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The Brain, Balance & Bone Density
March 5, 2016 by Dr Matthew D. Long
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The Brain, Balance & Bone Density
March 5, 2016 by Dr Matthew D. Long
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The Brain, Balance & Bone Density
March 5, 2016 by Dr Matthew D. Long
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In clinical practice there is much that we tend to take for granted. Some ideas and theories have become so entrenched that they are no longer questioned, nor do we seek new insights. But science often has a way of pulling the metaphorical rug out from under our complacency, and this has happened recently in the field of osteoporosis research.
The regulation of bone mineral density and its underlying microarchitecture is incredibly complex. For many years investigators have focussed upon the role of genetics, biochemistry and environmental factors (including exercise) in the puzzle of osteoporosis. While all of this remains important, it does not represent a complete picture of the disorder. Indeed, a number of interesting papers have recently highlighted the possible role that the balance system may have in bone remodelling.
It has been known for some time that there is an intriguing association between an individual's bone density and a predisposition towards vertigo (1,2). However, the mechanism behind this is unclear. According to Vibert et al (3), 75% of women between 50 - 85 years old will experience benign paroxysmal positional vertigo (BPPV). They suggest that alterations to calcium homeostasis might underly this association via:
The regulation of bone mineral density and its underlying microarchitecture is incredibly complex. For many years investigators have focussed upon the role of genetics, biochemistry and environmental factors (including exercise) in the puzzle of osteoporosis. While all of this remains important, it does not represent a complete picture of the disorder. Indeed, a number of interesting papers have recently highlighted the possible role that the balance system may have in bone remodelling.
It has been known for some time that there is an intriguing association between an individual's bone density and a predisposition towards vertigo (1,2). However, the mechanism behind this is unclear. According to Vibert et al (3), 75% of women between 50 - 85 years old will experience benign paroxysmal positional vertigo (BPPV). They suggest that alterations to calcium homeostasis might underly this association via:
"(i) disturbed internal structure of the otoconia or their interconnection and attachment to the gelatinous matrix due to decreased estrogen, and
(ii) reduced capacity to dissolve the dislodged otoconia owing to increased concentration of free calcium in the endolymph having resulted from increased calcium resorption."
(ii) reduced capacity to dissolve the dislodged otoconia owing to increased concentration of free calcium in the endolymph having resulted from increased calcium resorption."
While the role of disturbed calcium metabolism makes sense, and offers a biologically plausible link between balance and bone density, there is perhaps another angle that needs consideration. That is, the role of the nervous system.
In 2013 Vignaux and colleagues published an interesting paper (4) entitled, "Bone remodeling is regulated by inner ear vestibular signals". In this study they discussed how the vestibular system contributes to the homeostatic regulation of bone remodelling, by projecting upon central brain centres that regulate sympathetic outflow. In later papers they detailed how the sympathetic nervous system influences bone turnover - simultaneously inhibiting new bone formation by osteoblasts, and by promoting bone resorption by osteoclasts (5,6). They concluded,
In 2013 Vignaux and colleagues published an interesting paper (4) entitled, "Bone remodeling is regulated by inner ear vestibular signals". In this study they discussed how the vestibular system contributes to the homeostatic regulation of bone remodelling, by projecting upon central brain centres that regulate sympathetic outflow. In later papers they detailed how the sympathetic nervous system influences bone turnover - simultaneously inhibiting new bone formation by osteoblasts, and by promoting bone resorption by osteoclasts (5,6). They concluded,
"These results provide novel experimental evidence supporting a functional autonomic link between central proprioceptive vestibular structures and the skeleton. Because vestibular dysfunction often affects the elderly, these results also suggest that age-related bone loss might have a vestibular component and that patients with inner ear pathologies might be at risk for fracture."
This link between the brain, balance and bone density makes sense, and also helps to explain the observations of other authors who showed that seemingly benign exercises like Tai Chi can retard bone loss (7,8,9,10). Until now, mainstream management protocols have emphasised the importance of skeletal loading to drive new bone formation. However, Tai Chi does not seem to fit this bill, and many clinicians would be tempted to dismiss it as a management option because it is 'not strenuous enough'. Indeed, Chan et al (7) described Tai Chi as "characterized by a high demand for neuromuscular coordination, low velocity of muscle contraction, low impact, and no jumping."
So how might our viewpoint change if we now appreciate that there's more to maintaining bone density than simply lifting weights? Could it be that balance-challenging tasks may play an important role in preserving skeletal health? Perhaps so. We should also consider the role that chiropractors might play in facilitating this.
So how might our viewpoint change if we now appreciate that there's more to maintaining bone density than simply lifting weights? Could it be that balance-challenging tasks may play an important role in preserving skeletal health? Perhaps so. We should also consider the role that chiropractors might play in facilitating this.
'Could it be that balance-challenging tasks may play an important role in preserving skeletal health?'
Firstly, we can encourage our patients to pursue exercises that emphasise balance, not simply impact forces. For many older people this might come as a relief, as the enthusiasm for 'pumping iron' typically declines with age. Balance exercises, on the other hand, are often viewed with less disdain and are seen as 'realistic'.
Secondly, we should stop to consider the direct role that chiropractic treatment might have upon an individual's vestibular health. It is now known that the strategies our brain employs to balance and orientate our body change as we age. Over time we see declining populations of vestibular hair cells, ganglion cells and nerve fibres, resulting in a decreased accuracy of the vestibular apparatus. However, this loss is then compensated for by an increased gain in neck proprioception (11), particularly those signals arising from muscle spindles (and transmitted via 1a afferents). It has been shown that neck proprioception shapes body orientation and our perception of motion (12). According to Pettorossi et al,
Secondly, we should stop to consider the direct role that chiropractic treatment might have upon an individual's vestibular health. It is now known that the strategies our brain employs to balance and orientate our body change as we age. Over time we see declining populations of vestibular hair cells, ganglion cells and nerve fibres, resulting in a decreased accuracy of the vestibular apparatus. However, this loss is then compensated for by an increased gain in neck proprioception (11), particularly those signals arising from muscle spindles (and transmitted via 1a afferents). It has been shown that neck proprioception shapes body orientation and our perception of motion (12). According to Pettorossi et al,
"The information conveyed by the 1a fibers is rapidly transmitted to diverse parts of the CNS, and updates the brain on muscle length changes, and thus on movement. Its integration may occur at various level of the central nervous system, known to supervise the formation of reference frames for movement. Most likely, the vestibular nuclei, which receive neck muscle input, are the first stage for the integration of neck muscle vibratory signals and play a crucial role in conscious awareness of motion, spatial orientation, and navigation."
It stands to reason then, that maintaining a healthy cervical sensory system would be a logical aspiration for us. Interestingly, the primary neurological effect of an adjustment seems to be mediated by the muscle spindle system, rather than the articular mechanoreceptors (13,14,15). So it just might be beneficial for us to keep these pathways plastic using whatever stimuli we have at our disposal - whether these are adjustments or balance-challenging exercises.
Something to think about...
Dr Matthew D. Long
BSc (Syd) M.Chiro (Macq)
Something to think about...
Dr Matthew D. Long
BSc (Syd) M.Chiro (Macq)
References:
1. Yu, S., Liu, F., Cheng, Z., & Wang, Q. (2014). Association between osteoporosis and benign paroxysmal positional vertigo: a systematic review. BMC Neurology, 14(1), 110. http://doi.org/10.1186/1471-2377-14-110
2. Jeong, S.-H., Choi, S. H., Kim, J.-Y., Koo, J.-W., Kim, H. J., & Kim, J. S. (2009). Osteopenia and osteoporosis in idiopathic benign positional vertigo. Neurology, 72(12), 1069–1076. http://doi.org/10.1212/01.wnl.0000345016.33983.e0
3. Vibert D, Kompis M, Hausler R. Benign paroxysmal positional vertigo in older women may be related to osteoporosis and osteopenia. Ann Otol Rhinol Laryngol 2003;112: 885–889.
4. Vignaux, G., Besnard, S., Ndong, J., Philoxène, B., Denise, P., & Elefteriou, F. (2013). Bone remodeling is regulated by inner ear vestibular signals. Journal of Bone and Mineral Research, 28(10), 2136–2144. http://doi.org/10.1002/jbmr.1940
5. Guillaume Vignaux, Jean DLC Ndong, Daniel S Perrien and Florent Elefteriou. Inner Ear Vestibular Signals Regulate Bone Remodeling via the Sympathetic Nervous System. J Bone Minder Res 2015. DOI: 10.1002/jbmr.2426. Article first published online: 18 MAY 2015
6. G. Vignaux, S. Besnard, P. Denise, F. Elefteriou. The Vestibular System: A Newly Identified Regulator of Bone Homeostasis Acting Through the Sympathetic Nervous System. Current Osteoporosis Reports. August 2015, Volume 13, Issue 4, pp 198-205
7. Chan, K., Qin, L., Lau, M., Woo, J., Au, S., Choy, W., et al. (2004). A randomized, prospective study of the effects of Tai Chi Chun exercise on bone mineral density in postmenopausal women. Archives of Physical Medicine and Rehabilitation, 85(5), 717–722. http://doi.org/10.1016/j.apmr.2003.08.091
8. Qin, L., Au, S., Choy, W., Leung, P., Neff, M., Lee, K., et al. (2002). Regular Tai Chi Chuan exercise may retard bone loss in postmenopausal women: A case-control study. Archives of Physical Medicine and Rehabilitation, 83(10), 1355–1359. http://doi.org/10.1053/apmr.2002.35098
9. Wayne, P. M., Kiel, D. P., Krebs, D. E., Davis, R. B., Savetsky-German, J., Connelly, M., & Buring, J. E. (2007). The Effects of Tai Chi on Bone Mineral Density in Postmenopausal Women: A Systematic Review. Archives of Physical Medicine and Rehabilitation, 88(5), 673–680. http://doi.org/10.1016/j.apmr.2007.02.012
10. Wayne, P. M., Krebs, D. E., Wolf, S. L., Gill-Body, K. M., Scarborough, D. M., McGibbon, C. A., et al. (2004). Can Tai Chi improve vestibulopathic postural control? Archives of Physical Medicine and Rehabilitation, 85(1), 142–152. http://doi.org/10.1016/S0003-9993(03)00652-X
11. Schweigart, G., Chien, R.-D., & Mergner, T. (2002). Neck proprioception compensates for age-related deterioration of vestibular self-motion perception. Experimental Brain Research Experimentelle Hirnforschung Expérimentation Cérébrale, 147(1), 89–97. http://doi.org/10.1007/s00221-002-1218-2
12. Pettorossi, V. E., & Schieppati, M. (2014). Neck Proprioception Shapes Body Orientation and Perception of Motion. Frontiers in Human Neuroscience, 8. http://doi.org/10.3389/fnhum.2014.00895
13. Pickar, J. G., & Kang, Y.-M. (2006). Paraspinal Muscle Spindle Responses to the Duration of A Spinal Manipulation Under Force Control. Journal of Manipulative and Physiological Therapeutics, 29(1), 22–31. http://doi.org/10.1016/j.jmpt.2005.11.014
14. Pickar JG, Wheeler JD. Response of muscle proprioceptors to spinal manipulative-like loads in the anesthetized cat. J Manipulative Physiol Ther 2001; 24:2-11
15. Pickar, J. G., Sung, P. S., Kang, Y.-M., & Ge, W. (2007). Response of lumbar paraspinal muscles spindles is greater to spinal manipulative loading compared with slower loading under length control. The Spine Journal, 7(5), 583–595. http://doi.org/10.1016/j.spinee.2006.10.006
1. Yu, S., Liu, F., Cheng, Z., & Wang, Q. (2014). Association between osteoporosis and benign paroxysmal positional vertigo: a systematic review. BMC Neurology, 14(1), 110. http://doi.org/10.1186/1471-2377-14-110
2. Jeong, S.-H., Choi, S. H., Kim, J.-Y., Koo, J.-W., Kim, H. J., & Kim, J. S. (2009). Osteopenia and osteoporosis in idiopathic benign positional vertigo. Neurology, 72(12), 1069–1076. http://doi.org/10.1212/01.wnl.0000345016.33983.e0
3. Vibert D, Kompis M, Hausler R. Benign paroxysmal positional vertigo in older women may be related to osteoporosis and osteopenia. Ann Otol Rhinol Laryngol 2003;112: 885–889.
4. Vignaux, G., Besnard, S., Ndong, J., Philoxène, B., Denise, P., & Elefteriou, F. (2013). Bone remodeling is regulated by inner ear vestibular signals. Journal of Bone and Mineral Research, 28(10), 2136–2144. http://doi.org/10.1002/jbmr.1940
5. Guillaume Vignaux, Jean DLC Ndong, Daniel S Perrien and Florent Elefteriou. Inner Ear Vestibular Signals Regulate Bone Remodeling via the Sympathetic Nervous System. J Bone Minder Res 2015. DOI: 10.1002/jbmr.2426. Article first published online: 18 MAY 2015
6. G. Vignaux, S. Besnard, P. Denise, F. Elefteriou. The Vestibular System: A Newly Identified Regulator of Bone Homeostasis Acting Through the Sympathetic Nervous System. Current Osteoporosis Reports. August 2015, Volume 13, Issue 4, pp 198-205
7. Chan, K., Qin, L., Lau, M., Woo, J., Au, S., Choy, W., et al. (2004). A randomized, prospective study of the effects of Tai Chi Chun exercise on bone mineral density in postmenopausal women. Archives of Physical Medicine and Rehabilitation, 85(5), 717–722. http://doi.org/10.1016/j.apmr.2003.08.091
8. Qin, L., Au, S., Choy, W., Leung, P., Neff, M., Lee, K., et al. (2002). Regular Tai Chi Chuan exercise may retard bone loss in postmenopausal women: A case-control study. Archives of Physical Medicine and Rehabilitation, 83(10), 1355–1359. http://doi.org/10.1053/apmr.2002.35098
9. Wayne, P. M., Kiel, D. P., Krebs, D. E., Davis, R. B., Savetsky-German, J., Connelly, M., & Buring, J. E. (2007). The Effects of Tai Chi on Bone Mineral Density in Postmenopausal Women: A Systematic Review. Archives of Physical Medicine and Rehabilitation, 88(5), 673–680. http://doi.org/10.1016/j.apmr.2007.02.012
10. Wayne, P. M., Krebs, D. E., Wolf, S. L., Gill-Body, K. M., Scarborough, D. M., McGibbon, C. A., et al. (2004). Can Tai Chi improve vestibulopathic postural control? Archives of Physical Medicine and Rehabilitation, 85(1), 142–152. http://doi.org/10.1016/S0003-9993(03)00652-X
11. Schweigart, G., Chien, R.-D., & Mergner, T. (2002). Neck proprioception compensates for age-related deterioration of vestibular self-motion perception. Experimental Brain Research Experimentelle Hirnforschung Expérimentation Cérébrale, 147(1), 89–97. http://doi.org/10.1007/s00221-002-1218-2
12. Pettorossi, V. E., & Schieppati, M. (2014). Neck Proprioception Shapes Body Orientation and Perception of Motion. Frontiers in Human Neuroscience, 8. http://doi.org/10.3389/fnhum.2014.00895
13. Pickar, J. G., & Kang, Y.-M. (2006). Paraspinal Muscle Spindle Responses to the Duration of A Spinal Manipulation Under Force Control. Journal of Manipulative and Physiological Therapeutics, 29(1), 22–31. http://doi.org/10.1016/j.jmpt.2005.11.014
14. Pickar JG, Wheeler JD. Response of muscle proprioceptors to spinal manipulative-like loads in the anesthetized cat. J Manipulative Physiol Ther 2001; 24:2-11
15. Pickar, J. G., Sung, P. S., Kang, Y.-M., & Ge, W. (2007). Response of lumbar paraspinal muscles spindles is greater to spinal manipulative loading compared with slower loading under length control. The Spine Journal, 7(5), 583–595. http://doi.org/10.1016/j.spinee.2006.10.006