Kenneth J. McLeod

Anabolism: Low mechanical signals strengthen long bones

Although the skeletons adaptability to load-bearing has been recognized for over a century, the specific mechanical components responsible for strengthening it have not been identified. Here we show that after mechanically stimulating the hindlimbs of adult sheep on a daily basis for a year with 20-minute bursts of very-low-magnitude, high-frequency vibration, the density of the spongy (trabecular) bone in the proximal femur is significantly increased (by 34.2%) compared to controls. As the strain levels generated by this treatment are three orders of magnitude below those that damage bone tissue, this anabolic, non-invasive stimulus may have potential for treating skeletal conditions such as osteoporosis.

Prevention of Postmenopausal Bone Loss by a Low-Magnitude, High-Frequency Mechanical Stimuli: A Clinical Trial Assessing Compliance, Efficacy, and Safety†

A 1‐year prospective, randomized, double‐blind, and placebo‐controlled trial of 70 postmenopausal women demonstrated that brief periods (<20 minutes) of a low‐level (0.2g, 30 Hz) vibration applied during quiet standing can effectively inhibit bone loss in the spine and femur, with efficacy increasing significantly with greater compliance, particularly in those subjects with lower body mass.

Quantifying the strain history of bone: spatial uniformity and self-similarity of low-magnitude strains.

We hypothesize that when a broad spectrum of bone strain is considered, strain history is similar for different bones in different species. Using a data collection protocol with a fine resolution, mid-diaphyseal strains were measured in vivo for both weightbearing and non-weightbearing bones in three species: dog, sheep, and turkey, with strain information collected continuously while the animals performed their natural daily activities. The daily strain history was quantified by both counting cyclic strain events (to quantify the distribution of strains of different magnitudes) and by estimating the average spectral characteristics of the strain (to quantify the frequency content of the strain signals). Counting of the daily (12-24 h) strain events show that large strains (> 1000 microstrain) occur relatively few times a day, while very small strains (< 10 microstrain) occur thousands of times a day. The lower magnitude strains (< approximately 200 microstrain) are found to be more uniform around the bone cross-section than the higher magnitude, peak strains. Strain dynamics are found to be well described by a power-law relationship and exhibit self-similar characteristics. These data lead to the suggestion that the organization of bone tissue is driven by the continual barrage of activity spanning a wide but consistent range of frequency and amplitude, and until the mechanism of bones mechanosensory system is fully understood, all portions of bones strain history should be considered to possibly play a role in bone adaptation.

Quantity and Quality of Trabecular Bone in the Femur Are Enhanced by a Strongly Anabolic, Noninvasive Mechanical Intervention

The skeletons sensitivity to mechanical stimuli represents a critical determinant of bone mass and morphology. We have proposed that the extremely low level (<10 microstrain), high frequency (20‐50 Hz) mechanical strains, continually present during even subtle activities such as standing are as important to defining the skeleton as the larger strains typically associated with vigorous activity (>2000 microstrain). If these low‐level strains are indeed anabolic, then this sensitivity could serve as the basis for a biomechanically based intervention for osteoporosis. To evaluate this hypothesis, the hindlimbs of adult female sheep were stimulated for 20 minutes/day using a noninvasive 0.3g vertical oscillation sufficient to induce approximately 5 microstrain on the cortex of the tibia. After 1 year of stimulation, the physical properties of 10‐mm cubes of trabecular bone from the distal femoral condyle of experimental animals (n = 8) were compared with controls (n = 9), as evaluated using microcomputed tomography (μCT) scanning and materials testing. Bone mineral content (BMC) was 10.6% greater (p < 0.05), and the trabecular number (Tb.N) was 8.3% higher in the experimental animals (p < 0.01), and trabecular spacing decreased by 11.3% (p < 0.01), indicating that bone quantity was increased both by the creation of new trabeculae and the thickening of existing trabeculae. The trabecular bone pattern factor (TBPf) decreased 24.2% (p < 0.03), indicating trabecular morphology adapting from rod shape to plate shape. Significant increases in stiffness and strength were observed in the longitudinal direction (12.1% and 26.7%, respectively; both, p < 0.05), indicating that the adaptation occurred primarily in the plane of weightbearing. These results show that extremely low level mechanical stimuli improve both the quantity and the quality of trabecular bone. That these deformations are several orders of magnitude below those peak strains which arise during vigorous activity indicates that this biomechanically based signal may serve as an effective intervention for osteoporosis.

Mechanical strain, induced noninvasively in the high-frequency domain, is anabolic to cancellous bone, but not cortical bone

Departing from the premise that it is the large-amplitude signals inherent to intense functional activity that define bone morphology, we propose that it is the far lower magnitude, high-frequency mechanical signals that continually barrage the skeleton during longer term activities such as standing, which regulate skeletal architecture. To examine this hypothesis, we proposed that brief exposure to slight elevations in these endogenous mechanical signals would suffice to increase bone mass in those bones subject to the stimulus. This was tested by exposing the hind limbs of adult female sheep (n = 9) to 20 min/day of low-level (0.3g), high-frequency (30 Hz) mechanical signals, sufficient to induce a peak of approximately 5 microstrain (micro epsilon) in the tibia. Following euthanasia, peripheral quantitative computed tomography (pQCT) was used to segregate the cortical shell from the trabecular envelope of the proximal femur, revealing a 34.2% increase in bone density in the experimental animals as compared with controls (p = 0.01). Histomorphometric examination of the femur supported these density measurements, with bone volume per total volume increasing by 32% (p = 0.04). This density increase was achieved by two separate strategies: trabecular spacing decreased by 36.1% (p = 0.02), whereas trabecular number increased by 45.6% (p = 0.01), indicating the formation of cancellous bone de novo. There were no significant differences in the radii of animals subject to the stimulus, indicating that the adaptive response was local rather than systemic. The anabolic potential of the signal was evident only in trabecular bone, and there were no differences, as measured by any assay, in the cortical bone. These data suggest that subtle mechanical signals generated during predominant activities such as posture may be potent determinants of skeletal morphology. Given that these strain levels are three orders of magnitude below strains that can damage bone tissue, we believe that a noninvasive stimulus based on this sensitivity has potential for treating skeletal complications such as osteoporosis.

Suppression of the osteogenic response in the aging skeleton

SummaryThe ability of physical stimuli demonstrated as potently osteogenic in the young adult skeleton were evaluated for their capacity to stimulate new bone formation in the aging skeleton. Using the externally loadable, functionally isolated turkey ulna preparation, the ulnae of 1-year-old (n=5), and 3-year-old (n=3) turkeys were subjected to 300 cycles per day of a load regimen generating a high but physiologic level of normal strain (3,000 microstrain). Following 8 weeks of loading, areal properties and histomorphometry were performed on both the experimental and intact control ulnae. Bone cross-sectional areas in the 1-year-old animal increased by 30.2% (±7.8%) as compared with the intact contralateral control ulnae, whereas the areal properties of the older skeleton remained essentially unchanged (-3.3±7.5%). Renewed bone formation in the experimental ulnae of the 1-year-old animals was characterized by the activation of periosteal bone apposition (4.0±0.4 μm/day). In comparison, periosteal bone formation in the 3-year-old males was activated in only 1 animal, and this at a significantly attenuated level (less than 0.8 μm/day). The histomorphometric evaluation of intracortical bone remodeling revealed no significant differences between the control and experimental ulnae in either age group. However, osteon mean wall thickness and bone formation sigma were significantly increased in the 3-year-old males (P<0.05). In conclusion, these data suggest that a physical signal that is clearly osteogenic in the young adult skeleton is hardly acknowledged in older bone tissue. Whether this represents a deterioration of the bone cell populations ability to perceive these physical signals or a failure of their capacity to respond is not yet clear.

Enhancement of fracture healing by low intensity ultrasound.

Fracture healing is a highly complex regenerative process that is essentially a replay of developmental events. These events include the action of many different cell types, a myriad of proteins, and active gene expression that in the majority of cases ultimately will restore the bones natural integrity. Several biologic and biophysical approaches have been introduced to minimize delayed healing and nonunions, some with promising results. One example of such an approach is low intensity pulsed ultrasound, a noninvasive form of mechanical energy transmitted transcutaneously as high frequency acoustical pressure waves in biologic organisms. Numerous in vivo animal studies and perspective double blind placebo controlled clinical trials have shown that low intensity ultrasound is capable of accelerating and augmenting the healing of fresh fractures. Preliminary evidence suggests efficacy in the treatment of delayed healing and nonunions as well. This article reviews the animal and clinical studies that consider the effects of ultrasound on fracture healing, and the in vivo and in vitro work that strives to identify the biologic mechanism(s) responsible for the ultrasound induced enhancement of osteogenesis and fracture healing.

Strain Gradients Correlate with Sites of Periosteal Bone Formation

We examined the hypothesis that peak magnitude strain gradients are spatially correlated with sites of bone formation. Ten adult male turkeys underwent functional isolation of the right radius and a subsequent 4‐week exogenous loading regimen. Full field solutions of the engendered strains were obtained for each animal using animal‐specific, orthotropic finite element models. Circumferential, radial, and longitudinal gradients of normal strain were calculated from these solutions. Site‐specific bone formation within 24 equal angle pie sectors was determined by automated image analysis of microradiographs taken from the mid‐diaphysis of the experimental radii. The loading regimen increased mean cortical area (±SE) by 32.3 ± 10.5% (p = 0.01). Across animals, some periosteal bone formation was observed in every sector. The amount of periosteal new bone area contained within each sector was not uniform. Circumferential strain gradients (r2 = 0.36) were most strongly correlated with the observed periosteal bone formation. SED (a scalar measure of stress/strain magnitude with minimal relation to fluid flow) was poorly correlated with periosteal bone formation (r2 = 0.01). The combination of circumferential, radial, and longitudinal strain gradients accounted for over 60% of the periosteal new bone area (r2 = 0.63). These data indicate that strain gradients, which are readily determined given a knowledge of the bones strain environment and geometry, may be used to predict specific locations of new bone formation stimulated by mechanical loading.

Promotion of bony ingrowth by frequency-specific, low-amplitude mechanical strain.

The ability of extremely low-amplitude mechanical strains to promote bony ingrowth was evaluated in an in vivo animal model, the functionally isolated turkey ulna. A cylindrical, porous-coated titanium implant was placed across the dorsal and ventral cortices of the left ulna diaphysis of 12 animals. Back scatter electron microscopy was used to quantify the relative bony ingrowth after eight weeks of: (1) disuse alone, (2) disuse plus 100 seconds per day of a 1-Hz, 150-microstrain (mu epsilon) mechanical stimulus, or (3) disuse plus 100 seconds per day of a 20-Hz stimulus of similar strain magnitude. Disuse alone caused a mean 8.3% (+/- 5.5%) less of bone away from the implant, with the area between implant and bone actively filling with a fibrous membrane. A daily 100-second regimen of low-magnitude, 1-Hz mechanical stimulation caused 28% (+/- 6.2%) of the implant area available for ingrowth to be filled with bone. At 20 Hz, the amount of bony ingrowth increased to 69% (+/- 3.0%). These data demonstrate that brief exposure to extremely low-amplitude mechanical strains can enhance the biologic fixation of cementless implants. Moreover, the degree of ingrowth is dependent on the frequency of the applied strain.

Transmissibility of 15-Hertz to 35-Hertz Vibrations to the Human Hip and Lumbar Spine: Determining the Physiologic Feasibility of Delivering Low-Level Anabolic Mechanical Stimuli to Skeletal Regions at Greatest Risk of Fracture Because of Osteoporosis

Study Design. Experiments were undertaken to determine the degree to which high-frequency (15–35 Hz) ground-based, whole-body vibration are transmitted to the proximal femur and lumbar vertebrae of the standing human. Objectives. To establish if extremely low-level (<1 g, where 1 g = earth’s gravitational field, or 9.8 ms−2) mechanical stimuli can be efficiently delivered to the axial skeleton of a human. Summary of Background Data. Vibration is most often considered an etiologic factor in low back pain as well as several other musculoskeletal and neurovestibular complications, but recent in vivo experiments in animals indicates that extremely low-level mechanical signals delivered to bone in the frequency range of 15 to 60 Hz can be strongly anabolic. If these mechanical signals can be effectively and noninvasively transmitted in the standing human to reach those sites of the skeleton at greatest risk of osteoporosis, such as the hip and lumbar spine, then vibration could be used as a unique, nonpharmacologic intervention to prevent or reverse bone loss. Materials and Methods. Under sterile conditions and local anesthesia, transcutaneous pins were placed in the spinous process of L4 and the greater trochanter of the femur of six volunteers. Each subject stood on an oscillating platform and data were collected from accelerometers fixed to the pins while a vibration platform provided sinusoidal loading at discrete frequencies from 15 to 35 Hz, with accelerations ranging up to 1 gpeak-peak. Results. With the subjects standing erect, transmissibility at the hip exceeded 100% for loading frequencies less than 20 Hz, indicating a resonance. However, at frequencies more than 25 Hz, transmissibility decreased to approximately 80% at the hip and spine. In relaxed stance, transmissibility decreased to 60%. With 20-degree knee flexion, transmissibility was reduced even further to approximately 30%. A phase-lag reached as high as 70 degrees in the hip and spine signals. Conclusions. These data indicate that extremely low-level, high-frequency mechanical accelerations are readily transmitted into the lower appendicular and axial skeleton of the standing individual. Considering the anabolic potential of exceedingly low-level mechanical signals in this frequency range, this study represents a key step in the development of a biomechanically based treatment for osteoporosis.