Nonlinear dependence of loading intensity and cycle number in the maintenance of bone mass and morphology

Bone mineral density of the proximal femur is not related to dynamic joint loading during locomotion in young women

We characterized the extent to which body mass influences the relationship between hip joint moments during locomotion and bone mineral density (BMD) of the proximal femur in healthy young women (n = 24). There is some evidence of a direct relationship between hip joint moments during locomotion and BMD of the proximal femur in patients with osteoarthritis. Nevertheless, based on expected simultaneous influences of body mass on BMD and joint moments during locomotion, we hypothesized that BMD would not be significantly associated with hip joint moments during locomotion independently of body mass. BMD of the nondominant proximal femur was determined using DXA. The hip joint moments were determined by gait analysis. The correlation between peak internal rotation moment and BMD of the intertrochanteric region was significant (r = 0.48; P = 0.019). However, body mass was significantly correlated to both BMD and the internal rotation moment (r = 0.59 and 0.70; P = 0.002 and <0.001, respectively). After accounting for the relationship between body mass and hip joint moment, the internal rotation moment was not significantly correlated to BMD of the proximal femur (r = 0.04, P = 0.34) indicating that BMD is not significantly associated with hip joint moments during locomotion independent of body mass in young healthy women.

Analysis of avian bone response to mechanical loading—Part One: Distribution of bone fluid shear stress induced by bending and axial loading

Mechanical loading-induced signals are hypothesized to be transmitted and integrated by a bone-connected cellular network (CCN) before reaching the bone surfaces where adaptation occurs. Our objective is to establish a computational model to explore how bone cells transmit the signals through intercellular communication. In this first part of the study the bone fluid shear stress acting on every bone cell in a CCN is acquired as the excitation signal for the computational model. Bending and axial loading-induced fluid shear stress is computed in transverse sections of avian long bones for two adaptation experiments (Gross et al. in J Bone Miner Res 12:982-988, 1997 and Judex et al. in J Bone Miner Res 12:1737-1745, 1997). The computed fluid shear stress is found to be correlated with the radial strain gradient but not with bone formation. These results suggest that the radial strain gradient is the driving force for bone fluid flow in the radially distributed lacunar-canalicular system and that bone formation is not linearly related to the loading-induced local stimulus.

Low amplitude, high frequency strains imposed by electrically stimulated skeletal muscle retards the development of osteopenia in the tibiae of hindlimb suspended rats

The purpose of this study was to determine the extent to which high frequency, low amplitude skeletal muscle contractions, induced using electrical stimulation, could prevent or retard disuse osteopenia. Ten minutes of 30 Hz electrical stimulation was delivered, 5 days a week, during a 4 week rat-hindlimb suspension protocol. Each pulse generated a peak compressive dynamic strain on the tibia of approximately 200 microepsilon. We hypothesized that the electrical stimulation protocol would significantly reduce the loss of tibial bone mineral density compared to the contralateral control tibia that did not receive electrical stimulation. Compared to the contralateral control limb, the tibia of the stimulated limb had significantly higher bone mineral density and enhanced newly formed bone in the tibial diaphysis. The diaphysis, specifically the posterior bone cortex, of the tibia of the limb receiving the stimulation also demonstrated substantially larger mineral-binding fluorochrome biomarker within the osteocyte lacunae and canalicular volumes. Although the protocol did not prevent disuse osteopenia the evidence suggests that it was effective at reducing the extent of the osteopenia. One possibility for this outcome may be the insensitivity of bone to static, compared to dynamic compressive loads. In the present study there was a considerable static component to the compressive loads that accounted for a large component of the peak load generated by the stimulated skeletal muscle. Nevertheless, the results provide impetus for further development of the methods by which muscle contraction-induced loading of bone can be clinically exploited.

Dynamic shear stress in parallel-plate flow chambers

An in vitro model using a parallel-plate fluid flow chamber is supposed to simulate in vivo fluid shear stresses on various cell types exposed to dynamic fluid flow in their physiological environment. The metabolic response of cells in vitro is associated with the wall shear stress. However, parallel-plate flow chambers have not been characterized for dynamic fluid flow experiments. We use a dimensionless ratio h / lambda(v), in determining the exact magnitude of the dynamic wall shear stress, with its oscillating components scaled by a shear factor T. It is shown that, in order to expose cells to predictable levels of dynamic fluid shear stress, two conditions have to be met: (1) h / lambda(v) < 2, where h is the distance between the plates and lambda(v) is the viscous penetration depth; and (2) f(0) < f(c) / m, where the critical frequency f(c) is the upper threshold for this flow regime, m is the highest harmonic mode of the flow, and f(0) is the fundamental frequency of fluid flow.

Bone defect repair in immobilization-induced osteopenia: a pQCT, biomechanical, and molecular biologic study in the mouse femur

The present study was carried out to determine whether immobilization-induced (Im) osteopenic bone possesses the same reparative capacity as normal healthy bone. Furthermore, the effects of mechanical loading versus immobilization on bone defect healing were studied. Three-week cast-immobilization was used to induce local osteopenia in mice. A standardized metaphyseal bone defect of the distal femur was created unilaterally both in immobilization-induced (Im) osteopenic mice and in nonimmobilized (Mo) age-matched control animals. After creation of the bone defect, the animals in both groups were further divided into two groups: 3-week cast-immobilization (Im-Im and Mo-Im) groups, and unrestricted weight-bearing (Im-Mo and Mo-Mo) groups. The healing process was followed up to 3 weeks using RNA analysis, histomorphometry, biomechanical testing, and pQCT measurements. At 3 weeks of healing without immobilization, bone mineral density (BMD), as well as bone bending stiffness and strength were higher in normal (Mo-Mo) than in osteopenic (Im-Mo) bone. Although the levels of mRNAs characteristic to chondrocytes (Sox9 and type II collagen), hypertrophic chondrocytes (Type X collagen), osteoblasts (type I collagen and osteocalcin), and osteoclasts (cathepsin K) during the bone defect healing exhibited similarities in their expression profiles, mechanical loading conditions also caused characteristic differences. Mechanical loading during healing (Mo-Mo group) induced stronger expression of cartilage- and bone-specific genes and resulted in higher BMD than that seen in the cast-immobilized group (Mo-Im). In biomechanical analysis, increased bending stiffness and strength were also observed in animals that were allowed weight-bearing during healing. Thus, our study shows that bone healing follows the same molecular pathway both in osteopenic and normal bones and presents evidence for reduced or delayed regeneration of noncritical size defects in immobilization-induced osteopenic bone.

Computational simulation of axial dynamization on long bone fractures

BACKGROUND

Axial dynamization has been shown in previous studies to promote callus formation, improve bone healing at fracture sites, and enhance bone remodeling. However, the possibility of non-axial movements or uniform fracture site compression during dynamization, and the appropriate relaxation of fixator joints to achieve such function, have not been investigated.

METHODS

This study used previously developed computational models based on two commercially available unilateral external fixators (Dynafix and Orthofix) to analyze the fixator joint adjustments used and the fracture site movements generated during dynamization.

FINDINGS

When none of the fixator's sliding joints were parallel to the long bone axis, significant non-axial movements occurred during dynamization. The dual sliding joint design of the Dynafix fixator was beneficial in reducing these non-axial movements. When all of the fixator joints were allowed to adjust simultaneously during dynamization, exact axial movement or uniform compression at a complicated fracture site was achievable.

INTERPRETATION

This study revealed that significant non-axial movements may occur during dynamization, and that such a deficiency can be corrected by relaxing certain fixator joints in addition to the sliding mechanism. The same modeling technique can also be applied in bone lengthening application to assure desirable limb alignment during the distraction process. These analysis results can aid the performance assessment of an external fixator and facilitate appropriate application of such a device to achieve either active or controlled axial movement.

Wear-particle-induced osteoclast osteolysis: the role of particulates and mechanical strain

Periprosthetic osteolysis involves osteoclast activation by wear particulates and their exposure to mechanical perturbation through exposure to shear forces generated by periprosthetic fluid as well as interface micromotion. This study aimed to determine the interactions between wear particulates, mechanical stimulation, and osteoclasts. In static cultures, wear particulates increased osteoclast differentiation. Addition of neutralizing antibodies to RANKL (receptor activator of nuclear factor kappa ligand) inhibited the particle-induced increase in osteoclast numbers. Cyclic 5000 microstrains were applied with the use of a custom-built device to marrow-derived cultures to assess the effect on osteoclast differentiation. Mechanical strain application alone decreased osteoclast differentiation, which was further decreased by the addition of particles despite increases in the soluble RANKL to osteoprotegerin (OPG) ratio. Mechanical strain alone induced mature osteoclast apoptosis in a dose-dependent manner. In contrast, in the mature osteoclast model, the addition of nonmetal particulates protected the osteoclasts from becoming apoptopic. Titanium (Ti) and cobalt chromium (CoCr) particles, however, induced osteoclast apoptosis, whereas polyethylene (PE) and polymethylmethacrylate (PMMA) did not. Wear particulates and mechanical stimulation interact via an eicosanoid-dependent pathway to alter osteoclast function and survival. The addition of mechanical perturbation to a particle-laden system thus appears to enhance the potential for osteolytic activity by enhancing osteoclast survival.

Establishing the compliance in elderly women for use of a low level mechanical stress device in a clinical osteoporosis study

Non-pharmacologic approaches to prevent bone loss are well suited for elderly patients to avoid polypharmacy and medication side effects. One potential treatment is a vibrating platform that delivers low-level mechanical loading stimulating bone remodeling. However, compliance is a major concern with any daily treatment, and is unknown for an elderly group using this device. Thus we assessed compliance with standing 10 min/day on a vibrating platform device in elderly women, the target population for osteoporosis therapy. We also assessed satisfaction with daily use of the device. We conducted a randomized, placebo-controlled, double-blinded 6-month study for daily use of a 10-min vibrating platform treatment in elderly women who were residents of a Continuing Care Retirement community. Compliance for each subject was calculated as the number of days attended divided by the 182 days in the 6-month trial. The 24 elderly women (mean age 86, range 79-92 years) had 83% compliance (95% CI: 70.5, 94.5) for daily treatment over 6 months. Excluding three study drop-outs, the 21 women had 93% compliance (95% CI: 89.8, 95.6), with no difference in compliance between active and placebo treatment. Main reasons for missing treatment days over the 6 months were vacation (54% of missed days) and illness (29%). Three adverse events occurred; one (syncope) was possibly related to device use, whereas the other two were not related to device use. Among participants, 95% reported overall satisfaction with daily use of the vibrating platform, and 57% preferred the platform versus daily oral medications for prevention of bone loss. Elderly women showed high compliance, high satisfaction and few adverse experiences with a daily non-pharmacological treatment designed to inhibit bone loss. Larger randomized controlled trials should evaluate the long-term efficacy of vibrating platform devices for treatment of low bone mass and osteoporosis in elderly individuals.

Plantar vibration improves leg fluid flow in perimenopausal women

Recent studies have indicated that plantar-based vibration may be an effective approach for the prevention and treatment of osteoporosis. We addressed the hypothesis of whether the plantar vibration operated by way of the skeletal muscle pump, resulting in enhanced blood and fluid flow to the lower body. We combined plantar stimulation with upright tilt table testing in 18 women aged 46-63 yr. We used strain-gauge plethysmography to measure calf blood flow, venous capacitance, and the microvascular filtration relation, as well as impedance plethysmography to examine changes in leg, splanchnic, and thoracic blood flow while supine at a 35 degrees upright tilt. A vibrating platform was placed on the footboard of a tilt table, and measurements were made at 0, 15, and 45 Hz with an amplitude of 0.2 g point to point, presented in random order. Impedance-measured supine blood flows were significantly (P = 0.05) increased in the calf (30%), pelvic (26%), and thoracic regions (20%) by plantar vibration at 45 Hz. Moreover, the 25-35% decreases in calf and pelvic blood flows associated with upright tilt were reversed by plantar vibration, and the decrease in thoracic blood flow was significantly attenuated. Strain-gauge measurements showed an attenuation of upright calf blood flow. In addition, the microvascular filtration relation was shifted with vibration, producing a pronounced increase in the threshold for edema, P(i), due to enhanced lymphatic flow. Supine values for P(i) increased from 24 +/- 2 mmHg at 0 Hz to 27 +/- 3 mmHg at 15 Hz, and finally to 31 +/- 2 mmHg at 45 Hz (P < 0.01). Upright values for P(i) increased from 25 +/- 3 mmHg at 0 Hz, to 28 +/- 4 mmHg at 15 Hz, and finally to 35 +/- 4 mmHg at 45 Hz. The results suggest that plantar vibration serves to significantly enhance peripheral and systemic blood flow, peripheral lymphatic flow, and venous drainage, which may account for the apparent ability of such stimuli to influence bone mass.

The relations among upper-extremity loading characteristics and bone mineral density changes in young women

The relations among the reaction forces engendered during an upper-extremity dynamic impact-loading exercise (DILE) program and bone mineral density adaptations (DeltaBMD) in the radius were investigated in 24 healthy premenopausal women (mean age = 29 +/- 6 years). Subjects performed DILE 36 cycles/day, 3 days/week for 24 weeks. The exercised arm was allocated randomly to either the dominant or the nondominant limb. In addition, subjects were assigned randomly into either damped or nondamped treatment arms to examine the effects of both higher- and lower-magnitude loading prescriptions. Measurements including anthropometrics, self-reported physical activity levels, hand-grip strength, radial BMD (DEXA, Hologic QDR1500, MA) at the ultradistal radius (UD), distal 1/3 radius (DR), and total distal radius (TOTAL), and exercise-related loading characteristics (impact load, loading rate, and impulse) were recorded at baseline and at 6 months. Simple linear regression models were used to fit the regional BMD changes to the reaction force, changes in hand-grip strength (DeltaGRIP), and changes in body weight (DeltaBW). Findings demonstrated that the damping condition utilized during DILE influenced the relations between loading events and BMD changes. Specifically, none of the reaction-force characteristics significantly predicted changes in BMD in participants performing DILE using the damped condition, whereas, in the nondamped condition, impact load accounted for 58% of the variance in BMD change at DR and 66% of the variance in BMD change at TOTAL. Thresholds of 345 and 285 N of impact force to promote BMD increases at DR and TOTAL, respectively, were obtained from the regression models in the nondamped group. Impulse was also an independent predictor of BMD changes at TOTAL, accounting for 56% of the variance. Neither DeltaGRIP nor DeltaBW significantly predicted DeltaBMD at any radial site. These findings, in young adult women, parallel previous reports identifying significant, regionally specific relations among external loading events and BMD changes in both animal and human models.

Microfracture and changes in energy absorption to fracture of young vertebral cancellous bone following physiological fatigue loading

STUDY DESIGN

Fifty-five human thoracolumbar vertebrae were randomly fatigue loaded and analyzed.

OBJECTIVES

The purpose of this study was to explore the relationship between fatigue loading, trabecular microfracture, and energy absorption to fracture in human cadaveric thoracolumbar vertebrae.

BACKGROUND

Although trabecular microfractures are found in vivo and have been produced by fatigue loading in vitro, the effect of the level of physiologic fatigue loading on microfracture and energy absorption has not been investigated.

METHODS

Fifty-five human thoracolumbar vertebrae (T11-L4) were randomly divided into 5 groups: 1) control (no loading, n = 6); 2) axial compression to yield (n = 7); and 3-5) 20,000 cycles of fatigue loading at 2 Hz (each n = 14). The level of fatigue loading was determined as a proportion of the yield load of Group 2 as follows: 10% (Group 3), 20% (Group 4), and 30% (Group 5). Half of the specimens in groups 3 to 5 were used for radiographic and histomorphometric analysis to determine microfracture density and distribution, whereas the other half were tested to determine the energy absorption to yield failure.

RESULTS

No radiographic evidence of gross fracture was found in any of the groups following fatigue loading. A mean 7.5% increase in stiffness was found in specimens subject to cyclic loading at 10% of yield stress (Group 3). Fatigue at 20% (Group 4) and 30% of yield stress (Group 5) caused significantly higher (P < 0.05) increases in mean stiffness of 23.6% and 24.2%, respectively. Microfracture density increased from 0.46/mm in Group 3 to 0.66/mm in Group 4 and 0.94/mm in Group 5 (P < 0.05). The energy absorbed to failure decreased from 21.9 J in Group 3 to 18.1 J and 19.6 J in Groups 4 and 5, respectively (P < 0.05).

CONCLUSIONS

Fatigue loading at physiologic levels produced microfractures that are not detectable by radiography. Increased fatigue load results in an increase in microfracture density and decrease energy absorbed to fracture, indicating a reduced resistance to further fatigue loading.

Rest insertion combined with high-frequency loading enhances osteogenesis

Mechanical loading can significantly affect skeletal adaptation. High-frequency loading can be a potent osteogenic stimulus. Additionally, insertion of rest periods between consecutive loading bouts can be a potent osteogenic stimulus. Thus we investigated whether the insertion of rest-periods between short-term high-frequency loading bouts would augment adaptation in the mature murine skeleton. Right tibiae of skeletally mature (16 wk) female C57BL/6 mice were loaded in cantilever bending at peak of 800 μϵ, 30 Hz, 5 days/wk for 3 wk. Left tibiae were the contralateral control condition. Mice were randomly assigned into one of two groups: continuous high-frequency (CT) stimulation for 100 s ( n = 9), or 1-s pulses of high-frequency stimuli followed by 10 s of rest (RI) for 100 s ( n = 9). Calcein labels were administered on days 1 and 21; label incorporation was used to histomorphometrically assess periosteal and endosteal indexes of adaptation. Periosteal surface referent bone formation rate (pBFR/BS) was significantly enhanced in CT (>88%) and RI (>126%) loaded tibiae, relative to control tibiae. Furthermore, RI tibiae had significantly greater pBFR/BS, relative to CT tibiae (>72%). The endosteal surface was not as sensitive to mechanical loading as the periosteal surface. Thus short-term high-frequency loading significantly elevated pBFR/BS, relative to control tibiae. Furthermore, despite the 10-fold reduction in cycle number, the insertion of rest periods between bouts of high-frequency stimuli significantly augmented pBFR/BS, relative to tibiae loaded continually. Optimization of osteogenesis in response to mechanical loading may underpin the development of nonpharmacological regiments designed to increase bone strength in individuals with compromised bone structures.

Prevention of postmenopausal bone loss by a low-magnitude, high-frequency mechanical stimuli: a clinical trial assessing compliance, efficacy, and safety

A 1-year prospective, randomized, double-blind, and placebo-controlled trial of 70 postmenopausal women demonstrated that brief periods (<20 minutes) of a low-level (0.2g, 30 Hz) vibration applied during quiet standing can effectively inhibit bone loss in the spine and femur, with efficacy increasing significantly with greater compliance, particularly in those subjects with lower body mass.

INTRODUCTION

Indicative of the anabolic potential of mechanical stimuli, animal models have demonstrated that short periods (<30 minutes) of low-magnitude vibration (<0.3g), applied at a relatively high frequency (20-90 Hz), will increase the number and width of trabeculae, as well as enhance stiffness and strength of cancellous bone. Here, a 1-year prospective, randomized, double-blind, and placebo-controlled clinical trial in 70 women, 3-8 years past the menopause, examined the ability of such high-frequency, low-magnitude mechanical signals to inhibit bone loss in the human.

MATERIALS AND METHODS

Each day, one-half of the subjects were exposed to short-duration (two 10-minute treatments/day), low-magnitude (2.0 m/s2 peak to peak), 30-Hz vertical accelerations (vibration), whereas the other half stood for the same duration on placebo devices. DXA was used to measure BMD at the spine, hip, and distal radius at baseline, and 3, 6, and 12 months. Fifty-six women completed the 1-year treatment.

RESULTS AND CONCLUSIONS

The detection threshold of the study design failed to show any changes in bone density using an intention-to-treat analysis for either the placebo or treatment group. Regression analysis on the a priori study group demonstrated a significant effect of compliance on efficacy of the intervention, particularly at the lumbar spine (p = 0.004). Posthoc testing was used to assist in identifying various subgroups that may have benefited from this treatment modality. Evaluating those in the highest quartile of compliance (86% compliant), placebo subjects lost 2.13% in the femoral neck over 1 year, whereas treatment was associated with a gain of 0.04%, reflecting a 2.17% relative benefit of treatment (p = 0.06). In the spine, the 1.6% decrease observed over 1 year in the placebo group was reduced to a 0.10% loss in the active group, indicating a 1.5% relative benefit of treatment (p = 0.09). Considering the interdependence of weight, the spine of lighter women (<65 kg), who were in the highest quartile of compliance, exhibited a relative benefit of active treatment of 3.35% greater BMD over 1 year (p = 0.009); for the mean compliance group, a 2.73% relative benefit in BMD was found (p = 0.02). These preliminary results indicate the potential for a noninvasive, mechanically mediated intervention for osteoporosis. This non-pharmacologic approach represents a physiologically based means of inhibiting the decline in BMD that follows menopause, perhaps most effectively in the spine of lighter women who are in the greatest need of intervention.

Effect of 6-month whole body vibration training on hip density, muscle strength, and postural control in postmenopausal women: a randomized controlled pilot study

High-frequency mechanical strain seems to stimulate bone strength in animals. In this randomized controlled trial, hip BMD was measured in postmenopausal women after a 24-week whole body vibration (WBV) training program. Vibration training significantly increased BMD of the hip. These findings suggest that WBV training might be useful in the prevention of osteoporosis.

INTRODUCTION

High-frequency mechanical strain has been shown to stimulate bone strength in different animal models. However, the effects of vibration exercise on the human skeleton have rarely been studied. Particularly in postmenopausal women-who are most at risk of developing osteoporosis-randomized controlled data on the safety and efficacy of vibration loading are lacking. The aim of this randomized controlled trial was to assess the musculoskeletal effects of high-frequency loading by means of whole body vibration (WBV) in postmenopausal women.

MATERIALS AND METHODS

Seventy volunteers (age, 58-74 years) were randomly assigned to a whole body vibration training group (WBV, n = 25), a resistance training group (RES, n = 22), or a control group (CON, n = 23). The WBV group and the RES group trained three times weekly for 24 weeks. The WBV group performed static and dynamic knee-extensor exercises on a vibration platform (35-40 Hz, 2.28-5.09g), which mechanically loaded the bone and evoked reflexive muscle contractions. The RES group trained knee extensors by dynamic leg press and leg extension exercises, increasing from low (20 RM) to high (8 RM) resistance. The CON group did not participate in any training. Hip bone density was measured using DXA at baseline and after the 6-month intervention. Isometric and dynamic strength were measured by means of a motor-driven dynamometer. Data were analyzed by means of repeated measures ANOVA.

RESULTS

No vibration-related side effects were observed. Vibration training improved isometric and dynamic muscle strength (+15% and + 16%, respectively; p < 0.01) and also significantly increased BMD of the hip (+0.93%, p < 0.05). No changes in hip BMD were observed in women participating in resistance training or age-matched controls (-0.60% and -0.62%, respectively; not significant). Serum markers of bone turnover did not change in any of the groups.

CONCLUSION

These findings suggest that WBV training may be a feasible and effective way to modify well-recognized risk factors for falls and fractures in older women and support the need for further human studies.

Low magnitude mechanical loading is osteogenic in children with disabling conditions

The osteogenic potential of short durations of low-level mechanical stimuli was examined in children with disabling conditions. The mean change in tibia vTBMD was +6.3% in the intervention group compared with -11.9% in the control group. This pilot randomized controlled trial provides preliminary evidence that low-level mechanical stimuli represent a noninvasive, non-pharmacological treatment of low BMD in children with disabling conditions.

INTRODUCTION

Recent animal studies have demonstrated the anabolic potential of low-magnitude, high-frequency mechanical stimuli to the trabecular bone of weight-bearing regions of the skeleton. The main aim of this prospective, double-blind, randomized placebo-controlled pilot trial (RCT) was to examine whether these signals could effectively increase tibial and spinal volumetric trabecular BMD (vTBMD; mg/ml) in children with disabling conditions.

MATERIALS AND METHODS

Twenty pre-or postpubertal disabled, ambulant, children (14 males, 6 females; mean age, 9.1 +/- 4.3 years; range, 4-19 years) were randomized to standing on active (n = 10; 0.3g, 90 Hz) or placebo (n = 10) devices for 10 minutes/day, 5 days/week for 6 months. The primary outcomes of the trial were proximal tibial and spinal (L2) vTBMD (mg/ml), measured using 3-D QCT. Posthoc analyses were performed to determine whether the treatment had an effect on diaphyseal cortical bone and muscle parameters.

RESULTS AND CONCLUSIONS

Compliance was 44% (4.4 minutes per day), as determined by mean time on treatment (567.9 minutes) compared with expected time on treatment over the 6 months (1300 minutes). After 6 months, the mean change in proximal tibial vTBMD in children who stood on active devices was 6.27 mg/ml (+6.3%); in children who stood on placebo devices, vTBMD decreased by -9.45 mg/ml (-11.9%). Thus, the net benefit of treatment was +15.72 mg/ml (17.7%; p = 0.0033). In the spine, the net benefit of treatment, compared with placebo, was +6.72 mg/ml, (p = 0.14). Diaphyseal bone and muscle parameters did not show a response to treatment. The results of this pilot RCT have shown for the first time that low-magnitude, high-frequency mechanical stimuli are anabolic to trabecular bone in children, possibly by providing a surrogate for suppressed muscular activity in the disabled. Over the course of a longer treatment period, harnessing bone's sensitivity to these stimuli may provide a non-pharmacological treatment for bone fragility in children.

Predicting long bone loading from cross-sectional geometry

Long bone loading histories are commonly evaluated using a beam model by calculating cross-sectional second moments of areas (SMAs). Without in vivo strain data, SMA analyses commonly make two explicit or implicit assumptions. First, while it has long been known that axial compression superimposed on bending shifts neutral axes away from cross-sectional area centroids, most analyses assume that cross-sectional properties calculated through the area centroid approximate cross-sectional strength. Second, the orientation of maximum bending rigidity is often assumed to reflect the orientation of peak or habitual bending forces the bone experiences. These assumptions are tested in sheep in which rosette strain gauges mounted at three locations around the tibia and metatarsal midshafts measured in vivo strains during treadmill running at 1.5 m/sec. Calculated normal strain distributions confirm that the neutral axis of bending does not run through the midshaft centroid. In these animals, orientations of the principal centroidal axes around which maximum SMAs (Imax) are calculated are not in the same planes in which the bones experienced bending. Cross-sectional properties calculated using centroidal axes have substantial differences in magnitude (up to 55%) but high correlations in pattern compared to cross-sectional properties calculated around experimentally determined neutral axes. Thus interindividual comparisons of cross-sectional properties calculated from centroidal axes may be useful in terms of pattern, but are subject to high errors in terms of absolute values. In addition, cross-sectional properties do not necessarily provide reliable data on the orientations of loads to which bones are subjected.

Fluid pressure gradients, arising from oscillations in intramedullary pressure, is correlated with the formation of bone and inhibition of intracortical porosity

Fluid flow that arises from the functional loading of bone tissue has been proposed to be a critical regulator of skeletal mass and morphology. To test this hypothesis, the bone adaptive response to a physiological fluid stimulus, driven by low magnitude, high frequency oscillations of intramedullary pressure (ImP), were examined, in which fluid pressures were achieved without deforming the bone tissue. The ulnae of adult turkeys were functionally isolated via transverse epiphyseal osteotomies, and the adaptive response to four weeks of disuse (n=5) was compared to disuse plus 10 min per day of a physiological sinusoidal fluid pressure signal (60 mmHg, 20Hz). Disuse alone resulted in significant bone loss (5.7+/-1.9%, p< or =0.05), achieved by thinning the cortex via endosteal resorption and an increase in intracortical porosity. By also subjecting bone to oscillatory fluid flow, a significant increase in bone mass at the mid-diaphysis (18.3+/-7.6%, p<0.05), was achieved by both periosteal and endosteal new bone formation. The spatial distribution of the transcortical fluid pressure gradients (inverted Delta P(r)), a parameter closely related to fluid velocity and fluid shear stress, was quantified in 12 equal sectors across a section at the mid-diaphyses. A strong correlation was found between the inverted Delta P(r) and total new bone formation (r=0.75, p=0.01); and an inverse correlation (r=-0.75, p=0.01) observed between inverted Delta P(r) and the area of increased intracortical porosity, indicating that fluid flow signals were necessary to maintain bone mass and/or inhibit bone loss against the challenge of disuse. By generating this fluid flow in the absence of matrix strain, these data suggest that anabolic fluid movement plays a regulatory role in the modeling and remodeling process. While ImP increases uniformly in the marrow cavity, the distinct parameters of fluid flow vary substantially due to the geometry and ultrastructure of bone, which ultimately defines the spatial non-uniformity of the adaptive process.

Effects of implant healing time on crestal bone loss of a controlled-load dental implant

The universally accepted concept of delay-loaded dental implants has recently been challenged. This study hypothesizes that early loading (decreased implant healing time) leads to increased bone formation and decreased crestal bone loss. We used 17 minipigs to study implants under a controlled load, with non-loaded implants for comparison. Radiographic and histological assessments were made of the osseointegrated bone changes for 3 healing times (between implant insertion and loading), following 5 months of loading. The effect of loading on crestal bone loss depended on the healing time. Early loading preserved the most crestal bone. Delayed loading had significantly more crestal bone loss compared with the non-loaded controls (2.4 mm vs. 0.64 mm; P < 0.05). The histological assessment and biomechanical analyses of the healing bone suggested that loading and bioactivities of osteoblasts exert a synergistic effect on osseointegration that is likely to support the hypothesis that early loading produces more favorable osseointegration.

Ontogenetic and regional morphologic variations in the turkey ulna diaphysis: implications for functional adaptation of cortical bone

This study examines relationships between bone morphology and mechanically mediated strain/fluid-flow patterns in an avian species. Using mid-diaphyseal transverse sections of domestic turkey ulnae (from 11 subadults and 11 adults), we quantified developmental changes in predominant collagen fiber orientation (CFO), mineral content (%ash), and microstructure in cortical octants or quadrants (i.e., %ash). Geometric parameters were examined using whole mid-diaphyseal cross-sections. The ulna undergoes habitual bending and torsion, and demonstrates nonuniform matrix fluid-flow patterns, and high circumferential strain gradients along the neutral axis (cranial-caudal) region at mid-diaphysis. The current results showed significant porosity differences: 1) greater osteocyte lacuna densities (N.Lac/Ar) (i.e., "non-vascular porosity") in the caudal and cranial cortices in both groups, 2) greater N.Lac/Ar in the pericortex vs. endocortex in mature bones, and 3) greater nonlacunar porosity (i.e., "vascular porosity") in the endocortex vs. pericortex in mature bones. Vascular and nonvascular porosities were not correlated. There were no secondary osteons in subadults. In adults, the highest secondary osteon population densities and lowest %ash occurred in the ventral-caudal, caudal, and cranial cortices, where shear strains, circumferential strain gradients, and fluid displacements are highest. Changes in thickness of the caudal cortex explained the largest proportion of the age-related increase in cranial-caudal breadth; the thickness of other cortices (dorsal, ventral, and cranial) exhibited smaller changes. Only subadult bones exhibited CFO patterns corresponding to habitual tension (ventral) and compression (dorsal). These CFO variations may be adaptations for differential mechanical requirements in "strain-mode-specific" loading. The more uniform oblique-to-transverse CFO patterns in adult bones may represent adaptations for shear strains produced by torsional loading, which is presumably more prevalent in adults. The micro- and ultrastructural heterogeneities may influence strain and fluid-flow dynamics, which are considered proximate signals in bone adaptation.

Low-intensity, high-frequency vibration appears to prevent the decrease in strength of the femur and tibia associated with ovariectomy of adult rats

The effect of low-intensity, high-frequency vibration on bone mass, bone strength, and skeletal muscle mass was studied in an adult ovariectomized (OVX) rat model. One-year-old female rats were allocated randomly to the following groups: start control, sham OVX, OVX without vibration, OVX with vibration at 17 Hz (0.5g), OVX with vibration at 30 Hz (1.5g), OVX with vibration at 45 Hz (3.0g). Vibrations were given 30 min/day for 90 days. During vibration each group of rats was placed in a box on top of the vibration motor. The amplitude of the vibration motor was 1.0 mm. The animals were labeled with calcein at day 63 and with tetracycline at day 84. The tibia middiaphysis was studied by mechanical testing and dynamic histomorphometry and the femur distal metaphysis by mechanical compression. OVX without vibration increased the periosteal bone formation rate and increased the medullary cross-sectional area, i.e., increased the endocortical resorption and outward anteromedial and lateral drifts of cortical bone at the tibia middiaphysis. OVX also resulted in a reduced maximum bending stress of the tibia diaphysis and a reduced compressive stress of the femur distal metaphysis. Vibration at the highest intensity, i.e., 45 Hz, of OVX rats induced a further increase in periosteal bone formation rate and inhibited the endocortical resorption seen in OVX rats. Furthermore, vibration at 45 Hz inhibited the decline in maximum bending stress and compressive stress induced by OVX. Neither OVX nor OVX with vibration influenced skeletal muscle mass. In conclusion, the results support the idea of a possible beneficial effect of passive physical loading on the preservation of bone in OVX animals.

Low-intensity electromagnetic and mechanical modulation of bone growth and repair: are they equivalent?

Signals from both electromagnetic fields (EMF) and ultrasound (US) have a clinically significant effect upon bone repair. Both modalities are now a common part of the orthopedist's armamentarium for the care of delayed union, nonunion, and fresh fractures. Dynamization or controlled weight bearing also enhances bone repair. Consideration of the dosimetry of both EMF and US modalities suggests a possible unifying mechanism for the bioeffects from EMF, US, and strain-generated potentials (SGP) signals based on the time-varying electric field, E(t), associated with each type of stimulus. The E(t) field is directly induced with EMF devices and indirectly induced via the streaming potentials associated with the mechanical movement of ionic fluids within bone caniculi or directly past cell surfaces from US and SGP signals. It is shown that both electrically and mechanically induced E(t) have common waveform characteristics at the treatment site and thus can deliver similar doses of electrical stimulation. It is proposed that the time-varying endogenous electric field, E(t), from a time-varying change in the mechanical environment of healing or remodeling bone, can act as a dose-dependent growth stimulus. Thus, the primary messenger affecting cellular activity is E(t), suggesting that bone repair or remodeling may be interchangeably modulated using mechanical (including US) or electromagnetic signals.

Genetic predisposition to low bone mass is paralleled by an enhanced sensitivity to signals anabolic to the skeleton

The structure of the adult skeleton is determined, in large part, by its genome. Whether genetic variations may influence the effectiveness of interventions to combat skeletal diseases remains unknown. The differential response of trabecular bone to an anabolic (low-level mechanical vibration) and a catabolic (disuse) mechanical stimulus were evaluated in three strains of adult mice. In low bone-mineral-density C57BL/6J mice, the low-level mechanical signal caused significantly larger bone formation rates (BFR) in the proximal tibia, but the removal of functional weight bearing did not significantly alter BFR. In mid-density BALB/cByJ mice, mechanical stimulation also increased BFR, whereas disuse significantly decreased BFR. In contrast, neither anabolic nor catabolic mechanical signals influenced any index of bone formation in high-density C3H/HeJ mice. Together, data from this study indicate that the sensitivity of trabecular tissue to both anabolic and catabolic stimuli is influenced by the genome. Extrapolated to humans, these results may explain in part why prophylaxes for low bone mass are not universally effective, yet also indicate that there may be a genotypic indication of people who are at reduced risk of suffering from bone loss.

Mechanical strain, induced noninvasively in the high-frequency domain, is anabolic to cancellous bone, but not cortical bone

Departing from the premise that it is the large-amplitude signals inherent to intense functional activity that define bone morphology, we propose that it is the far lower magnitude, high-frequency mechanical signals that continually barrage the skeleton during longer term activities such as standing, which regulate skeletal architecture. To examine this hypothesis, we proposed that brief exposure to slight elevations in these endogenous mechanical signals would suffice to increase bone mass in those bones subject to the stimulus. This was tested by exposing the hind limbs of adult female sheep (n = 9) to 20 min/day of low-level (0.3g), high-frequency (30 Hz) mechanical signals, sufficient to induce a peak of approximately 5 microstrain (micro epsilon) in the tibia. Following euthanasia, peripheral quantitative computed tomography (pQCT) was used to segregate the cortical shell from the trabecular envelope of the proximal femur, revealing a 34.2% increase in bone density in the experimental animals as compared with controls (p = 0.01). Histomorphometric examination of the femur supported these density measurements, with bone volume per total volume increasing by 32% (p = 0.04). This density increase was achieved by two separate strategies: trabecular spacing decreased by 36.1% (p = 0.02), whereas trabecular number increased by 45.6% (p = 0.01), indicating the formation of cancellous bone de novo. There were no significant differences in the radii of animals subject to the stimulus, indicating that the adaptive response was local rather than systemic. The anabolic potential of the signal was evident only in trabecular bone, and there were no differences, as measured by any assay, in the cortical bone. These data suggest that subtle mechanical signals generated during predominant activities such as posture may be potent determinants of skeletal morphology. Given that these strain levels are three orders of magnitude below strains that can damage bone tissue, we believe that a noninvasive stimulus based on this sensitivity has potential for treating skeletal complications such as osteoporosis.

Quantity and quality of trabecular bone in the femur are enhanced by a strongly anabolic, noninvasive mechanical intervention

The skeleton's sensitivity to mechanical stimuli represents a critical determinant of bone mass and morphology. We have proposed that the extremely low level (< 10 microstrain), high frequency (20-50 Hz) mechanical strains, continually present during even subtle activities such as standing are as important to defining the skeleton as the larger strains typically associated with vigorous activity (>2000 microstrain). If these low-level strains are indeed anabolic, then this sensitivity could serve as the basis for a biomechanically based intervention for osteoporosis. To evaluate this hypothesis, the hindlimbs of adult female sheep were stimulated for 20 minutes/day using a noninvasive 0.3g vertical oscillation sufficient to induce approximately 5 microstrain on the cortex of the tibia. After 1 year of stimulation, the physical properties of 10-mm cubes of trabecular bone from the distal femoral condyle of experimental animals (n = 8) were compared with controls (n = 9), as evaluated using microcomputed tomography (microCT) scanning and materials testing. Bone mineral content (BMC) was 10.6% greater (p < 0.05), and the trabecular number (Tb.N) was 8.3% higher in the experimental animals (p < 0.01), and trabecular spacing decreased by 11.3% (p < 0.01), indicating that bone quantity was increased both by the creation of new trabeculae and the thickening of existing trabeculae. The trabecular bone pattern factor (TBPf) decreased 24.2% (p < 0.03), indicating trabecular morphology adapting from rod shape to plate shape. Significant increases in stiffness and strength were observed in the longitudinal direction (12.1% and 26.7%, respectively; both, p < 0.05), indicating that the adaptation occurred primarily in the plane of weightbearing. These results show that extremely low level mechanical stimuli improve both the quantity and the quality of trabecular bone. That these deformations are several orders of magnitude below those peak strains which arise during vigorous activity indicates that this biomechanically based signal may serve as an effective intervention for osteoporosis.

Bone-loading response varies with strain magnitude and cycle number

Mechanical loading stimulates bone formation and regulates bone size, shape, and strength. It is recognized that strain magnitude, strain rate, and frequency are variables that explain bone stimulation. Early loading studies have shown that a low number (36) of cycles/day (cyc) induced maximal bone formation when strains were high (2,000 microepsilon) (Rubin CT and Lanyon LE. J Bone Joint Surg Am 66: 397-402, 1984). This study examines whether cycle number directly affects the bone response to loading and whether cycle number for activation of formation varies with load magnitude at low frequency. The adult rat tibiae were loaded in four-point bending at 25 (-800 microepsilon) or 30 N (-1,000 microepsilon) for 0, 40, 120, or 400 cyc at 2 Hz for 3 wk. Differences in periosteal and endocortical formation were examined by histomorphometry. Loading did not stimulate bone formation at 40 cyc. Compared with control tibiae, tibiae loaded at -800 microepsilon showed 2.8-fold greater periosteal bone formation rate at 400 cyc but no differences in endocortical formation. Tibiae loaded at -1,000 microepsilon and 120 or 400 cyc had 8- to 10-fold greater periosteal formation rate, 2- to 3-fold greater formation surface, and 1-fold greater endocortical formation surface than control. As applied load or strain magnitude decreased, the number of cyc required for activation of formation increased. We conclude that, at constant frequency, the number of cyc required to activate formation is dependent on strain and that, as number of cyc increases, the bone response increases.

The anabolic activity of bone tissue, suppressed by disuse, is normalized by brief exposure to extremely low-magnitude mechanical stimuli

It is generally believed that mechanical signals must be large in order to be anabolic to bone tissue. Recent evidence indicates, however, that extremely low-magnitude (<10 microstrain) mechanical signals readily stimulate bone formation if induced at a high frequency. We examined the ability of extremely low-magnitude, high-frequency mechanical signals to restore anabolic bone cell activity inhibited by disuse. Adult female rats were randomly assigned to six groups: baseline control, age-matched control, mechanically stimulated for 10 min/day, disuse (hind limb suspension), disuse interrupted by 10 min/day of weight bearing, and disuse interrupted by 10 min/day of mechanical stimulation. After a 28 day protocol, bone formation rates (BFR) in the proximal tibia of mechanically stimulated rats increased compared with age-matched control (+97%). Disuse alone reduced BFR (-92%), a suppression only slightly curbed when disuse was interrupted by 10 min of weight bearing (-61%). In contrast, disuse interrupted by 10 min per day of low-level mechanical intervention normalized BFR to values seen in age-matched controls. This work indicates that this noninvasive, extremely low-level stimulus may provide an effective biomechanical intervention for the bone loss that plagues long-term space flight, bed rest, or immobilization caused by paralysis.

Primary adult human bone cells do not respond to tissue (continuum) level strains

Bone adapts to its mechanical environment, and, since the late 1800s, investigators have presumed that this adaptation relates to strain magnitude. Indeed, overwhelming evidence supports the view that either strain or some strain-related quantity stimulates bone adaptation or remodeling. Virtually all investigators, implicitly or explicitly, assume that the level of strain magnitude responsible for bone adaptation is that measured by strain gauges in vivo (i.e., 100-2500 microstrain) and that bone cells are directly deformed by strained matrix. We present evidence that bone cell deformation in this range does not cause bone adaptation. First, bone cells in vitro typically do not respond to average (continuum) levels of strain magnitude. Second, bone cells in vitro do respond to fluid flow-induced shear stresses in these ostensible physiological ranges. Third, in vivo strain magnitudes presumed to stimulate remodeling reflect only averages, and not local peaks, which are 2-15 times higher. Thus, we hypothesize that sensing cells do not respond to levels of strain presumed to be physiological.

Inhibition of osteopenia by low magnitude, high-frequency mechanical stimuli

The identification of anabolic agents for the treatment of metabolic bone disease is a highly prized, and elusive, goal. In searching for the osteogenic (bone-producing) constituents within mechanical stimuli, it was determined that high frequency (10-100 Hz) and low magnitude (<10 microstrain) stimuli were capable of augmenting bone mass and morphology, thereby benefiting both bone quantity and quality. Using animal models, it is shown that these mechanical signals can double bone-formation rates, inhibit disuse osteoporosis and increase the strength of trabecular bone by 25%. Considering that the magnitude of these mechanical signals are several orders of magnitude below those which cause damage to the bone tissue, it is proposed that this modality could be useful in the treatment of metabolic bone diseases.

Quantifying Force Magnitude and Loading Rate from Drop Landings That Induce Osteogenesis

Drop landings increase hip bone mass in children. However, force characteristics from these landings have not been studied. We evaluated ground and hip joint reaction forces, average loading rates, and changes across multiple trials from drop landings associated with osteogenesis in children. Thirteen prepubescent children who had previously participated in a bone loading program volunteered for testing. They performed 100 drop landings onto a force plate. Ground reaction forces (GRF) and two-dimensional kinematic data were recorded. Hip joint reaction forces were calculated using inverse dynamics. Maximum GRF were 8.5 ± 2.2 body weight (BW). At initial contact, GRF were 5.6 ± 1.4 BW while hip joint reactions were 4.7 ± 1.4 BW. Average loading rates for GRF were 472 ± 168 BW/s. Ground reaction forces did not change significantly across trials for the group. However, 5 individuals showed changes in max GRF across trials. Our data indicate that GRF are attenuated 19% to the hip at the first impact peak and 49% at the second impact peak. Given the skeletal response from the drop landing protocol and our analysis of the associated force magnitudes and average loading rates, we now have a data point on the response surface for future study of various combinations of force, rate, and number of load repetitions for increasing bone in children.

Effects of high-frequency, low-magnitude mechanical stimulus on bone healing

Recent studies have shown osteogenic effects of high-frequency mechanical stimuli. The purpose of this study was whether externally applied, high-frequency, low-magnitude interfragmentary movements affect the process of bone healing. In 12 sheep, a transverse osteotomy with a 3 mm gap was created in the right metatarsus and externally stabilized by a rigid circular fixator. External stimulation was performed in six sheep with the use of ground-based vibration. The sheep were standing with their hind limbs on a platform that produced vertical movements resulting in interfragmentary movements of approximately 0.02 mm magnitude at 20 Hz frequency. The other six sheep remained rigidly stabilized by external fixation during the 8-week study and served as a control group. Healing was assessed postmortem by densitometric and mechanical examinations. No significant differences were found between the two groups, although callus formation was slightly enhanced (11%) in the stimulated group compared with the control group. Mechanical stimuli attributable to weightbearing in the control group were sufficient enough to initiate callus formation even under rigid, external fixation. Thus, external mechanical stimulation with the stimulation design described in the current study might not be indicated for improvement of bone healing.

An extensometer for global measurement of bone strain suitable for use in vivo in humans

An axial extensometer able to measure global bone strain magnitudes and rates encountered during physiological activity, and suitable for use in vivo in human subjects, is described. The extensometer uses paired capacitive sensors mounted to intraosseus pins and allows measurement of strain due to bending in the plane of the extensometer as well as uniaxial compression or tension. Data are presented for validation of the device against a surface-mounted strain gage in an acrylic specimen under dynamic four-point bending, with square wave and sinusoidal loading inputs up to 1500 mu epsilon and 20 Hz, representative of physiological strain magnitudes and frequencies. Pearson's correlation coefficient (r) between extensometer and strain gage ranged from 0.960 to 0.999. Mean differences between extensometer and strain gage ranged up to 15.3 mu epsilon. Errors in the extensometer output were directly proportional to the degree of bending that occurs in the specimen, however, these errors were predictable and less than 1 mu epsilon for the loading regime studied. The device is capable of tracking strain rates in excess of 90,000 mu epsilon/s.

Mechanical strain inhibits expression of osteoclast differentiation factor by murine stromal cells

Normal dynamic loading prevents bone resorption; however, the means whereby biophysical factors reduce osteoclast activity are not understood. We show here that mechanical strain (2% at 10 cycles per minute) applied to murine marrow cultures reduced 1, 25(OH)(2)D(3)-stimulated osteoclast formation by 50%. This was preceded by decreased expression of osteoclast differentiation factor (ODF/TRANCE). RT-PCR for ODF/TRANCE revealed that ODF/TRANCE mRNA in strained cultures was 59 +/- 3% of that seen in control cultures. No significant effects on total cell count, thymidine uptake, or alkaline phosphatase activity were induced by strain. To isolate the cell targeted by strain, primary stromal cells were cultured from marrow. Mechanical strain also reduced mRNA for ODF/TRANCE to 60% that of control in these cells. In contrast, mRNA for membrane-bound macrophage colony-stimulating factor was not significantly affected. Soluble ODF ( approximately 2 ng/ml) was able to reverse the effect of strain, returning osteoclast numbers to control. Because osteoclast formation is dependent upon ODF/TRANCE expression, strain-induced reductions in this factor may contribute to the accompanying reduction in osteoclastogenesis.

Perspectives on bone mechanical properties and adaptive response to mechanical challenge

The bones of the human skeleton serve a mechanical function besides providing a reservoir for calcium and hematopoietic homeostatis. When mechanically challenged, they usually respond and adapt; failure to do so can result in fracture. The mechanical behavior of bone is determined by bone mass and its material properties and by its geometry and architecture. Therefore, in vivo noninvasive measurements of bone mass, geometry, and structure can predict bone strength and are usually employed as a useful-if not always reliable-way to estimate bone fragility, whereas direct bone biomechanical testing in vitro can provide detailed information about mechanical strength. Because bone strains are likely to be regulators of bone mass and strength, exercise protocols designed to counteract the effects of osteoporosis should load the target bone with repeated high peak forces and high strain rates or high impacts on a long-term basis. Such a protocol creates varied strain distributions throughout the bone structure, producing short, repeated strains on the bone in directions to which it is unaccustomed. Exercise in this manner can maintain and perhaps increase bone mass and improve mechanical properties and neuromuscular competency, reducing skeletal fragility and the predisposition to falls.