Julie Briody

Bone mineral density in adolescent female athletes: relationship to exercise type and muscle strength

PURPOSE This study investigated the influence of different exercise types and differences in anatomical distribution of mechanical loading patterns on bone mineral density (BMD) in elite female cyclists, runners, swimmers, triathletes, and controls (N = 15 per group). Associations between leg strength and BMD were also examined. METHODS Areal BMD (g x cm(-2)) was assessed by duel-energy x-ray absorptiometry (DXA) (total body (TB), lumbar spine (LS), femoral neck (FN), legs, and arms). Right knee flexion and extension strength was measured using a Cybex Norm isokinetic dynamometer at 60 degrees x s(-1). RESULTS Runners had significantly higher unadjusted TB, LS, FN, and leg BMD than controls (P < 0.05); higher TB, FN, and leg BMD than swimmers (P < 0.05); and greater leg BMD than cyclists (P < 0.05). Absolute knee extension strength was significantly (P < 0.01) correlated (0.33 < or = r < or = 0.44) with TB, FN, LS, and leg BMD for all groups combined. Weaker but still significant correlations (0.28 < or = r < or = 0.33) existed for normalized (per leg lean tissue mass) knee extension strength and all BMD sites, except FN BMD. There were no significant correlations between absolute or normalized knee flexion strength and any of the BMD variables. Absolute knee extension strength was entered as the second independent predictor for LS and leg BMD in stepwise multiple linear regression analysis (MLRA), accounting for increments of 4% and 12%, respectively, in total explained variation. CONCLUSION We conclude that running, a weight bearing exercise, is associated with larger site-specific BMD than swimming or cycling, that the generalized anatomical distribution of loads in triathlon appears not to significantly enhance total body BMD status, and that knee extension strength is only a weak correlate and independent predictor of BMD in adolescent females.

Importance of lean mass in the interpretation of total body densitometry in children and adolescents

OBJECTIVE Most studies that use total body dual energy x-ray absorptiometry (DEXA) in children rely on areal bone mineral density (BMD=bone mineral content [BMC]/bone area [BA]) and compare the output with age- and sex-specific normative data. Because this approach is prone to size-related misinterpretation, this study focuses on the interrelations among BMC, body size (height), and lean tissue mass (LTM). STUDY DESIGN This cross-sectional study presents normative total body LTM data in relation to height and BMC for 459 healthy white subjects (249 female), 3 to 30 years of age. Guidelines for DEXA interpretation in children are provided and illustrated for patients with growth hormone deficiency (n=5) and anorexia nervosa (n=5). RESULTS LTM/height tended to be greater in male than in girls. The BMC/LTM ratio was greater in female than in boys (P<.001), even after adjustment for age and height. Sex-specific reference curves were created for LTM/height, the BMC/LTM ratio, BA/height, and BMC/BA. CONCLUSIONS We recommend that total body DEXA in children should be interpreted in 4 steps: (1) BMD or BMC/age, (2) height/age, (3) LTM/height, and (4) BMC/LTM ratio for height. This allows differentiation of the origin of a low BMD or BMC/age, for example, short stature and primary, secondary, and mixed bone defects.

Zoledronic Acid Prevents Osteopenia and Increases Bone Strength in a Rabbit Model of Distraction Osteogenesis

Prolonged healing times and stress‐shielding osteopenia remain problematic in distraction osteogenesis. In this study of 30 rabbits, zoledronic acid increased regenerate volume, mineralization, and tibial strength and prevented osteopenia over a 6‐week period. Translation to the clinical setting, if safe, could improve outcomes in distraction osteogenesis in children.

Mid-femur geometry and biomechanical properties in 15- to 18-yr-old female athletes

PURPOSE Right-leg mid-femur geometry and biomechanical indices of bone strength were compared among elite cyclists (CYC), runners (RUN), swimmers (SWIM), triathletes (TRI), and controls (C)-10 subjects per group. METHODS Bone cross-sectional areas (CSA), volumes (Vol), and cross-sectional moments of inertia (CSMI) were assessed by magnetic resonance imaging (MRI), and cortical volumetric bone density (volBMD) was determined as the quotient of DXA-derived bone mineral content (BMC) and MRI-derived cortical bone volume. Bone strength index (BSI) was calculated as the product of cortical volBMD and CSMI. RESULTS RUN had higher (P < 0.05) size- (femur length and body mass) adjusted (ANCOVA) cortical CSA than C, SWIM, and CYC; and higher size, age, and years of sport-specific training- (YST) adjusted cortical CSA than SWIM and CYC. TRI had higher (P < 0.05) size-adjusted CSA than SWIM. SWIM and CYC had significantly larger (P < 0.05) size-adjusted medullary cavity CSA than RUN and TRI, and the difference between CYC and RUN persisted after additional adjustment for age and YST. RUN had significantly (P < 0.05) greater size-adjusted CSMI and BSI than C, SWIM, and CYC; and higher size, age, and YST-adjusted CSMI and BSI than SWIM and CYC. Mid-femur areal bone mineral density (BMD) was significantly (P < 0.05) higher for RUN compared with CYC only, but there were no other differences among groups for BMC, bone volumes, or volumetric total or cortical BMD. CONCLUSIONS Running, a weight-bearing exercise, is associated with more favorable geometric and biomechanical characteristics in relation to bone strength, compared with the weight supported activities of swimming and cycling. Differences may reflect skeletal adaptations to the specific mechanical-loading patterns inherent in these sports.

A comparison of bone geometry and cortical density at the mid-femur between prepuberty and young adulthood using magnetic resonance imaging

In upper extremity bones, a sexual dimorphism exists in the development of periosteal and endocortical bone surfaces during growth. Little is known about developmental patterns of bone geometry at weight-bearing bones like the femur. Using MRI and dual energy X-ray absorptiometry (DXA), this study assessed the differences in mid-femoral total (TA), cortical (CA) and medullary areas (MA), cortical thickness, and cortical density (BMD(compartment)) between prepuberty and young adulthood in 145 healthy subjects (94 females) 6 to 25 years old. Additionally, agreement between mid-femoral total bone volume (TV) measurements by DXA and MRI were investigated. In both sexes, TA, CA, MA, and cortical thickness were significantly larger in adults compared to prepubertal subjects (P < 0.001), and males had greater values than females. This sex difference persisted for TA, CA, and cortical thickness (P < 0.05), but not MA, after adjusting for femur length and weight. Mean (SD) cortical BMD increased from 1.05 (0.07) and 1.09 (0.10) g/cm(3) in prepubertal children to 1.46 (0.14) and 1.42 (0.1) g/cm(3) in young adults, females and males, respectively (P < 0.001). TV measurements by DXA were significantly greater than by MRI (P < 0.001) in young adults. In conclusion, periosteal and endocortical expansion and increasing cortical BMD are the growth processes found at the mid-femur in both sexes. Our findings contrast to that in upper extremity bones, where MA is constant in females during growth. The difference in femoral bone development may be due to higher strains caused by weight bearing and genetic factors. DXA, in contrast to MRI, is inaccurate in the determination of mid-femoral TV measures.

Decreased Bone Mineral Density in Neurofibromatosis Type 1: Results From a Pediatric Cohort

Neurofibromatosis type 1 (NF1) is a common genetic disorder affecting 1 in 3000 live births. It is well documented to be associated with bony deformities and other orthopaedic problems. Based on our observation that NF1 patients undergoing orthopaedic surgery often had osteopenic bone, we performed a study to assess the bone mineral density of a cohort of children with NF1 without orthopaedic defects. Twenty-three patients were recruited from the neurofibromatosis clinic. The bone mineral density of the total body, lumbar spine, and proximal femur was measured using dual-energy x-ray absorptiometry. Quantitative ultrasound was used to measure broadband ultrasonic attenuation at both heels. The groups mean dual-energy x-ray absorptiometry sex- and age-matched Z scores were below normal (−0.8 ± 1.1, −0.8 ± 1.2, −0.7 ± 0.8, −0.6 ± 1.1, −0.6 ± 0.9, −0.6 ± 1.1 for the total body, arms, legs, lumbar spine, and right and left femoral neck, respectively; all P < 0.01). Although some individuals had normal bone mass, 30% had total body Z scores below −1.5. The mean heel broadband ultrasonic attenuation Z score was also lower than normal (−0.8 ± 0.6; P < 0.001). Children with NF1 have a general tendency toward osteopenia, suggesting an abnormal underlying bone phenotype. This may be relevant when considering operative intervention and, if better understood, may partially explain poor bone healing associated with NF1.

Volumetric bone mineral density — a potential role in paediatrics

The use of areal bone mineral density (aBMD) in paediatric populations has aroused some concern, as it fails to take the age‐related increase in bone thickness into account. We have developed a measure of true bone density, volumetric bone mineral density (vBMD), which is independent of age and height. In order to examine the relationship between growth parameters, aBMD and vBMD, we studied patients with phenylketonuria (PKU, n = 40), chronic renal failure (CRF, n = 27) and chronic asthma (n = 19). aBMD of the femoral neck and the mid‐femoral shaft was measured using dual energy X‐ray absorptiometry (DXA), vBMD was calculated on the basis of values of bone mineral content and bone dimension provided by DXA, with the assumption that both sites are cylinders. aBMD and vBMD were then compared with the normal reference, expressed as a standard deviation score (SDS). aBMD and vBMD were normal in the femoral neck region of the PKU group, but aBMD, either standardized for age or for height, was low in the femoral shaft region (p < 0.01). In the CRF group, profound growth retardation was seen (mean height SDS, −3.2) and aBMD and vBMD were both low in the femoral shaft region but not in the femoral neck. In the asthma group, aBMD for age was low at both sites, but vBMD did not differ from that seen in normal individuals. We conclude that the true vBMD provides a different interpretation of bone density compared with aBMD and requires further evaluation in paediatrics because of its age and height independence.

Bone strength index in adolescent girls: does physical activity make a difference?

Background: Bone strength index (BSI) combines bone mineral and bone biomechanical properties to measure resistance to bending. This index may have greater clinical significance than the more often described markers of bone mineral content (BMC), areal density, or geometry alone and, in turn, may show a stronger relation to fracture risk. The BSI is the product of volumetric cortical bone mineral density (BMD) and cross sectional moment of inertia within a region of interest. Calculations combine dual energy x ray absorptiometry and magnetic resonance imaging technologies and provide a useful, non-invasive measure of in vivo bone strength. Objectives: (a) To compare BSI in adolescent female middle distance runners and age matched controls; (b) to examine factors predictive of BSI in adolescent girls. Methods: Twenty adolescent female middle distance runners (mean (SD) age 16 (1.7) years, physical activity 8.9 (2.1) hours a week) and 20 female controls (age 16 (1.8) years, physical activity 2.0 (0.07) hours a week) were recruited. To calculate BSI, a region of interest representing 10% of the mid-distal tibia was analysed for dual energy x ray absorptiometry derived BMC and was combined with bone geometry and biomechanical properties obtained by magnetic resonance imaging assessments. Potential predictors of BSI were also examined. Results: Independent t tests showed that BMC (p  =  0.028), cortical bone volume (p  =  0.002), volumetric cortical BMD (p  =  0.004), cross sectional moments of inertia (p  =  0.005), and BSI (p  =  0.002) were higher in the distal tibia of athletes than of controls. The strongest predictor of BSI was hours of physical activity a week (R2  =  0.46). Conclusions: Athletes habitually exposed to high training loads displayed greater BSI at the distal tibia than controls. The results further confirm BSI as a significant and discerning marker in musculoskeletal health in adolescent girls engaged in high and low mechanical loading.

Measurement of midfemoral shaft geometry: Repeatability and accuracy using magnetic resonance imaging and dual-energy X-ray absorptiometry

Although macroscopic geometric architecture is an important determinant of bone strength, there is limited published information relating to the validation of the techniques used in its measurement. This study describes new techniques for assessing geometry at the midfemur using magnetic resonance imaging (MRI) and dual‐energy X‐ray absorptiometry (DXA) and examines both the repeatability and the accuracy of these and previously described DXA methods. Contiguous transverse MRI (Philips 1.5T) scans of the middle one‐third femur were made in 13 subjects, 3 subjects with osteoporosis. Midpoint values for total width (TW), cortical width (CW), total cross‐sectional area (TCSA), cortical cross‐sectional area (CCSA), and volumes from reconstructed three‐dimensional (3D) images (total volume [TV] and cortical volume [CVol]) were derived. Midpoint TW and CW also were determined using DXA (Lunar V3.6, lumbar software) by visual and automated edge detection analysis. Repeatability was assessed on scans made on two occasions and then analyzed twice by two independent observers (blinded), with intra‐ and interobserver repeatability expressed as the CV (CV ± SD). Accuracy was examined by comparing MRI and DXA measurements of venison bone (and Perspex phantom for MRI), against “gold standard” measures made by vernier caliper (width), photographic image digitization (area) and water displacement (volume). Agreement between methods was analyzed using mean differences (MD ± SD%). MRI CVs ranged from 0.5 ± 0.5% (TV) to 3.1 ± 3.1% (CW) for intraobserver and 0.55 ± 0.5% (TV) to 3.6 ± 3.6% (CW) for interobserver repeatability. DXA results ranged from 1.6 ± 1.5% (TW) to 4.4 ± 4.5% (CW) for intraobserver and 3.8 ± 3.8% (TW) to 8.3 ± 8.1% (CW) for interobserver variation. MRI accuracy was excellent for TV (3.3 ± 6.4%), CVol (3.5 ± 4.0%), TCSA (1.8 ± 2.6%), and CCSA (1.6 ± 4.2%) but not TW (4.1 ± 1.4%) or CW (16.4 ± 14.9%). DXA results were TW (6.8 ± 2.7%) and CW (16.4 ± 17.0%). MRI measures of geometric parameters of the midfemur are highly accurate and repeatable, even in osteoporosis. Both MRI and DXA techniques have limited value in determining cortical width. MRI may prove valuable in the assessment of surface‐specific bone accrual and resorption responses to disease, therapy, and variations in mechanical loading.

DXA for bone density measurement in small rats weighing 150–250 grams

The present study evaluated the use of a small animal total body software of dual energy x-ray absorptiometry (DXA) in the assessment of total body and regional bone mineral content (BMC) and bone mineral density (BMD) in small rats. Twenty-three rats, with weights ranging from 146 to 246 g, were included in the study. All were scanned using the same software version and same scan procedure (speed and scanned area). Total body BMD, BMC, and body weight were measured by DXA in each rat. Femoral BMC and BMD were analyzed by using regional analysis facilities. The repeatability (precision) of this software version was assessed prior to the study and the coefficients of variation (CV) were 2.9% for total body BMC, 0.8% for total body BMD, 1.2% for body weight, and 2.2% for mean femoral BMD. DXA measurements were compared with the measurements obtained by using established standards, namely weight and bone ash content. Total body ash content and femoral ash content were measured separately in all rats. There was a strong linear correlation between BMC and ash content in total body (r2 = 0.98, p = 0.0001) and in femur (r2 = 0.94, p = 0.0001). There was also an excellent linear association between body weight measured by DXA and scale weight (r2 = 0.99, p = 0.0001). We conclude that this software version is suitable for study on small animals and is a useful tool for assessment of regional as well as total body bone mineral status.