Physical Training Outcome Predictions With Biomechanics, Part I: Army Physical Fitness Test Modeling.

OBJECTIVES: The U.S. Army Basic Combat Training (BCT) is the first step in preparing soldier trainees for the physical demands of the military. Unfortunately, a substantial number of trainees fail BCT due to failure on the final Army Physical Fitness Test (also known as the "end of cycle" APFT). Current epidemiological studies have used statistics to identify several risk factors for poor APFT performance, but these studies have had limited utility for guiding regimen design to maximize APFT outcome. This is because such studies focus on intrinsic risks to APFT failure and do not utilize detailed BCT activity data to build models which offer guidance for optimizing the training regimen to improve graduation rates. METHODS: In this study, a phenomenological run performance model that accounts for physiological changes in fitness and fatigue due to training was applied to recruits undergoing U.S. Army BCT using high resolution (minute-by-minute) activity data. RESULTS: The phenomenological model was better at predicting both the final as well as intermediate APFTs (R(2) range = 0.55-0.59) compared to linear regression models (LRMs) that used the same intrinsic input variables (R(2) range = 0.36-0.50). CONCLUSIONS: Unlike a statistical approach, a phenomenological model accounts for physiological changes and, therefore, has the potential to not only identify trainees at risk of failing BCT on novel training regimens, but offer guidance to regimen planners on how to change the regimen for maximizing physical performance. This paper is Part I of a 2-part series on physical training outcome predictions.

Physical Training Outcome Predictions With Biomechanics, Part II: Overuse Injury Modeling.

OBJECTIVES: In Part II of a two-part series, we develop a phenomenological model of a negative outcome of U.S. Army Basic Combat Training that affects a large proportion of trainees. Previous models have been epidemiological in nature and have focused on trainee risk factors such as previous injury, gender, and initial fitness. This approach is limited due to difficulties extrapolating results to other cohorts. In addition, training regimen is often neglected, limiting accuracy when applied to novel scenarios. METHODS: The prognostic Training Adaptation Injury Model (TAIM) developed accounts for both individual characteristics as well as regimen by integrating validated submodels of physiological and biomechanical principles known to be important for tibial stress fracture. RESULTS: We find that when used to predict any type of overuse injury, the TAIM is most accurate when the effect of training activities on both overall fitness as well as muscle fatigue during activities is accounted for area under the receiver-operator curve of 0.65. This compares favorably with statistical-based models that do not account for training regimen (area under the receiver-operator curve ≈ 0.56. CONCLUSIONS: The TAIM has the potential to both identify trainees at overuse injury risk as well as make recommendations on regimen changes to reduce that risk.

Increased density and periosteal expansion of the tibia in young adult men following short-term arduous training.

PURPOSE: Few human studies have reported early structural adaptations of bone to weight-bearing exercise, which provide a greater contribution to improved bone strength than increased density. This prospective study examined site- and regional-specific adaptations of the tibia during arduous training in a cohort of male military (infantry) recruits to better understand how bone responds in vivo to mechanical loading. METHODS: Tibial bone density and geometry were measured in 90 British Army male recruits (ages 21±3years, height: 1.78±0.06m, body mass: 73.9±9.8kg) in weeks 1 (Baseline) and 10 of initial military training. Scans were performed at the 4%, 14%, 38% and 66% sites, measured from the distal end plate, using pQCT (XCT2000L, Stratec Pforzheim, Germany). Customised software (BAMPack, L-3 ATI) was used to examine whole bone cross-section and regional sectors. T-tests determined significant differences between time points (P<0.05). RESULTS: Bone density of trabecular and cortical compartments increased significantly at all measured sites. Bone geometry (cortical area and thickness) and bone strength (i, MMi and BSI) at the diaphyseal sites (38 and 66%) were also significantly higher in week 10. Regional changes in density and geometry were largely observed in the anterior, medial-anterior and anterior-posterior sectors. Calf muscle density and area (66% site) increased significantly at week 10 (P<0.01). CONCLUSIONS: In vivo mechanical loading improves bone strength of the human tibia by increased density and periosteal expansion, which varies by site and region of the bone. These changes may occur in response to the nature and distribution of forces originating from bending, torsional and shear stresses of military training. These improvements are observed early in training when the osteogenic stimulus is sufficient, which may be close to the fracture threshold in some individuals.

Odd-impact loading results in increased cortical area and moments of inertia in collegiate athletes.

PURPOSE: The purpose of this study was to investigate tibial changes in volumetric bone mineral density and geometry that take place in athletes from pre- to post-season. METHODS: Female college athletes (n = 36) and ten controls recruited from the student population were included in the study. Participants had their left tibia scanned by pQCT at 4, 20, and 66 % of the overall length from the distal end before and after their competitive seasons. Subjects were divided into four groups: non-athlete (controls, n = 10), moderate-impact (cross-country runners, n = 13), high-impact (volleyball and basketball, n = 11), and odd-impact (soccer, n = 12). RESULTS: Anterior-posterior and medial-lateral diameter increased at the 4 % site in control subjects. In the moderate-impact group, medial-lateral moment of inertia (MOI) increased by 1.2 ± 1.8 (mean ± SD) percent at the 20 % site. In high-impact group, anterior-posterior MOI increased by 1.6 ± 2.0 percent at the 66 % site. In odd-impact group, cortical area (1.4 ± 2.3 %) and cortical thickness (1.8 ± 2.8 %) increased at the 20 % site increased, as did the polar MOI (1.8 ± 2.2 %) at the 66 % site. CONCLUSIONS: Load-specific changes resulting in improved measures of bone strength take place in athletes during a competitive season. These changes may result in improved resistance to fractures and stress fractures.

Variation in tibial functionality and fracture susceptibility among healthy, young adults arises from the acquisition of biologically distinct sets of traits.

Physiological systems like bone respond to many genetic and environmental factors by adjusting traits in a highly coordinated, compensatory manner to establish organ-level function. To be mechanically functional, a bone should be sufficiently stiff and strong to support physiological loads. Factors impairing this process are expected to compromise strength and increase fracture risk. We tested the hypotheses that individuals with reduced stiffness relative to body size will show an increased risk of fracturing and that reduced strength arises from the acquisition of biologically distinct sets of traits (ie, different combinations of morphological and tissue-level mechanical properties). We assessed tibial functionality retrospectively for 336 young adult women and men engaged in military training, and calculated robustness (total area/bone length), cortical area (Ct.Ar), and tissue-mineral density (TMD). These three traits explained 69% to 72% of the variation in tibial stiffness (p < 0.0001). Having reduced stiffness relative to body size (body weight × bone length) was associated with odds ratios of 1.5 (95% confidence interval [CI], 0.5-4.3) and 7.0 (95% CI, 2.0-25.1) for women and men, respectively, for developing a stress fracture based on radiography and scintigraphy. K-means cluster analysis was used to segregate men and women into subgroups based on robustness, Ct.Ar, and TMD adjusted for body size. Stiffness varied 37% to 42% among the clusters (p < 0.0001, ANOVA). For men, 78% of stress fracture cases segregated to three clusters (p < 0.03, chi-square). Clusters showing reduced function exhibited either slender tibias with the expected Ct.Ar and TMD relative to body size and robustness (ie, well-adapted bones) or robust tibias with reduced residuals for Ct.Ar or TMD relative to body size and robustness (ie, poorly adapted bones). Thus, we show there are multiple biomechanical and thus biological pathways leading to reduced function and increased fracture risk. Our results have important implications for developing personalized preventative diagnostics and treatments.

Biological constraints that limit compensation of a common skeletal trait variant lead to inequivalence of tibial function among healthy young adults.

Having a better understanding of how complex systems like bone compensate for the natural variation in bone width to establish mechanical function will benefit efforts to identify traits contributing to fracture risk. Using a collection of pQCT images of the tibial diaphysis from 696 young adult women and men, we tested the hypothesis that bone cells cannot surmount the nonlinear relationship between bone width and whole bone stiffness to establish functional equivalence across a healthy population. Intrinsic cellular constraints limited the degree of compensation, leading to functional inequivalence relative to robustness, with slender tibias being as much as two to three times less stiff relative to body size compared with robust tibias. Using Path Analysis, we identified a network of compensatory trait interactions that explained 79% of the variation in whole-bone bending stiffness. Although slender tibias had significantly less cortical area relative to body size compared with robust tibias, it was the limited range in tissue modulus that was largely responsible for the functional inequivalence. Bone cells coordinately modulated mineralization as well as the cortical porosity associated with internal bone multicellular units (BMU)-based remodeling to adjust tissue modulus to compensate for robustness. Although anecdotal evidence suggests that functional inequivalence is tolerated under normal loading conditions, our concern is that the functional deficit of slender tibias may contribute to fracture susceptibility under extreme loading conditions, such as intense exercise during military training or falls in the elderly. Thus, we show the natural variation in bone robustness was associated with predictable functional deficits that were attributable to cellular constraints limiting the amount of compensation permissible in human long bone. Whether these cellular constraints can be circumvented prophylactically to better equilibrate function among individuals remains to be determined.

Sex differences in parameters of bone strength in new recruits: beyond bone density.

BACKGROUND: Stress fracture (SF) injuries in new recruits have long been attributed to low bone mineral density (BMD). Low areal BMD assessed using two-dimensional dual-energy x-ray absorptiometry imaging, however, reflects structural density and is affected by smaller measures of bone geometry. Recent studies support a relationship between bone size and SF and indicate that slender bones are more susceptible to damage under identical loading conditions. Peripheral quantitative computed tomography (pQCT) is a three-dimensional imaging tool that provides measures of tissue density and geometry parameters of the tibia, a common site of SF. PURPOSE: To evaluate sex differences in parameters of volumetric BMD (vBMD), geometry, and strength of the tibia in new recruits using a novel pQCT image analysis procedure. METHODS: pQCT images were obtained from 128 healthy men and women (20 male, 108 female, aged 18-21 yr) entering a 4-month gender-integrated combat training program in the Israeli Defense Forces. Tibial scans taken at sites 4% (trabecular bone), 38%, and 66% (cortical bone) from the distal end plate were analyzed using MATLAB to assess whole-bone and regional parameters. Measures included vBMD, geometry (diameter, area, cortical thickness, and canal radius), and strength (moments of inertia and bone strength and slenderness indices). RESULTS: With the exception of normalized canal radius, which did not differ between sexes, all measures of bone geometry (P < 0.0001) and strength (P < 0.0001 to P = 0.07) were greater in men. Women exhibited 2.7% to 3.0% greater cortical vBMD than men, whereas trabecular vBMD was 8.4% lower in women (P < 0.001). These differences remained significant after adjusting for body size. CONCLUSION: Sex differences in bone geometry and mineralization of the tibia may contribute to a decreased ability to withstand the demands imposed by novel, repetitive exercise in untrained individuals entering recruit training.

A computational evaluation of the effect of intramedullary nail material properties on the stabilization of simulated femoral shaft fractures.

Titanium flexible intramedullary nails have become far more prevalent for stabilization of pediatric femur fractures in recent years. While steel may be expected to have superior fracture stability due to its higher elastic modulus; titanium alloy has experimentally demonstrated improved biomechanical stability, as measured by gap closure and nail slippage. The purpose of this study was to verify these observations computationally, and thus, explain why titanium alloy may be better suited for surgical fixation of fractured femurs. A finite element model of a femur with complete mid-diaphyseal fracture and having two 3.5 mm nails in a retrograde "C" pattern was created. Static analyses were run in which the nail material properties were titanium alloy or stainless steel, respectively. Gap closure for the stainless steel nails was 1.03 mm; while the titanium alloy nails had 0.69 mm of closure. Titanium alloy nails slipped slightly less at each loading increment than stainless steel nails. The titanium alloy nails distributed stress more evenly along the nail axis, resulting in lower peak magnitudes. These results agree with previously published clinical and biomechanical studies that reported increased gap closure and nail slippage with stainless steel nails. The increased deformation of the titanium alloy nail likely increases the contact area with the intramedullary canal wall, thus, increasing stability. Additionally, stainless steel nails had higher curve apex von Mises stresses, potentially inducing a stress-shielding effect which could hamper remodeling and consequently increase risk of re-fracture.

Continuum remodeling revisited : deformation rate driven functional adaptation using a hypoelastic constitutive law.

Recent research effort in bone remodeling has been directed toward describing interstitial fluid flow in the lacuno-canalicular system and its potential as a cellular stimulus. Regardless of the precise contents of the mechanotransduction "black box", it seems clear that the fluid flow on which the remodeling is predicated cannot occur under static loading conditions. In an attempt to help continuum remodeling simulations catch up with cellular and subcellular research, this paper presents a simple, strain rate driven remodeling algorithm for density allocation and principal material direction rotations. An explicit finite element code was written and deployed on a supercomputer which discretizes the remodeling process and uses an objective hypoelastic constitutive law to simulate trabecular realignment. Results indicate that a target strain rate for this dynamic approach is |D ( I )| = 1.7% per second which seems reasonable when compared to observed strain rates. Simulations indicate that a morpho-mechanically realistic three-dimensional bone can be synthesized by applying a few dynamic loads at the envelope of common daily physiological rates, even with no static loading component.