Medical Vibration Therapy in Osteopenic patients with Galileo900/2000 S.F.E. Praet MD MSc Trainee...
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Transcript of Medical Vibration Therapy in Osteopenic patients with Galileo900/2000 S.F.E. Praet MD MSc Trainee...
Medical Vibration Therapy in Osteopenic patients with Galileo900/2000
S.F.E. Praet MD MSc
Trainee Sports Medicine
Movement Scientist
Máxima Medical Centre
Veldhoven (Nl) N. Snelder, BSc
Masters student
Life Science and Technology
TU Delft / RU Leiden (Nl)
H. Mulder, MD PhD
Endocrinologist
Director Osteosupport SMO
Rotterdam (Nl)
• Introduction• Background• Research Question• Methods• The Galileo™ principle• Results• Discussion• Summary
Overview
IntroductionIntroduction
Definition of Bone Mineral Density Definition of Bone Mineral Density
(WHO)(WHO)
Healthy Bone = Reference BMD of 25 yrs old female(T-score < -1)(T-score < -1)
Osteopenic = BMD < 1 SD of reference BMD (T-score < -1)(T-score < -1)
Osteoporotic = BMD < 2.5 SD (T-score < -2.5)(T-score < -2.5)
Introduction
Natural BMD at Hip in Caucasian Females
• Approximately 30% of postmenopausal females have osteoporosis according to the World Health Organization (WHO) ( Kanis 1994, WHO 1994).
• The excess mortality associated with a hip fracture has been estimated to be at 20% ( Cooper 1993),
• Cumulative lifetime fracture risk for a 50 year-old women may be as high as 60% (Cummings 1989).
Introduction
Epidemiology of Osteoporosis
Introduction
Bone Mineral Density vs. Risk of Hip fracture
• The total dollar cost of osteoporosis was estimated at seven to ten billion annually in 1988 (WHO 1994).
• Hip fractures and hospitalization for all types of fracture accounted for most of these costs (Cooper 1993).
• Therefore, the prevention of fractures is the primary goal of intervention.
Introduction
Cost of Osteoporosis
• Anti-resorptive bone formation agents (e.g. estrogen and biophosphates)
• Bone formation agents (e.g. fluoride and PTH).
• Calcium and Vitamin D supplementation
JAMA 285: 785-795, 2001Chapuy et al. Osteoporos. Int. 2002
Introduction
Prevention of Osteoporosis
IntroductionOsteoporosis & Calcium
• “The value of exercise as an intervention for the prevention of postmenopausal bone loss is a controversial subject”
Kanis, WHO Study Group. Osteoporosis Int. 1994
Introduction
Prevention of Osteoporosis
IntroductionOsteoporosis & Exercise:
Background
Vibrations and Bone mass
Animal studies (Turkey)
Rubin et al. Nature 2001
Fritton, McLeod, Rubin, J. Biomech. 2000
Background
Normal Frequency & Microstrain Pattern in Bone
Animal studies (Turkey/Sheep/Dog)
Fritton, McLeod, Rubin, J. Biomech. 2000
Walking Turkey 12 h. Daily activity
1 microstrain is 0.0001% strain (e = dL/L)
Background
Vibrations and Bone mass
Animal studies (Ewes)
Rubin et al. Bone 2002
Rubin et al. J Bone Miner. Res. 2002
30Hz, 0.3 g, 20min/day5x/wk during 1 year
Femur: 34.2% BMD increaseTibia: 26.7% Strength increase
Background
Vibrations and Bone mass
Animal studies: Bone Formation (Prox. Tibia) in Rats
Rubin et al. FASEB 2001
28 days follow up period:
LTC=Long term controlMS=Mech. Stim/ @ 90Hz 0.25 g
10 min/day 5x/wkDis= Disuse Hindlimb suspensionWB=Weight Bearing
Background
Vibrations and Bone mass
Animal studies: Mineralization of Trabuculae
Rubin et al. FASEB 2001
Control Disuse Mech. Stim.
Research Question
What is the effect of Vibration Therapy
on patients with low bone mass?
Methods Subjects Selection
Inclusion Criteria:
•Osteopenia: BMD –2.0 < t-value < 1.0 (DEXA)•Able to stand on vibration platform•Motivation to participate
Exclusion Criteria:
•Use of Medication that influences Bone metabolism•History of Deep Venous Thrombosis
Methods Subjects Selection
January 2001- April 2001
•60 patients visiting Osteoporosis Clinic for DEXA measurement with osteopenia (-2.0 < t < -1.0)
•37 patients included
•23 patients excluded•10 not allowed medication•3 History of DVT•3 Disabled•7 Not interested to participate
Methods Therapeutical Intervention through Randomization
Group I (n=19 (13 F / 6 M)
Age: 61 yrs ± 7
10 post menopausal
•WBV on Galileo2000
1x/week: 3 x 3 min @16 Hz
Group II (n=18 (13 F / 5 M)
Age: 64 yrs ± 5
8 post menopausal
•WBV on Galileo2000
1x/week: 3 x 3 min @16 Hz
•Vitamin D 400 I.U. / day
•Calcium 500 mg / day
Galileo ™ 900/2000
Whole Body Vibration Platform
•Amplitude: 0-12 mm
•Frequency 5-30 Hz (continuum)
•Tilting platform
Whole Body Vibration
• Downward displacement / Acceleration of leg• Reactive upward force (cf. landing phase)
Dampening through:
• Eccentric muscle contraction:alternating left / right limb +contralateral trunk muscles
• Simultaneous Bone strain
Whole Body Vibration according to Galileo principle
Methods BMD measurements
Dual Energy X-Ray Absorptiometry (DEXA)
At 0 – 6 – 12 and 24 months
•Lunar DPX-L machine
Hip (Neck) Lumbar spine (L1-L4)
Methods Marker Bone Growth
Serum Alkaline Phosphatase measurements
At 0 – 12 and 24 months
Statistics
Multiple t-tests within and between the two groups
Confidence interval 99%
ResultsSerum Alkaline Phosphates
94,0%
96,0%
98,0%
100,0%
102,0%
104,0%
106,0%
108,0%
110,0%
0 12 24
Months
Serum Alkaline Phosphates
Change Alkaline Phosphates I
Change Alkaline Phosphates II
* * * *
* p<0.01
BMD L1-L4
98,0%
99,0%
100,0%
101,0%
102,0%
103,0%
104,0%
105,0%
106,0%
107,0%
108,0%
0 6 12 24
Months
Change BMD Spine I
Change BMD Spine II
ResultsBMD change Spine
*
*¶ ¶
¶
¶ p<0.01, * p<0.001
BMD Femoral Neck
98,0%
99,0%
100,0%
101,0%
102,0%
103,0%
104,0%
105,0%
106,0%
107,0%
108,0%
0 6 12 24
Months
Change BMD Hip I
Change BMD Hip II
ResultsBMD change Hip
*
* *
¶ p<0.01, * p<0.001
¶
¶¶
ResultsPercentual BMD change
Spine group 1 Hip group 1Months
0 100,0% 100,0%6 101,0% 101,7%
12 101,8% 103,3%24 102,1% 103,6%
Spine group 2 Hip group 2Months
0 100,0% 100,0%6 101,3% 102,0%
12 103,1% 104,2%24 104,0% 103,9%
Percental change in bonemass
Percental change in bonemass
I
II**
*
*
¶
*
¶¶
¶¶
¶
¶ p<0.01, * p<0.001
Results
Percental change in bonemass (spine and femoral neck of the hip) in patients with Osteopenia,
treated with WBV without (group 1) and with calcium-vitamin D supplementation (group 2)
Bone Mineral Density change (DEXA)
100,0%
100,5%
101,0%
101,5%
102,0%
102,5%
103,0%
103,5%
104,0%
104,5%
0 6 12 24months
Spine group 1 Hip group 1 Spine group 2 Hip group 2
ResultsTherapy compliance
Table IV Group Igroup IINote: Medical Vibraion Therapy each weak = 100%
90%93%94%
Compliance to the Whole Body Vibration protocol104 weeks52 weeks
92%
Reported side effects: none
Other Literature8 Months of Vertical WBV @ 25-45 Hz
in young healthy adults vs controls (RCT, n=56)
2-5x/wk, 4 min/day
Torvinen et al, J Bone Miner Res 2003 May 18:876-84
•No effect on BMC (DEXA/pQCT)
•No effect on Serum Bone Turnover Markers
•7.8 % net increase in Jump Height
Other LiteratureStrength training vs. Tilting WBV @ 25 Hz
12 mths, 2x/wk +/- HRT post-menopausal (n=51)
C. Kleinmond, PhD Thesis FU Berlin, 2002 http://darwin.inf.fu-berlin.de/2002/270
SpineSpine
HipHip
DiscussionWhole Body Vibration and Bone Metabolism
•Catabolic vs Anabolic state of Bone
•Secondary/functional hypoparathyreoidism•Pre vs Post menopausal•Base line BMD / Activity level
DiscussionWhole Body Vibration and Bone Metabolism
•Synergistic Effect with
•Ca++/Vit D•Hormone Replacement Therapy
DiscussionWhole Body Vibration and Bone Metabolism
Dose-response relationship ?
•Frequency•Duration•Amplitude•Vertical vs Tilting •Therapy Compliance
DiscussionWhole Body Vibration and Bone Cell
Theoretical Model of Osteogenesis and Vibration:
Perturbation Intermedullary PressurePerturbation Intermedullary PressureFluid flow through bone canuculi /lacunaeFluid flow through bone canuculi /lacunae
Shear Stress Cell Membrane Shear Stress Cell Membrane (>5 microstrain @ 30 Hz)(>5 microstrain @ 30 Hz)
Mechanotransduction Mechanotransduction Cytoskeletal stressCytoskeletal stress
Expression of mRNAExpression of mRNAOsteoblast Osteoblast
expression /activationexpression /activation Weinbaum et al. J. Biomech. 27, 1993Hsich& Turner J Bone Miner Res 16, 2001Rubin et al Nature 412, 200/ Bone 30, 2002
Qin, Rubin, McLeod J Orth Res 16 1998Cullen et al. J. Appl. Physiol 91, 2001
WBV and Fall risk
• ADL in Geriatric patients (Balance + chair rising test)(n=34, 67 yrs; 2 mths: 3x/wk 3 x 2 min WBV)
+ 18 % progress in Chair rising test
Runge et al. ; J. Musculoskeletal Interact. 1 (2000)
Summary Whole Body Vibration in Osteopenia
•Synergistic effect of WBV and Ca++/Vit D Supplementation
•Fast response at Femoral Neck
•Long term response at Lumbar Spine
•Leveling off after 12 months
•Optimal dose response?
•Fall and fracture risk reduction: still undetermined
Thank you for your attention