Toward a cure for osteoporosis: reversal of excessive bone fragility

Circaea mollis Siebold & Zucc. Alleviates postmenopausal osteoporosis in a mouse model via the BMP-2/4/Runx2 pathway

Background

Circaea mollis Sieb. & Zucc. has been used as a traditional herbal medicine in Hani Ethnopharmacy and possesses anti-arthritic activities. This study aimed to investigate the effect of Circaea mollis Siebold & Zucc on postmenopausal osteoporosis.

Methods

For in vitro study, MCF7 breast cancer cells and MC3T3-E1 pre-osteoblast cells were utilized to estimate estrogenic and osteogenic activity. Osteoblastic markers were measured by western blot and real-time PCR. For in vivo study, female mature C57BL/6 mice were ovariectomized and oral administrated with 10 mg/kg and 40 mg/kg of EECM respectively.

Results

EtOH extract of Circaea mollis Siebold & Zucc. (EECM) increased alkaline phosphatase activity and osteoblast marker levels at day 7 during differentiation of mouse preosteoblasts. EECM reduced osteoclast differentiation and bone resorption in an osteoblast-osteoclast primary co-culture system. In ovariectomized mice, EECM prevented the decrease in bone mineral density and recovered OSX and Runx2 via BMP2/4, Smad1/5/9 and p38.

Conclusions

The results suggest that EECM may be effective in preventing bone loss, offering a promising alternative for the nutritional management of postmenopausal osteoporosis.

Pregnant growth restricted female rats have bone gains during late gestation which contributes to second generation adolescent and adult offspring having normal bone health

Low birth weight, due to uteroplacental insufficiency, results in programmed bone deficits in the first generation (F1). These deficits may be passed onto subsequent generations. We characterized the effects of being born small on maternal bone health during pregnancy; and aimed to characterize the contribution of the maternal environment and germ line effects to bone health in F2 offspring from mothers born small. Bilateral uterine vessel ligation (or sham) surgery was performed on female F0 WKY rats on gestational day 18 (term 22days) to induce uteroplacental insufficiency and fetal growth restriction. Control and Restricted F1 female offspring were allocated to a non-pregnant or pregnant group. To generate F2 offspring, F1 females were allocated to either non-embryo or embryo transfer groups. Embryo transfer was performed on gestational day 1, where second generation (F2) embryos were gestated (donor-in-recipient) in either a Control (Control-in-Control, Restricted-in-Control) or Restricted (Control-in-Restricted, Restricted-in-Restricted) mother. Restricted F1 females were born 10-15% lighter than Controls. Restricted non-pregnant females had shorter femurs, reduced trabecular and cortical bone mineral contents, trabecular density and bone geometry measures determined by peripheral quantitative computed tomography (pQCT) compared to non-pregnant Controls. Pregnancy restored the bone deficits that were present in F1 Restricted females. F2 non-embryo transfer male and female offspring were born of normal weight, while F2 embryo transfer males and females gestated in a Control mother (Control-in-Control, Restricted-in-Control) were heavier at birth compared to offspring gestated in a Restricted mother (Restricted-in-Restricted, Control-in-Restricted). Male F2 Restricted embryo groups (Restricted-in-Control and Restricted-in-Restricted) had accelerated postnatal growth. There was no transmission of bone deficits present at 35days or 6months in F2 offspring. Embryo transfer procedure had confounding effects preventing the separation of maternal environment and germ line contribution to outcomes. Deficits present in F1 non-pregnant Restricted females were absent during late gestation, indicating that pregnant F1 Restricted females experienced gains in bone. These beneficial maternal pregnancy adaptations may have prevented transmission of bone deficits to F2 offspring.

Rosmarinic acid exerts an antiosteoporotic effect in the RANKL-induced mouse model of bone loss by promotion of osteoblastic differentiation and inhibition of osteoclastic differentiation

SCOPE

Bone homeostasis is ensured by the balance between bone formation and resorption. Thus, control of the recruitment, proliferation, and differentiation of bone cells is essential to maintain bone mass. The aim of this study was to elucidate the effects of rosmarinic acid as a potential therapeutic agent on bone metabolism using bone cells and a mouse model.

METHODS AND RESULTS

Rosmarinic acid increased alkaline phosphatase activity and induced mineralization in osteoblasts. Addition of rosmarinic acid to cultures of calvarial osteoblastic cells prepared from T-cell factor/β-catenin TOP-GAL mutant mice strongly induced the expression of LacZ and promoted stabilization of β-catenin in the cytoplasm of ST2 cells, suggesting that rosmarinic acid affects the canonical Wnt signaling pathway. Moreover, rosmarinic acid inhibited not only osteoclast formation in cocultures of mouse bone marrow cells and osteoblasts, but also receptor activator of nuclear factor kappa-B ligand (RANKL)-induced osteoclastic differentiation in bone marrow-derived macrophages. RANKL-induced p38 mitogen-activated protein kinase and the expression of nuclear factor of activated T cell, c-Jun, and c-Fos were inhibited by rosmarinic acid in bone marrow macrophages. Finally, we confirmed that rosmarinic acid improved bone mass in a soluble RANKL-induced bone loss mouse model.

CONCLUSION

Rosmarinic acid has dual regulatory effects on bone metabolism and may control the bone functions by controlling osteoblastic and osteoclastic differentiation.

Effects of Ethyl Acetate Extract of Poncirus trifoliata Fruit for Glucocorticoid-Induced Osteoporosis

Poncirus trifoliata fruit (PTF) affects the digestive and cardiovascular systems, and kidney function. The authors studied the effects of ethyl acetate (EtOAc) extract of PTF on the activities of osteoblasts and in an animal model. The main compounds of the EtOAc extract, naringin and poncirin have been confi rmed by HPLC and NMR analysis. Effects of osteoblastic differentiation were mea-sured by alkaline phosphatase (ALP) activity, osteopontin (OPN) protein expression and osteoprotegerin (OPG) mRNA expression in MC3T3-E1 cells. Also, osteoclast differentiation was measured by multinucleated cells (MNCs) formation through tartrate resistance acid phosphatase (TRAP)-positive staining. Bone mineral density (BMD) was measured before and after treatment with EtOAc extract of PTF in prednisolone-induced osteoporotic mice. Dexamethasone (DEX) decreased OPN and OPG expression level in MC3T3-E1 cells and ALP activity was decreased by DEX dose-dependently. EtOAc extract of PTF recovered the levels of ALP activity, and the expression of OPN and OPG in MC3T3-E1 cells treated with DEX. In osteoclast differentiation, multinucleated TRAP-positive cell formation was significantly suppressed by the EtOAc extract of PTF. Total body BMD was restored by EtOAc extract of PTF in prednisolone-induced osteoporotic mice. In conclusion, EtOAc extract of PTF recovered DEX-mediated deteriorations in osteoblastic and osteoclastic functions, and increased BMD in glucocorticoid-induced osteoporosis.

MSM enhances GH signaling via the Jak2/STAT5b pathway in osteoblast-like cells and osteoblast differentiation through the activation of STAT5b in MSCs

Methylsulfonylmethane (MSM) is a naturally occurring sulfur compound with well-known anti-oxidant properties and anti-inflammatory activities. But, its effects on bone are unknown. Growth hormone (GH) is regulator of bone growth and bone metabolism. GH activates several signaling pathways such as the Janus kinase (Jak)/signal transducers and activators of transcription (STAT) pathway, thereby regulating expression of genes including insulin-like growth factor (IGF)-1. GH exerts effects both directly and via IGF-1, which signals by activating the IGF-1 receptor (IGF-1R). In this study, we investigated the effects of MSM on the GH signaling via the Jak/STAT pathway in osteoblasts and the differentiation of primary bone marrow mesenchymal stem cells (MSCs). MSM was not toxic to osteoblastic cells and MSCs. MSM increased the expression of GH-related proteins including IGF-1R, p-IGF-1R, STAT5b, p-STAT5b, and Jak2 in osteoblastic cells and MSCs. MSM increased IGF-1R and GHR mRNA expression in osteoblastic cells. The expression of MSM-induced IGF-1R and GHR was inhibited by AG490, a Jak2 kinase inhibitor. MSM induced binding of STAT5 to the IGF-1R and increased IGF-1 and IGF-1R promoter activities. Analysis of cell extracts by immunoprecipitation and Western blot showed that MSM enhanced GH-induced activation of Jak2/STAT5b. We found that MSM and GH, separately or in combination, activated GH signaling via the Jak2/STAT5b pathway in UMR-106 cells. Using siRNA analysis, we found that STAT5b plays an essential role in GH signaling activation in C3H10T1/2 cells. Osteogenic marker genes (ALP, ON, OCN, BSP, OSX, and Runx2) were activated by MSM, and siRNA-mediated STAT5b knockdown inhibited MSM-induced expression of osteogenic markers. Furthermore, MSM increased ALP activity and the mineralization of MSCs. Taken together, these results indicated that MSM can promote osteogenic differentiation of MSCs through activation of STAT5b.

Poncirin prevents bone loss in glucocorticoid-induced osteoporosis in vivo and in vitro

Poncirin, a flavonoid isolated from the fruit of Poncirus trifoliata, possesses anti-bacterial and anti-inflammatory activities. However, the action of poncirin in bone biology is unclear. In this study, the in vivo and in vitro effects of poncirin in a glucocorticoid-induced osteoporosis (GIO) mouse model were investigated. Seven-month-old male mice were assigned to the following five groups: (1) sham-implantation (sham), (2) prednisolone 2.1 mg/kg/day (GC), (3) GC treated with 10 mg/kg/day of genistein, (4) GC treated with 3 mg/kg/day of poncirin, (5) and GC treated with 10 mg/kg/day of strontium (GC + SrCl(2)). After 8 weeks, bone loss was measured by microcomputed tomography. Osteocalcin (OC) and C-terminal telopeptides of type I collagen (CTX) were evaluated in sera. Runx2 protein, OC and osteoprotegerin (OPG) mRNA expression, alkaline phosphatase (ALP) activity, and mineral nodule assay were performed in C3H10T1/2 or primary bone marrow stromal cells. Poncirin significantly increased the bone mineral density and improved the microarchitecture. Poncirin increased serum OC, Runx2 protein production, expression of OC and OPG mRNA, ALP activity, and mineral nodule formation; and decreased serum CTX. These effects were more prominent in the poncirin group compared to the other positive control groups (genistein and strontium). The poncirin-mediated restoration of biochemical bone markers, increased bone mineral density, and improved trabecular microarchitecture likely reflect increased bone formation and decreased bone resorption in GIO mice.

Epidemiology and structural basis of racial differences in fragility fractures in Chinese and Caucasians

Chinese have similar vertebral fracture prevalence but lower incidence of hip and distal forearm fractures than in Caucasians. The underlying structural and biomechanical basis of racial differences in bone fragility is still largely undefined but Chinese assemble their smaller appendicular skeleton with thicker cortices and trabeculae compared with Caucasians. Vertebral fracture prevalence is similar by race, but the incidence of hip and distal forearm fractures is lower in Chinese than in Caucasians. This racial dimorphism cannot be explained by differences in areal bone mineral density (aBMD) as aBMD is lower in Chinese mainly due to their smaller size. The underlying structural and biomechanical basis of racial differences in bone fragility is still largely undefined but Chinese assemble their smaller appendicular skeleton with more mineralised bone matrix within it; the cortices are thicker and perhaps less porous while trabeculae are fewer but thicker and more connected. This configuration produces a bone with a lower surface/volume ratio, which in turn reduces the surface available for remodelling to occur upon so that the lower surface/volume ratio may make the bone less exposed to remodelling and the thicker cortices and trabeculae less vulnerable to remodelling when it does occur during advancing age. However, prospective studies are needed to define racial differences at the age of onset, rate of bone loss from the intracortical, endocortical and trabecular components of the endosteal envelope and bone formation upon the periosteal envelope; notions of bone 'loss' are derived mainly from cross-sectional studies. Studies of the site- and surface-specific changes in bone modelling and remodelling are needed to better define racial differences in bone fragility in old age.

Poncirin promotes osteoblast differentiation but inhibits adipocyte differentiation in mesenchymal stem cells

Poncirin, flavanone glycoside, isolated from the fruit of Poncirus trifoliata, has anti-bacterial and anti-inflammatory activities. In this study, the effects of poncirin on the differentiation of mesenchymal stem cells were investigated. The C3H10T1/2 mesenchymal stem cells and primary bone marrow mesenchymal stem cells were studied. In the C3H10T1/2 cells, poncirin prevented adipocyte differentiation, as demonstrated by inhibition of cytoplasm lipid droplet accumulation and peroxisome proliferator-activating receptor-γ (PPAR-γ) and CCAAT-enhancer-binding protein-β (C/EBP-β) mRNA expression. By contrast, poncirin enhanced the expression of the key osteogenic transcription factors, runt-related transcription factor 2 (Runx2) and transcriptional coactivator with PDZ-binding motif (TAZ). Poncirin also enhanced expression of the osteogenic marker genes including alkaline phosphatase (ALP) and osteocalcin (OC). Poncirin increased mineral nodule formation in primary bone marrow mesenchymal stem cells. These results suggest that poncirin prevents adipogenesis and enhances osteoblast differentiation in mesenchymal stem cells.

Effect of safflower seeds supplementation on stimulation of the proliferation, differentiation and mineralization of osteoblastic MC3T3-E1 cells

Anti-bone resorption properties of the Korean herbal formulation, Gami-Honghwain (HJ), which comprises Carthamus tinctorius L. seed and hominis placenta, were investigated. We demonstrate that the production of PGE2 is inhibited by 20-100 microg/ml HJ in nontransformed osteoblastic cells (MC3T3-E1 cells), indicating that HJ inhibits PGE2 production. The effect of HJ on the proliferation and osteoblastic differentiation in MC3T3-E1 was also studied. HJ dose-dependently increased DNA synthesis (significant at 20-100 microg/ml), and increased alkaline phosphatase (ALP) and prolyl hydroxylase activities of MC3T3-E1 cells (20-100 microg/ml), while anti-estrogen tamoxifen eliminated the stimulation of proliferation and ALP activity of MC3T3-E1 which was induced by HJ. These results indicate that HJ directly stimulates cell proliferation and differentiation of osteoblasts. Also, when we assessed the effects of HJ on osteoblastic differentiation in MC3T3-E1, HJ enhanced ALP activity and mineralization in a dose- and time-dependent fashion. This stimulatory effect of the HJ was observed at relatively low doses (significant at 20-100 microg/ml and maximal at 100 microg/ml). Northern blot analysis showed that the HJ (60 microg/ml) increased in bone morphogenetic protein-2 as well as ALP mRNA concentrations in MC3T3-E1 cells. HJ (100 microg/ml) slightly increased in type I collagen mRNA abundance throughout the culture period, whereas it markedly inhibited the gene expression of collagenase-1 between days 15 and 20 of culture. These results indicate that HJ has anabolic effect on bone through the promotion of osteoblastic differentiation, suggesting that it could be used for the treatment of common metabolic bone diseases.

EFFECTS OF ULMUS DAVIDIANA PLANCH ON MINERALIZATION, BONE MORPHOGENETIC PROTEIN-2, ALKALINE PHOSPHATASE, TYPE I COLLAGEN, AND COLLAGENASE-1 IN BONE CELLS

Ulmus davidiana Planch (Ulmaceae) (UD) long has been known to have anti-inflammatory and protective effects on damaged tissue, inflammation, and bone among other functions. The herbal medicine also is being used in Oriental medicine to treat osteoporosis. In a preliminary study, treatment of osteoclasts containing long bone cells with the water extract of UD bark prevented the intracellular maturation of cathepsin K (cat K), and thus, it was considered that UD is a pro-drug of a potent bone-resorption inhibitor. To further clarify the role of UD in ossification, we investigated the effects of UD on the proliferation and differentiation of osteoblastic cell lines in vitro. In this study, we assessed the effects of UD on osteoblastic differentiation in nontransformed osteoblastic cells (MC3T3-E1) and rat bone marrow cells. UD enhanced alkaline phosphatase (ALP) activity and mineralization in a dose- and time-dependent fashion. This stimulatory effect of the UD was observed at relatively low doses (significant at 5-50 microg/ml and maximal at 50 microg/ml). Northern blot analysis showed that UD (100 microg/ml) increases in bone morphogenic protein-2 as well as ALP mRNA concentrations in MC3T3-E1 cells. UD slightly increased in type I collagen mRNA abundance throughout the culture period, whereas it markedly inhibited the gene expression of collagenase-1 between days 15 and 20 of culture. These results indicate that UD has anabolic effects on bone through the promotion of osteoblastic differentiation, suggesting that it could be used for the treatment of common metabolic bone diseases such as osteoporosis.

Stimulative effects of Drynariae Rhizoma extracts on the proliferation and differentiation of osteoblastic MC3T3-E1 cells

Pharmacological factors are needed to prevent bone loss that occurs with increasing age. The chemical compounds that act on bone metabolism in herbal medicines, however, are poorly understood. Effects of traditional Korean medicine, Drynariae Rhizoma [Drynaria fortunei (kunze) J. Sm] extract (DR), on the osteoblastic proliferation and differentiation were investigated. The effect of DR, a natural phyto herb, on the proliferation and osteoblastic differentiation in non-transformed osteoblastic cells (MC3T3-E1) was studied. DR dose-dependently increased DNA synthesis (significant at 50-150 microg/ml). DR increased alkaline phosphatase (ALP) activity and prolyl hydroxylase activity of MC3T3-E1 cells (50-150 microg/ml). Antiestrogen tamoxifen eleminated the stimulation of proliferation and ALP activity of MC3T3-E1, which were induced by DR. DR at concentrations ranged from 30-100 microg/ml inhibited prostaglandin E2 production in MC3T3-E1. These results indicate that DR directly stimulates cell proliferation and differentiation of osteoblasts. These results also suggest and DR is effective for bone anti-resorptive action in bone cells.

Structural and biomechanical basis of sexual dimorphism in femoral neck fragility has its origins in growth and aging

The structural basis for sex differences in femoral neck (FN) fragility was studied in 1196 subjects and 307 patients with hip fracture. The absolute and relative patterns of modeling and remodeling on the periosteal and endocortical envelopes during growth and aging produce changes in FN geometry and structure that results in FN fragility in both sexes and sexual dimorphism in hip fracture risk in old age.

INTRODUCTION

Femoral neck (FN) fragility in old age is usually attributed to age-related bone loss, while the sex differences in hip fracture rate are attributed to less bone loss in men than in women. The purpose of this study was to define the structural and biomechanical basis underlying the increase in FN fragility in elderly men and women and the structural basis of sex differences in hip fracture incidence in old age.

MATERIALS AND METHODS

We measured FN dimensions and areal bone mineral density in 1196 healthy subjects (801 females) 18-92 years of age and 307 patients (180 females) with hip fracture using DXA. We then used the DXA-derived FN areal bone mineral density (BMD) and measured periosteal diameter to estimate endocortical diameter, cortical thickness, section modulus (a measure of bending strength), and buckling ratio (indices for structural stability).

RESULTS

Neither FN cortical thickness nor volumetric density differed in young adult women and men after height and weight adjustment. The sex differences in geometry were confined to the further displacement of the cortex from the FN neutral axis in young men, which produced 13.4% greater bending strength than in young women. Aging amplified this geometric difference; widening of the periosteal and endocortical diameters continued in both sexes but was greater in men, shifting the cortex even further from the neutral axis maintaining bending strength in men, not in women. In both sexes, less age-related periosteal than endocortical widening produced cortical thinning increasing the risk for structural failure by local buckling of the enlarged thin walled FN. Relative to age-matched controls, women and men with hip fractures had reduced cortical thickness, but FN periosteal diameter was increased in women and reduced in men, differences are likely to be originated in growth.

CONCLUSIONS

The absolute and relative patterns of modeling and remodeling on the periosteal and endocortical envelopes during growth and aging produce changes in FN diameters, cortical thickness, and geometry that results in FN fragility in both sexes and sexual dimorphism in hip fracture risk in old age.

Simulated movement termination for balance recovery: can movement strategies be sought to maintain stability in the presence of slipping or forced sliding?

Slipping during various kinds of movement often leads to potentially dangerous incidents of falling. The purpose of this study was to determine whether there was evidence to support the theory that movement strategies could be used by individuals to regain stability during an episode of slipping and whether forced sliding from a moving platform accurately simulated the effect of slipping on stability and balance. A single-link-plus-foot biomechanical model was used to mathematically simulate base of support (BOS) translation and body segment rotation during movement termination in sagittal plane. An optimization routine was used to determine region of stability [defined at given COM locations as the feasible range of horizontal velocities of the center of mass (COM) of human subject that can be reduced to zero with respect to the BOS while still allowing the COM to traverse within the BOS limits]. We found some 30% overlap in the region of stability for slipping and non-slipping conditions. This finding supports the theory that movement strategies can be sought for restoring stability and balance even if slipping unexpectedly occurs. We also found that forced sliding produces effects on stability that are similar to those of slipping, indicated by over 50% overlap in the regions of stability for the two conditions. In addition, forced sliding has distinctive effects on stability, including a "shift" of the region of stability extended beyond the BOS in the direction of sliding. These findings may provide quantifiable guidance for balance training aimed at reducing fall incidents under uncertain floor surface conditions.

Resveratrol stimulates the proliferation and differentiation of osteoblastic MC3T3-E1 cells

Nutritional and pharmacological factors are needed to prevent bone loss that occurs with increasing age. The chemical compounds that act on bone metabolism as nutrients in food, however, are poorly understood. The effect of resveratrol, a natural phytoestrogen, on the proliferation and differentiation of osteoblastic MC3T3-E1 cells was studied. Resveratrol dose-dependently increased DNA synthesis (10(-9)-10(-7) M) of MC3T3-E1 cells. In addition, resveratrol increased alkaline phosphatase (ALP) activity and prolyl hydroxylase activity of MC3T3-E1 cells (10(-6)-10(-5) M). Moreover, the antiestrogen tamoxifen eliminated the stimulation of MC3T3-E1 cells on the proliferation and ALP activity by resveratrol. On the other hand, resveratrol inhibited prostaglandin E2 production in MC3T3-E1 cells (10(-8)-10(-6) M). Our present study is the first to demonstrate that resveratrol directly stimulates cell proliferation and differentiation of osteoblasts.

Early effects of short-term parathyroid hormone administration on bone mass, mineral content, and strength in female rats

The present study was designed to examine the metabolic changes and early effects of short-term parathyroid hormone (PTH) treatment on bone mass, mineral content, and strength. Forty-eight 10-week-old intact female rats were randomized into six groups. The three PTH-treated groups were subcutaneously given PTH 50 microg/kg body weight daily for 5 (PTH5), 10 (PTH10), or 15 (PTH15) days. The three respective time control groups (C5, C10, and C15) were injected with saline solution. In serum, total calcium, alkaline phosphatase, and insulin-like growth factor-I (IGF-I) were analyzed. Bone mass was estimated with wet and dry weights of the femora and hydroxyproline content of the tibiae. Ash weight and calcium, magnesium, and phosphorus contents (determined by AAS) were used to measure femoral mineral content. Bone mineral density (BMD) of the femora was measured using dual-energy X-ray absorptiometry (DXA) and the biomechanical properties of the femoral neck were tested. After 5 days of PTH treatment, some trends of the anabolic actions of PTH could be observed, but there was no significant effect on relevant parameters of bone formation. After 10 days, bone mass, mineral content (assessed by ash weight), and BMD of the PTH-treated rats were significantly increased compared with those of controls. The relative femoral magnesium content of the PTH-treated animals was significantly higher than that of controls. After 15 days, the length of the femora, bone mass, mineral content, BMD, and the width of the femoral neck were increased, and its biomechanical properties were significantly improved in PTH-treated rats compared with the respective time control group. PTH treatment significantly increased circulating alkaline phosphatase and decreased systemic IGF-I concentrations throughout the study. In conclusion, intermittent PTH administration to still growing female rats is anabolic in bone with significant effects already taking place after 10 days of treatment. The effects of PTH consisted of: (1) an increase in bone mass and mineral content with a transient augmentation of relative magnesium content; and (2) improved width and mechanical properties of the femoral neck after 15 days of treatment. These effects are accompanied by an increase in longitudinal bone growth. They are unlikely related to any changes in systemic IGF-I concentrations.

A weight-bearing, water-based exercise program for osteopenic women: its impact on bone, functional fitness, and well-being

OBJECTIVE

To evaluate the effects of a weight-bearing, water-based, exercise program designed for women with low bone mass.

DESIGN

A test-retest cross-sectional, prospective study.

SETTING

Community-dwelling women from a Canadian city.

PARTICIPANTS

Seventy-seven postmenopausal women, 50 to 70 years of age, with spinal or femoral bone density below the fracture threshold.

INTERVENTION

Subjects exercised in a pool with waist-high water for 60 minutes, 3 days a week, over a 12-month period. Forty minutes of each session were devoted to successive jumps and muscular exercises designed to promote bone accretion, strength, and endurance.

MAIN OUTCOME MEASURES

Spinal and femoral bone mineral density (BMD) measured by dual-energy X-ray absorptiometry, functional fitness (flexibility, coordination, agility, strength/endurance, and cardiorespiratory endurance) assessed with the American Alliance for Health, Physical Education, Recreation and Dance battery, and psychological states evaluated with Dupuy's General Well-Being Schedule.

RESULTS

Spinal BMD decreased significantly (p < .001), whereas there was no change in femoral neck BMD (p = .90). Four of the parameters chosen to assess functional fitness, namely, flexibility, agility, strength/endurance, and cardiorespiratory endurance, were affected positively by the exercise program (all p values < .001). Psychological well-being also improved significantly after participation in the exercise program (p < .001).

CONCLUSION

The intervention was successful in improving the functional fitness and psychological well-being of the participants, despite a lack of effect on the skeletal system. Future studies are needed to identify water exercises that are safe yet exert enough stress on the bones to initiate a bone response.

Current and potential future drug treatments for osteoporosis

There has been a major interest in the drug treatment of osteoporosis and an increase in the number of drugs available in most countries. The ideal drug (one which increases or restores bone density and trabecular connectivity) is still not available. However, in patients with relatively preserved trabecular connectivity and moderately reduced bone density, several agents have shown substantial clinical benefit. Oestrogens are still the mainstay of drug treatment, but the risks of breast cancer versus the cardiovascular and skeletal benefits with long term use have to be assessed in the individual. Newer tissue specific oestrogens show some promise in this respect. The bisphosphonates and possibly fluoride are likely to be the major alternatives to oestrogens in the medium term. The newer bisphosphonates, alendronate and in the future risedronate, are likely to supersede etidronate. Calcitriol probably has a limited role, confined to those patients in whom HRT or bisphosphonates are not appropriate. Calcium supplementation, or an increase in dietary intake if deficient, irrespective of which agent is used, is also of benefit. In older patients there is considerable support for using a combination of calcium and vitamin D. Whether combination treatment, for example oestrogens, bisphosphonates, and calcium together, will result in greater efficacy remains to be conclusively shown, but may be an attractive option in younger patients with higher bone turnover. Apart from fluoride, bone formation stimulators are unlikely to have a major role until the next century, although it may be possible to use growth factors as part of an ADFR regimen (A = activate remodelling, D = depress resorption, F = free formation, and R = repeat). This is still an important theoretical approach and needs further work with newer agents to see if increased efficacy can be found. In addition sequential treatment may be necessary in view of the limited time periods over which particular agents, such as intermittent fluoride (four years), have been examined, and this will have to be individually tailored. Other approaches include trying to increase peak bone mineral density, although influencing the young to prevent a disease that may not manifest itself for half a century is daunting.

Impact of a 12-month exercise program on the physical and psychological health of osteopenic women

OBJECTIVE

To describe the effect of a supervised physical activity program on the physical and psychological health of osteopenic women.

DESIGN

A randomized controlled trial.

SETTING

Sherbrooke, Quebec, Canada.

PARTICIPANTS

A total of 124 community-living postmenopausal women, between 50 and 70 years of age, with low bone mass took part in the study.

INTERVENTION

Subjects allocated to the experimental group performed weight-bearing exercises (walking, stepping up and down from benches), aerobic dancing, and flexibility exercises for 60 minutes, three times a week, over a period of 12 months. All subjects were invited to attend bi-monthly educational seminars covering topics related to osteoporosis.

OUTCOME MEASURES

Spinal and femoral bone mineral density (BMD), functional fitness (flexibility, coordination, agility, strength/endurance, cardiorespiratory endurance), psychological well-being, back pain intensity, and self-perceived health.

RESULTS

Spinal BMD stabilized in the exercisers while decreasing significantly in the controls (P = .031). No change in femoral BMD was observed in either group (P = .597). Four of the five parameters chosen to evaluate functional fitness, namely flexibility, agility, strength, and endurance, were affected positively by the exercise program (all P < .01). Adjusting for prescores by means of an analysis of covariance revealed a significant difference between the groups in psychological well-being, which favored the exercisers (P = .012). After 12 months, back pain reported by exercisers was lower than that reported by controls (P = .008). Finally, self-perceived health increased in the exercise group, whereas no difference was observed in the control group (P = .790).

CONCLUSION

These results suggest that after 12 months, exercising can produce a significant increase above initial levels in the functional fitness, well-being, and self-perceived health of osteopenic women. Intensity of back pain can also be lowered by exercise. The exercise program succeeded in stabilizing spinal BMD but had no effect on femoral BMD.

Effects of unilateral strength training and detraining on bone mineral mass and estimated mechanical characteristics of the upper limb bones in young women

The aims of this study were to examine the effects of 12 months unilateral high-resistance strength training and 8-month detraining on bone mineral content (BMC), density (BMD) and estimated mechanical characteristics of upper limb bones, and also to estimate consequent loading induced strains on forearm bone shafts. Thirteen female physiotherapy students (mean 23.8 +/- 5.0 yrs, 166 +/- 7 cm, 64.4 +/- 7 cm, 64.4 +/- 13.3 kg) trained their left upper limbs with dumbbells on average 2.8 times per week for 12 months, followed by eight months detraining. Nineteen students served as controls (mean 25.7 +/- 5.2 yrs, 165 +/- 4 cm, 62.1 +/- 7.0 kg). BMC, BMD, and bone width and estimated cortical wall thickness (CWT) were measured at five different sites in both upper extremities (proximal humerus, humeral shaft, radial shaft, ulnar shaft, and distal forearm) using dual energy x-ray absorptiometry (DXA) scanner. In addition, cross-sectional moment of inertia (CSMI) was estimated from DXA data. The maximal isometric strength of the upper extremities was measured with an arm flexion-extension dynamometer. The training increased significantly the flexion strength by 14% (p = 0.001). During the detraining period, all measured strength values in the training group decreased in both limbs with respect to values after training. Despite the clear effect on muscular strength, no significant intergroup differences were observed in BMC, BMD, bone width, CWT, or CSMI values at any measured site after the training or detraining period. The estimated loading-induced strains remained within customary loading, and the change in strain level was only 15%. In conclusion, this study indicated that using high-resistance strength training may not provide an effective osteogenic stimulus for bone formation and geometric changes in upper limb bones of young, healthy, adult women. The interaction of bones and muscles may play an important and relatively unrecognized role in the development of bone strength, suggesting that the entire biomechanical environment should be carefully considered when evaluating the osteogenic efficiency of physical loading.

Mechanical validation of a tomographic (pQCT) index for noninvasive estimation of rat femur bending strength

Cross-sectional moment of inertia (CSMI) and volumetric cortical bone mineral density (vCtBMD) were assessed by peripheral quantitative computed tomography (pQCT) at femur midshafts from 103 Wistar female rats receiving 0 (n = 12) or 15-1000 mu g/kg/day sc of dexamethasone (n = 46) from 5 to 9 weeks of age, or 0 or 80 mg/kg 3/wk of AI(OH)(3) IP (n = 23,22) from 4 to 10 months of age. A bone strength index (BSI), calculated as the product CSMI x vCtBMD, was found to closely correlate (r = 0.94, R(2) = 0.89, p < 0.001) with the actual, mechanically tested bending breaking force of all bones. Correlation and determination coefficients obtained were higher than those usually reported employing different long-bone strength predictive formulae. The curve approached the origin and was linear throughout the wide range of CSMI, vCtBMD and BSI achieved because of age- and treatment-induced differences, showing a very low standard error of the estimate. Instead, different curve slopes and/or intercepts were found in separate analysis between data from each of the experiments when breaking force was correlated with CSMI or vCtBMD alone, or with the DEXA-assessed BMD of the mechanically assayed bone portion. Results suggest that noninvasive assessment of the BSI by means of pQCT technology provides an original tool for a precise and accurate estimation of long-bone bending strength that can be advantageously applied in crosssectional as well as longitudinal, in vivo studies employing animal models.

Bone density and shape as determinants of bone strength in IGF-I and/or pamidronate-treated ovariectomized rats

Areal bone mineral density (BMD) is a major determinant of bone strength and thereby of fracture risk. Other factors including trabecular microarchitecture and bone dimensions also contribute to bone strength. To investigate the relative importance for bone strength of BMD and bone dimensions, the relations between strength and the latter variables were evaluated under different experimental conditions in ovariectomized rats. Bone strength was assessed in compression and bending with measurement of BMD by dual-energy X-ray absorptiometry. Interventions were designed to increase trabecular BMD in rats with estrogen deficiency-induced bone loss (OVX) by treatment with pamidronate, an inhibitor of bone resorption, or to modify bone dimensions, particularly diameter, by administration of the growth factor IGF-I. In OVX rats, pamidronate treatment increased BMD with a commensurate increase in bone strength at the level of lumbar vertebrae and femoral neck (r = 0.789, p < 0.0001 and r = 0.535, p < 0.001, respectively). IGF-I increased the external diameter of midshaft tibia and femoral neck, which also correlated with bone strength (r = 0.678,p < 0.0001 and r = 0.507,p < 0.0002, respectively). Thus, both bone dimensions and BMD contributed to the determination of bone strength. In conclusion, adult rats with estrogen deficiency-induced bone loss represent a useful experimental model for investigating bone strength and its determinants such as BMD and external bone dimensions.

[Peak bone mass: facts and uncertainties]

Peak bone mass, which can be defined as the amount of bony tissue present at the end of the skeletal maturation, is an important determinant of osteoporotic fracture risk in adulthood. The techniques of single or dual energy absorptiometry measure the so-called "areal" or "surface" bone mineral density (BMD), a variable which has been shown to be directly related to bone strength. During puberty the gender difference in bone mass becomes expressed. This difference appears to be essentially due to a more prolonged bone maturation period in males than in females, with a larger increase in bone size and cortical thickness, as there is no significant sex difference in the volumetric trabecular density at the end of pubertal maturation. At the beginning of the 3rd decade, there is a large variability in the normal values of areal BMD in axial and appendicular skeleton. This large variance, which is observed at sites particularly susceptible to osteoporotic fractures in adulthood, such as lumbar spine and femoral neck, is barely reduced after correction for statural height, and does not appear to substantially increase during adult life. It is generally accepted that peak bone mass at any skeletal site is attained in both sexes during the mid-thirties. However, recent studies indicate that in healthy caucasian females, bone mass accumulation can virtually be completed before the end of the second decade, for both lumbar spine and femoral neck. Several variables are supposed to influence bone mass accumulation during growth: heredity, sex, diet components, endocrine factors, mechanical forces, and exposure to risk factors.(ABSTRACT TRUNCATED AT 250 WORDS)

The role of dual energy X-ray absorptiometry of lumbar spine and proximal femur in the diagnosis and follow-up of osteoporosis

Dual energy x-ray absorptiometry techniques have been validated for the quantitative assessment of bone mass at two skeletal sites particularly at risk of osteoporotic fracture, i.e., lumbar spine and proximal femur. These measurements assess areal bone mineral density (BMD), which integrates the size of the bone and its thickness, as well as the true volumetric density. Areal density provides useful information relative to fracture risk, since there is an inverse relationship between incidence of osteoporotic fractures and areal BMD. Although lumbar spine BMD measurements by a lateral view could offer the advantage over conventional anteroposterior projection of avoiding osteophytes and posterior element osteoarthritis, it does not seem to be superior in diagnostic sensitivity, except possibly for corticosteroid-induced bone loss. Femoral neck BMD appears to be a significantly better predictor of fracture of the proximal femur. Since this measurement does not appear to be influenced by osteoarthritis, it would be the most suitable for the diagnosis of osteoporosis in the elderly. However, the potential for error in terms of both accuracy and precision for dual x-ray absorptiometry measurements of lumbar spine and proximal femur emphasizes the need for strictly controlled conditions of measurement.

Etidronic acid. A review of its pharmacological properties and therapeutic efficacy in resorptive bone disease

Etidronic acid is an orally and intravenously active bisphosphonate, which is believed to inhibit resorption of bone via a number of cellular mechanisms, including alteration of osteoclastic activity. In studies of patients with symptomatic Paget's disease, etidronic acid 5 to 20 mg/kg/day administered orally rapidly decreased the biochemical indices of bone turnover. Mineralisation defects in forming bone may be avoided by the use of an initial dosage of 5 mg/kg/day for up to 6 months; dosages above 10 mg/kg/day should be limited to 3 months' duration, and dosages greater than 20 mg/kg/day should be avoided. Although 3-day intravenous therapy with etidronic acid 7.5 mg/kg/day has shown superior efficacy to rehydration and forced diuresis in the management of hypercalcaemia of malignancy, the efficacy of the drug is lower than that of the newer bisphosphonates, pamidronic acid and clodronic acid. Clinical studies involving postmenopausal women with established osteoporosis have indicated that oral etidronic acid 400 mg/day for 14 days as part of a 90-day cycle, repeated for up to 3 years, increases the bone mineral density (BMD) of the lumbar vertebrae and appears to reduce the incidence of vertebral fracture. Published data suggest that etidronic acid shows similar efficacy to hormone replacement therapy (HRT) in these respects. The above dosage also appears to be effective in preventing corticosteroid-induced osteoporosis when administered as part of an intermittent, cyclical regimen. Etidronic acid in higher dosages (10 to 20 mg/kg/day orally) is effective in reducing the incidence of heterotopic ossification and its ensuing complications in both neurological and post-surgical patients. Etidronic acid is well tolerated by the majority of patients, with gastrointestinal complaints reported most commonly, but tends to delay the normal mineralisation of forming bone when administered continuously at higher dosages for prolonged periods. This is of little consequence where short term treatment is involved, but may be detrimental to those patients receiving longer courses of therapy. This effect may be minimised or avoided by using the lowest effective dosage for as short a time as possible (as in the above recommendations for Paget's disease), or by the use of intermittent cyclical therapy (as in the management of osteoporosis). Etidronic acid therefore retains a role in the management of resorptive bone disease, particularly in the treatment of Paget's disease, the prevention of heterotopic ossification, and as a second-line option in postmenopausal osteoporosis. However, the development of newer bisphosphonates requires that these compounds be continually compared and re-evaluated.

Prevention of further bone mass loss by nasal calcitonin in patients on long term glucocorticoid therapy for asthma: a two year follow up study

BACKGROUND

Injectable calcitonin is effective in reducing spinal bone loss in steroid-dependent asthma but side effects are frequent. In contrast, a nasal spray presentation has been shown to be effective and well tolerated in involutional osteoporosis. To test the efficacy of nasal calcitonin a two year prospective trial was conducted in 44 steroid-dependent asthmatic patients.

METHODS

All patients received a calcium supplement of 1000 mg and were allocated randomly into two groups treated with either salmon calcitonin nasal spray (200 IU every other day, n = 22) or calcium alone (n = 22) for two years. All patients completed the first year of the study. Five patients in each group dropped out during the second year. In the calcitonin group one patient developed generalised pruritus and four lost steroid dependence, and in the calcium alone group five were no longer dependent on steroids. The efficacy of treatment was evaluated as follows: bone turnover assessed by biochemical markers, bone loss assessed by serial measurement of lumbar spine density, and rates of bone fractures.

RESULTS

The bone mass in the calcitonin group increased by 2.7% in the first year while in the group receiving calcium alone it decreased by 2.8%; this difference was significant. Calcitonin prevented more bone loss during the second year while the calcium alone group continued losing bone mass (-7.8%). The difference between means was 0.1077 (95% CI 0.0381 to 0.1773). Three new fractures occurred in both groups. No changes in biochemical parameters were detected in either group.

CONCLUSIONS

Calcitonin given intranasally increased spinal bone mass during the first year of treatment and maintained bone mass in a steady state during the second year. These results suggest that calcitonin may be a useful agent to prevent steroid-induced osteoporosis. However, the lack of effect of calcitonin on the rate of vertebral fractures does not permit its recommendation for routine use in preventing steroid-induced osteoporosis.

Peak bone mass

Peak bone mass, which can be defined as the amount of bony tissue present at the end of the skeletal maturation, is an important determinant of osteoporotic fracture risk. Measurement of bone mass development. The bone mass of a given part of the skeleton is directly dependent upon both its volume or size and the density of the mineralized tissue contained within the periosteal envelope. The techniques of single-1 and dural-energy photon or X-ray absorptiometry measure the so-called 'areal' or 'surface' bone mineral density (BMD), a variable which has been shown to be directly related to bone strength. Bone mass gain during puberty. During puberty the gender difference in bone mass becomes expressed. This difference appears to be essentially due to a more prolonged bone maturation period in males than in females, with a larger increase in bone size and cortical thickness. Puberty affects bone size much more than the volumetric mineral density. There is no significant sex difference in the volumetric trabecular density at the end of pubertal maturation. During puberty, the accumulation rate in areal BMD at both the lumbar spine and femoral neck levels increases to four- to sixfold over a 3- and 4-year period in females and males, respectively. Change in bone mass accumulation rate is less marked in long bone diaphyses. There is an asynchrony between the gain in statural height and bone mass growth. This phenomenon may be responsible for the occurrence of a transient period of a relative increase in bone fragility that may account for the pattern of fracture incidence during adolescence.(ABSTRACT TRUNCATED AT 250 WORDS)

Application of computer-based histomorphometry to the quantitative analysis of methylprednisolone-treated adjuvant arthritis in rats

Analyses of paw edema and histomorphometry were performed on tibio-talar joints to determine arthritic pathological responses in untreated 28-day adjuvant-induced polyarthritis (AIP) rats, and to determine the drug effect on inhibiting these responses in AIP rats treated with methylprednisolone. Histomorphometric measurements were performed on regions including articular joint space, synovial tissue, articular and epiphyseal cartilage, epiphyseal and metaphyseal bone marrow, and endosteal and periosteal cortical bone surfaces. Analysis of paw edema indicated that paw volume was significantly increased in untreated AIP rats. This increase in paw volume was partially prevented in AIP rats treated with 0.3 mg methylprednisolone/kg per day, and completely prevented in AIP rats treated with the two higher dose levels (1 and 3 mg/kg per day). Histomorphometric analysis of untreated AIP tibio-talar joints showed decreased articular joint space whereas synovial tissue area increased and a minor, but significant, articular cartilage erosion area occurred. Epiphyseal growth cartilage area was decreased. Trabecular bone area in distal tibial epiphyseal and metaphyseal regions was markedly decreased whereas bone marrow area increased involving a large number of macrophages and osteoclasts. Eroded endocortical bone area was increased while cortical bone area decreased. Marked osteophyte proliferation occurred on the periosteal surface. These arthritic pathological changes were inhibited by the treatment of methylprednisolone in a dose-dependent fashion. The animals treated with the highest dose of methylprednisolone complete prevented the development of the AIP-induced pathological changes. These data confirmed qualitative histological evaluation of arthritic changes but did not correlate with the anti-edema effects of methylprednisolone (100% inhibition at 1.0 and 3.0 mg/kg, p.o.). It is suggested that quantitative histomorphometry be used to determine more precisely the AIP rat model and the effects of drugs on different histopathological features in this experimental model of arthritis in preference to paw edema which gives a more limited picture of the arthritic response.