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188 LEADER

Bone strength that incorporate periods of rest between

....................................................................................... short vigorous skeletal loading sessions.

Exercises for improving bone strength ASSESSING EXERCISE: THE

OSTEOGENIC INDEX
Bone formation with exercise can be
C H Turner, A G Robling estimated using an osteogenic index
................................................................................... (OI). The OI depends on the exercise
intensity and degree of desensitisation.
The effectiveness of exercise on bone strength depends on its type, Laboratory data suggest that exercise
intensity should be calculated as peak
timing, and duration magnitude of load (or stress) multiplied
by the loading frequency.5 Translating

R
egular exercise has effects on bone fluid movement in bone’s lacunar-cana- the laboratory data in terms of human
density, size, and shape, resulting licular network, which in turn generates exercise suggests that the rate of
in substantial improvements in shear stresses on the plasma membranes increase of the ground reaction force
mechanical strength. The positive asso- of resident osteocytes, bone lining cells, will best estimate the skeletal response.
ciation between exercise and bone mass and osteoblasts. Bone cells are highly The OI for multiple bouts of loading
has prompted many physicians and sensitive to fluid shear stresses, and depends on the recovery time allowed
public health officials to recommend respond by initiating a cascade of cellular between sessions. The osteogenic poten-
that people engage in daily exercise, events. High impact exercises that pro- tial of exercise can be increased when
with the goal of reducing the incidence duce large rates of deformation of the the daily exercise is divided into two
of osteoporotic fracture and the morbid- bone matrix best drive fluid through the shorter sessions separated by eight
ity/mortality that ensues. However, lacunar-canalicular network system. Thus hours. For example, consider 120 jumps
there is no clear consensus on exactly increasing loading rate is one step toward a day performed in one session or
how one should exercise in order to reap more effective application of mechanical broken into either two sessions of 60
the greatest returns in terms of bone forces to promote osteogenesis. jumps separated by eight hours or three
health. What exercises are best? How sessions of 40 jumps separated by four
often should one exercise? Is it some- PROLONGED EXERCISE HAS hours. Breaking 120 jumps into two
times better not to exercise? DIMINISHING RETURNS sessions improves the OI by almost 50%
Bone cells become desensitised to pro- but dividing the day further into three
longed mechanical stimulation. Notably sessions four hours apart does not
A LITTLE BONE GOES A LONG further improve the OI.6 If one wishes
WAY Umemura et al3 showed that rats trained
to jump many times a day increased the to reduce exercise time, it is far better to
Proper exercise can add new bone and/ shorten each exercise session than to
or reduce bone loss to ultimately affect mass of their femora and tibiae, but the
anabolic response became saturated reduce the number of sessions.
bone mass, but bone mass (or areal
bone mineral density) is merely a after about 40 loading cycles; animals
surrogate measure for bone strength. trained to jump 100 times a day did not START EARLY TO PREVENT
The real issue at hand is whether or not improve their bone mass significantly OSTEOPOROSIS
a person will fracture their hip, spine, or over those trained to jump 40 times a Although exercise has clear benefits for
wrist. Bone mineral content and bone day. The data from Umemura et al fit the skeleton, engaging in exercise dur-
mineral density are related to bone almost perfectly a logarithmic relation- ing skeletal growth is unequivocally
strength, but sometimes inferring ship, indicating that bone loses over 95% more osteogenic than exercise during
strength from bone mineral measure- of its mechanosensitivity after only 20 skeletal maturity.7 The biological
ments can be misleading. With exercise, loading cycles. Presumably bone cell mechanisms for this phenomenon are
small gains in bone mineral can result in mechanosensitivity will return after a not yet fully understood but are prob-
large improvements in bone strength,1 period of no loading. This concept was ably related to the fact that, during
because new bone formation is often tested by Robling et al4 in an experiment growth, the bone surfaces are covered
localised to bone surfaces where in which rats were subjected to medio- with a greater proportion of active
mechanical strains (stresses) were lateral bending of the tibia. All six osteoblasts than after skeletal maturity.
greatest. groups of rats in the experiment Periosteal expansion occurs predomi-
received 360 cycles a day of the same nantly during growth, and consequently
loading stimulus, delivered as 90 con- the childhood and adolescent years
NOT ALL EXERCISES ARE EQUALLY tinuous cycles, four times a day. Some provide a window of opportunity to
EFFECTIVE of the rats were allotted eight hours significantly enhance periosteal growth
The pioneering studies of Hert et al2 between each of the four daily bouts, with exercise. Periosteal growth deter-
performed over 30 years ago showed others were given 4, 2, 1, 0.5, or 0 hours mines the periosteal breadth of a bone,
that bone tissue responds to dynamic of rest between each of the four daily which is important in skeletal health for
rather than static loading. This finding bouts. Load induced bone formation two main reasons. Firstly, addition of
provides important information about was improved by the rest periods, and bone to the periosteal surface improves
how bone cells detect mechanical load- as the rest (no loading) periods were the bending and torsional strength of
ing. As static loads (even those that lengthened, bone formation was the bone most effectively. Secondly,
produce fairly large stresses or strains) enhanced further. With a rest period of resorption of bone from the periosteal
do not initiate osteogenesis, stress or four hours between loading bouts, surface is extremely rare in the adult;
strain in the tissue cannot by itself be loading induced bone formation was usually it is the trabecular, endocortical,
the primary stimulus for cellular almost doubled. After 24 hours of rest, and Haversian bone surfaces that
response. Instead there must be some- 98% of bone mechanosensitivity returns. undergo remodelling. These observa-
thing special about dynamic loading— Consequently the osteogenic response to tions indicate that the periosteal
for instance, dynamic loading creates exercise can be enhanced by regimens breadth of a bone will remain intact

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LEADER 189

until senescence. Consequently, vigor- Correspondence to: Dr Turner, Department of 3 Umemura Y, Ishiko T, Yamauchi T, et al. Five
Biomedical Engineering, 1120 South Drive, FH jumps per day increase bone mass and
ous exercise during growth and young breaking force in rats. J Bone Miner Res
115, Indianapolis, IN 46202, USA; turnerch@
adulthood may well reduce fracture risk iupui.edu 1997;12:1480–5.
in later decades.8 4 Robling AG, Burr DB, Turner CH. Recovery
Competing interests: none declared periods restore mechanosensitivity to dynamically
Br J Sports Med 2005;39:188–189. loaded bone. J Exp Biol 2001;204(Pt 19):
doi: 10.1136/bjsm.2004.016923 3389–99.
5 Turner CH. Three rules for bone adaptation to
...................... REFERENCES mechanical stimuli. Bone 1998;23:399–407.
6 Turner CH, Robling AG. Designing exercise
1 Robling AG, Hinant FM, Burr DB, et al.
Authors’ affiliations Improved bone structure and strength after
regimens to increase bone strength. Exerc Sport
C H Turner, Department of Biomedical Sci Rev 2003;31:45–50.
long-term mechanical loading is greatest 7 Kannus P, Haapasalo H, Sankelo M, et al. Effect
Engineering, Indiana University, Purdue if loading is separated into short bouts. of starting age of physical activity on bone mass in
University Indianapolis, Indianapolis, J Bone Miner Res 2002;17: the dominant arm of tennis and squash players.
IN 46202, USA 1545–54. Ann Intern Med 1995;123:27–31.
A G Robling, Department of Anatomy & Cell 2 Hert J, Lisková M, Landa J. Reaction of bone to 8 Karlsson MK, Ahlborg H, Obrant KJ, et al.
mechanical stimuli. 1. Continuous and intermittent Exercise during growth and young adulthood is
Biology, Indiana University, Indianapolis, loading of tibia in rabbit. Folia Morphol (Praha) associated with reduced fracture risk in old ages.
IN 46202 1971;19:290–300. J Bone Miner Res 2002;17(suppl 1):S297.

ELECTRONIC PAGES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Online original articles

T
he following electronic only articles are published in
conjunction with this issue of BJSM (see also pages 211
and 216)

Neck injuries presenting to emergency departments in Methods: A consensus regarding definitions and methods
the United States from 1990 to 1999 for ice hockey, to calculate injury rates in cricket was sought between
soccer, and American football researchers in this field. This was arrived at through a variety
J S Delaney, A Al-Kashmiri of face to face meetings, email communication, and draft
Objective: To examine the number and rate of neck injuries reviews between researchers from six of the major cricket
in the community as a whole for ice hockey, soccer, and playing nations.
American football by analysing data from patients presenting Results: It is recommended that a cricket injury is defined
to emergency departments in the United States from 1990 to as any injury or other medical condition that either (a)
1999. prevents a player from being fully available for selection for a
Methods: Data compiled for the US Consumer Product major match or (b) during a major match, causes a player to
Safety Commission were used to generate estimates for the be unable to bat, bowl, or keep wicket when required by
total number of neck injuries and the more specific diagnoses either the rules or the team’s captain. Recommended
of neck fractures, dislocations, contusions, sprains, strains, definitions for injury incidence (for matches, training
and lacerations occurring nationally from 1990 to 1999. These sessions, and seasons) and injury prevalence are also
data were combined with yearly participation figures to provided. It is proposed that match injury incidence is
generate rates of injury presenting to emergency departments calculated using a denominator based on a standard time
for each sport. estimated for player exposure in matches, for the purposes of
Results: There were an estimated 5038 neck injuries from simplicity. This will allow all injury surveillance systems,
ice hockey, 19 341 from soccer, and 114 706 from American including those with limited resources, to make calculations
football. These could be broken down as follows: 4964 con- according to a standard definition.
tusions, sprains, or strains from ice hockey, 17 927 from soccer, Conclusion: The consensus statement presented provides
and 104 483 from football; 105 neck fractures or dislocations a standard which, if followed, allows meaningful comparison
from ice hockey, 214 from soccer, and 1588 from football; 199 of injury surveillance data from different countries and time
neck lacerations for ice hockey, 0 for soccer, and 621 for periods, which will assist in the possible identification of risk
football. The rates for total neck injuries and combined neck factors for injury in cricket.
contusions, sprains, or strains were higher for football than for
ice hockey or soccer in all years for which data were available. ‘‘Methods for injury surveillance in international cricket’’, a
Conclusion: The rate of neck injury in the United States collaboration between cricket authorities in Australia, the
was higher in football than in ice hockey or soccer in the time United Kingdom, South Africa, New Zealand, the West
period studied. Indies, and India, is being published simultaneously in
(Br J Sports Med 2005;39:e21) http://bjsm.bmjjournals.com/ the Journal of Science and Medicine in Sport, the British
cgi/content/full/39/1/e21 Journal of Sports Medicine, the South African Journal of Sports
Medicine, and the New Zealand Journal of Sports Medicine. The
Methods for injury surveillance in international cricket paper was concurrently reviewed and edited by the Journal of
J W Orchard, D Newman, R Stretch, et al Science and Medicine in Sport and the British Journal of Sports
Background: The varying methods of cricket injury surveil- Medicine.
lance have made direct comparison of published studies in (Br J Sports Med 2005;39:e22) http://bjsm.bmjjournals.com/
this field impossible. cgi/content/full/39/1/e22

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Exercises for improving bone strength

C H Turner and A G Robling

Br J Sports Med 2005 39: 188-189

doi: 10.1136/bjsm.2004.016923

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Topic Articles on similar topics can be found in the following collections

Collections Musculoskeletal syndromes (431)
Injury (957)
Trauma (845)

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