Bone structure of adolescent swimmers; a peripheral quantitative computed tomography (pQCT) study

Does Swimming Exercise Impair Bone Health? A Systematic Review and Meta-Analysis Comparing the Evidence in Humans and Rodent Models

BACKGROUND

The effect of swimming on bone health remains unclear, namely due to discrepant findings between studies in humans and animal models.

OBJECTIVE

The aim of this systematic review and meta-analysis is to identify the available evidence on the effects of swimming on bone mass, geometry and microarchitecture at the lumbar spine, femur and tibia in both humans and rodent animal models.

METHODS

The study followed PRISMA guidelines and was registered at PROSPERO (CRD4202236347 and CRD42022363714 for human and animal studies). Two different systematic literature searches were conducted in PubMed, Scopus and Web of Science, retrieving 36 and 16 reports for humans and animal models, respectively.

RESULTS

In humans, areal bone mineral density (aBMD) was similar between swimmers and non-athletic controls at the lumbar spine, hip and femoral neck. Swimmers' tibia diaphysis showed a higher cross-sectional area but lower cortical thickness. Inconsistent findings at the femoral neck cortical thickness were found. Due to the small number of studies, trabecular microarchitecture in human swimmers was not assessed. In rodent models, aBMD was found to be lower at the tibia, but similar at the femur. Inconsistent findings in femur diaphysis cross-sectional area were observed. No differences in femur and tibia trabecular microarchitecture were found.

CONCLUSION

Swimming seems to affect bone health differently according to anatomical region. Studies in both humans and rodent models suggest that tibia cortical bone is negatively affected by swimming. There was no evidence of a negative effect of swimming on other bone regions, both in humans and animal models.

Is it important to achieve physical activity recommendations at early stages of life to improve bone health?

Research in bone health during childhood is limited and important to prevent future diseases, particularly, osteoporosis. Bone parameters using DXA and pQCT in 295 Spanish children were evaluated and we found a benefit of meeting the World Health Organization physical activity recommendations in bone composition in childhood.

PURPOSE

To investigate the association between physical activity (PA) and bone health in a Spanish paediatric cohort, considering the influence of meeting/not meeting the current World Health Organization (WHO) PA recommendations and to elucidate if there are differences between boys and girls.

METHODS

In a cohort of children born in the region of Aragon (Spain) in 2009, followed until the age of 7 years, bone parameters were assessed using dual-energy X-ray absorptiometry (DXA) (whole body scan) and peripheral quantitative computed tomography (pQCT) (tibia scanned at the 8% (distal) and 38% (diaphyseal) of the total tibia length) in 295 7-year-old children (154 boys) in the last evaluation performed between 2016 and 2017. PA was assessed using GT3X Actigraph accelerometers.

RESULTS

Boys had significantly higher areal bone mineral density (aBMD), higher total bone mineral content (BMC) at the diaphyseal site and higher trabecular BMC and vBMD, and higher total bone area at the distal site than girls (p<0.01 for all of them). Both boys and girls complying with the WHO PA recommendations had significantly higher trabecular BMC than their inactive counterparts.

CONCLUSIONS

Meeting WHO PA recommendations has a beneficial effect in bone composition in childhood both in boys and in girls.

A systematic review and meta-analysis of pediatric normative peripheral quantitative computed tomography data

BACKGROUND

Peripheral-quantitative computed tomography (pQCT) provides an intriguing diagnostic alternative to dual-energy X-ray absorptiometry (DXA) since it can measure 3D bone geometry and differentiate between the cortical and trabecular bone compartments.

OBJECTIVE

To investigate and summarize the methods of pQCT image acquisition of in children, adolescents and/or young adults (up to age 20) and to aggregate the published normative pQCT data.

EVIDENCE ACQUISITION

A literature search was conducted in MEDLINE and EMBASE from 1947 to December 2020. Quality of the included articles was assessed using Standards for Reporting of Diagnostic Accuracy (STARD) scoring system and United States Preventative Services Task Force (USPSTF) Study Design Categorization. Seven articles, encompassing a total of 2134 participants, were aggregated in the meta-analysis. Due to dissimilar age groups and scan sites, only seven pQCT parameters of the 4% radius, 4% tibia and 38% tibia were analyzed in this meta-analysis.

EVIDENCE SYNTHESIS

The overall fixed-effect estimates of trabecular vBMD of the 4% radius were: 207.16 (201.46, 212.86), mg/cm3 in 8 to 9 year-old girls, 210.42 (201.91, 218.93)in 10 to 12 year-old girls, 226.99 (222.45, 231.54) in 12 to 13 year-old girls, 259.97 (254.85, 265.10) in 12 to 13 year-old boys and 171.55 (163.41,179.69) in 16 to 18 year-old girls. 21 of 54 (38.9%) primary papers received a 'good' STARD quality of reporting score (<90 and 70 ≥ %) (mean STARD score of all articles = 69.4%). The primary articles of this review had a 'good' level USPSTF study design categorization. However, most of the normative data in these articles were non-comparable and non-aggregable due to a lack of standardization of reference lines, acquisition parameters and/or age at acquisition.

CONCLUSION

There is not sufficient evidence to suggest that pQCT is appropriately suited for use in the pediatric clinical setting. Normative pediatric data must be systematically derived for pQCT should it ever be a modality that is used outside of research.

CLINICAL IMPACT

We demonstrate the need for normative pQCT reference data and for clinical guidelines that standardize pediatric acquisition parameters and delineate its use in pediatric settings.

Association Between Physical Fitness and Bone Strength and Structure in 3- to 5-Year-Old Children

BACKGROUND

The positive association between physical fitness and bone structure has been widely investigated in children and adolescents, yet no studies have evaluated this influence in young children (ie, preschoolers).

HYPOTHESIS

Fit children will present improved bone variables when compared with unfit children, and no sex-based differences will emerge in the sample.

STUDY DESIGN

Cross-sectional study.

LEVEL OF EVIDENCE

Level 3.

METHODS

Handgrip strength, standing long jump (SLJ), speed/agility, balance, and cardiorespiratory fitness (CRF) were assessed using the Assessing FITness levels in PREschoolers (PREFIT) test battery in 92 children (50 boys; age range, 3-5 years). A peripheral quantitative computed tomography scan was performed at 38% of the length of the nondominant tibia. Cluster analysis from handgrip strength, SLJ, speed/agility, and CRF was developed to identify fitness groups. Bone variables were compared between sexes and between cluster groups. The association between individual physical fitness components and different bone variables was also tested.

RESULTS

Three cluster groups emerged: fit (high values on all included physical fitness variables), strong (high strength values and low speed/agility and CRF), and unfit (low strength, speed/agility, and CRF). The fit group presented higher values than the strong and unfit groups for total and cortical bone mineral content, cortical area, and polar strength strain index (all P < 0.05). The fit group also presented a higher cortical thickness when compared with the unfit group (P < 0.05). Handgrip, SLJ, and speed/agility predicted all bone variables except for total and cortical volumetric bone mineral density. No differences were found for bone variables between sexes.

CONCLUSION

The results suggest that global fitness in preschoolers is a key determinant for bone structure and strength but not volumetric bone mineral density.

CLINICAL RELEVANCE

Physical fitness is a determinant for tibial bone mineral content, structure, and strength in very young children. Performing physical fitness tests could provide useful information related to bone health in preschoolers.

The muscle-bone unit in adolescent swimmers

Most researchers adjust bone by lean mass when comparing swimmers with controls. This adjustment is done under the assumption that lean affects bone similarly in both groups. Nonetheless, we found that the muscle-bone association is uncoupled in swimmers, and consequently, researchers should avoid this adjustment when evaluating swimmers' bone.

INTRODUCTION

To examine the functional and structural muscle-bone unit in adolescent swimmers.

METHODS

Sixty-five swimmers (34 girls/31 boys) and 119 controls (51 girls/68 boys) participated in the study. Muscle cross-sectional area (MCSA), bone mineral content (BMC), and polar strength-strain index (SSIPOL) were measured in the non-dominant radius by peripheral quantitative computed tomography (pQCT). Subtotal BMC and lean mass were evaluated with dual-energy X-ray absorptiometry (DXA). Handgrip and isometric knee extension (IKE) tests were performed to determine muscle force. The effect of MCSA, lean and force on SSIPOL, and BMC were tested, and the functional and structural muscle-bone ratios of swimmers and controls were compared.

RESULTS

Both muscle size (MCSA and lean) and muscle force (handgrip and IKE) influenced BMC and SSIPOL in swimmers and controls similarly. Swimmers presented normal MCSA and lean values for their height, but when compared with controls, swimmers presented a higher amount of lean and MCSA for the same BMC or SSIPOL (structural muscle-bone unit). For the functional muscle-bone unit, different results were found for the lower and upper limbs, as no differences were found for the upper limbs, while for the lower limbs, swimmers presented higher muscle force for the same amount of BMC.

CONCLUSIONS

The contradictory results regarding BMC in swimmers found in previous studies could partly be explained with the findings of the present study that reinforce the idea that swimming is not an effective sport to practice regarding bone mass and that the muscle-bone unit is different in swimmers than in controls.

Effects of Whole Body Vibration on Tibia Strength and Structure of Competitive Adolescent Swimmers: A Randomized Controlled Trial

BACKGROUND

Swimming has no effect on bone mass or structure. Therefore, adolescent swimmers present similar bone strength values when compared to normo-active controls, and lower values when compared to weight-bearing athletes. It thus seems necessary to try to improve bone structure and strength of adolescent swimmers through a weight-bearing intervention in order to reduce the risk of suffering osteoporosis later in life.

OBJECTIVE

To evaluate the effects of a 6-month whole body vibration (WBV) intervention on bone strength and structure of adolescent swimmers.

DESIGN

Randomized controlled trial.

SETTING

Research center.

PARTICIPANTS

A total of 51 swimmers (14.4 ± 2.0 years) participated in the study.

METHODS

Swimmers were randomly allocated into 2 groups: 20 swimmers (9 females) who only performed their swimming training, and 31 swimmers (15 females) who performed their swimming training and received a WBV intervention (3.6-11.6 g) 3 times per week during 6 months (VIB).

OUTCOME MEASUREMENTS

Peripheral quantitative computed tomography was performed in the nondominant tibia of all swimmers at 4%, 38%, and 66% of the tibia length before and after the intervention.

RESULTS

No differences between groups in any bone structure variable were found at pre- or postintervention. Both groups presented similar improvements in time, and no group by time interactions were found, suggesting that the WBV intervention was not intense enough to achieve positive changes in bone strength or structure.

CONCLUSION

WBV, at the chosen intensities and durations, had no effect on adolescent swimmers' bone strength or structure. Future studies should test other weight-bearing interventions aiming to improve bone strength and structure of adolescent swimmers.

LEVEL OF EVIDENCE

II.

Longitudinal effects of swimming on bone in adolescents: a pQCT and DXA study

The aims of the present study were, firstly, to evaluate areal bone mineral density (aBMD), bone strength and structure during a swimming season and compare them to those of normo-active controls (CG), and secondly to ascertain whether practising an additional weight-bearing sport other than swimming might improve bone. Twenty-three swimmers who only swam (SWI-PURE; 14 males, 9 females), 11 swimmers who combined swimming with an additional weight-bearing sport (SWI-SPORT; 8 males, 3 females) and 28 controls (CG; 16 males, 12 females) participated in the present study. aBMD was assessed with dual energy X-ray (DXA). Bone mass, area, structure and strength of the non-dominant tibia and radius were measured with peripheral quantitative computed tomography (pQCT). Measurements were performed at the beginning of the swimming season and 8 months later. The only difference among groups for DXA and pQCT variables was found for arm aBMD, which was higher in the SWI-SPORT than in the CG group at both pre- and post-evaluation. Group by time interactions (GxT) were found for trochanter aBMD when comparing SWI-SPORT to CG and SWI-SPORT to SWI-PURE, favouring in both cases SWI-SPORT. No GxT were found for the radius. For the tibia, GxT were found between SWI-SPORT and CG and between SWI-PURE and CG, in both cases favouring the swimmers. A season of swimming does not confer any additional benefits to aBMD, but may confer minor benefits to structure and mass. Complementing swimming with a weight-bearing activity is beneficial to bone.

Swimming and bone: Is low bone mass due to hypogravity alone or does other physical activity influence it?

Swimming during adolescence has shown neutral or even negative effects on bone mass. Nevertheless, it is still unknown if these effects are due to swimming or to other factors, such as sedentary behaviors.

INTRODUCTION

Three objectives were described (1) to measure objective physical activity (PA) additional to swimming performed by adolescent swimmers (SWI) and compare it to that performed by normo-active controls (CG), (2) to describe the relationship between objectively measured PA and bone mass, and (3) to compare bone mass of swimmers that meet the World Health Organization PA guidelines (active) WHO and those that do not (inactive).

METHODS

A total of 71 SWI (33 females) and 41 CG (17 females) wore an accelerometer for at least 4 days. PA was expressed as the amount of time (minutes/day) in each intensity [sedentary/light/moderate or vigorous (VPA), and the sum of moderate and vigorous (MVPA)]. Using the cutoff points proposed by Vanhelst et al. SWI were classified as active or inactive according to whether they reached 60 min of weight-bearing MVPA per day or not. Bone mineral density (BMD) was measured by dual energy X-ray absorptiometry, and bone strength values were calculated with peripheral quantitative computed tomography. Differences in PA intensities were calculated between SWI and CG. The relation of VPA to bone mass was studied in the SWI.

RESULTS

Male-SWI spend less time in VPA and MVPA than male-GC, which partly explains the lower BMD values in SWI than CG.

CONCLUSION

Swimming may displace weight-bearing VPA with serious implications on bone health.