1
|
Golden AP, Hogan KK, Morris JB, Pickens BB. The Impact of Blood Flow Restriction Training on Tibial Bone Stress Injury Rehabilitation: An Exploratory Case Series. Int J Sports Phys Ther 2024; 19:1126-1137. [PMID: 39229454 PMCID: PMC11368450 DOI: 10.26603/001c.122641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 07/29/2024] [Indexed: 09/05/2024] Open
Abstract
Background Lower extremity bone stress injuries (BSI) are common injuries among athletes and military members. Typical management involves a period of restricted weightbearing which can have rapid detrimental effects upon both muscle and bone physiology. Few studies have investigated the effect of blood flow restriction (BFR) training on bone in the rehabilitative setting. Purpose The purpose of this study was to investigate the effects of lower extremity exercise with the addition of BFR upon bone mineral density, bone mineral content, and lean body mass in military members with tibial BSIs. Study Design Case series. Methods Twenty military members with MRI-confirmed tibial BSI were recruited to complete lower extremity exercise with the addition of BFR twice per week for four weeks. The BFR cuff was applied proximally to the participant's involved limb while they performed gluteal, thigh, and leg resistance exercises. Outcomes were assessed at baseline and four weeks. The primary outcomes were whole leg bone mineral density (BMD), bone mineral content (BMC), and lean body mass (LM) as measured by dual-energy x-ray absorptiometry. Secondary outcomes included thigh and leg circumference measures and patient-reported outcomes, including the Lower Extremity Functional Scale (LEFS), Patient-Reported Outcomes Measurement Information System 57 (PROMIS-57), and Global Rating of Change (GROC). Results No significant differences were found in BMD (p=0.720) or BMC (p=0.749) between limbs or within limbs over time. LM was generally less in the involved limb (p=0.019), however there were no significant differences between or within limbs over time (p=0.404). For thigh circumference, significant main effects were found for time (p=0.012) and limb (p=0.015), however there was no significant interaction effect (p=0.510). No significant differences were found for leg circumference (p=0.738). Participants showed significant mean changes in LEFS (15.15 points), PROMIS physical function (8.98 points), PROMIS social participation (7.60 points), PROMIS anxiety (3.26 points), and PROMIS pain interference (8.39 points) at four weeks. Conclusion The utilization of BFR in the early rehabilitative management of tibial BSI may help mitigate decrements in both bone and muscle tissue during periods of decreased physical loading. Level of Evidence 4.
Collapse
Affiliation(s)
- Andrew P Golden
- Army-Baylor University Doctoral Fellowship in Orthopaedic Manual Physical Therapy, Fort Sam Houston, TX 78234, USA
| | - Kathleen K Hogan
- Special Warfare Human Performance Squadron, San Antonio, TX 78236, USA
| | - Jamie B Morris
- Army-Baylor University Doctoral Fellowship in Division 1 Sports Physical Therapy, West Point, NY 10996, USA
| | - Bryan B Pickens
- Army-Baylor University Doctoral Program in Physical Therapy, Fort Sam Houston, TX 78234, USA
| |
Collapse
|
2
|
George ERM, Sheerin KR, Reid D. Criteria and Guidelines for Returning to Running Following a Tibial Bone Stress Injury: A Scoping Review. Sports Med 2024; 54:2247-2265. [PMID: 39141251 PMCID: PMC11393297 DOI: 10.1007/s40279-024-02051-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/16/2024] [Indexed: 08/15/2024]
Abstract
Tibial bone stress injuries (BSIs) are common among long-distance runners. They have a high recurrence rate, and complexity emerges in the wider management and successful return to running. Following a tibial BSI, a critical component of complete rehabilitation is the successful return to running, and there is a lack of consistency or strong evidence to guide this process. The objectives of this review were to outline the criteria used in clinical decision-making prior to resuming running, and to establish evidence-based guidelines for the return to running process following a tibial BSI. Electronic databases including MEDLINE, CINAHL, Scopus, SPORTDiscus and AMED were searched for studies that stated criteria or provided guidelines on the objectives above. Fifty studies met the inclusion criteria and were included. Thirty-nine were reviews or clinical commentaries, three were retrospective cohort studies, two were randomised controlled trials, two were pilot studies, one was a prospective observational study, and three were case studies. Therefore, the recommendations that have been surmised are based on level IV evidence. Decisions on when an athlete should return to running should be shared between clinicians, coaches and the athlete. There are five important components to address prior to introducing running, which are: the resolution of bony tenderness, pain-free walking, evidence of radiological healing in high-risk BSIs, strength, functional and loading tests, and the identification of contributing factors. Effective return to running planning should address the athlete's risk profile and manage the risk by balancing the athlete's interests and reinjury prevention. An individualised graduated return to running programme should be initiated, often starting with walk-run intervals, progressing running distance ahead of speed and intensity, with symptom provocation a key consideration. Contributing factors to the initial injury should be addressed throughout the return to run process.
Collapse
Affiliation(s)
- Esther R M George
- Sports Performance Research Institute New Zealand (SPRINZ), Faculty of Health and Environmental Sciences, Auckland University of Technology, Auckland, New Zealand.
- InForm Physio, Silverstream, New Zealand.
| | - Kelly R Sheerin
- Sports Performance Research Institute New Zealand (SPRINZ), Faculty of Health and Environmental Sciences, Auckland University of Technology, Auckland, New Zealand
| | - Duncan Reid
- Sports Performance Research Institute New Zealand (SPRINZ), Faculty of Health and Environmental Sciences, Auckland University of Technology, Auckland, New Zealand
| |
Collapse
|
3
|
Sekel NM, Lovalekar M, Koltun KJ, Bird MB, Forse JN, Martin BJ, Nindl BC. Micronutrient Status During Military Training and Associations With Musculoskeletal Health, Injury, and Readiness Outcomes. Int J Sport Nutr Exerc Metab 2024:1-9. [PMID: 39168457 DOI: 10.1123/ijsnem.2024-0080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Revised: 06/27/2024] [Accepted: 06/28/2024] [Indexed: 08/23/2024]
Abstract
OBJECTIVE Micronutrient status, specifically vitamin D and iron, represent modifiable factors for optimizing military readiness. The primary purpose of this investigation was to determine associations between micronutrient deficiency (i.e., iron status and 25-hydroxy-vitamin D [25(OH)D]) and operationally relevant outcomes (i.e., skeletal health, musculoskeletal injury) at baseline and post-10 weeks of arduous military training. METHODS A total of 227 (177 men, 50 women) Marine Officer Candidates School (OCS) candidates who completed OCS training with complete data sets were included in this analysis. Vitamin D and iron status indicators were collected at two timepoints, pre (baseline) and post OCS. Musculoskeletal outcomes at the mid- and proximal tibial diaphysis were assessed via peripheral quantitative computed tomography. RESULTS Micronutrient status declined following OCS training in men and women and was associated with musculoskeletal outcomes including greater bone strength (strength strain index) at the mid-diaphysis site in those with optimal status (M = 38.26 mm3, SE = 15.59) versus those without (M = -8.03 mm3, SE = 17.27). In women (p = .037), endosteal circumference was greater in the deficient group (M = 53.26 mm, SE = 1.19) compared with the optimal group (M = 49.47 mm, SE = 1.31) at the proximal diaphysis. In men, greater baseline hepcidin concentrations were associated with an increased likelihood of suffering musculoskeletal injury during training. CONCLUSIONS Vitamin D and iron status declined over the course of training, suggesting impaired micronutrient status. Differences in musculoskeletal outcomes by micronutrient group suggests optimal vitamin D and ferritin concentrations may exert beneficial effects on bone fatigability and fracture reduction during military training.
Collapse
Affiliation(s)
- Nicole M Sekel
- Neuromuscular Research Laboratory/Warrior Human Performance Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Mita Lovalekar
- Neuromuscular Research Laboratory/Warrior Human Performance Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kristen J Koltun
- Neuromuscular Research Laboratory/Warrior Human Performance Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Matthew B Bird
- Neuromuscular Research Laboratory/Warrior Human Performance Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jennifer N Forse
- Neuromuscular Research Laboratory/Warrior Human Performance Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Brian J Martin
- Neuromuscular Research Laboratory/Warrior Human Performance Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Bradley C Nindl
- Neuromuscular Research Laboratory/Warrior Human Performance Research Center, University of Pittsburgh, Pittsburgh, PA, USA
| |
Collapse
|
4
|
Tenforde AS, Ackerman KE, Bouxsein ML, Gaudette L, McCall L, Rudolph SE, Gehman S, Garrahan M, Hughes JM, Outerleys J, Davis IS, Popp KL. Factors Associated With High-Risk and Low-Risk Bone Stress Injury in Female Runners: Implications for Risk Factor Stratification and Management. Orthop J Sports Med 2024; 12:23259671241246227. [PMID: 38779133 PMCID: PMC11110515 DOI: 10.1177/23259671241246227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 10/24/2023] [Indexed: 05/25/2024] Open
Abstract
Background Bone stress injury (BSI) is a common overuse injury in active women. BSIs can be classified as high-risk (pelvis, sacrum, and femoral neck) or low-risk (tibia, fibula, and metatarsals). Risk factors for BSI include low energy availability, menstrual dysfunction, and poor bone health. Higher vertical load rates during running have been observed in women with a history of BSI. Purpose/Hypothesis The purpose of this study was to characterize factors associated with BSI in a population of premenopausal women, comparing those with a history of high-risk or low-risk BSI with those with no history of BSI. It was hypothesized that women with a history of high-risk BSI would be more likely to exhibit lower bone mineral density (BMD) and related factors and less favorable bone microarchitecture compared with women with a history of low-risk BSI. In contrast, women with a history of low-risk BSI would have higher load rates. Study Design Cross-sectional study; Level of evidence, 3. Methods Enrolled were 15 women with a history of high-risk BSI, 15 with a history of low-risk BSI, and 15 with no history of BSI. BMD for the whole body, hip, and spine was standardized using z scores on dual-energy x-ray absorptiometry. High-resolution peripheral quantitative computed tomography was used to quantify bone microarchitecture at the radius and distal tibia. Participants completed surveys characterizing factors that influence bone health-including sleep, menstrual history, and eating behaviors-utilizing the Eating Disorder Examination Questionnaire (EDE-Q). Each participant completed a biomechanical assessment using an instrumented treadmill to measure load rates before and after a run to exertion. Results Women with a history of high-risk BSI had lower spine z scores than those with low-risk BSI (-1.04 ± 0.76 vs -0.01 ± 1.15; P < .05). Women with a history of high-risk BSI, compared with low-risk BSI and no BSI, had the highest EDE-Q subscores for Shape Concern (1.46 ± 1.28 vs 0.76 ± 0.78 and 0.43 ± 0.43) and Eating Concern (0.55 ± 0.75 vs 0.16 ± 0.38 and 0.11 ± 0.21), as well as the greatest difference between minimum and maximum weight at current height (11.3 ± 5.4 vs 7.7 ± 2.9 and 7.6 ± 3.3 kg) (P < .05 for all). Women with a history of high-risk BSI were more likely than those with no history of BSI to sleep <7 hours on average per night during the week (80% vs 33.3%; P < .05). The mean and instantaneous vertical load rates were not different between groups. Conclusion Women with a history of high-risk BSI were more likely to exhibit risk factors for poor bone health, including lower BMD, while load rates did not distinguish women with a history of BSI.
Collapse
Affiliation(s)
- Adam S Tenforde
- Department of Physical Medicine and Rehabilitation, Spaulding National Running Center, Spaulding Rehabilitation Hospital, Harvard Medical School, Cambridge, Massachusetts, USA
| | - Kathryn E Ackerman
- Wu Tsai Female Athlete Program, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mary L Bouxsein
- Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Center for Advanced Orthopedic Studies, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Logan Gaudette
- Department of Physical Medicine and Rehabilitation, Spaulding National Running Center, Spaulding Rehabilitation Hospital, Harvard Medical School, Cambridge, Massachusetts, USA
| | - Lauren McCall
- Wu Tsai Female Athlete Program, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sara E Rudolph
- Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sarah Gehman
- Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Margaret Garrahan
- Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Julie M Hughes
- Military Performance Division, United States Army Research Institute of Environmental Medicine, Natick, Massachusetts, USA
| | - Jereme Outerleys
- Department of Physical Medicine and Rehabilitation, Spaulding National Running Center, Spaulding Rehabilitation Hospital, Harvard Medical School, Cambridge, Massachusetts, USA
| | - Irene S Davis
- School of Physical Therapy Tampa, University of South Florida, Florida, USA
| | - Kristin L Popp
- Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Military Performance Division, United States Army Research Institute of Environmental Medicine, Natick, Massachusetts, USA
- Oak Ridge Associated Universities, Oak Ridge, Tennessee, USA. A.S.T., K.E.A., and M.L.B. contributed equally to this study. I.S.D. and K.L.P. contributed equally to this study
| |
Collapse
|
5
|
Watts V GJ, Tai R, Joshi G, Garwood E, Saha D. Reinjury Following Return to Play. Semin Musculoskelet Radiol 2024; 28:154-164. [PMID: 38484768 DOI: 10.1055/s-0043-1778022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Radiologists are frequently called on for guidance regarding return to play (RTP) for athletes and active individuals after sustaining a musculoskeletal injury. Avoidance of reinjury is of particular importance throughout the rehabilitative process and following resumption of competitive activity. Understanding reinjury risk estimation, imaging patterns, and correlation of clinical and surgical findings will help prepare the radiologist to identify reinjuries correctly on diagnostic imaging studies and optimize management for a safe RTP.
Collapse
Affiliation(s)
- George J Watts V
- Division of Musculoskeletal Imaging and Intervention, Department of Radiology, UMass Chan Medical School, Worcester, Massachusetts
| | - Ryan Tai
- Division of Musculoskeletal Imaging and Intervention, Department of Radiology, UMass Chan Medical School, Worcester, Massachusetts
| | - Ganesh Joshi
- Division of Musculoskeletal Imaging and Intervention, Department of Radiology, UMass Chan Medical School, Worcester, Massachusetts
| | - Elisabeth Garwood
- Division of Musculoskeletal Imaging and Intervention, Department of Radiology, UMass Chan Medical School, Worcester, Massachusetts
| | - Debajyoti Saha
- Division of Musculoskeletal Imaging and Intervention, Department of Radiology, UMass Chan Medical School, Worcester, Massachusetts
| |
Collapse
|
6
|
Haines MS, Kimball A, Dove D, Chien M, Strauch J, Santoso K, Meenaghan E, Eddy KT, Fazeli PK, Misra M, Miller KK. Deficits in volumetric bone mineral density, bone microarchitecture, and estimated bone strength in women with atypical anorexia nervosa compared to healthy controls. Int J Eat Disord 2024; 57:785-798. [PMID: 37322610 PMCID: PMC10721730 DOI: 10.1002/eat.24014] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 06/05/2023] [Accepted: 06/06/2023] [Indexed: 06/17/2023]
Abstract
OBJECTIVE Anorexia nervosa is associated with low bone mineral density (BMD) and deficits in bone microarchitecture and strength. Low BMD is common in atypical anorexia nervosa, in which criteria for anorexia nervosa are met except for low weight. We investigated whether women with atypical anorexia nervosa have deficits in bone microarchitecture and estimated strength at the peripheral skeleton. METHOD Measures of BMD and microarchitecture were obtained in 28 women with atypical anorexia nervosa and 27 controls, aged 21-46 years. RESULTS Mean tibial volumetric BMD, cortical thickness, and failure load were lower, and radial trabecular number and separation impaired, in atypical anorexia nervosa versus controls (p < .05). Adjusting for weight, deficits in tibial cortical bone variables persisted (p < .05). Women with atypical anorexia nervosa and amenorrhea had lower volumetric BMD and deficits in microarchitecture and failure load versus those with eumenorrhea and controls. Those with a history of overweight/obesity or fracture had deficits in bone microarchitecture versus controls. Tibial deficits were particularly marked. Less lean mass and longer disease duration were associated with deficits in high-resolution peripheral quantitative computed tomography (HR-pQCT) variables in atypical anorexia nervosa. DISCUSSION Women with atypical anorexia nervosa have lower volumetric BMD and deficits in bone microarchitecture and strength at the peripheral skeleton versus controls, independent of weight, and particularly at the tibia. Women with atypical anorexia nervosa and amenorrhea, less lean mass, longer disease duration, history of overweight/obesity, or fracture history may be at higher risk. This is salient as deficits in HR-pQCT variables are associated with increased fracture risk. PUBLIC SIGNIFICANCE Atypical anorexia nervosa is a psychiatric disorder in which psychological criteria for anorexia nervosa are met despite weight being in the normal range. We demonstrate that despite weight in the normal range, women with atypical anorexia nervosa have impaired bone density, structure, and strength compared to healthy controls. Whether this translates to an increased risk of incident fracture in this population requires further investigation.
Collapse
Affiliation(s)
- Melanie S Haines
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Allison Kimball
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Devanshi Dove
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Melanie Chien
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Julianne Strauch
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kate Santoso
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Erinne Meenaghan
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kamryn T Eddy
- Harvard Medical School, Boston, Massachusetts, USA
- Eating Disorders Clinical and Research Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Pouneh K Fazeli
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Madhusmita Misra
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Pediatric Endocrinology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Karen K Miller
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
7
|
Haines MS, Kaur S, Scarff G, Lauze M, Gerweck A, Slattery M, Oreskovic NM, Ackerman KE, Tenforde AS, Popp KL, Bouxsein ML, Miller KK, Misra M. Male Runners With Lower Energy Availability Have Impaired Skeletal Integrity Compared to Nonathletes. J Clin Endocrinol Metab 2023; 108:e1063-e1073. [PMID: 37079740 PMCID: PMC10505543 DOI: 10.1210/clinem/dgad215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 12/19/2022] [Accepted: 04/18/2023] [Indexed: 04/22/2023]
Abstract
CONTEXT Female athletes, particularly runners, with insufficient caloric intake for their energy expenditure [low energy availability (EA) or relative energy deficiency] are at risk for impaired skeletal integrity. Data are lacking in male runners. OBJECTIVE To determine whether male runners at risk for energy deficit have impaired bone mineral density (BMD), microarchitecture, and estimated strength. DESIGN Cross-sectional. SETTING Clinical research center. PARTICIPANTS 39 men (20 runners, 19 controls), ages 16-30 years. MAIN OUTCOME MEASURES Areal BMD (dual-energy x-ray absorptiometry); tibia and radius volumetric BMD and microarchitecture (high-resolution peripheral quantitative computed tomography); failure load (microfinite element analysis); serum testosterone, estradiol, leptin; energy availability. RESULTS Mean age (24.5 ± 3.8 y), lean mass, testosterone, and estradiol levels were similar; body mass index, percent fat mass, leptin, and lumbar spine BMD Z-score (-1.4 ± 0.8 vs -0.8 ± 0.8) lower (P < .05); and calcium intake and running mileage higher (P ≤ .01) in runners vs controls. Runners with EA CONCLUSIONS Despite weight-bearing activity, skeletal integrity is impaired in male runners with lower caloric intake relative to exercise energy expenditure, which may increase bone stress injury risk. Lower estradiol and lean mass are associated with lower tibial strength in runners.
Collapse
Affiliation(s)
- Melanie S Haines
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, MA 02114, USA
- Harvard Medical School, Boston, MA 02115, USA
| | - Snimarjot Kaur
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, MA 02114, USA
- Harvard Medical School, Boston, MA 02115, USA
| | - Geetanjali Scarff
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Meghan Lauze
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Anu Gerweck
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Meghan Slattery
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Nicolas M Oreskovic
- Harvard Medical School, Boston, MA 02115, USA
- Department of Internal Medicine and Pediatrics, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Kathryn E Ackerman
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, MA 02114, USA
- Harvard Medical School, Boston, MA 02115, USA
- Female Athlete Program, Division of Sports Medicine, Boston Children's Hospital, Boston, MA 02115, USA
| | - Adam S Tenforde
- Harvard Medical School, Boston, MA 02115, USA
- Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Cambridge, MA 02129, USA
| | - Kristin L Popp
- Harvard Medical School, Boston, MA 02115, USA
- Endocrine Unit, Massachusetts General Hospital, Boston, MA 02114, USA
- Military Performance Division, United States Army Research Institute of Environmental Medicine, Natick, MA 01760, USA
- Department of Energy, Oak Ridge Institute for Science and Education, Oak Ridge, TN 37830, USA
| | - Mary L Bouxsein
- Harvard Medical School, Boston, MA 02115, USA
- Endocrine Unit, Massachusetts General Hospital, Boston, MA 02114, USA
- Center for Advanced Orthopedic Studies, Beth Israel Deaconess Medical Center, Boston, MA 02115, USA
| | - Karen K Miller
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, MA 02114, USA
- Harvard Medical School, Boston, MA 02115, USA
| | - Madhusmita Misra
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, MA 02114, USA
- Harvard Medical School, Boston, MA 02115, USA
- Division of Pediatric Endocrinology, Massachusetts General Hospital, Boston, MA 02114, USA
| |
Collapse
|
8
|
Redinger AL, Allen SMF, Buchanan SR, Black CD, Baker BS. Non-traditional HIIT-style ROTC training elicits positive bone quality and performance adaptations. J Sports Sci 2023; 41:1587-1595. [PMID: 38126323 DOI: 10.1080/02640414.2023.2283998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 11/09/2023] [Indexed: 12/23/2023]
Abstract
Military personnel experience elevated bone injury incidence, partly due to arduous and repetitive training. Non-traditional High-Intensity Interval Training-style (HIIT) may benefit pre-enlisted Reserve Officer Training Corps (ROTC) cadet's musculoskeletal health and performance prior to military service. This study investigated 16 ROTC (n = 12 males; n = 4 females) and 15 physically active sex-, age-, and body mass-matched Controls' musculoskeletal health and performance from November to April. Total body, lumbar spine, and dual- hip dual-energy X-ray absorptiometry scans and 4%, 38%, 66% tibial peripheral quantitative computed tomography scans, blood draws (serum sclerostin and parathyroid hormone), and maximal muscle strength and aerobic capacity testing were completed. From November to April, ROTC improved bone density (DXA) of the dominant total hip and greater trochanter and non-dominant greater trochanter and 38% and 66% tibial total volumetric and cortical bone density (pQCT) similarly or more than Controls (all p ≤ 0.049). From November to April, ROTC also improved bench and leg press, and peak aerobic capacity (all p ≤ 0.013). From November to January, serum sclerostin increased (p ≤ 0.007) and remained elevated through April, while parathyroid hormone was unchanged. HIIT-style training induced positive musculoskeletal adaptations, suggesting it may be an excellent pre-service training modality for this injury prone group.
Collapse
Affiliation(s)
- Allen L Redinger
- Musculoskeletal Adaptations to Aging and eXercise (MAAX) Lab, Oklahoma State University, Stillwater, OK, USA
| | - Shawn M F Allen
- Musculoskeletal Adaptations to Aging and eXercise (MAAX) Lab, Oklahoma State University, Stillwater, OK, USA
| | - Samuel R Buchanan
- Department of Health and Human Performance, University of Texas Rio Grande Valley, Edinburg, TX, USA
- Department of Health and Exercise Science, University of Oklahoma, Norman, OK, USA
| | - Christopher D Black
- Department of Health and Exercise Science, University of Oklahoma, Norman, OK, USA
| | - Breanne S Baker
- Musculoskeletal Adaptations to Aging and eXercise (MAAX) Lab, Oklahoma State University, Stillwater, OK, USA
- Department of Health and Exercise Science, University of Oklahoma, Norman, OK, USA
| |
Collapse
|
9
|
Beling A, Saxena A, Hollander K, Tenforde AS. Outcomes Using Focused Shockwave for Treatment of Bone Stress Injury in Runners. Bioengineering (Basel) 2023; 10:885. [PMID: 37627770 PMCID: PMC10451564 DOI: 10.3390/bioengineering10080885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 07/13/2023] [Accepted: 07/17/2023] [Indexed: 08/27/2023] Open
Abstract
Bone stress injury (BSI) is a common overuse injury that can result in prolonged time away from sport. Limited studies have characterized the use of extracorporeal shockwave therapy (ESWT) for the treatment of BSI. The purpose of this study was to describe the use of ESWT for the management of BSI in runners. A retrospective chart review was performed to identify eligible patients in a single physician's clinic from 1 August 2018 to 30 September 2022. BSI was identified in 40 runners with 41 injuries (28 females; average age and standard deviation: 30 ± 13 years; average pre-injury training 72 ± 40 km per week). Overall, 63% (n = 26) met the criteria for moderate- or high-risk Female or Male Athlete Triad categories. Runners started ESWT at a median of 36 days (IQR 11 to 95 days; range 3 days to 8 years) from BSI diagnosis. On average, each received 5 ± 2 total focused ESWT treatments. Those with acute BSI (ESWT started <3 months from BSI diagnosis) had an average return to run at 12.0 ± 7.5 weeks, while patients with delayed union (>3 months, n = 3) or non-union (>6 months, n = 9) had longer time for return to running (19.8 ± 14.8 weeks, p = 0.032). All runners returned to pain-free running after ESWT except one runner with non-union of grade 4 navicular BSI who opted for surgery. No complications were observed with ESWT. These findings suggest that focused ESWT may be a safe treatment for the management of BSI in runners.
Collapse
Affiliation(s)
- Alexandra Beling
- Spaulding Rehabilitation Hospital, 300 First Avenue, Charlestown, MA 02129, USA
| | - Amol Saxena
- Palo Alto Medical Foundation, Palo Alto, CA 94301, USA
| | - Karsten Hollander
- Institute of Interdisciplinary Exercise Science and Sports Medicine, Medical School Hamburg, 20457 Hamburg, Germany
| | - Adam S. Tenforde
- Spaulding Rehabilitation Hospital, 300 First Avenue, Charlestown, MA 02129, USA
| |
Collapse
|
10
|
Hoenig T, Eissele J, Strahl A, Popp KL, Stürznickel J, Ackerman KE, Hollander K, Warden SJ, Frosch KH, Tenforde AS, Rolvien T. Return to sport following low-risk and high-risk bone stress injuries: a systematic review and meta-analysis. Br J Sports Med 2023; 57:427-432. [PMID: 36720584 DOI: 10.1136/bjsports-2022-106328] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2023] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Bone stress injuries (BSIs) are classified in clinical practice as being at low- or high-risk for complication based on the injury location. However, this dichotomous approach has not been sufficiently validated. The purpose of this systematic review was to examine the prognostic role of injury location on return-to-sport (RTS) and treatment complications after BSI of the lower extremity and pelvis. DESIGN Systematic review and meta-analysis. DATA SOURCES PubMed, Web of Science, Cochrane CENTRAL and Google Scholar databases were searched from database inception to December 2021. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Peer-reviewed studies that reported site-specific RTS of BSIs in athletes. RESULTS Seventy-six studies reporting on 2974 BSIs were included. Sixteen studies compared multiple injury sites, and most of these studies (n=11) described the anatomical site of injury as being prognostic for RTS or the rate of treatment complication. Pooled data revealed the longest time to RTS for BSIs of the tarsal navicular (127 days; 95% CI 102 to 151 days) and femoral neck (107 days; 95% CI 79 to 135 days) and shortest duration of time for BSIs of the posteromedial tibial shaft (44 days, 95% CI 27 to 61 days) and fibula (56 days; 95% CI 13 to 100 days). Overall, more than 90% of athletes successfully returned to sport. Treatment complication rate was highest in BSIs of the femoral neck, tarsal navicular, anterior tibial shaft and fifth metatarsal; and lowest in the fibula, pubic bone and posteromedial tibial shaft. CONCLUSION This systematic review supports that the anatomical site of BSIs influences RTS timelines and the risk of complication. BSIs of the femoral neck, anterior tibial shaft and tarsal navicular are associated with increased rates of complications and more challenging RTS. PROSPERO REGISTRATION NUMBER CRD42021232351.
Collapse
Affiliation(s)
- Tim Hoenig
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Julian Eissele
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - André Strahl
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kristin L Popp
- Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- U.S. Army Research Institute of Environmental Medicine, Natick, Massachusetts, USA
- TRIA Orthopedic Center, Bloomington, Minnesota, USA
| | - Julian Stürznickel
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kathryn E Ackerman
- Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Division of Sports Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Karsten Hollander
- Institute of Interdisciplinary Exercise Science and Sports Medicine, MSH Medical School Hamburg, Hamburg, Germany
| | - Stuart J Warden
- Department of Physical Therapy, School of Health & Human Sciences, Indiana University, Indianapolis, Indiana, USA
- Indiana Center for Musculoskeletal Health, Indiana University, Indianapolis, Indiana, USA
| | - Karl-Heinz Frosch
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Adam S Tenforde
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Cambridge, Massachusetts, USA
| | - Tim Rolvien
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
11
|
Haines MS, Kimball A, Meenaghan E, Santoso K, Colling C, Singhal V, Ebrahimi S, Gleysteen S, Schneider M, Ciotti L, Belfer P, Eddy KT, Misra M, Miller KK. Denosumab increases spine bone density in women with anorexia nervosa: a randomized clinical trial. Eur J Endocrinol 2022; 187:697-708. [PMID: 36134902 PMCID: PMC9746654 DOI: 10.1530/eje-22-0248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 09/21/2022] [Indexed: 12/15/2022]
Abstract
Objective Anorexia nervosa is complicated by high bone resorption, low bone mineral density (BMD), and increased fracture risk. We investigated whether off-label antiresorptive therapy with denosumab increases BMD in women with anorexia nervosa. Design Twelve-month, randomized, double-blind, placebo-controlled study. Methods Thirty ambulatory women with anorexia nervosa and areal BMD (aBMD) T-score <-1.0 at ≥1 sites were randomized to 12 months of denosumab (60 mg subcutaneously q6 months)(n = 20) or placebo (n = 10). Primary end point was postero-anterior (PA) lumbar spine aBMD by dual-energy x-ray absorptiometry. Secondary end points included femoral neck aBMD, tibia and radius volumetric BMD and bone microarchitecture by high-resolution peripheral quantitative CT, tibia and radius failure load by finite element analysis (FEA), and markers of bone turnover. Results Baseline mean (±s.d.) age (29 ± 8 (denosumab) vs 29 ± 7 years (placebo)), BMI (19.0 ± 1.7 vs 18.0 ± 2.0 kg/m2), and aBMD (PA spine Z-score -1.6±1.1 vs -1.7±1.4) were similar between groups. PA lumbar spine aBMD increased in the denosumab vs placebo group over 12 months (P = 0.009). The mean (95% CI) increase in PA lumbar spine aBMD was 5.5 (3.8-7.2)% in the denosumab group and 2.2 (-0.3-4.7)% in the placebo group. The change in femoral neck aBMD was similar between groups. Radial trabecular number increased, radial trabecular separation decreased, and tibial cortical porosity decreased in the denosumab vs placebo group (P ≤ 0.006). Serum C-terminal telopeptide of type I collagen and procollagen type I N-terminal propeptide decreased in the denosumab vs placebo group (P < 0.0001). Denosumab was well tolerated. Conclusions Twelve months of antiresorptive therapy with denosumab reduced bone turnover and increased spine aBMD, the skeletal site most severely affected in women with anorexia nervosa.
Collapse
Affiliation(s)
- Melanie S Haines
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Allison Kimball
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Erinne Meenaghan
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kate Santoso
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Caitlin Colling
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Vibha Singhal
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Pediatric Endocrinology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Seda Ebrahimi
- Cambridge Eating Disorder Center, Cambridge, Massachusetts, USA
| | - Suzanne Gleysteen
- Harvard Medical School, Boston, Massachusetts, USA
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Marcie Schneider
- Greenwich Adolescent & Young Adult Medicine, Greenwich, Connecticut, USA
| | - Lori Ciotti
- The Renfrew Center, Boston, Massachusetts, USA
| | - Perry Belfer
- Harvard Medical School, Boston, Massachusetts, USA
- Newton-Wellesley Eating Disorders & Behavioral Medicine, Brookline, Massachusetts, USA
- McLean Hospital, Belmont, Massachusetts, USA
| | - Kamryn T Eddy
- Harvard Medical School, Boston, Massachusetts, USA
- Eating Disorders Clinical and Research Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Madhusmita Misra
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Pediatric Endocrinology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Karen K Miller
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
12
|
Stürznickel J, Hinz N, Delsmann MM, Hoenig T, Rolvien T. Impaired Bone Microarchitecture at Distal Radial and Tibial Reference Locations Is Not Related to Injury Site in Athletes With Bone Stress Injury. Am J Sports Med 2022; 50:3381-3389. [PMID: 36053067 PMCID: PMC9527365 DOI: 10.1177/03635465221120385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Bone stress injuries (BSIs) are common sports injuries that occur because of an imbalance between microdamage accumulation and removal through bone remodeling. The underlying bone phenotype has been assumed to be a contributing factor. However, the bone microarchitecture of athletes with BSI is not well characterized, and no study has investigated whether impaired bone microarchitecture is associated with bone composition or anatomic site of injury. PURPOSE/HYPOTHESIS This cross-sectional study characterizes the bone microarchitecture at distal radial and tibial reference locations in athletes with BSI. Based on previous dual-energy X-ray absorptiometry (DXA) findings, the aim was to compare anatomic injury sites, hypothesizing that athletes with BSIs in bones with greater trabecular composition show impaired bone microarchitecture parameters compared with those with BSIs in bones with greater cortical composition. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS Athletes who had presented to our outpatient clinic because of a high-grade BSI (ie, stress fracture) were retrospectively included. Blood and urine samples were collected. Areal bone mineral density (aBMD) was assessed by DXA at the lumbar spine and both hips. Bone microarchitecture was analyzed by high-resolution peripheral quantitative computed tomography (HR-pQCT) at the distal radius and tibia. HR-pQCT parameters were expressed in relation to available sex-, age-, and device-adjusted reference values and compared with a cohort of 53 age- and sex-matched controls. RESULTS In total, 53 athletes had a BSI of the foot (n = 20), tibia/fibula (n = 18), pelvis (n = 9), femur (n = 5), or sternum (n = 1). Based on DXA measurements, a Z-score of -1.0 or lower was found in 32 of 53 (60.4%) of the athletes, of whom 16 of 53 (30.2%) had a Z score -2.0 or lower. While an impairment of cortical area (P = .034 and P = .001) and thickness (P = .029 and P < .001) was detected at the distal radius and tibia in the BSI cohort compared with controls, no differences in BMD or bone microarchitecture were observed between anatomic injury sites. Furthermore, no difference was revealed when BSIs were grouped into cortical- and trabecular-rich sites. CONCLUSION Reduced aBMD and impaired cortical bone microarchitecture were present in a considerable number of athletes with BSI. Neither aBMD nor bone microarchitecture was related to the injury site, highlighting the multifactorial etiology of BSI.
Collapse
Affiliation(s)
- Julian Stürznickel
- Department of Osteology and
Biomechanics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany,Department of Trauma and Orthopaedic
Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany,Julian Stürznickel, MD,
Department of Osteology and Biomechanics, University Medical Center
Hamburg-Eppendorf, Lottestraße 59, 22529 Hamburg, Germany (
); or Tim Rolvien, MD, PhD, MBA,
Division of Orthopaedics, Department of Trauma and Orthopaedic Surgery,
University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg,
Germany ()
| | - Nico Hinz
- Department of Trauma and Orthopaedic
Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany,Department of Trauma Surgery,
Orthopaedics and Sports Traumatology, BG Hospital Hamburg, Hamburg, Germany
| | - Maximilian M. Delsmann
- Department of Osteology and
Biomechanics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany,Department of Trauma and Orthopaedic
Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tim Hoenig
- Department of Trauma and Orthopaedic
Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tim Rolvien
- Department of Trauma and Orthopaedic
Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany,Julian Stürznickel, MD,
Department of Osteology and Biomechanics, University Medical Center
Hamburg-Eppendorf, Lottestraße 59, 22529 Hamburg, Germany (
); or Tim Rolvien, MD, PhD, MBA,
Division of Orthopaedics, Department of Trauma and Orthopaedic Surgery,
University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg,
Germany ()
| |
Collapse
|
13
|
Alway P, Peirce N, Johnson W, King M, Kerslake R, Brooke-Wavell K. Activity specific areal bone mineral density is reduced in athletes with stress fracture and requires profound recovery time: A study of lumbar stress fracture in elite cricket fast bowlers. J Sci Med Sport 2022; 25:828-833. [PMID: 36064501 DOI: 10.1016/j.jsams.2022.08.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 08/10/2022] [Accepted: 08/12/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The aims of this study were to determine whether lumbar areal bone mineral density differed between cricket fast bowlers with and without lumbar stress fracture, and whether bone mineral density trajectories differed between groups during rehabilitation. DESIGN Cross-sectional and cohort. METHODS 29 elite male fast bowlers received a post-season anteroposterior lumbar dual-energy X-ray absorptiometry scan and a lumbar magnetic resonance imaging scan to determine stress fracture status. Participants were invited for three additional scans across the 59 weeks post baseline or diagnosis of injury. Bone mineral density was measured at L1 - L4 and ipsilateral and contralateral L3 and L4 sites. Independent-sample t-tests determined baseline differences in bone mineral density and multilevel models were used to examine differences in bone mineral density trajectories over time between injured and uninjured participants. RESULTS 17 participants with lumbar stress fracture had lower baseline bone mineral density at L1 - L4 (7.6 %, p = 0.034) and contralateral sites (8.8-10.4 %, p = 0.038-0.058) than uninjured participants. Bone mineral density at all sites decreased 1.9-3.0 % by 20-24 weeks before increasing to above baseline levels by 52 weeks post injury. CONCLUSIONS Injured fast bowlers had lower lumbar bone mineral density at diagnosis that decreased following injury and did not return to baseline until up to a year post-diagnosis. Localised maladaptation of bone mineral density may contribute to lumbar stress fracture. Bone mineral density loss following injury may increase risk of recurrence, therefore fast bowlers require careful management when returning to play.
Collapse
Affiliation(s)
- Peter Alway
- School of Sport, Exercise and Health Sciences, Loughborough University, United Kingdom; Department of Science and Medicine, England and Wales Cricket Board, United Kingdom.
| | - Nicholas Peirce
- Department of Science and Medicine, England and Wales Cricket Board, United Kingdom
| | - William Johnson
- School of Sport, Exercise and Health Sciences, Loughborough University, United Kingdom
| | - Mark King
- School of Sport, Exercise and Health Sciences, Loughborough University, United Kingdom
| | | | | |
Collapse
|
14
|
Gabel L, Liphardt AM, Hulme PA, Heer M, Zwart SR, Sibonga JD, Smith SM, Boyd SK. Incomplete recovery of bone strength and trabecular microarchitecture at the distal tibia 1 year after return from long duration spaceflight. Sci Rep 2022; 12:9446. [PMID: 35773442 PMCID: PMC9247070 DOI: 10.1038/s41598-022-13461-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 05/05/2022] [Indexed: 11/17/2022] Open
Abstract
Determining the extent of bone recovery after prolonged spaceflight is important for understanding risks to astronaut long-term skeletal health. We examined bone strength, density, and microarchitecture in seventeen astronauts (14 males; mean 47 years) using high-resolution peripheral quantitative computed tomography (HR-pQCT; 61 μm). We imaged the tibia and radius before spaceflight, at return to Earth, and after 6- and 12-months recovery and assessed biomarkers of bone turnover and exercise. Twelve months after flight, group median tibia bone strength (F.Load), total, cortical, and trabecular bone mineral density (BMD), trabecular bone volume fraction and thickness remained − 0.9% to − 2.1% reduced compared with pre-flight (p ≤ 0.001). Astronauts on longer missions (> 6-months) had poorer bone recovery. For example, F.Load recovered by 12-months post-flight in astronauts on shorter (< 6-months; − 0.4% median deficit) but not longer (− 3.9%) missions. Similar disparities were noted for total, trabecular, and cortical BMD. Altogether, nine of 17 astronauts did not fully recover tibia total BMD after 12-months. Astronauts with incomplete recovery had higher biomarkers of bone turnover compared with astronauts whose bone recovered. Study findings suggest incomplete recovery of bone strength, density, and trabecular microarchitecture at the weight-bearing tibia, commensurate with a decade or more of terrestrial age-related bone loss.
Collapse
Affiliation(s)
- Leigh Gabel
- Human Performance Laboratory, Faculty of Kinesiology, University of Calgary, Calgary, Canada.,McCaig Institute for Bone and Joint Health, University of Calgary, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
| | - Anna-Maria Liphardt
- Department of Internal Medicine, Rheumatology and Immunology, German Centre for Immune Therapy, Friedrich-Alexander-Universität Erlangen-Nürnberg and Universitätsklinikum Erlangen, Erlangen, Germany
| | - Paul A Hulme
- McCaig Institute for Bone and Joint Health, University of Calgary, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
| | - Martina Heer
- IU International University of Applied Sciences Erfurt and Department of Nutrition and Food Science, Nutritional Physiology, University of Bonn, Bonn, Germany
| | - Sara R Zwart
- Department of Preventive Medicine and Population Health, University of Texas Medical Branch, Galveston, TX, USA
| | - Jean D Sibonga
- Human Heath and Performance Directorate, NASA Lyndon B. Johnson Space Center, Houston, USA
| | - Scott M Smith
- Human Heath and Performance Directorate, NASA Lyndon B. Johnson Space Center, Houston, USA
| | - Steven K Boyd
- McCaig Institute for Bone and Joint Health, University of Calgary, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada. .,Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, Canada.
| |
Collapse
|
15
|
Restrictive Eating and Prior Low-Energy Fractures Are Associated With History of Multiple Bone Stress Injuries. Int J Sport Nutr Exerc Metab 2022; 32:325-333. [PMID: 35523419 DOI: 10.1123/ijsnem.2021-0323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 04/01/2022] [Accepted: 04/05/2022] [Indexed: 11/18/2022]
Abstract
Bone stress injuries (BSIs) are common among athletes and have high rates of recurrence. However, risk factors for multiple or recurrent BSIs remain understudied. Thus, we aimed to explore whether energy availability, menstrual function, measures of bone health, and a modified Female Athlete Triad Cumulative Risk Assessment (CRA) tool are associated with a history of multiple BSIs. We enrolled 51 female runners (ages 18-36 years) with history of ≤1 BSI (controls; n = 31) or ≥3 BSIs (multiBSI; n = 20) in this cross-sectional study. We measured lumbar spine, total hip, and femoral neck areal bone mineral density by dual-energy X-ray absorptiometry, bone material strength index using impact microindentation, and volumetric bone mineral density, microarchitecture, and estimated strength by high-resolution peripheral quantitative computed tomography. Participants completed questionnaires regarding medical history, low-energy fracture history, and disordered eating attitudes. Compared with controls, multiBSI had greater incidence of prior low-energy fractures (55% vs. 16%, p = .005) and higher modified Triad CRA scores (2.90 ± 2.05 vs. 1.84 ± 1.59, p = .04). Those with multiBSI had higher Eating Disorder Examination Questionnaire (0.92 ± 1.03 vs. 0.46 ± 0.49, p = .04) scores and a greater percentage difference between lowest and highest body mass at their current height (15.5% ± 6.5% vs. 11.5% ± 4.9% p = .02). These preliminary findings indicate that women with a history of multiple BSIs suffered more prior low-energy fractures and have greater historical and current estimates of energy deficit compared with controls. Our results provide strong rationale for future studies to examine whether subclinical indicators of energy deficit contribute to risk for multiple BSIs in female runners.
Collapse
|
16
|
Jonvik KL, Torstveit MK, Sundgot-Borgen JK, Mathisen TF. Last Word on Viewpoint: Do we need to change the guideline values for determining low bone mineral density in athletes? J Appl Physiol (1985) 2022; 132:1325-1326. [PMID: 35608156 PMCID: PMC9208431 DOI: 10.1152/japplphysiol.00227.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 04/19/2022] [Indexed: 11/22/2022] Open
Affiliation(s)
- Kristin L Jonvik
- Department of Physical Performance, Norwegian School of Sport Sciences, Oslo, Norway
| | - Monica K Torstveit
- Department of Sport Science and Physical Education, University of Agder, Kristiansand, Norway
| | | | | |
Collapse
|
17
|
Popp KL, Cooke LM, Bouxsein ML, Hughes JM. Impact of Low Energy Availability on Skeletal Health in Physically Active Adults. Calcif Tissue Int 2022; 110:605-614. [PMID: 35171303 DOI: 10.1007/s00223-022-00957-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 02/04/2022] [Indexed: 12/13/2022]
Abstract
For decades researchers reported that pre-menopausal women who engage in extensive endurance exercise and have menstrual dysfunction can develop low bone mineral density (BMD) or osteoporosis. More recently, low energy availability has been recognized as the initiating factor for low BMD in these women. Furthermore, the relationship between low energy availability and poor skeletal health is not exclusive to women engaging in endurance exercise. Rather, both males and females commonly experience endocrine dysfunction resulting from low energy availability and high exercise levels that degrades skeletal health. Consequences to skeletal health can range from short-term changes in bone metabolism and increased risk of bone stress injuries to long-term consequences of low BMD, such as osteoporosis and related fragility fractures. The degree to which low energy availability degrades skeletal health may be dependent on the length and extent of the energy deficit. However, the complex relationships between under-fueling, short- and long-term skeletal consequences and the factors that mediate these relationships are not well described. In this review, we discuss the consequences of low energy availability on sex hormones and skeletal health in two highly-active populations-athletes and military trainees-and provide a summary of existing knowledge gaps for future study.
Collapse
Affiliation(s)
- Kristin L Popp
- United States Army Research Institute of Environmental Medicine, 10 General Greene Ave, Natick, MA, 01760, USA.
- Massachusetts General Hospital, Boston, MA, 02114, USA.
- Harvard Medical School, Boston, MA, 02215, USA.
| | - Laura M Cooke
- Massachusetts General Hospital, Boston, MA, 02114, USA
| | - Mary L Bouxsein
- United States Army Research Institute of Environmental Medicine, 10 General Greene Ave, Natick, MA, 01760, USA
- Massachusetts General Hospital, Boston, MA, 02114, USA
- Harvard Medical School, Boston, MA, 02215, USA
- Center for Advanced Orthopedic Studies, Beth Israel Deaconess Medical Center, Boston, MA, 02215, USA
| | - Julie M Hughes
- United States Army Research Institute of Environmental Medicine, 10 General Greene Ave, Natick, MA, 01760, USA
| |
Collapse
|
18
|
Hoenig T, Ackerman KE, Beck BR, Bouxsein ML, Burr DB, Hollander K, Popp KL, Rolvien T, Tenforde AS, Warden SJ. Bone stress injuries. Nat Rev Dis Primers 2022; 8:26. [PMID: 35484131 DOI: 10.1038/s41572-022-00352-y] [Citation(s) in RCA: 43] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/11/2022] [Indexed: 01/11/2023]
Abstract
Bone stress injuries, including stress fractures, are overuse injuries that lead to substantial morbidity in active individuals. These injuries occur when excessive repetitive loads are introduced to a generally normal skeleton. Although the precise mechanisms for bone stress injuries are not completely understood, the prevailing theory is that an imbalance in bone metabolism favours microdamage accumulation over its removal and replacement with new bone via targeted remodelling. Diagnosis is achieved by a combination of patient history and physical examination, with imaging used for confirmation. Management of bone stress injuries is guided by their location and consequent risk of healing complications. Bone stress injuries at low-risk sites typically heal with activity modification followed by progressive loading and return to activity. Additional treatment approaches include non-weight-bearing immobilization, medications or surgery, but these approaches are usually limited to managing bone stress injuries that occur at high-risk sites. A comprehensive strategy that integrates anatomical, biomechanical and biological risk factors has the potential to improve the understanding of these injuries and aid in their prevention and management.
Collapse
Affiliation(s)
- Tim Hoenig
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Kathryn E Ackerman
- Wu Tsai Female Athlete Program, Boston Children's Hospital, Boston, MA, USA.,Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Belinda R Beck
- School of Health Sciences & Social Work, Griffith University, Gold Coast, Queensland, Australia.,Menzies Health Institute Queensland, Gold Coast, Queensland, Australia.,The Bone Clinic, Brisbane, Queensland, Australia
| | - Mary L Bouxsein
- Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Department of Orthopedic Surgery, Harvard Medical School and Center for Advanced Orthopedic Studies, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - David B Burr
- Department of Anatomy, Cell Biology, and Physiology, Indiana University School of Medicine, Indiana University, Indianapolis, IN, USA.,Indiana Center for Musculoskeletal Health, Indiana University School of Medicine, Indiana University, Indianapolis, IN, USA
| | - Karsten Hollander
- Institute of Interdisciplinary Exercise Science and Sports Medicine, MSH Medical School Hamburg, Hamburg, Germany
| | - Kristin L Popp
- Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,U.S. Army Research Institute of Environmental Medicine, Natick, MA, USA
| | - Tim Rolvien
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Adam S Tenforde
- Spaulding Rehabilitation Hospital, Department of Physical Medicine and Rehabilitation, Harvard Medical School, Charlestown, MA, USA.
| | - Stuart J Warden
- Indiana Center for Musculoskeletal Health, Indiana University School of Medicine, Indiana University, Indianapolis, IN, USA. .,Department of Physical Therapy, School of Health & Human Sciences, Indiana University, Indianapolis, IN, USA. .,La Trobe Sport and Exercise Medicine Research Centre, La Trobe University, Bundoora, Victoria, Australia.
| |
Collapse
|
19
|
Bredella MA, Fazeli PK, Bourassa J, Rosen CJ, Bouxsein ML, Klibanski A, Miller KK. The effect of short-term high-caloric feeding and fasting on bone microarchitecture. Bone 2022; 154:116214. [PMID: 34571202 PMCID: PMC8671292 DOI: 10.1016/j.bone.2021.116214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 09/15/2021] [Accepted: 09/20/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND States of chronic overnutrition and undernutrition are both associated with impaired bone health and increased fracture risk but there are no data on bone microarchitecture following short-term controlled nutritional challenges. OBJECTIVE The purpose of our study was to evaluate the impact of short-term high-caloric feeding and fasting on bone microarchitecture. We hypothesized that both high-caloric feeding and fasting would have negative effects on microarchitecture. MATERIALS AND METHODS We recruited 23 adult healthy subjects (13 males, 10 females, mean age 33.2 ± 1.4 years, mean BMI 26.0 ± 1.5 kg/m2). Subjects underwent an in-patient 10-day high-caloric visit (caloric intake with goal to achieve 7% weight gain), after which they went home to resume a normal diet for 13-18 days (stabilization period), and were then readmitted for a 10-day in-patient fasting stay (no caloric intake). All subjects underwent HRpQCT (XtremeCT, Scanco Medical AG, Brüttisellen, Switzerland) of the distal tibia and distal radius after each visit to assess volumetric bone mineral density (vBMD), trabecular and cortical microarchitecture, and strength estimates. The Wilcoxon signed rank test was used to perform within group comparisons. RESULTS During the high-caloric period, there was a mean increase in weight by 6.3 + 1.7% (p < 0.0001). There were no significant changes in bone parameters in the distal tibia or distal radius (p > 0.05). During the stabilization period there was a significant reduction in weight by -2.7 + 1.9% (p < 0.0001) but no change in bone parameters (p > 0.05). During the fasting period there was a further reduction in weight by -8.8 + 1.2% (p < 0.0001). In the distal tibia, there was a significant increase in total and cortical vBMD, trabecular and cortical parameters as well as strength estimates (p < 0.05). In the distal radius there was an increase in total and trabecular vBMD (p < 0.05), while there were no changes in other microarchitecture parameters or strengths estimates. CONCLUSION Short-term fasting after high-caloric feeding improves vBMD, bone microarchitecture and strength estimates of the distal tibia, while short-term high-caloric feeding does not change vBMD or microarchitecture. These results suggest that short-term fasting after high-caloric feeding in healthy individuals improves bone health and that these changes can be detected using HRpQCT in-vivo.
Collapse
Affiliation(s)
- Miriam A Bredella
- Division of Musculoskeletal Imaging and Intervention, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, United States of America.
| | - Pouneh K Fazeli
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, United States of America
| | - Jenna Bourassa
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, United States of America
| | - Clifford J Rosen
- Maine Medical Center Research Institute, Scarborough, ME, United States of America
| | - Mary L Bouxsein
- Department of Orthopedic Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, United States of America
| | - Anne Klibanski
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, United States of America
| | - Karen K Miller
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, United States of America
| |
Collapse
|
20
|
Goggins L, Peirce N, Griffin S, Langley B, Jowitt H, McKay C, Stokes KA, Williams S. The impact of COVID-19 related disruption on injury rates in elite men's domestic cricket. Int J Sports Med 2021; 43:526-532. [PMID: 34555858 DOI: 10.1055/a-1652-5352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
This study aimed to investigate the impact of COVID-19 enforced prolonged training disruption and shortened competitive season, on in-season injury and illness rates. Injury incidence and percent proportion was calculated for the 2020 elite senior men's domestic cricket season and compared to a historical average from five previous regular seasons (2015 to 2019 inclusive). The injury profile for the shortened 2020 season was generally equivalent to what would be expected in a regular season, except for a significant increase in medical illness as a proportion of time loss (17% compared to historic average of 6%) and in-season days lost (9% compared to historic average of 3%) due to COVID-19 related instances (most notably precautionary isolation due to contact with a confirmed or suspected COVID-19 case). There was a significant increase in the proportion of in-season days lost to thigh injuries (24% compared to 9%) and a significant decrease in the proportion of days lost to hand (4% compared to 12%) and lumbar spine (7% compared to 21%) injuries. These findings enhance understanding of the impact prolonged period of training disruption and shortened season can have on cricket injuries and the challenges faced by practitioners under such circumstances.
Collapse
Affiliation(s)
- Luke Goggins
- Department of Health, University of Bath, Bath, United Kingdom of Great Britain and Northern Ireland
| | - Nicholas Peirce
- National Cricket Performance Centre, England and Wales Cricket Board, Loughborough, United Kingdom of Great Britain and Northern Ireland
| | - Steve Griffin
- National Cricket Performance Centre, England and Wales Cricket Board, Loughborough, United Kingdom of Great Britain and Northern Ireland
| | - Ben Langley
- National Cricket Performance Centre, England and Wales Cricket Board, Loughborough, United Kingdom of Great Britain and Northern Ireland
| | - Hannah Jowitt
- National Cricket Performance Centre, England and Wales Cricket Board, Loughborough, United Kingdom of Great Britain and Northern Ireland
| | - Carly McKay
- Health, University of Bath, Bath, United Kingdom of Great Britain and Northern Ireland
| | - Keith A Stokes
- Department for Health, University of Bath, Bath, United Kingdom of Great Britain and Northern Ireland
| | - Sean Williams
- Department for Health, University of Bath, Bath, United Kingdom of Great Britain and Northern Ireland
| |
Collapse
|
21
|
Hughes JM, O'Leary TJ, Koltun KJ, Greeves JP. Promoting adaptive bone formation to prevent stress fractures in military personnel. Eur J Sport Sci 2021; 22:4-15. [PMID: 34269162 DOI: 10.1080/17461391.2021.1949637] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Mechanical loading leads to adaptive bone formation - the formation of new bone on existing skeletal surfaces - which increases bone strength and fatigue resistance. The same mechanical loading can also cause microdamage to bone and development of a stress fracture through targeted remodelling. Stress fractures are common in military recruits and cause significant morbidity, lost training time, and discharge from military service. This narrative review proposes strategies to promote adaptive bone formation as a novel approach to mitigate the risk of stress fracture injuries during arduous military training. Exercise that is unaccustomed, dynamic, high-impact, multidirectional, intermittent, and includes extended rest periods to restore bone mechanosensitivity, is most osteogenic. New bone formation can take up to one year to mineralize, and so new exercise training programmes should be initiated well in advance of military activities with high risk of stress fracture. Bone mechanosensitivity is highest in adolescence, before puberty, and so increasing physical activity in youth is likely to protect skeletal health in later life, including for those in the military. Recent data show that adaptive bone formation takes place during initial military training. Adaptive bone formation can also be supported with adequate sleep, vitamin D, calcium, and energy availability. Further evidence on how strategies to promote adaptive bone formation affect stress fracture risk are required. Adaptive bone formation can be optimized with a range of training and nutritional strategies to help create a resilient skeleton, which may protect against stress fracture throughout military service.
Collapse
Affiliation(s)
- Julie M Hughes
- Military Performance Division, United States Army Research Institute of Environmental Medicine, Natick, MA, USA
| | - Thomas J O'Leary
- Army Health and Performance Research, Army Headquarters, Andover, UK.,Division of Surgery and Interventional Science, University College London, London, UK
| | - Kristen J Koltun
- Neuromuscular Research Laboratory/Warrior Human Performance Research Center, Department of Sports Medicine and Nutrition, University of Pittsburgh, Pittsburgh, PN, USA
| | - Julie P Greeves
- Army Health and Performance Research, Army Headquarters, Andover, UK.,Division of Surgery and Interventional Science, University College London, London, UK.,Norwich Medical School, University of East Anglia, Norwich, UK
| |
Collapse
|
22
|
Ackerman KE, Popp KL, Bouxsein ML. Rocket science: what spaceflight can tell us about skeletal health on Earth. Br J Sports Med 2021; 55:1182-1183. [PMID: 33883169 DOI: 10.1136/bjsports-2021-104164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/2021] [Indexed: 11/04/2022]
Affiliation(s)
- Kathryn E Ackerman
- Division of Sports Medicine, Boston Children's Hospital, Boston, Massachusetts, USA .,Endocrine Division, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Kristin L Popp
- Endocrine Division, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,United States Army Research Institute of Environmental Medicine, Natick, Massachusetts, USA
| | - Mary L Bouxsein
- Endocrine Division, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Center for Advanced Orthopedic Studies, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| |
Collapse
|
23
|
Gabbett T, Sancho I, Dingenen B, Willy RW. When progressing training loads, what are the considerations for healthy and injured athletes? Br J Sports Med 2021; 55:947-948. [PMID: 33837004 DOI: 10.1136/bjsports-2020-103769] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2021] [Indexed: 11/04/2022]
Affiliation(s)
- Tim Gabbett
- Gabbett Performance Solutions, Brisbane, Queensland, Australia .,Centre for Health Research, University of Southern Queensland, Ipswich, Queensland, Australia
| | - Igor Sancho
- Sports and Exercise Medicine, Queen Mary University of London, London, UK.,Physiotherapy Department, University of Deusto, San Sebastian, Spain
| | - Bart Dingenen
- Reval Rehabilitation Research Centre, Faculty of Rehabilitation Sciences, Hasselt University, Diepenbeek, Belgium
| | - Richard W Willy
- Physical Therapy and Movement Science, University of Montana Missoula, Missoula, Montana, USA
| |
Collapse
|