Targeted exercise against osteoporosis : a systematic review and meta-analysis for optimising bone strength throughout life

Background
Exercise is widely recommended to reduce osteoporosis, falls and related fragility fractures, but its effect on whole bone strength has remained inconclusive. The primary purpose of this systematic review and meta-analysis was to evaluate the effects of long-term supervised exercise (≥6 months) on estimates of lower-extremity bone strength from childhood to older age.

Methods
We searched four databases (PubMed, Sport Discus, Physical Education Index, and Embase) up to October 2009 and included 10 randomised controlled trials (RCTs) that assessed the effects of exercise training on whole bone strength. We analysed the results by age groups (childhood, adolescence, and young and older adulthood) and compared the changes to habitually active or sedentary controls. To calculate standardized mean differences (SMD; effect size), we used the follow-up values of bone strength measures adjusted for baseline bone values. An inverse variance-weighted random-effects model was used to pool the results across studies.

Results
Our quality analysis revealed that exercise regimens were heterogeneous; some trials were short in duration and small in sample size, and the weekly training doses varied considerably between trials. We found a small and significant exercise effect among pre- and early pubertal boys [SMD, effect size, 0.17 (95% CI, 0.02-0.32)], but not among pubertal girls [-0.01 (-0.18 to 0.17)], adolescent boys [0.10 (-0.75 to 0.95)], adolescent girls [0.21 (-0.53 to 0.97)], premenopausal women [0.00 (-0.43 to 0.44)] or postmenopausal women [0.00 (-0.15 to 0.15)]. Evidence based on per-protocol analyses of individual trials in children and adolescents indicated that programmes incorporating regular weight-bearing exercise can result in 1% to8% improvements in bone strength at the loaded skeletal sites. In premenopausal women with high exercise compliance, improvements ranging from 0.5% to 2.5% have been reported.

Conclusions
The findings from our meta-analysis of RCTs indicate that exercise can significantly enhance bone strength at loaded sites in children but not in adults. Since few RCTs were conducted to investigate exercise effects on bone strength, there is still a need for further well-designed, long-term RCTs with adequate sample sizes to quantify the effects of exercise on whole bone strength and its structural determinants throughout life.

Flexible multibody approach in forward dynamic simulation of locomotive strains in human skeleton with flexible lower body bones

A method for bone strain estimation is examined in this article. The flexibility of a single bone in an otherwise rigid human skeleton model has been studied previously by various authors. However, in the previous studies, the effect of the flexibility of multiple bones on the musculoskeletal model behavior was ignored. This study describes a simulation method that can be used to estimate the bone strains at both tibias and femurs of a 65-year old Caucasian male subject. The verification of the method is performed by the comparison of the results with other studies available in literature. The results of the study show good correlation with the results of previous empirical studies. A damping effect of the flexible bones on the model is also studied in this paper.

Innervation zone shift at different levels of isometric contraction in the biceps brachii muscle

Experiments were carried out to examine whether innervation zone (IZ) location remains stable at different levels of isometric contraction in the biceps brachii muscle (BB), and to determine how the proximity of the IZ affects common surface electromyography (sEMG) parameters. Twelve subjects performed maximal (MVC) and submaximal voluntary isometric contractions at 10%, 20%, 30%, 40%, 50% and 75% of MVC. sEMG signals were recorded with a 13 rows  5 columns grid of electrodes from the short head of BB. The IZ shifted in the proximal direction by up to 2.4 cm, depending upon the subject and electrode column. The mean shift of all the columns was 0.6 ± 0.4 cm (10% vs. 100% MVC, P < 0.001). This shift biased the average values of mean frequency (+21.8 ± 9.9 Hz, P < 0.001), root mean square (0.16 ± 0.15 mV, P < 0.05) and conduction velocity (1.15 ± 0.93 m/s, P < 0.01) in the channels immediately proximal to the IZ. The shift in IZ could be explained by shortening of the muscle fibers, and thus lengthening of the (distal) tendon due to increasing force. These results underline the importance of individual investigation of IZ locations before the placement of sEMG electrodes, even in isometric contractions.

Differential effects of exercise on tibial shaft marrow density in young female athletes

Context:
Increased mechanical loading can promote the preferential differentiation of bone marrow mesenchymal stem cells to osteoblastogenesis, but it is not known whether long-term bone strength-enhancing exercise in humans can reduce marrow adiposity.

Objective:
Our objective was to examine whether bone marrow density (MaD), as an estimate of marrow adiposity 1) differs between young female athletes with contrasting loading histories and bone strengths and 2) is an independent predictor of bone strength at the weight-bearing tibia.

Design:
Mid-tibial MaD, cortical area (CoA), total area, medullary area, strength strain index (SSI), and cortical volumetric bone mineral density (vBMD) (total, endocortical, midcortical, and pericortical) was assessed using peripheral quantitative computed tomography in 179 female athletes involved in both impact and nonimpact loading sports and 41 controls aged 17–40 years.

Results:
As we have previously reported CoA, total area, and SSI were 16% to 24% greater in the impact group compared with the controls (all P < .001) and 12% to 18% greater than in the nonimpact group (all P < .001). The impact group also had 0.5% higher MaD than the nonimpact and control groups (both P < .05). Regression analysis further showed that midtibial MaD was significantly associated with SSI, CoA, endocortical vBMD, and pericortical vBMD (P < .05) in all women combined, after adjusting for age, bone length, loading groups, medullary area, muscle cross-sectional area, and percent fat.

Conclusion:
In young female athletes, tibial bone MaD was associated with loading history and was an independent predictor of tibial bone strength. These findings suggest that an exercise-induced increase in bone strength may be mediated via reduced bone marrow adiposity and consequently increased osteoblastogenesis.

Physical activity and exercise in the maintenance of the adult skeleton and the prevention of osteoporotic fractures

In the prevention of osteoporosis and osteoporoticrelated fractures, strategies aimed at maximizing peak bone mass during childhood and adolescence; maintaining or attenuating bone loss during the adult years; and increasing or preserving muscle mass, strength, power, and function are all considered critical. To this end, physical activity and exercise are recognized as important modifiable lifestyle variables that can strengthen the skeleton and muscles and reduce the risk of falls and subsequent fracture, as well as enhance quality of life... 

An application of the flexible multibody approach used to estimate human skeleton loading

Skeletal loading can be estimated using several approaches. The most common approach is based on utilizing mechanical principles and ground reaction forces as predictors for skeletal loading. This method can be considered as a relatively simple approach since it cannot account for muscle forces. Flexible multibody approach allows for estimating skeletal loading and strains within the bones; once bone flexibility, muscle forces, ground reaction forces and the natural motion of a subject have been accounted for. This paper presents a summary that describes how deformable bodies can be introduced to the standard multibody formulation and explains the benefits and drawbacks. As an example of application, models used to assess tibial strains among two subjects are presented. The results of the multibody simulations are compared to in vivo studies, showing acceptable correlation and method performance.