Bone 51 (2012) 826827
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Bone
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Commentary
Dynamic muscle loading and mechanotransduction
amcv, seminario Mecanotransduccin
The benecial effects of exercise on skeletal health have been known
for many years. Experimental data regarding the physical and biological
processes that control bone adaptation reveal new avenues of therapy,
which have the potential to augment bone mass and strength signi-
cantly. One such area is the manipulation of bone's physical environ-
ment by unconventional methods (e.g., high-frequency vibration and
ultrasound). These unconventional methods permit some of the bone-
building effects of mechanotransduction to occur, while preventing
some of the detrimental effects of conventional mechanical loading
(e.g., fracture or soft tissue injury from high strain application). In this
issue of Bone, Hu et al. [1] present a novel, unconventional technique
for applying mechanical loading to bone, with the goal of enhancing
bone formation and/or preventing bone loss. This loading scheme, re-
ferred to as dynamic hydraulic stimulation (DHS), applies noninvasive
dynamic pressure (30 mm Hg static + 30 mm Hg dynamic) to the
skin and muscle tissues that surround the tibia of a hindlimb-
suspended rat for 20 min per day, 5 days per week. After 4 weeks of
DHS treatment, bone volume fraction and bone formation rate were
increased by 83% and 190%, respectively, compared to their non-
stimulated, tail-suspended counterparts.
Two unique features of this non-invasive loading method are the
stimulation of bone formation through muscle compression and the ap-
plication of lateral loads at low frequency. Qin et al. [2] previously
reported increased bone formation in response to direct intramedullary
pressure (ImP) applied to an isolated turkey ulna. The same group also
reported that electric stimulation of the quadriceps muscle elevates ImP
and increases bone formation in the femur [3]. In this report, DHS addi-
tionally applies mechanical stimulation through the gastrocnemius and
other muscles around the tibia. Instead of applying axial loads, which
are more closely linked to routine physical activities, DHS employs
lateral loads. Application of lateral loads is also used in a joint-loading
modality (JL) such as knee loading and ankle loading [4]. It is reported
that JL to a mouse knee alters ImP [5]. DHS applies loads to the diaphysis
by constricting circumferentially, while JL applies loads to the epiphysis
and metaphysis by compressing at two conned regions. Although the
mechanism of action underlying enhanced bone formation by DHS
might not represent natural adaptation of bone through physical activ-
ity, this modality not only offers a potential strategy for strengthening
bone in patients with osteoporosis, but also provides a model system
for dissecting mechanotransduction of bone.
The working hypothesis of DHS' mechanism of action consists of
three major steps: alterations in ImP, induction of interstitial uid
ow (IFF), and mechanosensing by osteocytes followed by activation
of Wnt signaling in osteoblasts. In the rst step, constrictive loads
might induce a volumetric change in the intramedullary space, and
this change may result in an ImP increase. A small amount of strain,
in the order of 10 strain in the diaphysis, might be the cause of
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http://dx.doi.org/10.1016/j.bone.2012.07.025
this pressure change. The effect of strain is likely to be local at the
site of loading; however, the effect of the increased ImP is not con-
ned to the loading site but is distributed throughout the
intramedullary cavity. This rst step seems consistent with a series
of experiments conducted by the Frangos group. These experiments
correlate bone formation to enhanced ImP using an implanted minia-
ture pump that cyclically modulated pressure [6] and partial femoral
vein ligation in hindlimb-suspended rats [7]. However, in the case of
vein ligation, it is not clear that the change in ImP is the predominant
factor in counteracting bone loss as many other conditions are affect-
ed by this procedure.
It is also unclear whether temporal alteration of ImP is sufcient to
induce mechanosensing, since cells are in general more sensitive to
shear stress than normal stress. Therefore, in the second step, a mecha-
nism for converting a temporal change in ImP into a spatial gradient of
ImP is proposed. On the one hand, in order to elevate ImP, a bone cavity
must be liquid-tight; on the other hand, to induce a special gradient of
ImP, uid in the cavity needs to ow somewhere and restrictions should
be relaxed. The bone cavity consists of a mixture of uid and solid ma-
terials, and the question is how liquid-tight and permeable the bone
cavity should be in order to generate a temporal change in ImP followed
by a special gradient of ImP. One of the important parameters to answer
this question is conductivity as a function of Darcy's permeability (m2).
This conductivity dictates pressure-driven ow induction, and it de-
pends on the bone matrix porosities, including collagenapatite poros-
ity, the lacunarcanalicular porosity, and the vascular porosity [8]. A
layer of tissues that surrounds bone is also important, since it provides
a semipermeable boundary layer characterized by another kind of
permeability (m/s), dened by the thickness of the layer and a diffusion
coefcient. Porous structures in bone and the surrounding layer may all
be connected and their network as a whole may dene temporal and
spatial distributions of ImP.
The third step is the transition from IFF to load-driven molecular
events represented by Wnt signaling [9]. An energy level of thermal
noise is estimated in the order of kT (4 10 21 J), where k is the
Boltzmann constant and T is the body absolute temperature. In
order to induce a meaningful mechanical stimulation, one assump-
tion is that IFF should be able to generate the amount of energy equiv-
alent to one ATP molecule or ~ 10kT (the energy generated by one ATP
molecule is approximately 10 times larger than kT). A rough estima-
tion of this concept is as follows: in order to move part of a
mechanosensing molecule by several nanometers, 10kT of energy
can generate a force of ~ 10 pN. This amount of force corresponds to
a surface area of 10 m 2 under shear stress at 1 Pa (10 dyn/cm 2). In
order for a single osteocyte process (~ 20 m long, 50400 nm in di-
ameter) [10] to receive 10 pN and move a molecular sensor by sever-
al nanometers, it is plausible that there is an amplication mechanism
 Commentary
such as the one proposed by Weinbaum [11]. Alternatively, local uctu-
ations from anisotropic and stochastic dynamics may induce a spectrum
of stress distributions that might facilitate activation of molecular inter-
actions [12].
Besides the above-mentioned working hypothesis, DHS allows us
to consider other mechanisms indirectly linked to mechanical stimu-
lation. Mechanical loading must trigger migration of osteoblasts to
the endosteum and periosteum. Because ImP is altered in the
intramedullary cavity, it is interesting to ask whether alterations in
ImP accelerate migration of osteoblasts and whether any differences
exist in the rate of bone formation in the endosteum and periosteum.
An additional question is whether bone formation would take place
equally throughout the length of the tibia in cortical and trabecular
bone or whether any preferential location exists. Lastly, an intriguing
question is the importance of local vs. systemic effects in connection
to blood circulation and neuronal signaling [7,13]. DHS seems to pro-
vide a promising model system for evaluating the role of blood circu-
lation and neuronal signaling in load-driven bone formation.
In summary, as the eld continues to make advances in our under-
standing of the physical and structural conditions that stimulate bone
formation, safer and perhaps more effective approaches to load-
induced bone formation can be achieved. These developments could
not be more timely, as physicians look for alternative means to maintain
bone mass in patients once they complete an osteoporosis drug treat-
ment regimen. Several recently-discovered therapies (e.g., Rank-L in-
hibitors, PTH fragments, and cathepsin K inhibitors) appear to have
little to no residual effects once treatment is stopped because they are
not stored in the bone tissues in active form. Therefore, bone density
is likely to return to baseline once these next-generation therapies are
stopped. As the more long-lasting bisphosphonate therapies fall out of
favor and newly generated compounds rise in popularity among physi-
cians, the need to maintain bone mass after treatment withdrawal will
become more urgent. Therefore, a safe, effective mechanical loading
modality potentially provides an alternative treatment for maintaining
BMD without inducing deleterious side effects. Although DHS has not
been tested clinically, it is not difcult to envision its implementation
via a portable loading device that may resemble the inatable cuff of a
blood pressure monitoring system. Its extension from diaphysis to the
femoral neck and head seems natural, but its application to spine treat-
ment is less evident. It would be interesting to explore DHS' potential
capability not only to enhance bone formation beyond the immediate
local environment, but also to stimulate fracture healing without direct
application of mechanical loads to the fracture site.
Acknowledgment
The work is in part supported by NIH R01AR052144 (HY) and
R01AR053237 (AR).
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Hiroki Yokota
Biomechanics and Biomaterials Research Center,
Indiana University Purdue University Indianapolis,
Indianapolis, IN 46202, USA
Department of Biomedical Engineering,
Indiana University Purdue University Indianapolis,
Indianapolis, IN 46202, USA
Department of Anatomy and Cell Biology,
Indiana University School of Medicine,
Indianapolis, IN 46202, USA
Corresponding author at: Biomechanics and Biomaterials Research Center,
Department of Biomedical Engineering,
Indiana University Purdue University Indianapolis,
723 West Michigan Street, Indianapolis, IN 46202, USA.
Fax: +1 317 278 5244.
E-mail address: hyokota@iupui.edu.
Andrs Tovar
Biomechanics and Biomaterials Research Center,
Indiana University Purdue University Indianapolis,
Indianapolis, IN 46202, USA
Department of Mechanical Engineering,
Indiana University Purdue University Indianapolis,
Indianapolis, IN 46202, USA
Alexander Robling
Biomechanics and Biomaterials Research Center,
Indiana University Purdue University Indianapolis,
Indianapolis, IN 46202, USA
Department of Biomedical Engineering,
Indiana University Purdue University Indianapolis,
Indianapolis, IN 46202, USA
Department of Anatomy and Cell Biology,
Indiana University School of Medicine,
Indianapolis, IN 46202, USA
8 June 2012