into the PG (n ¼ 15) and CG (n ¼ 14).
Physical therapy protocol
The physical activity program was based on the Moyer-Mileur
protocol, increasing the time to 15 min and began after the
previously randomized preterm infants had developed a tolerance
for enteral feeding at a caloric mean of 110 cal kg1 day1. Ten
repetitions of each movement were performed on the wrists, elbows,
shoulders, ankles, knees and hips. The sequence was performed
slowly and in the cephalocaudal direction, with an average of six
movements per min, and in the following sequence: right arm, left
arm, right leg, left leg and, finally, simultaneous movements on
both legs. The physical therapist then performed ten movements
with his/her hands on the infant’s thorax, following the respiratory
movements, for a total of 15 min intervention. Physical therapy was
performed in the right and left lateral decubitus, respecting
organization principles to cause a minimum of stress for the
patient. Treatment was always performed by the same physical
therapist, at least 30 min after being fed, 5 times per week. This
protocol was interrupted when the newborn reached an average
2 kg of body weight criterion for being discharged from the
hospital. The CG received routine care from the nursing team as
well as daily maternal care, such as being held in the mother’s
arms, however, without movement and standardized articular
compression. All the infants were fed fortified maternal milk or
nutritional formula (Pré-Nan).
Variables
Weight and length measurements, nutritional data (total
parenteral nutrition, vitamins, and so on), medications,
Physical therapy for bone mineralization in premature infants
CM Vignochi et al
625
intercurrences, start date for enteral feeding and mother’s presence
or absence were recorded from birth to release from hospital. Infant
vital signs were monitored during treatment. Body weight was
evaluated daily, at the same time, with the patients undressed.
Length measurements were taken weekly and before release. Total
length measurement was taken with a horizontal anthropometric
ruler, twice, and the average of the two measurements was used for
analysis. The patients were measured in dorsal decubitus, the head
held by an assistant, knees stretched and feet forming a 90 degree
angle, supported on the base of the ruler, always undressed and
supported on a hard table protected by a sheet. Tibial length was
measured in centimeter using an inextensible metric tape with the
lateral malleolus and the flexion fold of the right knee as the
limits.22
Bone mineralization was assessed by total body densitometry
using DEXA, with fan beam 4500 A, HOLOGIC equipment,
using pediatric whole body V5. 64 p. software with an exam
performed upon entering the study and another before being
discharged from the hospital. The exam was carried out by a
technician who had no knowledge of the research data. Analysis
was automatic and performed by densitometer software. The device
was calibrated daily and the coefficient of variation remained below
2%. The patients were positioned in pronation, with lower and
upper limbs extended and in abduction.23 To secure the infants in
position, they were taken to the exam after being fed, using a
cotton blanket wrapped around them from the waist down.
Adhesive tape was used at the hips and elbows to avoid movements.
A space 60 cm in length was delimited for all exams, to begin
scanning, with the patient positioned at the midline of the table
with the top of their head 5 cm from the edge of the table. Air-
conditioning was shut off before and during the exams to keep the
room warm. DEXA evaluates body composition (total body) by
measuring BMC (mg), BMD (mg cm2), bone area (BA, cm2),
lean mass (LM, g) and fat mass (g). Serum and urine levels
of calcium and phosphorus were collected weekly, and serum
levels of parathyroid hormone were collected at the onset and
the end of the study.
The Student’s t or w2 tests were performed to analyze data and
compare the means for the two groups in relation to gender,
gestational age, birth weight, days in study, days on mechanical
ventilation, gestational age corrected at entry, feeding, energy, days
on total parenteral nutrition and anthropometric variables. Analysis
of covariance (ANCOVA) was used to compare the bone
densitometry results (DEXA) between the groups. Linear correlation
tests were realized between bone mass gains and other
anthropometric and body composition variables (DEXA) to assess
whether these also interfered in mass gain and bone density.
P<0.05 was considered to be statistically significant. Data are
presented as mean±standard error using SPSS software to analyze
the data. The project was approved by the Research and Bioethics
Group of the Hospital de Clı́nicas de Porto Alegre (number 05-520)
Journal of Perinatology
 Physical therapy for bone mineralization in premature infants
CM Vignochi et al
626

and obtained funding from FIPE and CAPES. Parents or legal
guardians responsible for study participants signed the written
informed consent form.
Results
Demographic data
Upon entry to the study, the groups presented similar
characteristics. Average birth weight (g) was 1326±259 g in the
PG and 1342±226 g in the CG. Total body length (cm) in the PG
was 37.7±2.7 cm and 38.5±2.0 cm in the CG. Age (days) when
entering the study in the PG was 21±8.5 days and 21.9±10 days
in the CG. Both groups were also similar regarding ethnicity,
gender, days submitted to mechanical ventilation, gestational age
corrected at entry and APGAR 1 and 5 (Table 1).
Supply of nutrients
Before intervention, no significant differences were observed
between the groups in energy intake (kcal day1) and weight gain
per day. During the study, no differences were ascertained in the
type of food or caloric quantities between the groups. In the CG,
21.4% of the patients received fortified maternal milk; another
14.3% received nutritional formula for premature infants and the
remaining 64.3% received a combination of the two. In the PG, the
proportions were 13.3% for fortified maternal milk, 33.3% for the
formula and 53.3% for the mixed diet.
The average supply of protein, calcium, phosphorus and
vitamin D were similar for both groups and they were maintained
within the recommended values for premature infants. The days of
total parenteral nutrition use were also similar in both groups
(Table 1).
Anthropometric alterations
During the period that preceded the study, average weight gains (g)
were similar between the PG and CG (9.3±4.6 vs 9.6±0.9,
respectively; P ¼ 0.863). However, upon entering the study, patients
in the CG presented higher body weight (g) when compared to the
PG (1373±93.8 vs 1462±90.6). Daily weight gain (g) was

Table 1 Characterization of sample and supply of nutrients

Variables Group Pw

Physical therapy (n ¼ 15) Control (n ¼ 14)

Gestational age (weeks) 30.87±1.41 30.71±1.59 0.786

Birth weight (g) 1326.33±250.2 1341.43±226.4 0.866
Days in study 24.73±2.19 25.57±3.03 0.398
Days of life at entry 21.13±8.44 21.86±10.04 0.835
GA corrected at entry 33.85±0.62 33.74±0.65 0.663

Gender
Female 8 9 0.825
Male 7 5

Mechanical ventilation (days) 4.53±5.25 3.14±4.02 0.505

Feeding
Fortified maternal milk 2 3 0.470
Nutritional formula 5 2
Mixed 8 9

Energy (kcal kg1 day1)

From birth to entry 83.40±6.74 83.21±6.96 0.942
During the study 118.87±3.02 121.08±3.18 0.06
Protein (g kg1 day1) 3.22±0.17 3.24±0.17 0.743
Calcium (mg kg1 day1) 162.09±5.24 164.51±6.26 0.272
Phosphorus (mg kg1 day1) 85.40±1.35 85.71±1.49 0.558
Vitamin D (UI day1) 310.66±10.33 310.00±10.38 0.864
Days under total parenteral nutrition 5.00±1.2 4.50±0.8 0.561
Abbreviation: GA, gestational age.
The data are shown as average±s.d.
w
Not significant for all comparisons.

Journal of Perinatology
 Physical therapy for bone mineralization in premature infants
CM Vignochi et al
627

Table 2 Anthropometric changes during the study

Variables Group P

Physical therapy (n ¼ 15) Control (n ¼ 14)

Weight gain (g day1)

From birth to entry 9.33±4.57 9.64±4.99 0.863
During treatment 27.43±3.73 21.01±4.4 0.001
Birth weighta (g) 1326.33±250.17 1341.43±226.45 0.866
Weight at entrya (g) 1373±93.84 1462±90.57 0.014
Weight at dischargea (g) 2037±36.73 2035.71±57.71 0.943
Initial cephalic perimeter 28.11±1.26 27.9±1.22 0.421
Final cephalic perimeter 30.6±1.0 30.9±0.9 0.390
Length at birth (cm) 37.66±2.74 38.54±1.98 0.340
Gain in length (cm week1) 1.28±0.34 0.78±0.23 0.001
Gain in tibial length (cm week1) 0.16±0.4 0.10±0.3 0.02
The data are shown as average±s.d.
a
Data represented in Figure 1.

40 2500
P=0.943
WEIGHT GAIN BEFORE ENTRY

30
2000
WEIGHT GAIN

30 P=0.014

WEIGHT
20 1500 P=0.866

20 1000
10

500 CONTROL GROUP

PHYSICAL THERAPY
0 10 GROUP
N= 14 15 N= 14 15 0
CONTROL PHYSICAL THERAPY CONTROL PHYSICAL THERAPY Birth Weight at Weight at
Weight Entry Discharge
GROUP GROUP

Figure 1 Behavior of the Corporal Weight During the Study within the groups. (a) Mean of body weight gain from birth to entry (g day1), P ¼ 0.863. (b) Mean of
body weight gain after enrollment (g day1), P ¼ 0.001. (c) Mean of body weight from birth to discharge (g).

2.0 greater in the PG (27.4±2.4) compared to the CG (21.01±4.4)

(P<0.001). Length gain (cm week1) was also greater in the PG
(1.3±0.3) compared to the CG (0.8±0.2) (P<0.001) (Table 2
GAIN IN LENGTH(cm/week)

1.5 and Figures 1 and 2).

DEXA
1.0 Table 3 shows the results that refer to DEXA and their adjusted
values, using milk type as a covariant (ANCOVA). Regarding BMC
and BMD, the PG showed gains during the study, whereas the CG
0.5
showed a loss in these values during the same period, with the
same supply of nutrients. The average BMC (mg) gain in the PG
was 434±247.5, whereas in the CG, it was negative, 8.2±11.4
0.0
N= 14 15 (P<0.001). The same behaviour was observed with the BMD
CONTROL PHYSICAL THERAPY (mg cm2): PG was 8.37±5.63 and CG was 3.15±5.53
GROUP (P ¼ 0.001) (Figures 3 and 4). Controlling the following factors:
Figure 2 Length gain during the study period, P ¼ 0.001. type of milk used and growth catch-up (ANCOVA), BMC and BMD

Journal of Perinatology
 Physical therapy for bone mineralization in premature infants
CM Vignochi et al
628

Table 3 Bone densitometry results (DEXA) during the study period

Variables Group P Difference between averages

Physical therapy (n ¼ 15) Control (n ¼ 14)

IG corrected at entry 33.8±0.6 33.7±0.6 0.663

IG corrected at discharge 37.5±1.1 37.1±1.2 0.368

BMC (mg)
Entry 253.47±175.04 306.57±177.81 0.425 53.10
Final 687.47±262.32 298.39±167.51 0.001 389.07
Gain 434.00±247.55 8.18±111.37 0.001 442.18

Gain: corrected averagesa 348.25±59.55 29.142±61.20 0.005

Group interaction-type of milka 0.247

BMD (mg cm2)

Entry 25.51±5.66 25.93±6.05 0.519 1.42
Final 32.87±5.70 22.77±7.43 0.001 10.10
Gain 8.37±5.63 3.15±5.53 0.001 11.52

Gain: corrected averagesa 7.31±1.86 3.41±1.91 0.001

Group interaction-type of milka 0.743

BA (cm2)
Entry 9.79±4.86 11.55±5.19 0.356 1.75
Final 21.13±6.07 13.07±4.76 0.002 7.06
Gain 10.34±5.55 1.52±1.92 0.001 8.81

Fat (g)
Entry 151.69±32.29 207.72±52.57 0.002 56.05
Final 207.72±61.28 297.61±51.45 0.072 39.62
Gain 106.29±55.43 89.88±55.32 0.432 16.41

Muscle mass (g)

Entry 877.10±36.22 1033.03±42.01 0.002 155.93
Final 1148.23±54.91 1142.13±39.13 0.071 6.10
Gain 271.13±21.44 109.10±12.33 0.009 162.03
Abbreviations: BA, bone area; BMC, bone mineral content; BMD, bone mineral density; IG, gestational age (weeks).
The data are shown as average±s.d.
a
ANCOVA: adjusted values using type of milk as cofactor.

in the PG remained high in relation to the CG (P ¼ 0.005 and
0.001, respectively).
Average LM (g) gain in the PG was 272.1±21.4, whereas in the
CG it was 109.10±12.3 (P<0.009). No significant difference
occurred in body fat mass gain (P<0.434). A positive correlation
occurred between BMC gain and weight gain (r ¼ 0.4; P<0.01) and
between BMC gain and LM gain (r ¼ 0.5; P<0.002) (Table 4 and
Figure 5).
Bone area in the CG was greater at the onset compared to the
PG, although no statistical significance was observed. At the end of
the study, the PG presented greater gain in BA (P<0.001).
Serum and urine calcium, phosphorus and parathyroid
hormone levels was analyzed. All parameters were similar during
the study (Table 5).
Discussion
No reports exist in the literature concerning the use of total body
DEXA for analyzing the effects of 15 min daily motor physical
therapy on bone mineralization in premature infants. However,
some studies have demonstrated that passive exercise for 5 min per
day in the first weeks of life promotes greater bone mineralization,

Journal of Perinatology
 Physical therapy for bone mineralization in premature infants
CM Vignochi et al
629

800 1000
P =0.001
700
800
600
600

Gain in BMC
500
400
400
P =0.425
200
300
0
200
CONTROL
100 PHYSICAL -200
THERAPY
0 -250 0 250 500 750
BMC AT ENTRY BMC AT DISCHARGE
Gain in lean mass
Figure 3 Changes in bone mineral content (BMC) during the study period. BMC
Figure 5 Linear correlation (r) between gain in bone mineral content (BMC)
(mg) improve in the physical therapy group and decrease in the control group.
and gain in lean mass for the study period. It had positive correlation between
gain in BMC (mg) and gain in lean mass (g) during the study period. (r ¼ 0.55),
35 P<0.001.
P =0.001

30 Table 4 Linear correlations between BMC, BMD and independent variables

P =0.519

25 Variables BMD (r) BMC (r)

Birth weight 0.08 0.03

20
Gestational age 0.02 0.06
15
Mechanical ventilation (days) 0.29 0.18
Days under total parenteral nutrition 0.27 0.17
10 Days of life 0.04 0.01
CONTROL Corrected gestational age 0.09 0.09
5 PHYSICAL Calories 0.12 0.03
THERAPY Calcium 0.08 0.09
0 Phosphorus 0.02 0.04
BMD AT ENTRY BMD AT DISCHARGE Vitamin D 0.06 0.05
Pretreatment weight gain 0.06 0.09
Figure 4 Changes in bone mineral density (BMD) during the study period. BMD
(mg cm2) improve in the physical therapy group and decrease in the control kcal pretreatment 0.18 0.04
group. Urine calcium 0.01 0.22
Parathyroid hormone 0.17 0.23
Weight gain 0.400a 0.59b
using other evaluation methods.17–21,23–25 This study clearly Abbreviations: BMC, Bone Mineral Content; BMD, Bone Mineral Density.
a
demonstrated that specific motor physical therapy applied 5 times It had positive correlation between BMD and weight gain (r ¼ 0.4), P ¼ 0.032.
b
per week for 15 min, over a period of 4 weeks, produced a It had positive correlation between BMC and weight gain (r ¼ 0.59), P ¼ 0.001.
significant improvement in weight gain, body length, BMC, BMD,
LM and BA values measured by total body DEXA when compared to growth equivalent to in utero gain during the third trimester.
the CG, which did not receive motor physical therapy. Nutritional intervention, while promoting adequate weight gain,
Multiple factors influence bone growth and development. has variable effect on postnatal bone mineralization in preterm
Previous longitudinal studies using single-photon absorptiometry infants.18
confirmed the need for higher intakes of dietary calcium, With the same supply of nutrients, observation revealed that
phosphorus and vitamin D to improve bone mineralization in motor physical therapy improved bone mineralization, whereas
preterm hospitalized infants.1,26 movement limitation restrains the bone formation process and
Although the positive effects of passive exercise on bone promotes reabsorption. A meta-analysis of three other studies
mineralization in preterm infants have been demonstrated, the demonstrated the positive effects of daily physical activity on weight
American Academy of Pediatrics has stated that the nutritional goal gain, with an average gain of 2.77 g kg1 day1 (with 95% CI
for preterm infants is to provide optimal nutrition to support between 1.62 and 3.93 g) during the study period. However, it has

Journal of Perinatology
 Physical therapy for bone mineralization in premature infants
CM Vignochi et al
630

Table 5 Complementary exams: markers of bone metabolism population. To minimize these errors, segment values were used,
Variables Group Pw
the examiners were blinded and both the segment and total length
measurements were realized in duplicate.
Physical therapy (n ¼ 15) Control (n ¼ 14) Serum and urinary levels of calcium and phosphorus were
evaluated. In this study, the calcium and phosphorus values at the
Serum calcium (mg per 100 ml)
end of the 4-week period were greater in the CG, despite presenting
Initial 8.95±0.58 8.92±0.67 0.892
Final 8.74±0.53 8.93±0.43 0.306
no statistically significant difference. These findings show that
greater urinary excretion of calcium and phosphorus occurred in
Urine calcium (mg per 100 ml) the CG, demonstrating greater bone reabsorption25–30, similar to
Initial 0.29±0.02 0.30±0.018 0.955 results obtained by Beyers et al.29. They noted that preterm infants
Final 0.30±0.009 0.31±0.007 0.428 showed increased urinary excretion of calcium (2.9-fold) and
phosphorus (4.3-fold) when compared to the levels detected in full-
Serum phosphorus (mg per 100 ml) term babies
Initial 6.72±0.9 6.72±0.9 0.626 These results can be attributed to a high bone turnover state
Final 6.87±0.6 6.88±0.6 0.982 that occurs in the first three postnatal weeks, as described by Shiff
et al.31. Thus, it is possible that the marked early postnatal increase
Urine phosphorus (mg per 100 ml)
in these markers may have masked more subtle physical activity-
Initial 0.41±0.039 0.42±0.374 0.617
associated effects.
Final 0.40±0.083 0.41±0.009 0.337
In relation to the techniques of bone mineralization evaluation,
Parathyroid hormone (pg ml1) the principal techniques used in previous studies included
Initial 24.24±2.79 25.53±3.52 0.280 quantitative ultrasound and portable DEXA, both at specific bone
Final 24.91±2.56 24.77±4.03 0.920 locations and not of the entire body. The use of such techniques have
not validated studies for predicting total bone mass in premature
The data are shown as average±s.d.
w
Not significant for all comparisons. infants.31 The only instrument that has been validated in studies that
prove its precision and accuracy is total body DEXA, especially the
fan beam 4500 A model by HOLOGIC, used in this study, according
been verified that the effects observed on weight gain from bone to the recommendations of other validation studies.23,32–35
mineralization in premature infants are still limited to the first One pertinent subject, the question of when is the best moment
month of life, and the studies presented different methodological to initiate motor physical therapy, still requires an answer. A recent
procedures with a weak degree of evidence.27,28 Recently, Moyer- study showed that initiating a physical therapy protocol between
Mileur et al.18 used single-photon absorptiometry and portable the first and second weeks of life did not produce any improvement
DEXA to demonstrate that daily passive range-of-motion exercise in bone mineralization.20 However, those who began at between
increased BMC and BMD in preterm infants. 4 and 5 weeks after the onset of 110 kcal kg1 day1 of enteral
In the present research, the weight gain presented higher values nutrition obtained results similar to those reported here.18,19
in the PG. A statistical treatment was performed considering weight The ideal levels of stimulation for bone development in
gain as a covariant to verify how much of the weight gain was the premature infants still need to be determined. In this study, this
result of bone mass gain or growth catch-up. Previous factors, such stimulation was performed for 15 min every day, 5 times per week.
as birth weight, prior conditions, gestational age and previous In previous studies, this was performed for about 5 min. This study
weight gain, presented no correlation with BMC or BMD and were obtained higher values for BMC and BMD than those obtained in
similar between the groups, suggesting that BMC and BMD were previous studies, suggesting that 15 min stimulation per day may
not probably influenced by these factors, but by physical therapy be more appropriate than 5 min.17–21
intervention. Linear correlation tests were performed and found A 5% increase in BMC represents a 40% reduction in the risk of
that weight gain was correlated with a gain in LM, but not with fat broken bones.26 For this reason, despite the limitations of studies
mass, which suggests that the factor responsible for greater body on preterm infants, it is important to remember that a small
weight gain in the PG is related to bone mass and muscle mass. improvement in bone mass can represent important clinical
In relation to linear growth, the intervention group presented implications for the growth and development of these individuals.
more growth in relation to the CG patients in both total and
segment length, contrary to other studies that presented
heterogeneous results.28 We believe that the results concerning Conclusion
linear growth proved to be heterogeneous between these studies as Motor physical therapy in premature newborns for 15 min per day,
a result of the difficulties inherent in taking measurements in this 5 times per week for 4 weeks permitted significantly greater weight

Journal of Perinatology

gain, length, BMC, BMD, BA and LM, which could contribute to the
prevention of osteopenia in prematurity. As the short-term effects of
this treatment were favorable and safe, an observation of the long-
term effects of this type of treatment on growth and development
would be indicated in future studies.
Conflicts of interest: Nothing to declare.
Funding source: FIPE (Hospital de Clı́nicas de Porto Alegre) and
Graduate Studies in Pediatrics, Federal University of RS.
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