The combined effect of Parathyroid hormone (1-34) and whole-body Vibration exercise in the treatment of postmenopausal OSteoporosis (PaVOS study): a randomized controlled trial

[Osteoporosis-Definition, risk assessment, diagnosis, prevention and treatment (update 2024) : Guidelines of the Austrian Society for Bone and Mineral Research]

BACKGROUND

Austria is among the countries with the highest incidence and prevalence of osteoporotic fractures worldwide. Guidelines for the prevention and management of osteoporosis were first published in 2010 under the auspices of the then Federation of Austrian Social Security Institutions and updated in 2017. The present comprehensively updated guidelines of the Austrian Society for Bone and Mineral Research are aimed at physicians of all specialties as well as decision makers and institutions in the Austrian healthcare system. The aim of these guidelines is to strengthen and improve the quality of medical care of patients with osteoporosis and osteoporotic fractures in Austria.

METHODS

These evidence-based recommendations were compiled taking randomized controlled trials, systematic reviews and meta-analyses as well as European and international reference guidelines published before 1 June 2023 into consideration. The grading of recommendations used ("conditional" and "strong") are based on the strength of the evidence. The evidence levels used mutual conversions of SIGN (1++ to 3) to NOGG criteria (Ia to IV).

RESULTS

The guidelines include all aspects associated with osteoporosis and osteoporotic fractures, such as secondary causes, prevention, diagnosis, estimation of the 10-year fracture risk using FRAX®, determination of Austria-specific FRAX®-based intervention thresholds, drug-based and non-drug-based treatment options and treatment monitoring. Recommendations for the office-based setting and decision makers and institutions in the Austrian healthcare system consider structured care models and options for osteoporosis-specific screening.

CONCLUSION

The guidelines present comprehensive, evidence-based information and instructions for the treatment of osteoporosis. It is expected that the quality of medical care for patients with this clinical picture will be substantially improved at all levels of the Austrian healthcare system.

Whole Body Vibration Training Has No Effect on Vascular Endothelial and Inflammatory Markers in Young Healthy Women

Background: The aim of the study was to comparatively assess the impact of single and repeated whole body vibration training (WBVT) and training without vibration on changes in the concentration of vascular endothelial growth factor (VEGF), endothelial nitric oxide synthase (eNOS), and high-sensitivity C-reactive protein (hsCRP) in healthy, young, non-training women. Methods: The study involved 46 women (age 20.48 ± 1.72 years), who were divided into three groups: the experimental group participating in WBVT (EVG, n = 17); the comparison group performing the same exercises but without the vibration factor (EXG, n = 12); and the control group, which did not participate in any training (CON, n = 17). The program included participation in 36 training sessions conducted over 12 weeks, with a frequency of 3 times per week. In the EVG and EXG groups, venous blood was collected before and after the first and last training sessions, while in the CON group, blood was collected twice at a 3-month interval. Results: No significant changes were observed in the concentrations of the studied markers either after a single or repeated training session in both experimental groups (p > 0.05). Conclusions: The proposed WBVT protocol appears to be a safe form of exercise that does not induce negative inflammatory reactions. The applied vibration stimulus combined with physical exercises did not initiate pro-angiogenic processes or stimulate eNOS activity in healthy women, suggesting that similar studies should be conducted in individuals with circulatory problems or chronic inflammatory diseases.

Regulation of intracellular cAMP levels in osteocytes by mechano-sensitive focal adhesion kinase via PDE8A

Osteocytes are the primary mechano-sensitive cell type in bone. Mechanical loading is sensed across the dendritic projections of osteocytes leading to transient reductions in focal adhesion kinase (FAK) activity. Knowledge regarding the signaling pathways downstream of FAK in osteocytes is incomplete. We performed tyrosine-focused phospho-proteomic profiling in osteocyte-like Ocy454 cells to identify FAK substrates. Gsα, parathyroid hormone receptor (PTH1R), and phosphodiesterase 8A (PDE8A), all proteins associated with cAMP signaling, were found as potential FAK targets based on their reduced tyrosine phosphorylation in both FAK- deficient or FAK inhibitor treated cells. Real time monitoring of intracellular cAMP levels revealed that FAK pharmacologic inhibition or gene deletion increased basal and GPCR ligand-stimulated cAMP levels and downstream phosphorylation of protein kinase A substrates. Mutating FAK phospho-acceptor sites in Gsα and PTH1R had no effect on PTH- or FAK inhibitor-stimulated cAMP levels. Since FAK inhibitor treatment augmented cAMP levels even in the presence of forskolin, we focused on potential FAK substrates downstream of cAMP generation. Indeed, PDE8A inhibition mimicked FAK inhibition at the level of increased cAMP, PKA activity, and expression of cAMP-regulated target genes. In vitro kinase assay showed that PDE8A is directly phosphorylated by FAK while immunoprecipitation assays revealed intracellular association between FAK and PDE8A. Thus, FAK inhibition in osteocytes acts synergistically with signals that activate adenylate cyclase to increase intracellular cAMP. Mechanically-regulated FAK can modulate intracellular cAMP levels via effects on PDE8A. These data suggest a novel signal transduction mechanism that mediates crosstalk between mechanical and cAMP-linked hormonal signaling in osteocytes.

Does adding exercise or physical activity to pharmacological osteoporosis therapy in patients with increased fracture risk improve bone mineral density and lower fracture risk? A systematic review and meta-analysis

This prospectively registered systematic review and meta-analysis examines whether exercise (EX) training has an additive effect to osteoanabolic and/or antiresorptive pharmacological therapy (PT) in people with osteoporosis on bone mineral density (BMD), bone turnover markers (BTMs), fracture healing, and fractures. Four databases (inception to 6 May 2022), 5 trial registries, and reference lists were searched. Included were randomized controlled trials comparing the effect of EX + PT vs. PT with regard to BMD, BTM, fracture healing, and fractures. Risk of bias was assessed using the Cochrane RoB2 and certainty of evidence by the GRADE approach. Random-effects meta-analysis with Hartung-Knapp-Sidik-Jonkman adjustment was used to estimate standardized mean differences and 95% confidence intervals. Out of 2593 records, five RCTs with 530 participants were included. Meta-analysis showed with very low certainty evidence and wide confidence intervals that EX + PT compared to PT had larger effect sizes for BMD at 12 months at the hip (SMD [95%CI]: 0.18 [- 1.71; 2.06], n = 3 studies), tibia (0.25 [- 4.85; 5.34], n = 2), lumbar spine (0.20 [- 1.15; 1.55], n = 4), and forearm (0.05 [- 0.35; 0.46], n = 3), but not femoral neck (- 0.03 [- 1.80; 1.75], n = 3). Furthermore, no improvement was revealed for BTM such as bone ALP (- 0.68 [- 5.88; 4.53], n = 3), PINP (- 0.74 [- 10.42; 8.93], n = 2), and CTX-I (- 0.69 [- 9.61; 8.23], n = 2), but with very wide confidence intervals. Three potentially relevant ongoing trials were identified via registries. No data were found for fracture healing or fracture outcomes. It remains unclear whether EX has an additive impact to PT in people with osteoporosis. High-quality, adequately powered, targetted RCTs are required. PROTOCOL REGISTRATION: PROSPERO CRD42022336132.

Resting metabolic rate is increased after a series of whole body vibration in young men

Resting metabolic rate (RMR) is the largest component of total energy expenditure and increasing it can be of great importance in reducing excess body fatness. Whole body vibration (WBV) can affect energy expenditure during single session of WBV, but the effects of repeated WBV on resting metabolic rate have not been reported. The purpose of this study was to investigate whether a series of WBV would increase resting metabolism in young men. Thirty-two healthy men aged of 21-23 were recruited and randomly assigned to two 16-member groups: a group participating in the WBV intervention and a group without the intervention. The intervention lasted 2 weeks and WBV was performed 5 times a week. Diet, physical activity, body composition and resting metabolic rate were analyzed in the participants. In WBV group significantly increased resting oxygen uptake (p = 0.049) and consequently RMR (p = 0.035) after the intervention. Similar changes were not observed in the control group. This indicates that applied type of vibration in this study can be an addition to obesity therapy, in which, WBV can, among other beneficial metabolic effects, increase RMR and thus total energy expenditure.

What are the Effects of Exercise on Trabecular Microarchitecture in Older Adults? A Systematic Review and Meta-analysis of HR-pQCT Studies

The objective of this review was to determine the effects of exercise on high-resolution peripheral quantitative computed tomography (HR-pQCT) derived trabecular microarchitecture parameters in older adults. Five electronic databases were systematically searched by two independent reviewers. Inclusion criteria were adults age ≥ 50, any type of exercise as part of the intervention, and trabecular microarchitecture assessed via HR-pQCT. Data was extracted from included studies, and where suitable, included in a meta-analysis. Quality of included studies was appraised. Seven studies (397 participants) were included. All participants were postmenopausal women. Interventions included jumping, whole-body vibration, and power/plyometric training. All studies were rated as either weak or moderate quality. Meta-analysis (5 studies) showed no significant changes in any parameters when considering all exercise or sub-analysing based on type. Exercise was not found to have significant effects on trabecular microarchitecture in postmenopausal women over the age of 50. These findings should be interpreted with caution due to the small number of studies investigating few modes of exercise, their weak to moderate quality, and risk of bias. High-quality studies are needed to determine the effects of additional types of exercise in a more diverse population of older adults, including men.

Exercise for optimizing bone health after hormone-induced increases in bone stiffness

Hormones and mechanical loading co-regulate bone throughout the lifespan. In this review, we posit that times of increased hormonal influence on bone provide opportunities for exercise to optimize bone strength and prevent fragility. Examples include endogenous secretion of growth hormones and sex steroids that modulate adolescent growth and exogenous administration of osteoanabolic drugs like teriparatide, which increase bone stiffness, or its resistance to external forces. We review evidence that after bone stiffness is increased due to hormonal stimuli, mechanoadaptive processes follow. Specifically, exercise provides the mechanical stimulus necessary to offset adaptive bone resorption or promote adaptive bone formation. The collective effects of both decreased bone resorption and increased bone formation optimize bone strength during youth and preserve it later in life. These theoretical constructs provide physiologic foundations for promoting exercise throughout life.

Position Statement: Exercise Guidelines for Osteoporosis Management and Fall Prevention in Osteoporosis Patients

BACKGROUND

The effectiveness of exercise for improving osteoporosis and fall prevention in patients diagnosed with osteoporosis or osteopenia has not been fully summarized. The Korean Society for Bone and Mineral Research and the Korean Society of Exercise Physiology has developed exercise guidelines for patients with osteoporosis or osteopenia and provide evidence-based recommendations.

METHODS

A systematic review identified randomized controlled trials (RCT) assessing the effect of resistance, impact, balance, aerobic training, and physical activity in osteoporosis and osteopenia on bone quality, physical performance, quality of life, and fall prevention. PubMed, Embase, KoreaMed, and RISS were searched from January 2000 to August 2022. Ten key questions were established to review the evidence and formulate recommendations.

RESULTS

The 50 RCTs reported that even with osteoporosis and osteopenia, resistance and impact training consistently maximized bone strength, improved body strength and balance, and eventually reduced fall incidences. Resistance exercise combining 3 to 10 types of free weight and mechanical exercise of major muscle groups performed with an intensity of 50% to 85% 1-repetition maximum, 5 to 12 repetitions/set, 2 to 3 days/week, for 3 to 12 months is recommended. Impact exercises such as jumping chin-ups with drop landings and jump rope performed 50 jumps/session for at least 6 months with 3 or more days/week are recommended.

CONCLUSIONS

A multi-component exercise mainly comprised of resistance and impact exercise seems to be an effective strategy to attenuate the risk factors of osteoporosis and osteopenia. The integration of exercise guidelines and individualized exercise plans has significant potential to reduce the morbidity and mortality of osteoporosis.

Relationship of blood heavy metals and osteoporosis among the middle-aged and elderly adults: A secondary analysis from NHANES 2013 to 2014 and 2017 to 2018

Objective

This study aimed to assess the relationship between blood heavy metals and a higher prevalence of osteoporosis in middle-aged and elderly US adults using the National Health and Nutritional Examination Surveys (NHANES).

Methods

The secondary data analysis was performed using the data of NHANES 2013–2014 and 2017–2018. We used the information, including physical examination, laboratory tests, questionnaires, and interviews, provided by participants in NHANES. Logistic regression and weighted quantile sum (WQS) regression models were used to explore the relationships between levels of blood heavy metals and a higher prevalence of osteoporosis.

Results

A total of 1,777 middle-aged and elderly participants were analyzed in this study, comprising 115 participants with osteoporosis and 1,662 without osteoporosis. Adjusted model 1 showed a significant positive relationship between cadmium (Cd) levels and a higher prevalence of osteoporosis (quartile 2, OR = 7.62; 95% CI, 2.01–29.03; p = 0.003; quartile 3, OR = 12.38; 95% CI, 3.88–39.60; p < 0.001; and quartile 4, OR = 15.64; 95% CI, 3.22–76.08; p = 0.001). The fourth quartile of selenium (Se) level (OR = 0.34; 95% CI, 0.14–0.39; p < 0.001) led to a lower prevalence of osteoporosis and exerted a protective effect on model 1. Other models produced similar results to those of model 1. A subgroup analysis showed that Cd levels were positively related to a higher prevalence of osteoporosis in all three models in women, while this relationship was not found in men. The fourth quartile of the Se level was related to a lower prevalence of osteoporosis in both male and female analyses. A significant positive relationship was found between the blood Cd level and a higher prevalence of osteoporosis in the non-smoking subgroup. Blood Se level showed a protective effect on the fourth quartile in both the smoking and non-smoking subgroups.

Conclusion

Blood Cd level aggravated the prevalence of osteoporosis, while blood Se level could be a protective factor in osteoporosis among the US middle-aged and older populations.

Whole-Body Vibration Therapy as a Modality for Treatment of Senile and Postmenopausal Osteoporosis: A Review Article

Whole-body vibration therapy is an intentional biomechanical stimulation of the body using various frequencies of vibrations with the motive of health improvement. Ever since its discovery, this therapy has been extensively used in physiotherapeutic measures and the sports industry. For its property of increasing bone mass and density, space agencies use this therapy on astronauts who return to Earth after long-term space missions to regain lost bone and muscle mass. The potential of this therapy to restore bone mass encouraged researchers to look for its scope in the treatment of age-related bone degenerative diseases such as osteoporosis and sarcopenia, as well as in the correction of posture control and gait in geriatrics and post-menopausal women. Osteoporosis and osteopenia account for roughly half of all fractures worldwide. These degenerative diseases also cause gait and posture changes. Bisphosphonates, monoclonal antibodies, parathyroid hormone fragments, hormone replacement therapies, and calcium and vitamin D supplementation are among the medical treatments available. Lifestyle changes and physical exercise are advised. However, vibration therapy's scope as a treatment option is yet to be explored. The safe range of frequency, amplitude, duration, and intensity of the therapy is still to be determined. This article is a review of the results of various clinical trials done in the last 10 years that target the effect of vibration therapy in both osteoporotic women and the elderly for the treatment of such ailments and deformities. We collected data from PubMed using advanced search and applied the exclusion criteria. In total, we analyzed nine clinical trials.

Effectiveness of whole-body vibration on bone mineral density in postmenopausal women: a systematic review and meta-analysis of randomized controlled trials

The present study observed significant effects of whole-body vibration (WBV) on bone mineral density (BMD) in postmenopausal women, with high-quality evidence for high-frequency, low-magnitude, and high-cumulative-dose use. The aim was to update a previous systematic review with meta-analysis to observe the effects of WBV on BMD in postmenopausal women. For the meta-analysis, the weighted mean difference between WBV and control groups, or WBV and conventional exercise, was used for the area of bone mineral density (aBMD) of the lumbar spine, femoral neck, total hip, trochanter, intertrochanter, and Ward's area, or volumetric trabecular bone mineral density (vBMDt) of the radius and tibia. Methodological quality was assessed using the PEDro scale and the quality of evidence using the GRADE system. In total, 23 studies were included in the systematic review and 20 in the meta-analysis. Thirteen studies showed high methodological quality. WBV compared with control groups showed significant effects on aBMD in the primary analysis (lumbar spine and trochanter), sensitivity (lumbar spine), side-alternating vibration (lumbar spine and trochanter), synchronous vibration (lumbar spine), low frequency and high magnitude (lumbar spine and trochanter), high frequency and low magnitude (lumbar spine), high frequency and high magnitude (lumbar spine, trochanter, and Ward's area), high cumulative dose and low magnitude (lumbar spine), low cumulative dose and high magnitude (lumbar spine and trochanter), and positioning with semi-flexed knees (trochanter). Of these results, only high frequency associated with low magnitude and high cumulative dose with low magnitude showed high-quality evidence. At this time, considering the high quality of evidence, it is possible to recommend WBV using high frequency (≈ 30 Hz), low magnitude (≈ 0.3 g), and high cumulative dose (≈ 7000 min) to improve lumbar spine aBMD in postmenopausal women. Other parameters, although promising, need to be better investigated, considering, when applicable, the safety of the participants, especially in vibrations with higher magnitudes (≥ 1 g).

Functional quality assessment of whole-body vibration training devices based on instantaneous amplitude and frequency of photogrammetric vibration measurements

The practical use of whole-body vibration training (WBVT) and such research may be negatively influenced by generated vibrations with amplitudes, frequencies, and/or patterns that deviate from preset adjustments on WBVT devices. This study examined whether prolonged regular use can generate respective deviations. Four WBVT devices, used for 19 months in a research project on the effects of WBVT, were analyzed using photogrammetry before start of the research project and after 19 months. Divergences between preset and measured amplitudes and frequencies were calculated for all measurements. To quantify how well the output of devices correlates with the target setting, the vibration characteristics were calculated. In particular, exact long-term measurements related to the vibration amplitude is conducted and analyzed for the first time, which has been found as an important measure of the device functional quality. One device had a significantly (p<0.01) larger machine run time than the other three. This one showed the most pronounced signs of functional impairments concerning instantaneous amplitudes, frequencies and the mode of vibration after prolonged use. These results based on photometric measurements underline again that prolonged use can result in divergences between preset and actual applied amplitudes, frequencies, mode of vibration and other accuracy measurement metrics.

Effect of transcutaneous electrical acupoint stimulation on bone loss for patients with foot and ankle fracture: a pragmatic randomized controlled trial

OBJECTIVE

The aim for this trial was to preliminarily evaluate the effectiveness and safety of transcutaneous electrical acupoint stimulation (TEAS) for bone loss in patients with immobilization after surgical fixation of ankle and foot fractures.

METHODS

A total of 80 patients with immobilization after surgical fixation of ankle and foot fractures were randomly divided into an intervention group (n=40) or control group (n=40). The intervention group was given TEAS treatment combined with routine orthopedic treatment, and the control group was given only routine orthopedic treatment. The CT attenuation values, bone turnover markers (ALP, PINP, BGP, CTX, Ca/Cr), bone mineral density (BMD), blood phosphorus, and blood calcium were observed and compared between the two groups at 8 weeks. This was a prospective study. The protocol was registered in the Chinese clinical trial registry (No. ChiCTR2000039944).

RESULTS

The CT attenuation values of the intervention group decreased more than those of the control group (P<0.05), however the between group differences in ALP, BGP, Ca/Cr, CTX and BMD (all P>0.05) were not statistically significant. Three mild adverse events were recorded.

CONCLUSION

TEAS treatment may confer additional benefits for bone loss in patients with immobilization after surgical fixation of ankle and foot fractures. Since this was a pilot study, the efficacy of TEAS requires further evaluation through full-scale randomized controlled trials.

Improvement of Osteoporosis in Rats With Hind-Limb Unloading Treated With Pulsed Electromagnetic Field and Whole-Body Vibration

OBJECTIVE

Physical factors have been used to address disuse osteoporosis, but their effects and mechanism remain unclear. The purpose of this study was to determine the effects of pulsed electromagnetic field (PEMF) and whole-body vibration (WBV) on disuse osteoporosis to increase knowledge about treating osteoporosis.

METHODS

A disuse osteoporosis rat model was developed by hind-limb unloading (HU) for 6 weeks. Forty 4-month-old female Sprague-Dawley rats were divided into 5 groups and given the following interventions: HU, HU treated with PEMF (HUP), HU treated with WBV (HUW), HU treated with both PEMF and WBV (HUPW), and no intervention (controls). After 8 weeks of intervention, measurements were taken.

RESULTS

HU induced a decrease in bone mineral density (BMD), whereas HUP, HUW, and HUPW increased it. Moreover, the bone resorption markers tartrate-resistant acid phosphatase (TRAP) and C-terminal peptide of type 1 collagen in the HU group significantly increased, whereas the osteogenesis markers osteocalcin and N-terminal propeptide of type 1 procollagen significantly decreased. The markers osteocalcin and N-terminal propeptide of type 1 procollagen significantly increased, but TRAP and C-terminal peptide of type 1 collagen significantly decreased in the HUPW, HUP, and HUW groups compared with the HU group. In particular, HUPW effectively increased osteocalcin and decreased TRAP compared with HUP and WBV. Microcomputed tomography analysis of the femur indicated that HUPW improved trabecular number, bone volume over total volume, bone surface over bone volume, trabecular separation, and the structure model index compared with HUP and that it improved bone surface over bone volume, trabecular separation, and structure model index compared with HUW. The HUPW group showed a significant increase in maximum load compared with the HUW group and a significant increase in elastic modulus compared with the HUP group.

CONCLUSION

PEMF, WBV, and their combination all attenuated bone resorption and enhanced osteogenesis. WBV and the combination of treatments have great potential to improve osteogenesis compared with PEMF. In addition, HUPW significantly attenuated bone resorption compared with HUW and HUP.

IMPACT

The results of this study indicated that HUPW could effectively improve disuse osteoporosis compared with HUP, given that trabecular number and bone volume over total volume are associated with disuse osteoporosis. Moreover, BMD recovered well with HUP, HUW, and HUPW but the bone structure-especially mechanical performance-did not, indicating that osteoporosis should be evaluated with BMD and mechanical performance, not with BMD in isolation.

The effect of whole-body vibration in osteopenic patients after total knee arthroplasty: a randomized controlled trial

BACKGROUND

Total knee arthroplasty (TKA) is an important treatment for knee osteoarthritis, but the result of whole-body vibration (WBV) in knee function rehabilitation and bone loss with osteopenia was unknown. Therefore, the purpose of this study is to study whether low-frequency, low-amplitude WBV can improve the clinical outcome of knee osteoarthritis.

METHODS

This study was randomized and included 67 osteopenic patients (55-90 years, 85% women) for TKA surgery (control group N = 32, WBV group N = 35). All selected patients after TKA surgery tested clinical results, such as knee function and bone mass in baseline, 3 months after surgery, and 6 months after surgery.

RESULTS

Compared to the control group, the WBV group improved pain scores, thigh circumference, lower limb muscle strength, joint activity, and joint function in 6 months after surgery. WBV intervention also improves bone density in the spine, the microstructure of the radius and tibia, and the bone turnover marker. At 3 months after TKA surgery, the WBV group had no significant effect on knee function and bone loss.

CONCLUSIONS

Whole-body vibration for osteopenic patients with knee arthroplasty showed good therapeutic results in 6 months after TKA surgery, but the long-term therapeutic effect still needs to be further observed.

Beneficial effects of whole-body vibration exercise for brain disorders in experimental studies with animal models: a systematic review

Brain disorders have been a health challenge and is increasing over the years. Early diagnosis and interventions are considered essential strategies to treat patients at risk of brain disease. Physical exercise has shown to be beneficial for patients with brain diseases. A type of exercise intervention known as whole-body vibration (WBV) exercise gained increasing interest. During WBV, mechanical vibrations, produced by a vibrating platform are transmitted, to the body. The purpose of the current review was to summarize the effects of WBV exercise on brain function and behavior in experimental studies with animal models. Searches were performed in EMBASE, PubMed, Scopus and Web of Science including publications from 1960 to July 2021, using the keywords "whole body vibration" AND (animal or mice or mouse or rat or rodent). From 1284 hits, 20 papers were selected. Rats were the main animal model used (75%) followed by mice (20%) and porcine model (5%), 16 studies used males species and 4 females. The risk of bias, accessed with the SYRCLE Risk of Bias tool, indicated that none of the studies fulfilled all methodological criteria, resulting in possible bias. Despite heterogeneity, the results suggest beneficial effects of WBV exercise on brain functioning, mainly related to motor performance, coordination, behavioral control, neuronal plasticity and synapse function. In conclusion, the findings observed in animal studies justifies continued clinical research regarding the effectiveness and potential of WBV for the treatment of various types of brain disorders such as trauma, developmental disorders, neurogenetic diseases and other neurological diseases.

Disuse Osteoporosis: Clinical and Mechanistic Insights

Disuse osteoporosis describes a state of bone loss due to local skeletal unloading or systemic immobilization. This review will discuss advances in the field that have shed light on clinical observations, mechanistic insights and options for the treatment of disuse osteoporosis. Clinical settings of disuse osteoporosis include spinal cord injury, other neurological and neuromuscular disorders, immobilization after fractures and bed rest (real or modeled). Furthermore, spaceflight-induced bone loss represents a well-known adaptive process to microgravity. Clinical studies have outlined that immobilization leads to immediate bone loss in both the trabecular and cortical compartments accompanied by relatively increased bone resorption and decreased bone formation. The fact that the low bone formation state has been linked to high levels of the osteocyte-secreted protein sclerostin is one of the many findings that has brought matrix-embedded, mechanosensitive osteocytes into focus in the search for mechanistic principles. Previous basic research has primarily involved rodent models based on tail suspension, spaceflight and other immobilization methods, which have underlined the importance of osteocytes in the pathogenesis of disuse osteoporosis. Furthermore, molecular-based in vitro and in vivo approaches have revealed that osteocytes sense mechanical loading through mechanosensors that translate extracellular mechanical signals to intracellular biochemical signals and regulate gene expression. Osteocytic mechanosensors include the osteocyte cytoskeleton and dendritic processes within the lacuno-canalicular system (LCS), ion channels (e.g., Piezo1), extracellular matrix, primary cilia, focal adhesions (integrin-based) and hemichannels and gap junctions (connexin-based). Overall, disuse represents one of the major factors contributing to immediate bone loss and osteoporosis, and alterations in osteocytic pathways appear crucial to the bone loss associated with unloading.

Effects of teriparatide and loading modality on modeling-based and remodeling-based bone formation in the human femoral neck

PURPOSE

We have previously shown that a brief course of teriparatide (TPTD) stimulates bone formation in the cancellous and endocortical envelopes of the human femoral neck, and the regions of tension and compression respond differently. The purpose of the present study was to determine how much of the new bone was formed by modeling-based formation (MBF) or remodeling-based formation (RBF).

METHODS

We performed a double-blind trial of TPTD vs. placebo (PBO) in patients about to undergo a total hip replacement (THR) for osteoarthritis. Participants were randomized to receive daily TPTD 20 μg or PBO for an average of 6.1 weeks (range 4.1-11.8 weeks) prior to THR. After an average of 3 weeks of study drug, double tetracycline labels were administered per standard protocol. During the THR an intact sample of the mid-femoral neck (FN) was procured; this was fixed, embedded, and sectioned transversely. Histomorphometric analysis was performed in the cancellous, endocortical, and periosteal envelopes. Additionally, separate analyses were performed in the tensile and compressive regions of the endocortical and periosteal envelopes. Sites of new bone formation were identified by the presence of tetracycline labels and designated as MBF if the underlying cement line was smooth and as RBF if it was scalloped. New bone formation on smooth cement lines adjacent to scalloped reversal lines was designated as overflow RBF (oRBF). The referent for all indices was bone surface (BS).

RESULTS

In the cancellous and endocortical envelopes, the proportion of mineralizing surface engaged in RBF and oRBF was higher in the TPTD-treated than the PBO-treated subjects. There was also a trend toward higher MBF in TPTD vs. PBO in both envelopes. In linear mixed-effects models, TPTD was predicted to increase formation differently on the tensile and compressive surfaces depending on patient-specific anatomy, including body weight, FN angle, offset, and cortical width and porosity. Eroded surface was not different between groups in either envelope and no significant differences were observed in any parameter in the periosteal envelope.

CONCLUSION

We conclude that the predominant early effect of TPTD in the human femoral neck is to stimulate RBF and oRBF with a trend toward an increase in MBF in the endocortical and cancellous envelopes.

Effects of teriparatide and low-intensity aerobic exercise on osteopenia in type 2 diabetes mellitus rats

INTRODUCTION

In patients with type 2 diabetes mellitus (T2DM), bone fragility increases fracture risk. Teriparatide (TPTD) improves bone strength, and exercise therapy suppresses blood glucose levels in T2DM. In this study, the combined effects of TPTD and exercise therapy on trabecular and cortical bone were examined in advanced T2DM model rats.

MATERIALS AND METHODS

Thirty-week-old Otsuka Long-Evans Tokushima Fatty rats were divided into four groups (n = 9-10 in each group at two time points): Cont group (vehicle-treated control), TPTD group (TPTD 30 μg/kg injected subcutaneously, 3 times/week), Exe group (treadmill exercise, 10 m/min, 60 min/day, 5 times/week), and Comb group (TPTD-treated and treadmill exercise combined). Five and 10 weeks after treatment, bone mineral density (BMD), bone strength, and bone micro-architecture were measured.

RESULTS

TPTD and combined treatment significantly increased BMDs of the lumbar spine and femur compared to the Cont group (p < 0.05 to p < 0.01). In the three-point bending test of the femur, only combined treatment increased the maximum load at 5 weeks compared with the Cont and Exe groups (p < 0.01). In the compression test of the distal femoral metaphysis, both TPTD and combined treatment increased the trabecular bone strength compared with the Cont and Exe groups (p < 0.05 to p < 0.01). Although TPTD and combined treatment improved the micro-architecture of trabecular bone (p < 0.05 to p < 0.01), only combined treatment improved the micro-structures of cortical bone from 5 weeks of treatment (p < 0.05 to p < 0.01).

CONCLUSION

The combination of TPTD and treadmill exercise increased BMD and trabecular and cortical bone strength of the femur with improved micro-architecture in T2DM model rats.

Mechanical Stimulation on Mesenchymal Stem Cells and Surrounding Microenvironments in Bone Regeneration: Regulations and Applications

Treatment of bone defects remains a challenge in the clinic. Artificial bone grafts are the most promising alternative to autologous bone grafting. However, one of the limiting factors of artificial bone grafts is the limited means of regulating stem cell differentiation during bone regeneration. As a weight-bearing organ, bone is in a continuous mechanical environment. External mechanical force, a type of biophysical stimulation, plays an essential role in bone regeneration. It is generally accepted that osteocytes are mechanosensitive cells in bone. However, recent studies have shown that mesenchymal stem cells (MSCs) can also respond to mechanical signals. This article reviews the mechanotransduction mechanisms of MSCs, the regulation of mechanical stimulation on microenvironments surrounding MSCs by modulating the immune response, angiogenesis and osteogenesis, and the application of mechanical stimulation of MSCs in bone regeneration. The review provides a deep and extensive understanding of mechanical stimulation mechanisms, and prospects feasible designs of biomaterials for bone regeneration and the potential clinical applications of mechanical stimulation.

The effect of low-intensity whole-body vibration with or without high-intensity resistance and impact training on risk factors for proximal femur fragility fracture in postmenopausal women with low bone mass: study protocol for the VIBMOR randomized controlled trial

BACKGROUND

The prevailing medical opinion is that medication is the primary (some might argue, only) effective intervention for osteoporosis. It is nevertheless recognized that osteoporosis medications are not universally effective, tolerated, or acceptable to patients. Mechanical loading, such as vibration and exercise, can also be osteogenic but the degree, relative efficacy, and combined effect is unknown. The purpose of the VIBMOR trial is to determine the efficacy of low-intensity whole-body vibration (LIV), bone-targeted, high-intensity resistance and impact training (HiRIT), or the combination of LIV and HiRIT on risk factors for hip fracture in postmenopausal women with osteopenia and osteoporosis.

METHODS

Postmenopausal women with low areal bone mineral density (aBMD) at the proximal femur and/or lumbar spine, with or without a history of fragility fracture, and either on or off osteoporosis medications will be recruited. Eligible participants will be randomly allocated to one of four trial arms for 9 months: LIV, HiRIT, LIV + HiRIT, or control (low-intensity, home-based exercise). Allocation will be block-randomized, stratified by use of osteoporosis medications. Testing will be performed at three time points: baseline (T0), post-intervention (T1; 9 months), and 1 year thereafter (T2; 21 months) to examine detraining effects. The primary outcome measure will be total hip aBMD determined by dual-energy X-ray absorptiometry (DXA). Secondary outcomes will include aBMD at other regions, anthropometrics, and other indices of bone strength, body composition, physical function, kyphosis, muscle strength and power, balance, falls, and intervention compliance. Exploratory outcomes include bone turnover markers, pelvic floor health, quality of life, physical activity enjoyment, adverse events, and fracture. An economic evaluation will also be conducted.

DISCUSSION

No previous studies have compared the effect of LIV alone or in combination with bone-targeted HiRIT (with or without osteoporosis medications) on risk factors for hip fracture in postmenopausal women with low bone mass. Should either, both, or combined mechanical interventions be safe and efficacious, alternative therapeutic avenues will be available to individuals at elevated risk of fragility fracture who are unresponsive to or unwilling or unable to take osteoporosis medications.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (www. anzctr.org.au ) (Trial number ANZCTR12615000848505, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id = 368962 ); date of registration 14/08/2015 (prospectively registered). Universal Trial Number: U1111-1172-3652.

Long-term effect of full-body pulsed electromagnetic field and exercise protocol in the treatment of men with osteopenia or osteoporosis: A randomized placebo-controlled trial

Background: Osteoporosis is the most prevalent metabolic disease affecting bones. Objective: To investigate the long-term effect of pulsed electromagnetic field (PEMF) combined with exercise protocol on bone mineral density (BMD) and bone markers in men with osteopenia or osteoporosis. Methods: Ninety-five males with osteopenia or osteoporosis (mean age, 51.26 ± 2.41 years; mean height, 176 ± 2.02 cm; mean weight, 83.08 ± 2.60 kg; mean body–mass index (BMI), 26.08 ± 1.09 kg/m ²) participated in the study, and they were randomly assigned to one of three groups: Group 1 received a full-body PEMF and exercise protocol (PEMF +EX), Group 2 received a placebo full-body PEMF and exercise protocol (PPEMF +EX), and Group 3 received a full-body PEMF alone (PEMF). PEMF was applied for the whole body using a full-body mat three times per week for 12 weeks, with an exercise protocol that includes flexibility, aerobic exercise, strengthening, weight-bearing, and balance exercises followed by whole-body vibration (WBV) training. Outcome measures include BMD of total hip and lumbar spine and bone markers [serum osteocalcin (s-OC), Serum amino-terminal cross-linking telopeptide of type I collagen (s-NTX), Serum carboxy-terminal cross-linking telopeptide of type I collagen (s-CTX), Parathyroid hormones (PTH), Bone-specific Alkaline Phosphatase (BSAP), and 25-hydroxy vitamin D (Vit D)]. Results: The BMD of total hip and lumbar spine was significantly increased post-treatment in all groups, and more so in Group 1 and Group 2 than Group 3. There was a significant difference in bone markers in all groups, more so in Group 1 and Group 2 than in Group 3. Conclusion: PEMF combined with exercise protocol exerts a potent role for treating OP, is more effective than exercise and PEMF alone for increasing BMD and enhancing bone formation, and suppresses bone-resorption markers after 12-weeks of treatment with the impact lasting up to 6 months.

Anabolic Bone Stimulus Requires a Pre-Exercise Meal and 45-Minute Walking Impulse of Suprathreshold Speed-Enhanced Momentum to Prevent or Mitigate Postmenopausal Osteoporosis within Circadian Constraints

Osteoporosis currently afflicts 8 million postmenopausal women in the US, increasing the risk of bone fractures and morbidity, and reducing overall quality of life. We sought to define moderate exercise protocols that can prevent postmenopausal osteoporosis. Our previous findings singled out higher walking speed and pre-exercise meals as necessary for suppression of bone resorption and increasing of markers of bone formation. Since both studies were amenable to alternate biomechanical, nutritional, and circadian interpretations, we sought to determine the relative importance of higher speed, momentum, speed-enhanced load, duration of impulse, and meal timing on osteogenic response. We hypothesized that: (1) 20 min of exercise one hour after eating is sufficient to suppress bone resorption as much as a 40-min impulse and that two 20 min exercise bouts separated by 7 h would double the anabolic effect; (2) early morning exercise performed after eating will be as effective as mid-day exercise for anabolic outcome; and (3) the 08:00 h 40-min. exercise uphill would be as osteogenic as the 40-min exercise downhill. Healthy postmenopausal women, 8 each, were assigned to a no-exercise condition (SED) or to 40- or 20-min exercise bouts, spaced 7 h apart, for walking uphill (40 Up and 20 Up) or downhill (40 Down and 20 Down) to produce differences in biomechanical variables. Exercise was initiated at 08:00 h one hour after eating in 40-min groups, and also 7 h later, two hours after the midday meal, in 20-min groups. Measurements were made of CICP (c-terminal peptide of type I collagen), osteocalcin (OC), and bone-specific alkaline phosphatase (BALP), markers of bone formation, and of the bone resorptive marker CTX (c-terminal telopeptide of type 1 collagen). The osteogenic ratios CICP/CTX, OC/CTX, and BALP/CTX were calculated. Only the 40-min downhill exercise of suprathreshold speed-enhanced momentum, increased the three osteogenic ratios, demonstrating the necessity of a 40-min, and inadequacy of a 20-min, exercise impulse. The failure of anabolic outcome in 40-min uphill exercise was attributed to a sustained elevation of PTH concentration, as its high morning elevation enhances the CTX circadian rhythm. We conclude that postmenopausal osteoporosis can be prevented or mitigated in sedentary women by 45 min of morning exercise of suprathreshold speed-enhanced increased momentum performed shortly after a meal while walking on level ground, or by 40-min downhill, but not 40-min uphill, exercise to avoid circadian PTH oversecretion. The principal stimulus for the anabolic effect is exercise, but the prerequisite for a pre-exercise meal demonstrates the requirement for nutrient facilitation.

Osteoporosis Prevention, Screening, and Diagnosis: ACOG Clinical Practice Guideline No. 1

PURPOSE

To provide updated evidence-based recommendations for the prevention, screening, and diagnosis of postmenopausal osteoporosis.

TARGET POPULATION

Postmenopausal patients without identified risk factors for fracture, low bone mineral density, or secondary osteoporosis related to medication or a medical condition.

METHODS

This guideline was developed using an a priori protocol in conjunction with a writing team consisting of two specialists in obstetrics and gynecology appointed by the ACOG Committee on Clinical Practice Guidelines-Gynecology and one external subject matter expert. ACOG medical librarians completed a comprehensive literature search for primary literature within the Cochrane Library, Cochrane Collaboration Registry of Controlled Trials, EMBASE, PubMed, and MEDLINE. Studies that moved forward to the full-text screening stage were assessed by two authors from the writing team on the basis of standardized inclusion and exclusion criteria. Included studies underwent quality assessment, and a modified GRADE (Grading of Recommendations, Assessment, Development and Evaluations) evidence-to-decision framework was applied to interpret and translate the evidence into recommendation statements.

RECOMMENDATIONS

This Clinical Practice Guideline includes updated recommendations on the role of exercise, calcium, and vitamin D in osteoporosis prevention; osteoporosis screening and diagnosis; rescreening intervals; and interventions to prevent falls. Recommendations are classified by strength and evidence quality. Ungraded Good Practice Points are included to provide guidance when a formal recommendation could not be made because of inadequate or nonexistent evidence.

Biophysical Modulation of the Mitochondrial Metabolism and Redox in Bone Homeostasis and Osteoporosis: How Biophysics Converts into Bioenergetics

Bone-forming cells build mineralized microstructure and couple with bone-resorbing cells, harmonizing bone mineral acquisition, and remodeling to maintain bone mass homeostasis. Mitochondrial glycolysis and oxidative phosphorylation pathways together with ROS generation meet the energy requirement for bone-forming cell growth and differentiation, respectively. Moderate mechanical stimulations, such as weight loading, physical activity, ultrasound, vibration, and electromagnetic field stimulation, etc., are advantageous to bone-forming cell activity, promoting bone anabolism to compromise osteoporosis development. A plethora of molecules, including ion channels, integrins, focal adhesion kinases, and myokines, are mechanosensitive and transduce mechanical stimuli into intercellular signaling, regulating growth, mineralized extracellular matrix biosynthesis, and resorption. Mechanical stimulation changes mitochondrial respiration, biogenesis, dynamics, calcium influx, and redox, whereas mechanical disuse induces mitochondrial dysfunction and oxidative stress, which aggravates bone-forming cell apoptosis, senescence, and dysfunction. The control of the mitochondrial biogenesis activator PGC-1α by NAD+-dependent deacetylase sirtuins or myokine FNDC/irisin or repression of oxidative stress by mitochondrial antioxidant Nrf2 modulates the biophysical stimulation for the promotion of bone integrity. This review sheds light onto the roles of mechanosensitive signaling, mitochondrial dynamics, and antioxidants in mediating the anabolic effects of biophysical stimulation to bone tissue and highlights the remedial potential of mitochondrial biogenesis regulators for osteoporosis.

Current Lack of Evidence for an Effect of Physical Activity Intervention Combined with Pharmacological Treatment on Bone Turnover Biomarkers in People with Osteopenia and Osteoporosis: A Systematic Review

The process of bone loss occurs silently and progressively with age, often appearing as osteopenia or osteoporosis or related fractures. Given the rapid raise in disease burden and socio-economic costs of these conditions worldwide, drug therapy combined with physical activity can be a useful strategy and bone biomarkers, can represent a useful evaluation tool to assess their effects. The objective of this systematic review, conducted according to PRISMA statement, was to investigate the effects of physical activity interventions combined with drug treatments on bone biomarkers in people with osteopenia and osteoporosis. Through PubMed, Cochrane, Cinahl, Embase, Trip, a comprehensive literature search was performed. Each study's quality was assessed according to the Cochrane risk-of-bias tool. Out of 582 identified articles, 50 full texts were screened. Only one matched the eligibility criteria. The study, scored as high quality, showed, in both experimental and control groups, an increase of CTX and P1NP bone biomarkers, without statistically significant differences. Based on available evidence, no exhaustive conclusion can be drawn. However, this systematic review critically analyses the literature, highlighting the knowledge gap on combined treatments efficacy assessed by bone biomarkers. Moreover, an outlook is provided for the planning of future studies.

Osteoporosis was associated with severe abdominal aortic calcification based on a cross-sectional study

Abdominal aortic calcification and osteoporosis are age-related diseases. Based on a nationally representative US population, we concluded that osteoporosis may be independently associated with severe abdominal aortic calcification, which could improve our insights into the prevention and management of vascular disease.

INTRODUCTION

Abdominal aortic calcification (AAC) and osteoporosis are age-related diseases and share similar pathological mechanisms. However, the association between osteoporosis and AAC is uncertain.

METHODS

A total of 3134 participants with complete record of AAC score calculated from dual-energy X-ray absorptiometry (DXA) were enrolled from the National Health and Nutrition Examination Survey (NHANES) 2013-2014. The diagnosis of osteoporosis was obtained from self-reported interview. The baseline covariates were compared between participants with and without osteoporosis. Multivariable logistic regression was performed to examine the association between abdominal aortic calcification and osteoporosis.

RESULTS

Compared with those without osteoporosis, participants with osteoporosis had higher AAC scores. Osteoporosis was positively associated with higher odds of severe AAC (OR = 2.65; 95%CI, 1.89-3.71; P < 0.001), and the association was not altered (OR = 2.17; 95%CI, 1.23-3.83; P = 0.008) after adjusting for numerous covariates.

CONCLUSIONS

Our findings suggest that osteoporosis may be independently associated with severe abdominal aortic calcification.

The effect of whole-body vibration exercise on postmenopausal women with osteoporosis: A protocol for systematic review and meta-analysis

BACKGROUND

Osteoporosis (OP) is an age-related disease characterized by reduced bone mass and increased bone fragility. It is more common in older people and postmenopausal women. As a new type of exercise training for OP, whole-body vibration (WBV) exercise has been proved to have a good effect on postmenopausal women with OP. It can increase bone density and improve strength and balance in postmenopausal population, which has certain clinical value, but lacks evidence-based medicine evidence. This study aims to systematically study the effectiveness of WBV exercise on postmenopausal women with OP.

METHODS

The English databases (PubMed, Embase, Web of Science, The Cochrane Library) and Chinese databases (China National Knowledge Network, Wanfang, Weipu, China Biomedical Database) were searched by computer. From the establishment of the database to February 2021, the randomized controlled clinical studies on WBV exercise on postmenopausal women with OP were conducted. The quality of the included studies was independently extracted by 2 researchers and literature quality was evaluated. Meta-analysis of the included studies was performed using RevMan5.3 software.

RESULTS

In this study, the efficacy and safety of WBV exercise on postmenopausal women with OP were evaluated by lumbar spine bone density, femoral neck bone density, pain, incidence of falls, incidence of fractures, and quality of life scale score, etc.

CONCLUSION

This study will provide reliable evidences for the clinical application of WBV exercise on postmenopausal women with OP.

ETHICS AND DISSEMINATION

Private information from individuals will not be published. This systematic review also does not involve endangering participant rights. Ethical approval will not be required. The results may be published in a peer-reviewed journal or disseminated at relevant conferences.

OSF REGISTRATION NUMBER

DOI 10.17605/OSF.IO/WPYT9.

Transmission of whole body vibration - Comparison of three vibration platforms in healthy subjects

The potential of whole body vibration (WBV) to maintain or enhance musculoskeletal strength during ageing is of increasing interest, with both low and high magnitude WBV having been shown to maintain or increase bone mineral density (BMD) at the lumbar spine and femoral neck. The aim of this study was to determine how a range of side alternating and vertical WBV platforms deliver vibration stimuli up through the human body. Motion capture data were collected for 6 healthy adult participants whilst standing on the Galileo 900, Powerplate Pro 5 and Juvent 100 WBV platforms. The side alternating Galileo 900 WBV platform delivered WBV at 5-30 Hz and amplitudes of 0-5 mm. The Powerplate Pro 5 vertical WBV platform delivered WBV at 25 and 30 Hz and amplitude settings of 'Low' and 'High'. The Juvent 1000 vertical WBV platform delivered a stimulus at a frequency between 32 and 37 Hz and amplitude 10 fold lower than either the Galileo or Powerplate, resulting in accelerations of 0.3 g. Motion capture data were recorded using an 8 camera Vicon Nexus system with 21 reflective markers placed at anatomical landmarks between the toe and the forehead. Vibration was expressed as vertical RMS accelerations along the z-axis which were calculated as the square root of the mean of the squared acceleration values in g. The Juvent 1000 did not deliver detectable vertical RMS accelerations above the knees. In contrast, the Powerplate Pro 5 and Galileo 900 delivered vertical RMS accelerations sufficiently to reach the femoral neck and lumbar spine. The maximum vertical RMS accelerations at the anterior superior iliac spine (ASIS) were 1.00 g ±0.30 and 0.85 g ±0.49 for the Powerplate and Galileo respectively. For similar accelerations at the ASIS, the Galileo achieved greater accelerations within the lower limbs, whilst the Powerplate recorded higher accelerations in the thoracic spine at T10. The Powerplate Pro 5 and Galileo 900 deliver vertical RMS accelerations sufficiently to reach the femoral neck and lumbar spine, whereas the Juvent 1000 did not deliver detectable vertical RMS accelerations above the knee. The side alternating Galileo 900 showed greater attenuation of the input accelerations than the vertical vibrations of the Powerplate Pro 5. The platforms differ markedly in the transmission of vibration with strong influences of frequency and amplitude. Researchers need to take account of the differences in transmission between platforms when designing and comparing trials of whole body vibration.

Four-Year Teriparatide Followed by Denosumab vs. Continuous Denosumab in Glucocorticoid-Induced Osteoporosis Patients With Prior Bisphosphonate Treatment

OBJECTIVES

In our previous 24-month study, we observed that teriparatide had some advantages over denosumab for bone mineral density (BMD) in glucocorticoid-induced osteoporosis (GIO) patients with prior bisphosphonate treatment. We conducted this extension study to investigate whether the advantage of teriparatide obtained in the first 2 years would be maintained after the switch to denosumab.

MATERIALS AND METHODS

We switched patients who had completed 24-month daily teriparatide treatment to denosumab (switch group, n=18) and compared their BMD every 6 months up to 48 months with the group who continued to receive denosumab (denosumab group, n=16).

RESULTS

At 48 months, the lumbar spine BMD was significantly increased from baseline in both groups (denosumab: 10.4 ± 8.7%, p<0.001; switch: 14.2 ± 6.8%, p<0.001). However, a significant increase in femoral neck BMD from baseline occurred only in the switch group (11.2 ± 14.6%, p<0.05); denosumab (4.1 ± 10.8%). The total hip BMD increased significantly from baseline in both groups (denosumab: 4.60 ± 7.4%, p<0.05; switch: 7.2 ± 6.9%, p<0.01). Femoral neck BMD was significantly increased in the switch versus the denosumab group (p<0.05).

CONCLUSION

In GIO patients with prior bisphosphonate treatment, the advantage of teriparatide may be maintained after the treatment period. A continuous increase in BMD can be expected with teriparatide followed by denosumab.

Impact of whole-body vibration exercise on physical performance and bone turnover in patients with monoclonal gammopathy of undetermined significance

OBJECTIVE

Monoclonal Gammopathy of Undetermined Significance (MGUS) is a risk factor for reduced physical performance, osteoporosis, and fractures due to compromised musculoskeletal metabolism. In this condition it is unknown whether whole-body vibration (WBV) exercise favorably alters physical performance and bone metabolism.

METHODS

To evaluate the effect of three-months WBV exercise (30 min; 2x/week) including an optional three-month extension on physical performance, bone metabolism and bone mineral density. Endpoints included functional assessments, bone turnover markers and bone mineral density assessed by peripheral quantitative computed tomography of the tibia.

RESULTS

Fifteen MGUS patients (median age 62.0, nine female) completed the first three months of which ten completed the three-month extension. Measures of physical functioning including chair rise test, timed up and go and 6-minute walk test improved (p = 0.007; p = 0.009; p = 0.005) after three and six months of WBV exercise. Total tibial bone mineral density remained unaltered (p > 0.05). WBV exercise tended to increase levels of sclerostin (p = 0.093) with a transient increase in osteoclast resorption markers (N-terminal telopeptide of collagen type 1, tartrate resistant acid phosphatase 5b) after three months while Dickkopf-1 (p = 0.093), procollagen I N-terminal propeptide (p = 0.074) and total alkaline phosphatase (p = 0.016) appeared to decline. No exercise-related adverse events were reported.

CONCLUSION

WBV exercise in MGUS patients improves indicators of physical performance. Observed trends in bone turnover markers and changes in distal tibial bone mineral density may indicate a regulatory effect of WBV exercise on bone metabolism and warrants further evaluation by large scale studies.

The combined effect of parathyroid hormone (1-34) and whole-body vibration exercise on physical performance in OSteoporotic women (PaVOS study): a secondary analysis from a randomised controlled trial

Background

The aim of this study was to investigate the effect on physical performance of combining whole-body vibration exercise (WBV) with parathyroid hormone 1-34 (teriparatide) compared to teriparatide alone.

Methods

A secondary analysis from a RCT where postmenopausal women with severe osteoporosis were randomised to WBV plus teriparatide (intervention) or teriparatide alone (control). WBV was applied three times/week (6x1min WBV:1 min rest, (peak acceleration 3.6 g)) for twelve months. Both groups received teriparatide 20 μg s.c./day. The primary endpoint (bone mineral density) is reported elsewhere. Physical performance measures (Short Physical Performance Battery (SPPB), Timed-Up-and-Go (TUG), leg extension power, and grip strength) were obtained at baseline, three-, six-, and twelve months, lean mass at baseline and twelve months. Data were analysed with mixed linear regression model or robust cluster regression in an intention to treat analysis.

Results

Thirty-five women aged (mean ± SD) 69 ± 7) years were recruited of which thirty-two (91%) completed the twelve months follow-up (WBV + teriparatide = 15, teriparatide = 17). SPPB score (mean ± SD) improved significantly at three months in the WBV + teriparatide group from 9.13 ± 2.03 to 10.35 ± 1.69 (p = 0.014) with a statistical trend towards a between-group change in favor of the WBV + teriparatide group (0.86 [95%CI(- 0.05,1.77), p = 0.065]). Both groups improved in leg extension power during the study period whereas no changes were seen in TUG, grip strength, or lean mass in either group. No statistical significant between-group differences were observed.

Conclusion

WBV may improve some short-term aspects of physical performance in severely osteoporotic postmenopausal women who are receiving teriparatide treatment.

Trial Registration

ClinicalTrials.gov, ID:NCT02563353.

Regional improvements in lumbosacropelvic Hounsfield units following teriparatide treatment

OBJECTIVE

Opportunistic Hounsfield unit (HU) determination from CT imaging has been increasingly used to estimate bone mineral density (BMD) in conjunction with assessments from dual energy x-ray absorptiometry (DXA). The authors sought to compare the effect of teriparatide on HUs across different regions in the pelvis, sacrum, and lumbar spine, as a surrogate measure for the effects of teriparatide on lumbosacropelvic instrumentation.

METHODS

A single-institution retrospective review of patients who had been treated with at least 6 months of teriparatide was performed. All patients had at least baseline DXA as well as pre- and post-teriparatide CT imaging. HUs were measured in the pedicle, lamina, and vertebral body of the lumbar spine, in the sciatic notch, and at the S1 and S2 levels at three different points (ilium, sacral body, and sacral ala).

RESULTS

Forty patients with an average age of 67 years underwent a mean of 20 months of teriparatide therapy. Mean HUs of the lumbar lamina, pedicles, and vertebral body were significantly different from each other before teriparatide treatment: 343 ± 114, 219 ± 89.2, and 111 ± 48.1, respectively (p < 0.001). Mean HUs at the S1 level for the ilium, sacral ala, and sacral body were also significantly different from each other: 124 ± 90.1, −10.7 ± 61.9, and 99.1 ± 72.1, respectively (p < 0.001). The mean HUs at the S2 level for the ilium and sacral body were not significantly different from each other, although the mean HU at the sacral ala (−11.9 ± 52.6) was significantly lower than those at the ilium and sacral body (p = 0.003 and 0.006, respectively). HU improvement occurred in most regions following teriparatide treatment. In the lumbar spine, the mean lamina HU increased from 343 to 400 (p < 0.001), the mean pedicle HU increased from 219 to 242 (p = 0.04), and the mean vertebral body HU increased from 111 to 134 (p < 0.001). There were also significant increases in the S1 sacral body (99.1 to 130, p < 0.05), S1 ilium (124 vs 165, p = 0.01), S1 sacral ala (−10.7 vs 3.68, p = 0.04), and S2 sacral body (168 vs 189, p < 0.05).

CONCLUSIONS

There was significant regional variation in lumbar and sacropelvic HUs, with most regions significantly increasing following teriparatide treatment. The sacropelvic area had lower HU values than the lumbar spine, more regional variation, and a higher degree of correlation with BMD as measured on DXA. While teriparatide treatment resulted in HUs > 110 in the majority of the lumbosacral spine, the HUs in the sacral ala remained suggestive of severe osteoporosis, which may limit the effectiveness of fixation in this region.

PTH(1-34) treatment and/or mechanical loading have different osteogenic effects on the trabecular and cortical bone in the ovariectomized C57BL/6 mouse

In preclinical mouse models, a synergistic anabolic response to PTH(1–34) and tibia loading was shown. Whether combined treatment improves bone properties with oestrogen deficiency, a cardinal feature of osteoporosis, remains unknown. This study quantified the individual and combined longitudinal effects of PTH(1–34) and loading on the bone morphometric and densitometric properties in ovariectomised mice. C57BL/6 mice were ovariectomised at 14-weeks-old and treated either with injections of PTH(1–34); compressive loading of the right tibia; both interventions concurrently; or both interventions on alternating weeks. Right tibiae were microCT-scanned from 14 until 24-weeks-old. Trabecular metaphyseal and cortical midshaft morphometric properties, and bone mineral content (BMC) in 40 different regions of the tibia were measured. Mice treated only with loading showed the highest trabecular bone volume fraction at week 22. Cortical thickness was higher with co-treatment than in the mice treated with PTH alone. In the mid-diaphysis, increases in BMC were significantly higher with loading than PTH. In ovariectomised mice, the osteogenic benefits of co-treatment on the trabecular bone were lower than loading alone. However, combined interventions had increased, albeit regionally-dependent, benefits to cortical bone. Increased benefits were largest in the mid-diaphysis and postero-laterally, regions subjected to higher strains under compressive loads.