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O'Leary TJ, Izard RM, Tang JCY, Fraser WD, Greeves JP. Hormonal contraceptive use is associated with altered bone structural and metabolic responses to military training in women: An observational cohort study. Bone 2024; 181:117012. [PMID: 38216077 DOI: 10.1016/j.bone.2024.117012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 12/19/2023] [Accepted: 01/05/2024] [Indexed: 01/14/2024]
Abstract
Military training increases tibial density and size. Female sex hormones may influence the adaption of bone to loading, but it is unknown if women using different hormonal contraceptives adapt similarly to military training. One hundred and sixteen women (57 women not using hormonal contraceptives [non-users], 38 combined oral contraceptive pill [COCP] users, 21 depot medroxyprogesterone acetate [DMPA] users) completed this study. Tibial volumetric bone mineral density (vBMD) and geometry were measured by peripheral quantitative computed tomography (4 %, 14 %, 38 %, and 66 % sites) at the start (week 1) and end (week 14) of British Army basic training. Circulating markers of bone and calcium metabolism were measured at weeks 1, 2, 4, 6, 10, and 14. Training increased trabecular vBMD at the 4 % site, periosteal perimeter at the 14 % and 66 % sites, and total area, cortical area, cortical thickness, and bone strength at all sites (0.1 to 1.6 %, p ≤ 0.009), with no differences between hormonal contraceptive groups (p ≥ 0.127). Trabecular vBMD increased at the 14 % site in non-users (0.8 %, p = 0.005), but not in COCP or DMPA users (p ≥ 0.205). Periosteal perimeter increased at the 38 % site in COCP (0.4 %, p < 0.001) and DMPA (0.5 %, p < 0.001) users, but not in non-users (p = 0.058). Training had no effect on periosteal perimeter at the 4 % site or cortical vBMD or endosteal perimeter at any site (p ≥ 0.168). βCTX decreased and PINP increased during training with no difference between hormonal contraceptive groups. Training increased iPTH in non-users, but not COCP or DMPA users. Hormonal contraceptives may exert site-specific effects on the mechanobiology of bone, with higher endogenous oestradiol promoting trabecularisation and inhibiting periosteal expansion in non-users compared with hormonal contraceptive users.
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Affiliation(s)
- Thomas J O'Leary
- Army Health and Performance Research, Army HQ, Andover, UK; Division of Surgery and Interventional Science, UCL, London, UK
| | | | - Jonathan C Y Tang
- Bioanalytical Facility, Norwich Medical School, University of East Anglia, Norwich, UK; Clinical Biochemistry, Departments of Laboratory Medicine and Departments of Diabetes and Endocrinology, Norfolk and Norwich University Hospital, Norwich, UK
| | - William D Fraser
- Bioanalytical Facility, Norwich Medical School, University of East Anglia, Norwich, UK; Clinical Biochemistry, Departments of Laboratory Medicine and Departments of Diabetes and Endocrinology, Norfolk and Norwich University Hospital, Norwich, UK
| | - Julie P Greeves
- Army Health and Performance Research, Army HQ, Andover, UK; Division of Surgery and Interventional Science, UCL, London, UK; Bioanalytical Facility, Norwich Medical School, University of East Anglia, Norwich, UK.
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Edwards NA, Talarico MK, Chaudhari A, Mansfield CJ, Oñate J. Use of accelerometers and inertial measurement units to quantify movement of tactical athletes: A systematic review. APPLIED ERGONOMICS 2023; 109:103991. [PMID: 36841096 DOI: 10.1016/j.apergo.2023.103991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 01/25/2023] [Accepted: 02/02/2023] [Indexed: 06/18/2023]
Abstract
The dynamic work environments of tactical athletes are difficult to replicate in a laboratory. Accelerometers and inertial measurement units provide a way to characterize movement in the field. This systematic review identified how accelerometers and inertial measurement units are currently being used to quantify movement patterns of tactical athletes. Seven research and military databases were searched, producing 26,228 potential articles with 78 articles included in this review. The articles studied military personnel (73.1%), firefighters (19.2%), paramedics (3.8%), and law enforcement officers (3.8%). Accelerometers were the most used type of sensor, and physical activity was the primarily reported outcome variable. Seventy of the studies had fair or poor quality. Research on firefighters, emergency medical services, and law enforcement officers was limited. Future research should strive to make quantified movement data more accessible and user-friendly for non-research personnel, thereby prompting increased use in tactical athlete groups, especially first responder agencies.
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Affiliation(s)
- Nathan A Edwards
- School of Health and Rehabilitation Sciences, The Ohio State University, 453 W 10th Ave, Columbus, OH, 43210, USA; Human Performance Collaborative, The Ohio State University, 1961 Tuttle Park Place, Columbus, OH, 43210, USA; Sports Medicine Research Institute, The Ohio State University, 4835 Fred Taylor Drive, Columbus, OH, 43210, USA.
| | - Maria K Talarico
- Human Systems Integration Division, DEVCOM Analysis Center, U.S. Army Futures Command, 7188 Sustainment Rd, Aberdeen Proving Ground, MD, 21005, USA.
| | - Ajit Chaudhari
- School of Health and Rehabilitation Sciences, The Ohio State University, 453 W 10th Ave, Columbus, OH, 43210, USA; Sports Medicine Research Institute, The Ohio State University, 4835 Fred Taylor Drive, Columbus, OH, 43210, USA; Department of Mechanical and Aerospace Engineering, The Ohio State University, 201 W. 19th Avenue, Columbus, OH, 43210, USA; Department of Biomedical Engineering, The Ohio State University, 140 W. 19th Avenue, Columbus, OH, 43210, USA.
| | - Cody J Mansfield
- School of Health and Rehabilitation Sciences, The Ohio State University, 453 W 10th Ave, Columbus, OH, 43210, USA; Sports Medicine Research Institute, The Ohio State University, 4835 Fred Taylor Drive, Columbus, OH, 43210, USA.
| | - James Oñate
- School of Health and Rehabilitation Sciences, The Ohio State University, 453 W 10th Ave, Columbus, OH, 43210, USA; Human Performance Collaborative, The Ohio State University, 1961 Tuttle Park Place, Columbus, OH, 43210, USA; Division of Athletic Training, School of Health and Rehabilitation Sciences, The Ohio State University, 453 W 10th Ave, Columbus, OH, 43210, USA; Sports Medicine Research Institute, The Ohio State University, 4835 Fred Taylor Drive, Columbus, OH, 43210, USA.
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O'Leary TJ, Wardle SL, Rawcliffe AJ, Chapman S, Mole J, Greeves JP. Understanding the musculoskeletal injury risk of women in combat: the effect of infantry training and sex on musculoskeletal injury incidence during British Army basic training. BMJ Mil Health 2023; 169:57-61. [PMID: 32111683 DOI: 10.1136/jramc-2019-001347] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 12/11/2019] [Accepted: 12/13/2019] [Indexed: 01/26/2023]
Abstract
INTRODUCTION Until recently, women were excluded from British combat roles. Their risk for musculoskeletal injury during basic training is two to three times higher than men. To better understand the musculoskeletal injury risk of women in British Army infantry basic training, we compared injury incidence between (1) men in standard entry training and men in infantry training, to assess the risk of infantry training; and (2) men and women in both standard entry and officer basic training, to assess the risk in women compared with men. METHODS The incidence of musculoskeletal injury was determined from defence medical records for all men entering infantry training, and for all men and women entering standard entry and officer training, between April 2015 and March 2016. RESULTS 7390 men (standard entry, n=4229; infantry, n=2683; officer, n=478) and 696 women (standard entry, n=626; officer, n=70) entered basic training. Men in infantry training had a lower incidence of musculoskeletal injury (391 vs 417 per 1000 personnel, OR 0.90 (95% CI 0.81 to 0.99), p=0.028) and a higher incidence of stress fracture (14 vs 5 per 1000 personnel, OR 2.80 (95% CI 1.64 to 4.80), p<0.001) than men in standard entry training. Women had a higher incidence of musculoskeletal injury than men in standard entry training (522 vs 417 per 1000 personnel, OR 1.53 (95% CI 1.29 to 1.81), p<0.001) and a higher incidence of stress fracture than men in officer training (114 vs 19 per 1000 personnel, OR 6.72 (95% CI 2.50 to 18.07), p<0.001). CONCLUSION Women in infantry training may be at similar risk for musculoskeletal injury, but at higher risk for stress fracture, compared with their non-infantry counterparts. Women in infantry training may be at higher risk for musculoskeletal injury and stress fracture compared with men in infantry training.
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Affiliation(s)
- Thomas J O'Leary
- Army Health and Performance Research, British Army, Andover, Hampshire, UK
| | - S L Wardle
- Army Health and Performance Research, British Army, Andover, Hampshire, UK
| | - A J Rawcliffe
- Army Recruiting and Initial Training Command, British Army, Upavon, Wiltshire, UK
| | - S Chapman
- Army Recruiting and Initial Training Command, British Army, Upavon, Wiltshire, UK
| | - J Mole
- Defence Statistics (Health), Defence Statistics, Abbey Wood, Bristol, UK
| | - J P Greeves
- Army Health and Performance Research, British Army, Andover, Hampshire, UK.,Norwich Medical School, University of East Anglia, Norwich, Norfolk, UK
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O'Leary TJ, Izard RM, Tang JCY, Fraser WD, Greeves JP. Sex differences in tibial adaptations to arduous training: An observational cohort study. Bone 2022; 160:116426. [PMID: 35470123 DOI: 10.1016/j.bone.2022.116426] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Revised: 04/12/2022] [Accepted: 04/19/2022] [Indexed: 12/31/2022]
Abstract
Military training increases tibial density and size, but it is unknown if men and women adapt similarly to the same arduous training. Seventy-seven men and 57 women not using hormonal contraceptives completed this study. Tibial volumetric bone mineral density (vBMD) and geometry were measured by peripheral quantitative computed tomography (4%, 14%, 38%, and 66% sites) at the start (week 1) and end (week 14) of British Army basic training. Training increased trabecular vBMD (4% site in men; 4% and 14% sites in women), cortical vBMD (38% site), total area (14% and 38% sites), trabecular area (14% site), cortical area and thickness (14%, 38%, and 66% sites), periosteal perimeter (14%, 38%, and 66% sites), and all indices of estimated strength (14%, 38%, and 66% sites); and, decreased endosteal perimeter (66% site) in men and women (all p ≤ 0.045). The increase in trabecular vBMD (4% and 14% sites) was greater in women and the increases in cortical area and strength (38% site) were greater in men (sex × time interactions, all p ≤ 0.047). P1NP increased and βCTX and sclerostin decreased during training in men and women, consistent with adaptive bone formation. PTH decreased in men but increased in women. Arduous weight-bearing activity increased the density and size of the tibia after 14 weeks. Women experienced similar tibial adaptations as men, however, a greater increase in trabecular vBMD in women compared with men could be due to higher loading at this skeletal site in women, whereas the small increase in cortical area could be due to inhibitory effects of oestradiol.
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Affiliation(s)
- Thomas J O'Leary
- Army Health and Performance Research, Army HQ, Andover, UK; Division of Surgery and Interventional Science, UCL, London, UK
| | | | | | - William D Fraser
- Norwich Medical School, University of East Anglia, Norwich, UK; Norfolk and Norwich University Hospital, Norwich, UK
| | - Julie P Greeves
- Army Health and Performance Research, Army HQ, Andover, UK; Division of Surgery and Interventional Science, UCL, London, UK; Norwich Medical School, University of East Anglia, Norwich, UK.
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Use of Wearable Technology to Measure Activity in Orthopaedic Trauma Patients: A Systematic Review. Indian J Orthop 2022; 56:1112-1122. [PMID: 35813536 PMCID: PMC9232686 DOI: 10.1007/s43465-022-00629-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 03/18/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Patient-Reported Outcome Measures (PROMs) are widely used for measurement of functional outcomes after orthopaedic trauma. However, PROMs rely on patient collaboration and suffer from various types of bias. Wearable Activity Monitors (WAMs) are increasingly used to objectify functional assessment. The objectives of this systematic review were to identify and characterise the WAMs technology and metrics currently used for orthopaedic trauma research. METHODS PubMed and Embase biomedical literature search engines were queried. Eligibility criteria included: Human clinical studies published in the English language between 2010 and 2019 involving fracture management and WAMs. Variables collected from each article included: Technology used, vendor/product, WAM body location, metrics measured, measurement time period, year of publication, study geographic location, phase of treatment studied, fractures studied, number of patients studied, sex and age of the study subjects, and study level of evidence. Six investigators reviewed the resulting papers. Descriptive statistics of variables of interest were used to analyse the data. RESULTS One hundred and thirty-six papers were available for analysis, showing an increasing trend of publications per year. Accelerometry followed by plantar pressure insoles were the most commonly employed technologies. The most common location for WAM placement was insoles, followed by the waist. The most commonly studied fracture type was hip fractures followed by fragility fractures in general, ankle, "lower extremity", and tibial fractures. The rehabilitation phase following surgery was the most commonly studied period. Sleep duration, activity time or step counts were the most commonly reported WAM metrics. A preferred, clinically validated WAM metric was not identified. CONCLUSIONS WAMs have an increasing presence in the orthopaedic trauma literature. The optimal implementation of this technology and its use to understand patients' pre-injury and post-injury functions is currently insufficiently explored and represents an area that will benefit from future study. SYSTEMATIC REVIEW REGISTRATION NUMBER PROSPERO ID:210344. SUPPLEMENTARY INFORMATION The online version contains supplementary material available at 10.1007/s43465-022-00629-0.
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6
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Lennox GM, Wood PM, Schram B, Canetti EFD, Simas V, Pope R, Orr R. Non-Modifiable Risk Factors for Stress Fractures in Military Personnel Undergoing Training: A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 19:422. [PMID: 35010681 PMCID: PMC8744653 DOI: 10.3390/ijerph19010422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 12/20/2021] [Accepted: 12/20/2021] [Indexed: 11/16/2022]
Abstract
A fracture, being an acquired rupture or break of the bone, is a significant and debilitating injury commonly seen among athletes and military personnel. Stress fractures, which have a repetitive stress aetiology, are highly prevalent among military populations, especially those undergoing training. The primary aim of this review is to identify non-modifiable risk factors for stress fractures in military personnel undergoing training. A systematic search was conducted of three major databases to identify studies that explored risk factors for stress fractures in military trainees. Critical appraisal, data extraction, and a narrative synthesis were conducted. Sixteen articles met the eligibility criteria for the study. Key non-modifiable risk factors identified were prior stress fracture and menstrual dysfunction, while advancing age and race other than black race may be a risk factor. To reduce the incidence of stress fractures in military trainees, mitigating modifiable risk factors among individuals with non-modifiable risk factors (e.g., optimising conditioning for older trainees) or better accommodating non-modifiable factors (for example, extending training periods and reducing intensity to facilitate recovery and adaptation) are suggested, with focus on groups at increased risk identified in this review.
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Affiliation(s)
- Grace M. Lennox
- Doctor of Physiotherapy Program, Bond University, Gold Coast, QLD 4226, Australia; (G.M.L.); (P.M.W.); (E.F.D.C.); (R.P.); (R.O.)
| | - Patrick M. Wood
- Doctor of Physiotherapy Program, Bond University, Gold Coast, QLD 4226, Australia; (G.M.L.); (P.M.W.); (E.F.D.C.); (R.P.); (R.O.)
| | - Ben Schram
- Doctor of Physiotherapy Program, Bond University, Gold Coast, QLD 4226, Australia; (G.M.L.); (P.M.W.); (E.F.D.C.); (R.P.); (R.O.)
- Tactical Research Unit, Bond University, Gold Coast, QLD 4226, Australia;
| | - Elisa F. D. Canetti
- Doctor of Physiotherapy Program, Bond University, Gold Coast, QLD 4226, Australia; (G.M.L.); (P.M.W.); (E.F.D.C.); (R.P.); (R.O.)
- Tactical Research Unit, Bond University, Gold Coast, QLD 4226, Australia;
| | - Vini Simas
- Tactical Research Unit, Bond University, Gold Coast, QLD 4226, Australia;
| | - Rodney Pope
- Doctor of Physiotherapy Program, Bond University, Gold Coast, QLD 4226, Australia; (G.M.L.); (P.M.W.); (E.F.D.C.); (R.P.); (R.O.)
- Tactical Research Unit, Bond University, Gold Coast, QLD 4226, Australia;
- School of Community Health, Charles Sturt University, Albury-Wodonga, NSW 2640, Australia
| | - Robin Orr
- Doctor of Physiotherapy Program, Bond University, Gold Coast, QLD 4226, Australia; (G.M.L.); (P.M.W.); (E.F.D.C.); (R.P.); (R.O.)
- Tactical Research Unit, Bond University, Gold Coast, QLD 4226, Australia;
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7
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Hughes JM, O'Leary TJ, Koltun KJ, Greeves JP. Promoting adaptive bone formation to prevent stress fractures in military personnel. Eur J Sport Sci 2021; 22:4-15. [PMID: 34269162 DOI: 10.1080/17461391.2021.1949637] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Mechanical loading leads to adaptive bone formation - the formation of new bone on existing skeletal surfaces - which increases bone strength and fatigue resistance. The same mechanical loading can also cause microdamage to bone and development of a stress fracture through targeted remodelling. Stress fractures are common in military recruits and cause significant morbidity, lost training time, and discharge from military service. This narrative review proposes strategies to promote adaptive bone formation as a novel approach to mitigate the risk of stress fracture injuries during arduous military training. Exercise that is unaccustomed, dynamic, high-impact, multidirectional, intermittent, and includes extended rest periods to restore bone mechanosensitivity, is most osteogenic. New bone formation can take up to one year to mineralize, and so new exercise training programmes should be initiated well in advance of military activities with high risk of stress fracture. Bone mechanosensitivity is highest in adolescence, before puberty, and so increasing physical activity in youth is likely to protect skeletal health in later life, including for those in the military. Recent data show that adaptive bone formation takes place during initial military training. Adaptive bone formation can also be supported with adequate sleep, vitamin D, calcium, and energy availability. Further evidence on how strategies to promote adaptive bone formation affect stress fracture risk are required. Adaptive bone formation can be optimized with a range of training and nutritional strategies to help create a resilient skeleton, which may protect against stress fracture throughout military service.
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Affiliation(s)
- Julie M Hughes
- Military Performance Division, United States Army Research Institute of Environmental Medicine, Natick, MA, USA
| | - Thomas J O'Leary
- Army Health and Performance Research, Army Headquarters, Andover, UK.,Division of Surgery and Interventional Science, University College London, London, UK
| | - Kristen J Koltun
- Neuromuscular Research Laboratory/Warrior Human Performance Research Center, Department of Sports Medicine and Nutrition, University of Pittsburgh, Pittsburgh, PN, USA
| | - Julie P Greeves
- Army Health and Performance Research, Army Headquarters, Andover, UK.,Division of Surgery and Interventional Science, University College London, London, UK.,Norwich Medical School, University of East Anglia, Norwich, UK
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8
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O'Leary TJ, Wardle SL, Gifford RM, Double RL, Reynolds RM, Woods DR, Greeves JP. Tibial Macrostructure and Microarchitecture Adaptations in Women During 44 Weeks of Arduous Military Training. J Bone Miner Res 2021; 36:1300-1315. [PMID: 33856703 DOI: 10.1002/jbmr.4290] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 03/01/2021] [Accepted: 03/12/2021] [Indexed: 12/14/2022]
Abstract
Bone adapts to unaccustomed, high-impact loading but loses mechanosensitivity quickly. Short periods of military training (≤12 weeks) increase the density and size of the tibia in women. The effect of longer periods of military training, where the incidence of stress fracture is high, on tibial macrostructure and microarchitecture in women is unknown. This observational study recruited 51 women (age 19 to 30 years) at the start of 44 weeks of British Army Officer training. Tibial volumetric bone mineral density (vBMD), geometry, and microarchitecture were measured by high-resolution peripheral quantitative computed tomography (HRpQCT). Scans of the right tibial metaphysis (4% site) and diaphysis (30% site) were performed at weeks 1, 14, 28, and 44. Measures of whole-body areal bone mineral density (aBMD) were obtained using dual-energy X-ray absorptiometry (DXA). Blood samples were taken at weeks 1, 28, and 44, and were analyzed for markers of bone formation and resorption. Trabecular vBMD increased from week 1 to 44 at the 4% site (3.0%, p < .001). Cortical vBMD decreased from week 1 to 14 at the 30% site (-0.3%, p < .001). Trabecular area decreased at the 4% site (-0.4%); trabecular bone volume fraction (3.5%), cortical area (4.8%), and cortical thickness (4.0%) increased at the 4% site; and, cortical perimeter increased at the 30% site (0.5%) from week 1 to 44 (p ≤ .005). Trabecular number (3.5%) and thickness (2.1%) increased, and trabecular separation decreased (-3.1%), at the 4% site from week 1 to 44 (p < .001). Training increased failure load at the 30% site from week 1 to 44 (2.5%, p < .001). Training had no effect on aBMD or markers of bone formation or resorption. Tibial macrostructure and microarchitecture continued to adapt across 44 weeks of military training in young women. Temporal decreases in cortical density support a role of intracortical remodeling in the pathogenesis of stress fracture. © 2021 Crown copyright. Journal of Bone and Mineral Research © 2021 American Society for Bone and Mineral Research (ASBMR). This article is published with the permission of the Controller of HMSO and the Queen's Printer for Scotland.
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Affiliation(s)
- Thomas J O'Leary
- Army Health and Performance Research, Army Headquarters, Andover, UK.,Division of Surgery and Interventional Science, University College London (UCL), London, UK
| | - Sophie L Wardle
- Army Health and Performance Research, Army Headquarters, Andover, UK.,Division of Surgery and Interventional Science, University College London (UCL), London, UK
| | - Robert M Gifford
- University/British Heart Foundation Centre for Cardiovascular Science, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK.,Research and Clinical Innovation, Royal Centre for Defence Medicine, Birmingham, UK
| | - Rebecca L Double
- Army Health and Performance Research, Army Headquarters, Andover, UK
| | - Rebecca M Reynolds
- University/British Heart Foundation Centre for Cardiovascular Science, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - David R Woods
- Research and Clinical Innovation, Royal Centre for Defence Medicine, Birmingham, UK.,Research Institute for Sport, Physical Activity and Leisure, Leeds Beckett University, Leeds, UK.,Northumbria and Newcastle National Health Service (NHS) Trusts, Wansbeck General and Royal Victoria Infirmary, Newcastle, UK.,University of Newcastle, Newcastle, UK
| | - Julie P Greeves
- Army Health and Performance Research, Army Headquarters, Andover, UK.,Division of Surgery and Interventional Science, University College London (UCL), London, UK.,Norwich Medical School, University of East Anglia, Norwich, UK
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O'Leary TJ, Rice HM, Greeves JP. Biomechanical Basis of Predicting and Preventing Lower Limb Stress Fractures During Arduous Training. Curr Osteoporos Rep 2021; 19:308-317. [PMID: 33635518 DOI: 10.1007/s11914-021-00671-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/12/2021] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW Stress fractures at weight-bearing sites, particularly the tibia, are common in military recruits and athletes. This review presents recent findings from human imaging and biomechanics studies aimed at predicting and preventing stress fractures. RECENT FINDINGS Peripheral quantitative computed tomography (pQCT) provides evidence that cortical bone geometry (tibial width and area) is associated with tibial stress fracture risk during weight-bearing exercise. The contribution of bone trabecular microarchitecture, cortical porosity, and bone material properties in the pathophysiology of stress fractures is less clear, but high-resolution pQCT and new techniques such as impact microindentation may improve our understanding of the role of microarchitecture and material properties in stress fracture prediction. Military studies demonstrate osteogenic outcomes from high impact, repetitive tibial loading during training. Kinetic and kinematic characteristics may influence stress fracture risk, but there is no evidence that interventions to modify biomechanics can reduce the incidence of stress fracture. Strategies to promote adaptive bone formation, in combination with improved techniques to assess bone strength, present exciting opportunities for future research to prevent stress fractures.
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Affiliation(s)
- Thomas J O'Leary
- Army Health and Performance Research, Army Headquarters, Andover, Hampshire, UK
- Division of Surgery and Interventional Science, UCL, London, UK
| | - Hannah M Rice
- Sport and Health Sciences, University of Exeter, Exeter, UK
| | - Julie P Greeves
- Army Health and Performance Research, Army Headquarters, Andover, Hampshire, UK.
- Division of Surgery and Interventional Science, UCL, London, UK.
- Norwich Medical School, University of East Anglia, Norwich, UK.
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10
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Orejel Bustos A, Belluscio V, Camomilla V, Lucangeli L, Rizzo F, Sciarra T, Martelli F, Giacomozzi C. Overuse-Related Injuries of the Musculoskeletal System: Systematic Review and Quantitative Synthesis of Injuries, Locations, Risk Factors and Assessment Techniques. SENSORS (BASEL, SWITZERLAND) 2021; 21:2438. [PMID: 33916269 PMCID: PMC8037357 DOI: 10.3390/s21072438] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 03/24/2021] [Accepted: 03/30/2021] [Indexed: 12/19/2022]
Abstract
Overuse-related musculoskeletal injuries mostly affect athletes, especially if involved in preseason conditioning, and military populations; they may also occur, however, when pathological or biological conditions render the musculoskeletal system inadequate to cope with a mechanical load, even if moderate. Within the MOVIDA (Motor function and Vitamin D: toolkit for risk Assessment and prediction) Project, funded by the Italian Ministry of Defence, a systematic review of the literature was conducted to support the development of a transportable toolkit (instrumentation, protocols and reference/risk thresholds) to help characterize the risk of overuse-related musculoskeletal injury. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) approach was used to analyze Review papers indexed in PubMed and published in the period 2010 to 2020. The search focused on stress (overuse) fracture or injuries, and muscle fatigue in the lower limbs in association with functional (biomechanical) or biological biomarkers. A total of 225 Review papers were retrieved: 115 were found eligible for full text analysis and led to another 141 research papers derived from a second-level search. A total of 183 papers were finally chosen for analysis: 74 were classified as introductory to the topics, 109 were analyzed in depth. Qualitative and, wherever possible, quantitative syntheses were carried out with respect to the literature review process and quality, injury epidemiology (type and location of injuries, and investigated populations), risk factors, assessment techniques and assessment protocols.
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Affiliation(s)
- Amaranta Orejel Bustos
- Interuniversity Centre of Bioengineering of the Human Neuromusculoskeletal System (BOHNES), Department of Movement, Human and Health Sciences, University of Rome “Foro Italico”, 00135 Rome, Italy; (A.O.B.); (V.B.); (V.C.); (L.L.)
| | - Valeria Belluscio
- Interuniversity Centre of Bioengineering of the Human Neuromusculoskeletal System (BOHNES), Department of Movement, Human and Health Sciences, University of Rome “Foro Italico”, 00135 Rome, Italy; (A.O.B.); (V.B.); (V.C.); (L.L.)
| | - Valentina Camomilla
- Interuniversity Centre of Bioengineering of the Human Neuromusculoskeletal System (BOHNES), Department of Movement, Human and Health Sciences, University of Rome “Foro Italico”, 00135 Rome, Italy; (A.O.B.); (V.B.); (V.C.); (L.L.)
| | - Leandro Lucangeli
- Interuniversity Centre of Bioengineering of the Human Neuromusculoskeletal System (BOHNES), Department of Movement, Human and Health Sciences, University of Rome “Foro Italico”, 00135 Rome, Italy; (A.O.B.); (V.B.); (V.C.); (L.L.)
| | - Francesco Rizzo
- Joint Veterans Defence Center, Army Medical Center, 00184 Rome, Italy; (F.R.); (T.S.)
| | - Tommaso Sciarra
- Joint Veterans Defence Center, Army Medical Center, 00184 Rome, Italy; (F.R.); (T.S.)
| | - Francesco Martelli
- Department of Cardiovascular and Endocrine-Metabolic Diseases and Aging, Italian National Institute of Health, 00161 Rome, Italy;
| | - Claudia Giacomozzi
- Department of Cardiovascular and Endocrine-Metabolic Diseases and Aging, Italian National Institute of Health, 00161 Rome, Italy;
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11
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Armitage M, Beato M, McErlain-Naylor SA. Inter-unit reliability of IMU Step metrics using IMeasureU Blue Trident inertial measurement units for running-based team sport tasks. J Sports Sci 2021; 39:1512-1518. [PMID: 33541230 DOI: 10.1080/02640414.2021.1882726] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The aim of this study was to determine the inter-unit reliability of IMU Step biomechanical load monitoring metrics using IMeasureU Blue Trident inertial measurement units in tasks common to running-based team sports. Knowledge of variability between units is required before researchers and practitioners can make informed decisions on "true" differences between limbs. Sixteen male college soccer players performed five running-based tasks, generating 224 trials and 17,012 steps. Data were analysed for each task and for the whole session, investigating six IMU Step metrics: step count; impact load; bone stimulus; and low, medium and high intensity steps. Inter-unit reliability was excellent (ICC ≥ 0.90) for 21 out of 26 metrics, and good (0.83 ≤ ICC ≤ 0.86) for all other metrics except for Yo-Yo impact load (ICC = 0.79) which was acceptable. These findings confirm the inter-unit reliability of IMU Step metrics using IMeasureU Blue Trident inertial measurement units for running-based team sports. Now that inter-unit variability has been quantified, researchers and practitioners can use this information when interpreting inter-limb differences for monitoring external biomechanical training load.
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Affiliation(s)
- Mark Armitage
- School of Health and Sports Sciences, University of Suffolk, Ipswich, UK
| | - Marco Beato
- School of Health and Sports Sciences, University of Suffolk, Ipswich, UK
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12
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Rawcliffe AJ, Hinde KL, Graham SM, Martindale R, Morrison A, Krajewski KT, Connaboy C. Altered Dynamic Postural Stability and Joint Position Sense Following British Army Foot-Drill. Front Sports Act Living 2020; 2:584275. [PMID: 33345154 PMCID: PMC7739694 DOI: 10.3389/fspor.2020.584275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 09/23/2020] [Indexed: 11/13/2022] Open
Abstract
Impaired proprioceptive acuity negatively affects both joint position sense and postural control and is a risk factor for lower-extremity musculoskeletal injury in athletes and military personnel. British Army foot-drill is an occupational military activity involving cyclical high impact loading forces greater than those observed in athletes during high level plyometrics. Foot-drill may contribute to the high rates of lower-extremity overuse injuries observed in recruits during basic training. There is limited research investigating foot-drill specific injury risk factors in women, despite greater incidences of musculoskeletal injury reported in women (522 vs. 417 per 1,000 personnel, OR: 1.53) when compared to men during basic training. This study aimed to quantify changes in ankle joint proprioception and dynamic postural stability following a period of British Army foot-drill. Fourteen women of similar age to British Army female recruits underwent pre-post foot-drill measures of frontal plane ankle joint position sense (JPS) and dynamic postural stability using the dynamic postural stability index (DPSI). Passive ankle JPS was assessed from relative test angles of inversion 30% (IN30%) and eversion 30% (EV30%) and IN60% of participants range of motion using an isokinetic dynamometer. The DPSI and the individual stability indices (medio-lateral [MLSI], anterior-posterior [APSI], and vertical [VSI]) were calculated from lateral and forward jump-landing conditions using force plates. Foot-drill was conducted by a serving British Army drill instructor. Significantly greater absolute mean JPS error for IN30% and EV30% was observed post foot-drill (p ≤ 0.016, d ≥ 0.70). For both the lateral and forward jump-landing conditions, significantly greater stability index scores were observed for MLSI, APSI, and DPSI (p ≤ 0.017, d ≥ 0.52). Significantly greater JPS error and stability index scores are associated with the demands of British Army foot-drill. These results provide evidence that foot-drill negatively affects lower-extremity proprioceptive acuity in recruit age-matched women, which has implications for increased injury risk during subsequent military physical activity, occurring in a normal training cycle.
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Affiliation(s)
- Alex J Rawcliffe
- Head Quarters Army Recruiting and Initial Training Command, Ministry of Defence, London, United Kingdom
| | - Katrina L Hinde
- Defence Science and Technology Laboratory, Porton Down, Salisbury, United Kingdom
| | - Scott M Graham
- School of Applied Sciences, Edinburgh Napier University, Edinburgh, United Kingdom
| | - Russell Martindale
- School of Applied Sciences, Edinburgh Napier University, Edinburgh, United Kingdom
| | - Andrew Morrison
- Cambridge Centre for Sport and Exercise Sciences, Anglia Ruskin University, Cambridge, United Kingdom
| | - Kellen T Krajewski
- Neuromuscular Research Laboratory, University of Pittsburgh, Pittsburgh, PA, United States
| | - Chris Connaboy
- Neuromuscular Research Laboratory, University of Pittsburgh, Pittsburgh, PA, United States
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13
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O'Leary TJ, Izard RM, Walsh NP, Tang JCY, Fraser WD, Greeves JP. Skeletal macro- and microstructure adaptations in men undergoing arduous military training. Bone 2019; 125:54-60. [PMID: 31077851 DOI: 10.1016/j.bone.2019.05.009] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 05/07/2019] [Accepted: 05/07/2019] [Indexed: 12/14/2022]
Abstract
PURPOSE Short periods of basic military training increase the density and size of the tibia, but the adaptive response of bone microarchitecture, a key component of bone strength, is not fully understood. METHODS Tibial volumetric bone mineral density (vBMD), geometry, microarchitecture and mechanical properties were measured using high-resolution peripheral quantitative computed tomography in 43 male British Army infantry recruits (mean ± SD, age 21 ± 3 years, height 1.76 ± 0.06 m, body mass 76.5 ± 9.4 kg). Bilateral scans were performed at the distal tibia at the start (week 1) and end (week 13) of basic military training. Concurrent measures were obtained for whole-body areal bone mineral density (aBMD) using DXA, and markers of bone metabolism (βCTX, P1NP, PTH, total 25(OH)D and ACa) from venous blood. RESULTS Training increased areal BMD for total body (1.4%) and arms (5.2%) (P ≤ 0.031), but not legs and trunk (P ≥ 0.094). Training increased trabecular (1.3 to 1.9%) and cortical vBMD (0.6 to 0.9%), trabecular volume (1.3 to 1.9%), cortical thickness (3.2 to 5.2%) and cortical area (2.6 to 2.8%), and reduced trabecular area (-0.4 to -0.5%) in both legs (P < 0.001). No changes in trabecular number, thickness and separation, cortical porosity, stiffness or failure load were observed (P ≥ 0.188). βCTX decreased (-0.11 μg∙l-1, P < 0.001) and total 25(OH)D increased (9.4 nmol∙l-1, P = 0.029), but no differences in P1NP, PTH or ACa were observed between timepoints (P ≥ 0.233). CONCLUSION A short period of basic military training increased density and altered geometry of the distal tibia in male military recruits. The osteogenic effects of basic military training are likely due to an increase in unaccustomed, dynamic and high-impact loading.
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Affiliation(s)
- Thomas J O'Leary
- Army Personnel Research Capability, Army Headquarters, Andover, United Kingdom.
| | - Rachel M Izard
- Department of Occupational Medicine, HQ Army Recruiting and Initial Training Command, Upavon, United Kingdom.
| | - Neil P Walsh
- Extremes Research Group, Bangor University, Bangor, United Kingdom.
| | - John C Y Tang
- Norwich Medical School, University of East Anglia, Norwich, United Kingdom.
| | - William D Fraser
- Norwich Medical School, University of East Anglia, Norwich, United Kingdom; Norfolk and Norwich University Hospital, Norwich, United Kingdom.
| | - Julie P Greeves
- Army Personnel Research Capability, Army Headquarters, Andover, United Kingdom; Norwich Medical School, University of East Anglia, Norwich, United Kingdom.
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14
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O'Leary TJ, Gifford RM, Double RL, Reynolds RM, Woods DR, Wardle SL, Greeves JP. Skeletal responses to an all-female unassisted Antarctic traverse. Bone 2019; 121:267-276. [PMID: 30735797 DOI: 10.1016/j.bone.2019.02.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 02/03/2019] [Accepted: 02/05/2019] [Indexed: 12/17/2022]
Abstract
PURPOSE To investigate the skeletal effects of the first all-female trans-Antarctic traverse. METHODS Six women (mean ± SD, age 32 ± 3 years, height 1.72 ± 0.07 m, body mass 72.8 ± 4.0 kg) hauled 80 kg sledges over 1700 km in 61 days from coast-to-coast across the Antarctic. Whole-body areal bone mineral density (aBMD) (dual-energy X-ray absorptiometry) and tibial volumetric BMD (vBMD), geometry, microarchitecture and estimated mechanical properties (high-resolution peripheral quantitative computed tomography) were assessed 39 days before (pre-expedition) and 15 days after the expedition (post-expedition). Serum and plasma markers of bone turnover were assessed pre-expedition, and 4 and 15 days after the expedition. RESULTS There were reductions in trunk (-2.6%), ribs (-5.0%) and spine (-3.4%) aBMD from pre- to post-expedition (all P ≤ 0.046); arms, legs, pelvis and total body aBMD were not different (all P ≥ 0.075). Tibial vBMD, geometry, microarchitecture and estimated mechanical properties at the metaphysis (4% site) and diaphysis (30% site) were not different between pre- and post-expedition (all P ≥ 0.082). Bone-specific alkaline phosphatase was higher 15 days post- than 4 days post-expedition (1.7 μg∙l-1, P = 0.028). Total 25(OH)D decreased from pre- to 4 days post-expedition (-36 nmol∙l-1, P = 0.008). Sclerostin, procollagen 1 N-terminal propeptide, C-telopeptide cross-links of type 1 collagen and adjusted calcium were unchanged (all P ≥ 0.154). CONCLUSION A decline in aBMD of the axial skeleton may be due to indirect and direct effects of prolonged energy deficit. We propose that weight-bearing exercise was protective against the effects of energy deficit on tibial vBMD, geometry, microarchitecture and strength.
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Affiliation(s)
- Thomas J O'Leary
- Army Personnel Research Capability, Army Headquarters, Andover, UK.
| | - Robert M Gifford
- University/British Heart Foundation Centre for Cardiovascular Science, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK; Research and Clinical Innovation, Royal Centre for Defence Medicine, Birmingham, UK.
| | - Rebecca L Double
- Army Personnel Research Capability, Army Headquarters, Andover, UK.
| | - Rebecca M Reynolds
- University/British Heart Foundation Centre for Cardiovascular Science, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK.
| | - David R Woods
- Research and Clinical Innovation, Royal Centre for Defence Medicine, Birmingham, UK; Research Institute for Sport, Physical Activity and Leisure, Leeds Beckett University, Leeds, UK; Northumbria and Newcastle NHS Trusts, Wansbeck General and Royal Victoria Infirmary, Newcastle, UK; University of Newcastle, Newcastle, UK.
| | - Sophie L Wardle
- Army Personnel Research Capability, Army Headquarters, Andover, UK.
| | - Julie P Greeves
- Army Personnel Research Capability, Army Headquarters, Andover, UK.
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