Search

Background Exercise interventions focusing on balance and strength training have been shown to be effective for falls prevention. The aim of this 20-year register-based follow-up was to examine whether long-term participation in recreational female gymnastics is associated with a lower risk of medically-attended injurious falls. Methods Health care register data of 187 women (103 recreational gymnasts and 84 sedentary controls) from the original cohort of 243 women were assessed. The mean age (sd) at baseline was 62.8 (5.4) years and the mean follow-up time was 19.4 (2.7) years (range from 5.6 to 21.0 years). Injurious falls were scrutinized from medical records. An injurious fall was defined as an event in which falling was mentioned as a reason for making contact with health-care professionals. Negative binomial regression was used to estimate incidence rate ratios (IRR) for injurious falls, and Cox-regression models for calculating hazard ratios (HR) for injured fallers with the control group as reference. Results Recreational gymnasts had about 30% less injurious falls compared to controls, the mean IRR (95% CI) being 0.71 (0.51 to 0.96). The HR for injured fallers was 0.73 (0.52 to 1.02) favoring the recreational gymnasts. There were no statistically significant between-group differences for fractures. Conclusions Long-term recreational gymnastics appears to reduce the risk of injurious falls in old age.

Introduction. Low bone mineral density is a risk factor for fractures. The aim of this follow-up study was to assess the association of various bone properties with fall-related fractures. Materials and Methods. 187 healthy women aged 55 to 83 years at baseline who were either physically active or inactive were followed for 20 years. They were divided into two groups by whether or not they sustained fall-related fractures: fracture group (F) and nonfracture group (NF). At baseline, several bone properties were measured with DXA and pQCT, and their physical performance was also assessed. Results. During the follow-up, 120 women had no fall-related fractures, while 67 (38%) sustained at least one fall with fracture. NF group had about 4 to 11% greater BMD at the femoral neck and distal radius; the mean differences (95% CI) were 4.5 (0.3 to 8.6) % and 11.1 (6.3 to 16.1) %, respectively. NF group also had stronger bone structure at the tibia, the mean difference in BMC at the distal tibia was 6.0 (2.2 to 9.7) %, and at the tibial shaft 3.6 (0.4 to 6.8) %. However, there was no mean difference in physical performance. Conclusions. Low bone properties contribute to the risk of fracture if a person falls. Therefore, in the prevention of fragility fractures, it is essential to focus on improving bone mass, density, and strength during the lifetime. Reduction of falls by improving physical performance, balance, mobility, and muscle power is equally important.

This study assessed the cost-effectiveness of vitamin D supplementation and exercise, separately and combined, in preventing medically attended injurious falls among older home-dwelling Finnish women. Given a willingness to pay of €3000 per injurious fall prevented, the exercise intervention had an 86 % probability of being cost-effective in this population. The costs of falling in older persons are high, both to the individual and to society. Both vitamin D and exercise have been suggested to reduce the risk of falls. This study assessed the cost-effectiveness of vitamin D supplementation and exercise, separately and combined, in preventing medically attended injurious falls among older Finnish women. Economic evaluation was based on the results of a previously published 2-year randomized controlled trial (RCT) where 409 community-dwelling women aged 70 to 80 years were recruited into four groups: (1) no exercise + placebo (D−Ex−), (2) no exercise + vitamin D 800 IU/day (D+Ex−), (3) exercise + placebo (D−Ex+), and (4) exercise + vitamin D 800 IU/day (D+Ex+). The outcomes were medically attended injurious falls and fall-related health care utilization costs over the intervention period, the latter evaluated from a societal perspective based on 2011 unit costs. Incremental cost-effectiveness ratios (ICER) were calculated for the number of injurious falls per person-year prevented and uncertainty estimated using bootstrapping. Incidence rate ratios (95 % CI) for medically attended injurious falls were lower in both Ex+ groups compared with D−Ex−: 0.46 (0.22 to 0.95) for D−Ex+, 0.38 (0.17 to 0.81) for D+Ex+. Step-wise calculation of ICERs resulted in exclusion of D+Ex− as more expensive and less effective. Recalculated ICERs were €221 for D−Ex−, €708 for D−Ex+, and €3820 for D+Ex+; bootstrapping indicated 93 % probability that each injurious fall avoided by D−Ex+ per person year costs €708. At a willingness to pay €3000 per injurious fall prevented, there was an 85.6 % chance of the exercise intervention being cost-effective in this population. Exercise was effective in reducing fall-related injuries among community-dwelling older women at a moderate cost. Vitamin D supplementation had marginal additional benefit. The results provide a firm basis for initiating feasible and cost-effective exercise interventions in this population.

BACKGROUND AND OBJECTIVE: previously, a randomised controlled exercise intervention study (RCT) showed that combined resistance and balance-jumping training (COMB) improved physical functioning and bone strength. The purpose of this follow-up study was to assess whether this exercise intervention had long-lasting effects in reducing injurious falls and fractures. DESIGN: five-year health-care register-based follow-up study after a 1-year, four-arm RCT. SETTING: community-dwelling older women in Finland. SUBJECTS: one hundred and forty-five of the original 149 RCT participants; women aged 70-78 years at the beginning. METHODS: participants' health-care visits were collected from computerised patient register. An injurious fall was defined as an event in which the subject contacted the health-care professionals or was taken to a hospital, due to a fall. The rate of injured fallers was assessed by Cox proportional hazards model (hazard ratio, HR), and the rate of injurious falls and fractures by Poisson regression (risk ratio, RR). RESULTS: eighty-one injurious falls including 26 fractures occurred during the follow-up. The rate of injured fallers was 62% lower in COMB group compared with the controls (HR 0.38, 95% CI 0.17 to 0.85). In addition, COMB group had 51% less injurious falls (RR 0.49, 95% CI 0.25 to 0.98) and 74% less fractures (RR 0.26, 95% CI 0.07 to 0.97). CONCLUSIONS: home-dwelling older women who participated in a 12-month intensive multi-component exercise training showed a reduced incidence for injurious falls during 5-year post-intervention period. Reduction in fractures was also evident. These long-term effects need to be confirmed in future studies. Language: en

Three hundred eighty-seven home-dwelling older women were divided into quartiles based on mean serum 25-hydroxyvitamin D (S-25(OH)D) levels. The rates of falls and fallers were about 40% lower in the highest S-25(OH)D quartile compared to the lowest despite no differences in physical functioning, suggesting that S-25(OH)D levels may modulate individual fall risk. Vitamin D supplementation of 800 IU did not reduce falls in our previous 2-year vitamin D and exercise RCT in 70–80 year old women. Given large individual variation in individual responses, we assessed here effects of S-25(OH)D levels on fall incidence. Irrespective of original group allocation, data from 387 women were explored in quartiles by mean S-25(OH)D levels over 6–24 months; means (SD) were 59.3 (7.2), 74.5 (3.3), 85.7 (3.5), and 105.3 (10.9) nmol/L. Falls were recorded monthly with diaries. Physical functioning and bone density were assessed annually. Negative binomial regression was used to assess incidence rate ratios (IRRs) for falls and Cox-regression to assess hazard ratios (HR) for fallers. Generalized linear models were used to test between-quartile differences in physical functioning and bone density with the lowest quartile as reference. There were 37% fewer falls in the highest quartile, while the two middle quartiles did not differ from reference. The respective IRRs (95% CI) for falls were 0.63 (0.44 to 0.90), 0.78 (0.55 to 1.10), and 0.87 (0.62 to 1.22), indicating lower falls incidence with increasing mean S-25(OH)D levels. There were 42% fewer fallers (HR 0.58; 040 to 0.83) in the highest quartile compared to reference. Physical functioning did not differ between quartiles. Falls and faller rates were about 40% lower in the highest S-25(OH)D quartile despite similar physical functioning in all quartiles. Prevalent S-25(OH)D levels may influence individual fall risk. Individual responses to vitamin D treatment should be considered in falls prevention.

Background: Both exercise and vitamin D are recommended means to prevent falls among older adults, but their combined effects on fallinduced injuries are scarcely studied. Methods: A 2-year follow-up of a previous 2-year randomized controlled trial with vitamin D and exercise (Ex) of 409 older home-dwelling women using a factorial 2 x 2 design (D(-)Ex(-), D(+)Ex(-), D(-)Ex(+), D(+)Ex(+)). Besides monthly fall diaries, femoral neck bone mineral density (fn-BMD), and physical functioning were assessed at 1 and 2 years after the intervention. Results: After the intervention, S-25OHD concentrations declined to baseline levels in both supplement groups. The groups did not differ for change in fn-BMD or physical functioning, except for leg extensor muscle strength, which remained about 10% greater in the exercise groups compared with the reference group (D(-)Ex(-)). There were no between-group differences in the rate of all falls, but medically attended injurious falls reduced in D+ Ex-and D(-)Ex(+) groups compared with D(-)Ex(-). However, all former treatment groups had less medically attended injured fallers, HRs (95% CI) being 0.62 (0.39-1.00) for D+ Ex-, 0.46 (0.28-0.76) for D(-)Ex(+), and 0.55 (0.34-0.88) for D(+)Ex(+), compared with D(-)Ex(-). Conclusions: Exercise-induced benefits in physical functioning partly remained 2 years after cessation of supervised training. Although there was no difference in the rate of all falls, former exercise groups continued to have lower rate of medically attended injured fallers compared with referents even 2 years after the intervention. Vitamin D without exercise was associated with less injurious falls with no difference in physical functioning.

Objective The aim of this study was to investigate whether the polymorphisms of the fat mass and obesity-associated gene (FTO, rs9939609:T > A) and the β2-adrenergic receptor gene (ADRB2, rs1042714:Gln > Glu) are associated with weight loss in dieting obese premenopausal women and the association of these SNPs with body weight, body composition and distribution of fat mass. Methods 75 obese (BMI > 30) premenopausal women participated in the intervention including a 3-month weight reduction period and a subsequent 9-month weight maintenance period. Weight and height were measured and BMI calculated. Body composition and fat mass distribution were assessed by dual energy X-ray absorptiometry. Results At baseline, the AA homozygotes of the FTO gene were 10.1 kg heavier ( p = 0.031), they had higher BMI ( p = 0.038), and greater waist and greater hip circumference ( p = 0.08 and p = 0.067, respectively) compared to the TT homozygotes. Gln/Gln carriers of the ADRB2 gene had smaller gynoid fat-% compared with both the Gln/Glu and Glu/Glu carriers ( p = 0.050 and p = 0.009, respectively). The Gln homozygotes had also smaller total body fat-% and higher total body lean mass-% than that of the Glu homozygotes ( p = 0.018 and p = 0.019, respectively). Conclusion FTO genotype was associated with body weight in general, whereas ADRB2 genotype was associated with fat distribution. However, all women in the study group lost weight similarly independently of their genotypes. Neither the FTO nor ADRB2 genotype had statistically significant effect on weight reduction or weight maintenance.

Introduction.Osteoarthritis (OA) of the hip is one of the major causes of pain and disability in the older population. Although exercise is an effective treatment for knee OA, there is lack of evidence regarding hip OA. The aim of this trial was to test the safety and feasibility of a specifically designed exercise program in relieving hip pain and improving function in hip OA participants and to evaluate various methods to measure changes in their physical functioning.Materials and Methods. 13 women aged ≥ 65 years with hip OA were recruited in this 12-week pilot study.Results. Pain declined significantly over 30% from baseline, and joint function and health-related quality of life improved slightly. Objective assessment of physical functioning showed statistically significant improvement in the maximal isometric leg extensor strength by 20% and in the hip extension range of motion by 30%.Conclusions. The exercise program was found to be safe and feasible. The present evidence indicates that the exercise program is effective in the short term. However, adequate powered RCTs are needed to determine effects of long-term exercise therapy on pain and progression of hip OA.

Purpose The number of hip fractures among Finns over 50-years of age rose constantly between 1970 and 1997, but since then, there has been a nationwide decline in incidence of hip fractures. One possible explanation, although not the only one, for the declining fracture rates, could be improved bone mineral density (BMD). The aim of this study was to evaluate differences in femoral neck BMD between older Finnish women born about a decade apart. Methods We compared the baseline data of two population-based samples of home-dwelling 70–80-year-old women who were initially recruited in exercise intervention studies ( N = 216 in Cohort1, and N = 389 in Cohort 2). Femoral neck BMD was measured with DXA. Between-cohort differences were evaluated with analysis of covariance using age, height, weight, and use of hormone therapy as covariates. Results The later-born Cohort 2 was somewhat older and taller than Cohort 1. Adjusted mean difference (95% CI) in femoral neck BMD between the cohorts was 0.043 g/cm 2 (0.023–0.064) corresponding the mean difference of 0.36 (0.19–0.53) in T -score in favor of Cohort 2. Conclusions Despite several factors that basically could have indicated lower mean BMD in Cohort 2, the finding was the opposite. This suggests that the mean femoral neck BMD has increased substantially among older Finnish women within a decade, but primary reason for this improvement remains unclear, but improved social and economic resources may have at least partly accounted for this favorable phenomenon.

This randomized, controlled trial evaluated the effects of exercise on health-related quality of life (HRQoL) and fear of falling (FoF) among 149 home-dwelling older women. The 12-mo exercise program was intended to reduce the risk of falls and fractures. HRQoL was assessed by the RAND-36 Survey, and FoF, with a visual analog scale, at baseline, 12 mo, and 24 mo. On all RAND-36 scales, the scores indicated better health and well-being. The exercise had hardly any effect on HRQoL; only the general health score improved slightly compared with controls at 12 mo (p = .019), but this gain was lost at 24 mo. FoF decreased in both groups during the intervention with no between-groups difference at 12 or 24 mo. In conclusion, despite beneficial physiological changes, the exercise intervention showed rather limited effects on HRQoL and FoF among relatively high-functioning older women. This modest result may be partly because of insufficient responsiveness of the assessment instruments used.

We evaluated the adult bone structural traits in relation to childhood overweight in 832 men and women. Childhood overweight was associated with larger cross-sections at long bones in both sexes. Excess weight in childhood may also lead to higher trabecular density in females and somewhat lower cortical density in men. Excess body weight in childhood may impose more loading on growing skeleton and thus lead to more robust structure in adulthood. This prospective cohort study evaluated the adult bone structural traits in relation to childhood overweight in a subgroup of 456 women and 376 men from the population-based cohort of Cardiovascular Risks in Young Finns Study. Between-group differences were evaluated with analysis of covariance. According to established body mass index (BMI) criterion at the age of 12 years, 31 women and 34 men were classified overweight in childhood. At the mean age (SD) of 36.1 (2.7) years, total cross-sectional (ToA) and cortical area (CoA) at the distal and shaft sites and cortical (shaft CoD) and trabecular (distal TrD) bone density of the nonweight-bearing radius and weight-bearing tibia were evaluated with pQCT. Despite being taller in adolescence, the adult body height of overweight children was similar. In both sexes, childhood overweight was consistently associated with 5–10% larger ToA at all bone sites measured in adulthood. CoA did not show such a consistent pattern. Women, who were overweight in childhood, had ~5% denser TrD with no difference in CoD. In contrast, TrD in men who were overweight in childhood was not different but their CoD was ~1% lower. Childhood overweight was consistently associated with larger long bone cross-sections in both sexes. Excess weight in childhood may also lead to higher trabecular density in women and somewhat lower cortical density in men. Specific mechanisms underlying these associations are not known.

Falls and fall-related injuries, such as fractures, are a growing problem among older adults, often causing longstanding pain, functional impairments, reduced quality of life and excess health-care costs and mortality. These problems have led to a variety of single component or multicomponent intervention strategies to prevent falls and subsequent injuries. The most effective physical therapy approach for the prevention of falls and fractures in community-dwelling older adults is regular multicomponent exercise; a combination of balance and strength training has shown the most success. Home-hazard assessment and modification, as well as assistive devices, such as canes and walkers, might be useful for older people at a high risk of falls. Hip protectors are effective in nursing home residents and potentially among other high-risk individuals. In addition, use of anti-slip shoe devices in icy conditions seems beneficial for older people walking outdoors. To be effective, multifactorial preventive programs should include an exercise component accompanied by individually tailored measures focused on high-risk populations. In this Review, we focus on evidence-based physical therapy approaches, including exercise, vibration training and improvements of safety at home and during periods of mobility. Additionally, the benefits of multifaceted interventions, which include risk factor assessment, dietary supplements, elements of physical therapy and exercise, are addressed.

The association of long-term sport-specific exercise loading with cross-sectional geometry of the weight-bearing tibia was evaluated among 204 female athletes representing five different exercise loadings and 50 referents. All exercises involving ground impacts (e.g., endurance running, ball games, jumping) were associated with thicker cortex at the distal and diaphyseal sites of the tibia and also with large diaphyseal cross-section, whereas the high-magnitude (powerlifting) and non-impact (swimming) exercises were not.Bones adapt to the specific loading to which they are habitually subjected. In this cross-sectional study, the association of long-term sport-specific exercise loading with the geometry of the weight-bearing tibia was evaluated among premenopausal female athletes representing 11 different sports.A total of 204 athletes were divided into five exercise loading groups, and the respective peripheral quantitative computed tomographic data were compared to data obtained from 50 physically active, non-athletic referents. Analysis of covariance was used to estimate the between-group differences.At the distal tibia, the high-impact, odd-impact, and repetitive low-impact exercise loading groups had approximately 30% to 50% (p0.05) greater cortical area (CoA) than the referents. At the tibial shaft, these three impact groups had approximately 15% to 20% (p0.05) greater total area (ToA) and approximately 15% to 30% (p0.05) greater CoA. By contrast, both the high-magnitude and repetitive non-impact groups had similar ToA and CoA values to the reference group at both tibial sites.High-impact, odd-impact, and repetitive low-impact exercise loadings were associated with thicker cortex at the distal tibia. At the tibial shaft, impact loading was not only associated with thicker cortex, but also a larger cross-sectional area. High-magnitude exercise loading did not show such associations at either site but was comparable to repetitive non-impact loading and reference data. Collectively, the relevance of high strain rate together with moderate-to-high strain magnitude as major determinants of osteogenic loading of the weight-bearing tibia is implicated.

This study showed that about a half of the exercise-induced gain in dynamic balance and bone strength was maintained one year after cessation of the supervised high-intensity training of home-dwelling elderly women. However, to maintain exercise-induced gains in lower limb muscle force and physical functioning, continued training seems necessary. Maintenance of exercise-induced benefits in physical functioning and bone structure was assessed one year after cessation of 12-month randomized controlled exercise intervention. Originally 149 healthy women 70–78 years of age participated in the 12-month exercise RCT and 120 (81%) of them completed the follow-up study. Self-rated physical functioning, dynamic balance, leg extensor force, and bone structure were assessed. During the intervention, exercise increased dynamic balance by 7% in the combination resistance and balance-jumping training group (COMB). At the follow-up, a 4% (95% CI: 1–8%) gain compared with the controls was still seen, while the exercise-induced isometric leg extension force and self-rated physical functioning benefits had disappeared. During the intervention, at least twice a week trained COMB subjects obtained a significant 2% benefit in tibial shaft bone strength index compared to the controls. A half of this benefit seemed to be maintained at the follow-up. Exercise-induced benefits in dynamic balance and rigidity in the tibial shaft may partly be maintained one year after cessation of a supervised 12-month multi-component training in initially healthy elderly women. However, to maintain the achieved gains in muscle force and physical functioning, continued training seems necessary.

This 10-year follow-up evaluated the effect of physical activity and calcium intake on proximal femur bone mass (BMC) and structural indices (CSA and Z) and physical performance. A cohort of 133 premenopausal and 134 postmenopausal women with contrasting levels of physical activity (high [PA+]) and low [PA-]) and calcium intake (high [Ca+] and low [Ca-]) was measured with DXA at baseline and 5 and 10 years thereafter. Among premenopausal women, the mean (95% CI) femoral neck BMC was 3.8% (-0.1 to 7.8%) and the trochanter BMC 6.7% (2.4 to 11.3%) greater in the PA+ group than the PA- group. There was no difference between the Ca-intake groups. Among postmenopausal women, the mean femoral neck BMC was 4.2% (-0.2 to 8.8%) greater in the Ca+ group than in the Ca- group and 6.9% (2.2 to11.8%) greater in the PA+ group than in the PA- group. For trochanter BMC, the corresponding differences were 2.7% (-1.6 to 7.2%) and 5.5% (0.9 to 10.3%). The mean differences in CSA and Z were 3.8% (-0.9 to 8.7%) and 4.4% (-2.1 to 11.4%) in favor of the Ca+ group and 6.8% (1.9 to 12.0%) and 9.6% (2.5 to 17.1%) in favor of the PA+ group, respectively. Proximal femur BMC declined generally, but the initial differences between the physical activity and the calcium intake groups were maintained. High calcium intake seemed to slow the decline in trochanter BMC in premenopausal women, while high physical activity was beneficial for proximal femur, particularly among older women.

Targeted exercise training and sufficient vitamin D intake may significantly improve muscle performance and balance and thus reduce the risk of falling among older people.

This 5-year prospective study assessed changes in trabecular and cortical volumetric bone density at the non-weight-bearing radius and weight-bearing tibia among clinically healthy pre- and postmenopausal women. Altogether 79 premenopausal (mean age +/- SD at baseline 33 +/- 2 years) and 108 postmenopausal (68 +/- 2 years) women participated in the baseline and follow-up measurements. Trabecular density (TrD) of the distal radius and tibia and cortical density (CoD) of the radial and tibial shafts were assessed by peripheral quantitative computed tomography (pQCT). Repeated measures analysis of variance was used to analyze differences of means and mean changes between the age groups. As expected, TrD and CoD values were greater among premenopausal than postmenopausal women. Changes in radial TrD were similar in both age groups: mean (95% confidence interval) TrD of the distal radius declined by 3.0 mg/cm(3) (-0.9 to 7.0) and 5.1 mg/cm(3) (1.8-8.5) in the younger and older age groups, respectively. The respective declines in TrD of the distal tibia were 4.1 mg/cm(3) (2.1-6.0) and 2.8 mg/cm(3) (1.2-4.3). Decline in CoD was greater in the older than younger age group at both the radial and tibial shafts (P0.001). The mean absolute declines in radial CoD were 33.3 mg/cm(3) (27.9-38.7) and 49.4 mg/cm(3) (44.9-53.9) in younger and older women, and the declines in tibial CoD were 16.5 mg/cm(3) (12.6-20.2) and 28.1 mg/cm(3) (25.0-31.2), respectively. In conclusion, volumetric TrD in the weight-bearing tibia and non-weight-bearing radius showed similar age-related declines among pre- and postmenopausal women, while the decline in CoD was greater among postmenopausal women.

To investigate the effects of multimodal supervised exercise on physical functioning, falls, and related injuries in older women.Two-year randomized controlled trial.Tampere, Finland.Women aged 70 to 80 who had fallen in the previous year (n = 409).Participants were randomly assigned to an exercise or control group (ClinicalTrial.gov NCT00986466). Exercisers participated in group exercise classes twice a week for 12 months and once a week for the subsequent 12 months and home exercises. Controls maintained their current physical activity.Physical functioning assessed at baseline and at 6-month intervals during the intervention. Falls and related injuries monitored with fall diaries.Intention-to-treat analyses showed that exercise led to significant improvements in physical functioning. Leg strength differed significantly between the groups (mean change: 14.1%, 95% confidence interval (CI) = 8.0 to 20.2 in exercisers; 1.6%, 95% CI = -4.5 to 7.7 in controls; P.001). Chair stand time also differed significantly between groups (7.4%, 95% CI 3.8 to 10.8% in exercisers; 2.4%, 95% CI = -1.6 to 6.2) in controls; P = .02). Between-group differences were significant for fast walking speed (P = .003) and probability of completing the backward walking test (P.001), favoring exercisers. Timed Up-and-Go and grip strength did not differ between groups. There was no difference in the total falls incidence rate ratio (IRR = 1.0, 95% CI = 0.79 to 1.26), but exercisers were less likely to have medically attended injurious falls (IRR = 0.45, 95% CI = 0.27 to 0.78; P = .004).Twenty-four months of multimodal exercise enhanced physical functioning in women aged 70 to 80 with a history of falls. Although the total number of falls was not lower than in controls, the rate of medically attended injurious falls was more than 50% lower.

IMPORTANCE: While vitamin D supplementation and exercise are recommended for prevention of falls for older people, results regarding these 2 factors are contradictory. OBJECTIVE: To determine the effectiveness of targeted exercise training and vitamin D supplementation in reducing falls and injurious falls among older women. DESIGN, SETTING, AND PARTICIPANTS: A 2-year randomized, double-blind, placebo-controlled vitamin D and open exercise trial conducted between April 2010 and March 2013 in Tampere, Finland. Participants were 409 home-dwelling women 70 to 80 years old. The main inclusion criteria were at least 1 fall during the previous year, no use of vitamin D supplements, and no contraindication to exercise. INTERVENTIONS: Four study groups, including placebo without exercise, vitamin D (800 IU/d) without exercise, placebo and exercise, and vitamin D (800 IU/d) and exercise. MAIN OUTCOMES AND MEASURES: The primary outcome was monthly reported falls. Injurious falls and the number of fallers and injured fallers were reported as secondary outcomes. In addition, bone density, physical functioning (muscle strength, balance, and mobility), and vitamin D metabolism were assessed. RESULTS: Intent-to-treat analyses showed that neither vitamin D nor exercise reduced falls. Fall rates per 100 person-years were 118.2, 132.1, 120.7, and 113.1 in the placebo without exercise, vitamin D without exercise, placebo and exercise, and vitamin D and exercise study groups, respectively; however, injurious fall rates were 13.2, 12.9, 6.5, and 5.0, respectively. Hazard ratios for injured fallers were significantly lower among exercisers with vitamin D (0.38; 95% CI, 0.17-0.83) and without vitamin D (0.47; 95% CI, 0.23-0.99). Vitamin D maintained femoral neck bone mineral density and increased tibial trabecular density slightly. However, only exercise improved muscle strength and balance. Vitamin D did not enhance exercise effects on physical functioning. CONCLUSIONS AND RELEVANCE: The rate of injurious falls and injured fallers more than halved with strength and balance training in home-dwelling older women, while neither exercise nor vitamin D affected the rate of falls. Exercise improved physical functioning. Future research is needed to determine the role of vitamin D in the enhancement of strength, balance, and mobility. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00986466. Language: en

This study showed that combination of strength, balance, agility and jumping training prevented functional decline and bone fragility in home-dwelling elderly women. The finding supports the idea that it is possible to maintain good physical functioning by multi-component exercise program and thus postpone the age-related functional problems. This 1-year randomized, controlled exercise intervention trial assessed the effects of two different training programs and their combination on physical functioning and bone in home-dwelling elderly women. One hundred and forty-nine healthy women aged 70–78 years were randomly assigned into: group 1—resistance training (RES), group 2—balance-jumping training (BAL), group 3—combination of resistance and balance-jumping training (COMB), and group 4—controls (CON). Self-rated physical functioning, leg extensor force, dynamic balance, and bone mass and structure were measured. Self-rated physical functioning improved in the COMB group, but was reduced in the CON group; the mean inter-group difference was 10% (95% CI: 0–22%). Mean increase in the leg extensor force was higher in the RES (14%; 4–25%) and COMB (13%; 3–25%) compared with the CON groups. Dynamic balance improved in the BAL (6%; 1–11%) and in the COMB (8%; 3–12%) groups. There were no inter-group differences in BMC at the proximal femur. In those COMB women who trained at least twice a week, the tibial shaft structure weakened 2% (0–4%) less than those in the CON group. Strength, balance, agility, and jumping training (especially in combination) prevented functional decline in home-dwelling elderly women. In addition, positive effects seen in the structure of the loaded tibia indicated that exercise may also play a role in preventing bone fragility.

Raloxifene improves spine bone mineral density (BMD), and its ability to reduce vertebral fractures by 40–50% suggests that it increases vertebral strength. Positive effects on hip BMD suggest a similar strengthening of the hip, but dimensional ambiguities in BMD by dual energy x-ray absorptiometry (DXA) make it difficult to infer strength effects directly. Hip fractures may be too infrequent to evaluate in practical clinical trials; even the Multiple Outcomes of Raloxifene Evaluation (MORE) study with 7,705 subjects was insufficiently powered to show a comparable reduction in hip fractures. An alternative evaluation of hip DXA data in structural terms should provide more direct evidence of treatment effects on hip strength. Hip scans from a subset of the MORE study, including 4,806 postmenopausal women with osteoporosis randomized to daily oral doses of placebo, 60 mg, or 120 mg of raloxifene were reanalyzed by the hip structure analysis (HSA) method. Scans acquired at baseline, 1, 2, and 3 years were evaluated to extract BMD and cross-sectional geometry across the narrowest point on the neck (NN), the intertrochanteric region (IT), and the proximal shaft 1.5 times the minimum neck width distal to the intersection of the neck and shaft axes. While femur outer diameter expanded during follow-up at all three regions, there were no differences in expansion between groups; treatment influenced mainly the amount and distribution of bone within cross-sections. Effects were similar at the two dose levels at the NN region although the 120 mg dose produced a greater effect on section modulus (SM) at the IT region and on BMD, bone cross-sectional area (CSA), SM, average cortical thickness (CT), and buckling ratio (BR) at the shaft region. Compared with placebo after 3 years, treatment groups showed 0.4–2% higher BMD, CSA, SM, and CT and 1–2% lower BR. The smallest treatment effects were evident at the shaft at 60 mg. We conclude that raloxifene does not influence periosteal apposition in the proximal femur but it nevertheless produces small but significant improvement in resistance to axial and bending stresses (CSA and SM, respectively) at all analyzed regions. The significant reductions in buckling ratio suggest that additional strength loss due to cortical instability is also ameliorated by treatment.

Introduction: We evaluated effects of teriparatide (rDNA origin) injection [teriparatide, rhPTH (1–34), TPTD] on hip structure among a subset 558 postmenopausal women enrolled in the Fracture Prevention Trial. Methods: Patients were randomized to once-daily, self-administered subcutaneous injections of placebo (N = 189), teriparatide 20 μg (TPTD20; N = 186), or 40 μg (TPTD40; N = 183) for a median of 20 months. Repeated dual energy X-ray absorptiometry (DXA) hip scans were analyzed with the Hip Structure Analysis (HSA) program to derive structural geometry. Results and conclusions: There were no significant differences in age or body size between groups at baseline, 1 year, or study termination. At the femoral neck, teriparatide increased bone mass and improved bone geometric strength in both treatment groups compared to the placebo group, with the response being dose-related. The mean difference (95% CI) in bone cross-sectional area (CSA) in the TPTD20 was 3.5% (1.8% to 5.3%), and 6.3% (4.5% to 8.2%) in TPTD40 at study termination, compared to placebo controls. Teriparatide treatment increased bending strength, with the mean difference in section modulus being 3.6% (1.4% to 5.8%) and 6.8% (4.6% to 9.1%) greater in the TPTD20 and TPTD40 groups, respectively. Compared to placebo, local cortical instability characterized by the buckling ratio decreased by 5.5% (3.5% to 7.5%) and 8.6% (6.6% to 10.5%) in the TPTD20 and TPTD40 groups, respectively, during the study period. The changes at the intertrochanteric region were comparable to those at the narrow neck although between-group differences were slightly smaller. Except for an inconsequential (1%) improvement in section modulus in TPTD20, teriparatide effects did not reach significance at the femoral shaft. In conclusion, teriparatide treatment improved axial and bending strength, and increased cortical thickness and stability at the femoral neck and intertrochanteric region. Teriparatide treatment effects were not apparent at the purely cortical femoral shaft.

Bone fractures affecting elderly people are a true public health burden, because they represent one of the most important causes of long-standing pain, functional impairment, disability, and death among this population. Compromised bone strength (osteoporosis) and falling, alone, or more frequently in combination, are the two independent and immediate risk factors of elderly people's fractures through which all the other, more distant risk factors, such as aging, inactivity, poor nutrition, smoking, use of alcohol, diseases, medications, functional impairments, and disabilities, operate. Of these two, falling, not osteoporosis, is the strongest single risk factor for a fracture. The most usual occurrence resulting in a fracture of an older adult is a 'simple' fall from standing height or less. Although in general terms this type of trauma is mild or moderate only (compared with, for example, motor vehicle collisions), to the specific injury site these traumas are high-impact injuries often creating forces clearly exceeding the breaking strength of the bone. Therefore, fractures affecting elderly people should be called 'fall-induced high-impact injuries' instead of the commonly used, partly misleading terms of osteoporotic fractures or minimal-trauma fractures. Prevention of elderly people's fractures consists of prevention of osteoporosis and of falling, and prevention of fractures using injury-site protection. Concerning osteoporosis, maximizing peak bone mass and preventing bone loss by regular exercise, calcium, and vitamin D, and, treatment of established osteoporosis with bone-specific drugs, have a strong scientific basis. In fall prevention, regular strength and balance training, reducing psychotropic medication, and diet supplementation with vitamin D and calcium have been shown to be effective. The multifaceted risk factor-assessing and modifying interventions have also been successful in preventing falls among the older adults by simultaneously affecting many of the risk factors of falling. Finally, concerning injury-site protection, padded strong-shield hip protectors whose effectiveness is scientifically proven seem to be a promising option in preventing hip fractures.

We studied clinical performance of serum TRACP 5b and other bone turnover markers, including S-CTX, U-DPD, S-PINP, S-BALP, and S-OC, for monitoring alendronate treatment. TRACP 5b had higher clinical sensitivity, area under the ROC curve, and signal-to-noise ratio than the other markers. INTRODUCTION: The purpose of this study was to compare the clinical performance of serum TRACP 5b (S-TRACP5b) with that of other markers of bone turnover in the monitoring of alendronate treatment. MATERIALS AND METHODS: This double-blinded study included 148 healthy postmenopausal women that were randomly assigned into two groups: one receiving 5 mg alendronate daily (n=75) and the other receiving placebo (n=73) for 12 months. All individuals in both groups received calcium and vitamin D daily. The bone resorption markers S-TRACP5b, serum C-terminal cross-linked telopeptides of type I collagen (S-CTX), and total urinary deoxypyridinoline (U-DPD), and the serum markers of bone formation procollagen I N-terminal propeptide (S-PINP), bone-specific alkaline phosphatase (S-BALP), and total osteocalcin (S-OC) were assessed at baseline and at 3, 6, and 12 months after initiation of treatment. Lumbar spine BMD (LBMD) was measured at baseline and 12 months. RESULTS: Compared with the placebo group, LBMD increased, and all bone markers decreased significantly more in the alendronate group (p

Before puberty, there are only small sex differences in body shape and composition. During adolescence, sexual dimorphism in bone, lean, and fat mass increases, giving rise to the greater size and strength of the male skeleton. The question remains as to whether there are sex differences in bone strength or simply differences in anthropometric dimensions. To test this, we applied hip structural analysis (HSA) to derive strength and geometric indices of the femoral neck using bone densitometry scans (DXA) from a 6-year longitudinal study in Canadian children. Seventy boys and sixty-eight girls were assessed annually for 6 consecutive years. At the femoral neck, cross-sectional area (CSA, an index of axial strength), subperiosteal width (SPW), and section modulus (Z, an index of bending strength) were determined, and data were analyzed using a hierarchical (random effects) modeling approach. Biological age (BA) was defined as years from age at peak height velocity (PHV). When BA, stature, and total-body lean mass (TB lean) were controlled, boys had significantly higher Z than girls at all maturity levels (P < 0.05). Controlling height and TB lean for CSA demonstrated a significant independent sex by BA interaction effect (P < 0.05). That is, CSA was greater in boys before PHV but higher in girls after PHV. The coefficients contributing the greatest proportion to the prediction of CSA, SPW, and Z were height and lean mass. Because the significant sex difference in Z was relatively small and close to the error of measurement, we questioned its biological significance. The sex difference in bending strength was therefore explained by anthropometric differences. In contrast to recent hypotheses, we conclude that the CSA-lean ratio does not imply altered mechanosensitivity in girls because bending dominates loading at the neck, and the Z -lean ratio remained similar between the sexes throughout adolescence. That is, despite the greater CSA in girls, the bone is strategically placed to resist bending; hence, the bones of girls and boys adapt to mechanical challenges in a similar way.

This prospective study set out to determine factors that underlie changes in bone characteristics and physical performance during postmenopausal years. Of 101 peri-menopausal women that originally participated in a randomized, controlled exercise intervention trial, 80 attended the follow-up measurements 9 years later. At follow-up, bone mineral content (BMC) of the lumbar spine, femoral neck and distal radius, as well as the maximal isometric muscle strength of leg extensors and arm flexors, and maximal oxygen uptake, were measured with the same protocols and devices as at the baseline. In addition, the hip structure analysis (HSA) was used to assess changes in the structure and strength at the narrowest section of the femoral neck. Changes in physical fitness or bone characteristics were independent of the original exercise intervention. In general, physical fitness declined with age from 5% to 30% and bone characteristics from 3% to 10%, except for the lumbar spine BMC and the periosteal diameter of the femoral neck, where no changes were observed. The use of hormone therapy (HRT) was the major factor accounting for the maintenance of BMC. Use of HRT alone explained 44% of the variability in the change at the femoral neck BMC, but it was not associated with changes in physical fitness. Change in the body weight was the only factor associated with the change in physical fitness: better maintenance in body weight predicted better maintenance of physical fitness. In conclusion, our results indicate that HRT helps to maintain bone mass and structure, which are important factors in prevention of fragility fractures in later life. However, HRT had no effect on physical fitness, which is highly associated with the risk of falling, the most important cause of fractures.

The purpose of this study was to evaluate the remaining effects of 12-month intervention of alendronate and exercise on selected risk factors of fragility fractures in 15-month follow-up after withdrawal of intervention among early postmenopausal women. The trial consisted four experimental groups: (1) 5 mg of alendronate daily + exercise (Al+Ex+), (2) 5 mg alendronate daily (Al+Ex-), (3) placebo + exercise (Al-Ex+), and (4) placebo (Al-Ex-). At the follow-up measurements, bone mass and physical fitness of 102 women (mean age 53.5 +/- 2.5 years) out of initial 150 subjects could be evaluated. Alendronate increased bone mass significantly [mean; 95% confidence interval (CI)] during the intervention at the lumbar spine (3.9%; 2.2% to 5.7%) and femoral neck (2.1%; 0.9% to 3.4%). After withdrawal of alendronate, bone loss resumed to the rate comparable to that evident in the placebo group. Despite the declining bone mass, the between-group mean difference (3.2%; 1.0% to 5.4%) remained at the lumbar spine. However, the benefits at the femoral neck had disappeared 15 months after the withdrawal of alendronate. The 12-month exercise training resulted in significant increases in muscle power, dynamic balance, and aerobic capacity with no benefits on bone mass. Fifteen months later, these performance variables had declined among both the exercisers and nonexercisers. Although the between-group differences were no longer statistically significant, muscle power, dynamic balance, and aerobic capacity of those who exercised still remained above the pretraining levels. In conclusion, 12-month treatment with alendronate prevented postmenopausal bone loss, and residual effect was seen 15 months after withdrawal of the drug at the lumbar spine. Similarly, exercise improved muscle power, agility, and aerobic capacity during the intervention, but the improvement was lost after the cessation of the exercise program. Based on these results, it was evident that to maintain the benefits of alendronate or exercise, therapy should be continued.

The purpose of this cohort study was to focus on factors associated with bone mass and structure of lower limbs and physical performance after menopause. Eighty nonsmoking women with a mean age of 62.1 (SD 0.8) years participated in the study. They were classified into two groups by their use of hormone replacement therapy (HRT), either the current users (n = 43) or the never or discontinued users (n = 37). The tibial shaft and distal tibia were scanned with peripheral computed tomography. For the shaft region, the bone mineral content (BMC, g), cortical density (CoD, g/cm(3)), cortical area (CoA, mm(2)), and section modulus (BSI, mm(3)) were determined. For the distal part, the evaluated variables were BMC, total area (ToA), ratio of cortical to total area (CoA/ToA), trabecular density (TrD, g/mm(3)), cortical thickness, BSI, and buckling ratio. Isometric and dynamic muscle strength of the leg extensors, agility and postural sway, and cardiorespiratory capacity (VO(2max)) were measured. Unadjusted values for all bone variables were slightly higher among the HRT users compared to nonusers, with the exception of TrD with no difference. After controlling for body weight, the mean differences (95% confidence interval) remained significant for CoD of the tibial shaft and BSI of the distal tibia, the mean between-group differences being 1.5% (0.4 to 2.5%) and 23.0% (7.1 to 41.3%), respectively. Underlying the greater bending strength, HRT users had thicker cortices and a greater ratio of CoA/ToA. No differences existed between the two study groups for lower limb isometric or dynamic power, cardiorespiratory capacity, or postural balance or sway. HRT may offer protection against bone loss and maintain bone strength, although its ability to improve physical performance is not evident.

The purpose of this cross-sectional study was to examine the impact of long-term physical activity (PA) and calcium intake on non-weight-bearing radius and weight-bearing tibia. Altogether, 218 healthy, nonsmoking women, [92 premenopausal women, mean age, 32.6 years (SD, 2.2 years), and 126 postmenopausal women, mean age, 67.3 years (SD, 2.0 years)] participated. The subjects were divided according to their habitual levels of physical activity (PA+ or PA-) and calcium intake (Ca+ or Ca-). The distal end and shaft regions of the radius and tibia were evaluated with peripheral quantitative tomography (pQCT). For the shaft regions, bone mineral content (BMC), cortical cross-sectional area (CoA), cortical density (CoD), and bone strength index, that is, 1-11.9% of the density-weighted section modulus (BSI) were determined. For the distal ends, BMC, total cross-sectional area (ToA), trabecular density (TrD), and BSI were determined. The BMC at the distal radius in the young PA+ group was 6.6% (95% CI, 1- to 11.9%) lower than that of the PA- group. A similar nonsignificant trend was found for the radial shaft. The radial shaft showed a mechanically more competent structure among the older subjects with a BSI 8.5% (95% CI, 1.8-15.6%) higher in the older PA+ group than in the older PA- group. The associations between calcium intake and the radial bone characteristics were systematically positive in both age groups. PA seemed to benefit the distal tibia. In the younger age group the TrD was 6.9% (95% CI, 1.8-12.4%) higher in the PA+ group, and in the elderly the BMC was 5% (95% CI, 0.3-9.9%) higher in the PA+ group than in the PA- group. Note that in the younger age group the ToA was 5.1% (95% CI, 0-9.1%) smaller in the PA+ group than in the PA- group, and in the older age group the ToA was 4.2% (95% CI, -0.3-8.9%) greater in the PA+ group than in the PA- group. The association of PA and bone characteristics at the tibial shaft was positive in both age groups (statistically significant for the older subjects). The tibial shaft BSI of the older PA+ group was 8.6% (95% CI, 2.6-14.9%) better than that of the old PA- group. There was no association between calcium intake and the tibial bone characteristics in either age group. In conclusion, high calcium intake was positively associated with a mechanically competent structure in the radius among both younger and older women, whereas the influence of PA did not become apparent until older ages. PA seemed to benefit particularly the weight-bearing tibia, whereas calcium intake was not associated with the tibia.

While physical activity is an essential factor for muscle performance and development and also for the maintenance of bone mass in the loaded bones, apparently low intensity of physical activity of blind persons may compromise the muscle performance and bone mineral density (BMD). Therefore, the aim was to study whether there are differences in BMD of the weight-bearing or non-weight-bearing bones between visually handicapped persons and those with normal sight. Nineteen visually handicapped premenopausal women and their matched pairs were recruited to the study. The mean age of the visually handicapped women was 39.9 years (SD 8.1) and that of the women with normal vision 39.7 years (6.5). BMD of the distal radius, femoral neck and trochanter was measured with dual energy X-ray absorptiometry (DXA), and isometric muscle strength of the extremities and trunk with a dynamometer. Between-group differences were compared with paired Student's t-test. The BMD at the femur was 8% higher in favour of the group with normal sight, whereas radial BMD was similar in the two groups. The t-score was -1.0 (95% confidence interval -1.5 to -0.5) for the femoral neck BMD and -0.7 (-1.1 to -0.2) for the trochanter BMD in the group with impaired vision. The respective t-scores for the group with normal sight were -0.3 (-0.9 to 0.3) for the femoral neck and 0 (-0.7 to 0.7) for the trochanter. Visual handicap seems to be a risk for lower BMD of the weight-bearing proximal femur, but not for lower BMD of the non-weight-bearing distal radius.

This prospective study focused on lifestyle factors and weight maintenance that may modulate the rate of bone loss at the weight-bearing proximal femur and non-weight-bearing distal radius in elderly women. Altogether 128 women of 134 subjects participated in this study with a mean follow-up time 3.9 years (range 2.9–5.3 years). The initially 60- to 65-year-old subjects were originally selected by their level of physical activity [high (PA+) and low (PA–)] and calcium intake [high (Ca+) and low (Ca–)], and the original groups were maintained in this study. Physical fitness and bone mineral content (BMC) decreased significantly at a similar rate in all four study groups without any statistically significant between-group difference. The mean change in the muscle strength of leg extensors was −3.3% (95% CI −5% to −1.5 %) at follow-up when including all individuals. The leg extension strength was still 9.2% (95% CI 2.7% to 16.1%) better in the PA+ groups compared with PA– groups at follow-up. The mean change in the forearm flexion strength was −14% (95% CI −16.5% to −11.3%) at follow-up with no difference in the strength level between PA+ and PA– groups. The mean change in the estimated oxygen uptake was −3.4% (95% CI −5.6% to −1.1%) at follow-up. The PA+ groups were still fitter, the between-group difference in the estimated oxygen uptake being 11.9% (95% CI 4.8% to 19.5%). The mean changes in BMC at follow-up were −2.1% (95% CI −3.0% to −1.2%) at the femoral neck, −1.9% (95% CI −3.2% to −0.5%) at the trochanter, and −12.4% (95% CI −15.4% to −9.4%) at the distal radius, indicating mean annual losses of 0.6% (95% CI 0.3% to 0.8%), 0.5% (95% CI 0.1% to 0.8%), and 3.2% (95% CI 2.4% to 4.0%), respectively. Decreased body weight was associated with higher bone loss in all measured bone sites. High calcium intake and better preservation of physical fitness were associated with a smaller decrease in femoral neck BMC.

The purpose of this cross-sectional study was to examine whether long-term participation in recreational gymnastics or folk dancing or estrogen replacement therapy (ERT) is associated with mechanically more competent bones and improved muscular strength and body balance. One hundred and seventeen healthy, female postmenopausal recreational gymnasts (mean age 62.1 [SD 4.7] years) and 116 sedentary controls (mean age 61.5 [4.6] years) were enrolled in the study. Bone mineral content (BMC) of the distal radius, femoral neck, and trochanter were measured with dual-energy X-ray absorptiometry. BMC of the midshaft and distal tibia and trabecular density (TrD) of the distal tibia were measured with peripheral computed quantitative tomography. Maximal isometric strength, muscular power, cardiorespiratory fitness, and body balance of the participants were also assessed. The cardiorespiratory fitness, muscular strength, and dynamic balance of the recreational gymnasts and folk dancers combined were significantly better than those of the controls, the average group difference ranging from 7.5% (95% confidence interval 5.0-9.9%) in dynamic balance to 12.8% (6.6-19. 4%) in dynamic muscular power. ERT was not associated with the fitness indicators, muscular power, or balance, but was significantly associated with the BMC at all the measured bone sites, the mean group difference between estrogen users and nonusers ranging from 6.5% (3.7-9.3%) for the tibial shaft to 11.8% (6.4-17. 0%) for the distal radius. Recreational gymnastics, in turn, was significantly associated with higher BMC at the tibia only, the mean group difference being 3.9% (0.9-6.9%) for the tibial shaft and 7.7% (3.7-11.9%) for the distal tibia. Recreational gymnastics was also associated with higher TrD at the distal tibia (5.2%; 1.2-9.2%), whereas estrogen usage did not show such association. The results indicate that ERT seems especially effective in preventing postmenopausal bone loss, whereas recreational gymnastics and folk dancing improve muscular performance and body balance in addition to increased bone mass and bone size in the tibia. All these factors are essential in prevention of fall-related fractures of the elderly.

High peak bone mass in early adulthood is an important protective factor against osteoporotic fractures in later life, but little is known about the effects of exercise on growing bone. The purpose of this cross-sectional study was to determine at which state of maturity (Tanner stage), the areal bone mineral density (BMD) differences between the playing and nonplaying arms of junior tennis players become obvious, and to clarify in each developmental stage which training and background variables, if any, could explain the interindividual differences in bones' response to mechanical loading. Ninety-one 7- to 17-year-old female tennis players and 58 healthy female controls were measured. In each Tanner stage, differences in BMD in playing and nonplaying (dominant and nondominant) arms (proximal humerus, humeral shaft, and distal radius) and BMD of the lumbar spine and nondominant distal radius were compared between the controls and players. Within each Tanner stage of players, the associations between training and background variables and BMD differences were analyzed with Spearman rank correlation coefficients. In players, BMD differences between the playing and nonplaying arms were significant (P < 0.05- < 0.001) in all Tanner stages, with the mean difference ranging from 1.6 to 15.7%. In controls, these dominant-to-nondominant arm differences were clearly smaller (ranging from -0.2 to 4.6%), but significant at some measured sites. In comparison with the relative side-to-side arm differences between the players and controls (i.e., examination of the training effect), the mean difference was not obvious and significant until the adolescent growth spurt (i.e., the girls in Tanner stage III with a mean age of 12.6 years). In the lumbar spine, significant BMD differences between players and controls were not found until Tanner stage IV (mean age 13.5 years; 8.7%, P < 0.05) and V (mean age 15.5 years; 12.4%, P < 0.05). In a nonloaded site of the skeleton (nondominant distal radius), no significant BMD differences were found between the players and controls in any Tanner stage. In the correlation analysis, the Tanner I and II players (mean ages 9.4 and 10.8 years) showed no significant associations between any of the predictive variables and the side-to-side BMD differences, while in Tanner stages III, IV, and V, such associations could be found; the total amount of training hours during the playing career and the number of training sessions per week showed a significant and systematic correlation (rs ranging from 0.43 to 0.80) with the side-to-side BMD differences in several measured bone sites. In conclusion, this study suggests that in a majority of female junior tennis players, the benefit of unilateral activity on bone density does not become clearly evident until the adolescent growth spurt or Tanner stage III. The total amount of training during the player's career and the current training frequency (sessions per week) seem to best explain the training effect on bone tissue, leaving, however, room for speculation on the still unknown factors that modulate the loading response of a growing bone.

The hypothesis that a history of one or more weight reductions and regains (weight cycling) is associated with lower site-specific bone mineral density (BMD) was examined in 169 premenopausal women, aged 29-46 years. Data on the previous 10-years' weight cycling history, present weight-bearing physical exercise, number of deliveries, present use of contraceptive pills or hormone-releasing coils, age at menarche and present menstrual status were collected by a self-administered questionnaire. Dietary intake was calculated from food records. The areal BMD (g/cm2) was measured with dual-energy X-ray absorptiometry (Norland XR-26). The lumbar spine (L2-4) BMD, adjusted to weight and age at menarche (ANCOVA), was 0.062 g/cm2 (95% confidence interval: 0.015 to 0.011 g/cm2; p = 0.01) higher in the non-cyclers (n = 68) than in subjects with reported weight-cycling history (n = 101). The corresponding difference for femoral neck BMD was 0.019 g/cm2 (-0.018 to 0.056; p = 0.30), for trochanter BMD 0.013 g/cm2 (-0.025 to 0.05 g/cm2; p = 0.50) and for distal radius BMD 0.022 g/cm2 (0.006 to 0.397 g/cm2; p = 0.008). A pairwise comparison of 34 weight-matched subjects (non-cycler vs cycler) gave similar BMD differences as found in the above (ANCOVA) analyses. The results suggest that weight cycling might be associated with lower spine and distal radius BMD.

Background : Calcium (Ca) is an essential nutrient for the human body. Despite lively research, there is uncertainty about Ca requirements in terms of desirable health outcomes including an upper intake level above which the potential for harm increases. Objectives : The aim was to conduct a review to update requirements and desirable or harmful health effects of Ca on the current scientific evidence. Methods :We searched Medline and Swemed from January 2000 to December 2011 and included all systematic reviews that reported Ca supplementation or usual Ca intake on health outcomes. Meta-analyses, randomized clinical trials and cohort studies were included in the second search between May 2009 and March 2011 and an additional search covering studies till the end of 2011. This review concentrated on studies reporting independent effects of Ca, although a few recent trials report sole effects of Ca on health outcomes, most trials use Ca in combination with vitamin D vs. placebo. Results : In total, we reviewed 38 studies addressing the effects of Ca on bone, pregnancy-related outcomes, cancers, cardiovascular outcomes, obesity, and mortality. There was a lot of heterogeneity in the study protocols, which made it difficult to draw any strong conclusions. According to the literature, high Ca intake seems to have a small positive effect on bone mineral content (BMC) or bone mineral density (BMD) in children and postmenopausal women. We did not find any consistent evidence on the effects of Ca on bone health in premenopausal women or men. Also, the evidence that Ca supplementation reduces fracture incidence is scarce and inconsistent. Maternal diet may influence the peak bone mass of offspring but more studies are required. There was no overall effect of Ca intake on cancers. Ca was associated with a decreased risk of breast cancer and a slightly increased risk of prostate cancer in two of the three studies. No associations were found with other cancers. We found no consistent association between cardiovascular outcomes and Ca intake except for blood pressure. A small decrease of 2-4 mmHg in systolic blood pressure was found in pregnant and in hypertensive subjects with Ca supplementation. Reviewed studies did not show consistent evidence relating Ca intake to either mortality or obesity. Conclusion : Based on this evidence, there is no need to change the Nordic recommendations for Ca intake. However, due to heterogeneity in the studies it is difficult to interpret the results and provide single summary statement. Keywords : Calcium intake; calcium requirements; disease prevention; osteoporosis; bone mineral density; health maintenance; health outcomes (Published: 16 May 2013) Citation: Food & Nutrition Research 2013. 57 : 21082 - http://dx.doi.org/10.3402/fnr.v57i0.21082 Special Issue: This paper is part of the Nordic Nutrition Recommendations - The NNR5 project . More papers from this issue can be found at http://www.foodandnutritionresearch.net

Background: Fear of falling has been linked to activity restriction, functional decline, decreased quality of life and increased risk of falling. Factors that distinguish persons with a high concern about falling from those with low concern have not been systematically studied. Objective: This study aimed to expose potential health-related, functional and psychosocial factors that correlate with fear of falling among independently living older women who had fallen in the past year. Methods: Baseline data of 409 women aged 70-80 years recruited to a randomised falls prevention trial (DEX) (NCT00986466) were used. Participants were classified according to their level of concern about falling using the Falls Efficacy Scale International (FES-I). Multinomial logistic regression analyses were performed to explore associations between health-related variables, functional performance tests, amount of physical activity, quality of life and FES-I scores. Results: 68% of the participants reported a moderate to high concern (FES-I ≥20) about falls. Multinomial logistic regression showed that highly concerned women were significantly more likely to have poorer health and quality of life and lower functional ability. Reported difficulties in instrumental activities of daily living, balance, outdoor mobility and poorer quality of life contributed independently to a greater concern about falling. Conclusions: Concern about falling was highly prevalent in our sample of community-living older women. In particular, poor perceived general health and mobility constraints contributed independently to the difference between high and low concern of falling. Knowledge of these associations may help in developing interventions to reduce fear of falling and activity avoidance in old age.

Purpose: This study evaluated the training effects of an 18-month exercise intervention and subsequent 3.5-year follow-up on femoral neck structure in premenopausal women. Methods: Of 98 women who participated in this randomized controlled study, 84 (39 trainees and 45 controls) completed the 18-month intervention. At both 18 months and 3.5 years, dual-energy X-ray absorptiometry data on 22 trainees and 22 control participants (ages 35–45 y) were available for hip structural analysis. The section modulus (Z), cross-sectional area (CSA), and subperiosteal width at the femoral neck were analyzed. Lower-leg explosive power and estimated maximal oxygen uptake (Vo2max) were assessed by vertical countermovement jump and standardized 2 km walking test, respectively. Progressive supervised high-impact exercises were done three times per week for 18 months. Results: Significant between-group differences in favour of trainees were observed after the 18-month intervention in Z (3.2%, p=0.047) and CSA (2.8%, p=0.043). At the 3.5-year follow-up point, the exercise-induced benefits in Z and CSA had diminished and were statistically insignificant. A between-group difference in favour of trainees was observed in lower-limb power after intervention (4.2%, p=0.002) and at 3.5-year follow-up (5.1%, p=0.003). A similar difference was seen in estimated Vo2max (5.6% after intervention, p=0.002, and 4.6% at 3.5-y follow-up, p=0.005). Conclusion: The 18-month high-impact exercise intervention strengthened the femoral neck in premenopausal women by enhancing its structural properties; however, this benefit was not maintained at 3.5-year follow-up. In contrast, the exercise benefits on physical performance continued to be maintained 3.5 years after intervention.

Background Costs of falling in older persons are high, both to individuals and to society. Both vitamin D and exercise are suggested to reduce the risk of falls. This study assessed the cost-effectiveness of vitamin D supplementation and exercise, separately and combined, in preventing medically attended injurious falls among older Finnish women. Methods Economic evaluation was conducted alongside a previously published 2-year randomised controlled trial where 409 community-dwelling women aged 70 to 80 years were recruited into four groups: 1) no exercise + placebo (D−Ex−) 2) no exercise + vitamin D 800 IU/day (D+Ex−) 3) exercise + placebo (D−Ex+) 4) exercise + vitamin D 800 IU/day (D+Ex+). Outcomes were medically attended injurious falls and fall-related health care utilisation costs over the intervention period, the latter evaluated from a societal perspective based on 2011 unit costs. Incremental cost-effectiveness ratios (ICER) were calculated for the number of injurious falls per person-year prevented, and uncertainty estimated using bootstrapping. Results Incidence rate ratios (95% CI) for medically attended injurious falls were lower in both Ex+ groups compared with D−Ex−: 0.46 (0.22 to 0.95) for D−Ex+, 0.38 (0.17 to 0.81) for D+Ex+. Step-wise calculation of ICERs resulted in exclusion of D+Ex− as more expensive and less effective. Recalculated ICERs were €221 for D−Ex−, €708 for D−Ex+ and €3,820 for D+Ex+; bootstrapping indicated 93% probability that each injurious fall avoided by D−Ex+ per person-year costs €708. At a willingness to pay of €3,000 per injurious fall prevented, there was an 85.6% chance of the exercise intervention being cost-effective in this population. Conclusions Exercise was effective in reducing fall-related injuries among community dwelling older women at a moderate cost. Vitamin D supplementation had marginal additional benefit. The results provide a firm basis for initiating feasible and cost-effective exercise interventions in this population.

Background Osteoarthritis (OA) is a chronic joint disease with the hip and knee being commonly affected lower limb sites. There is evidence supporting that aerobic and strength training is beneficial for reducing pain and improving physical function in older adults with mild-to-moderate knee and hip OA. Good physical function is crucial in preventing fall-induced injuries in OA patients. Methods The aim of this pilot study is to test the safety and feasibility of a tailored exercise program with particular emphasis on maintaining appropriate training intensity while minimising adverse events and injuries. The self-reported disease-specific pain and physical function will be assessed using the pain and functioning subscales of the WOMAC questionnaire (range 0–100 mm) at baseline and at 12 weeks. The maximal leg-extensor strength, dynamic balance, Timed-up and go (TUG), Short physical performance battery (SPPB; includes tests of balance, 4-metre walking speed and 5-time chair stand) will be used in assessing physical functioning objectively. In addition, hip range of motion and stair-climb-test (step height 20 cm) will be used. Thirteen women with diagnosed hip OA were recruited and received the exercise program 3 times a week. Main inclusion criteria were age ≥65 years, pain experienced in the hip region and living at home independently. Results The pilot study started in September 2015, and the end point measurements will be done in December 2015. Dimensions such as intensity progression, individual tailoring of exercises and suitability for varying pain levels and functional ability will be evaluated. In assessing the treatment outcomes, each participant will function as her own control. Conclusions Training intensity needs to be optimal to insure safety as well as progression in physical function and pain relief. The larger randomised controlled trial will be planned according to experience and feedback received from this pilot study.

Dear Editor, As we discussed in our paper [1], our study population consisted of 70to 80-year-old home-dwelling women who voluntarily participated in the DEX randomized controlled trial [2], and it is likely that the prevalence of sarcopenia in the unselected Finnish population of elderly women would have been higher than that reported by us. We estimated muscle mass with dual-energy X-ray absorptiometry, which is the preferred method for research and clinical use [3]. In the study by ArangoLopera and colleagues, muscle mass was determined by calf circumference [4]. Diagnostic criteria (including those used in the European Working Group on Sarcopenia in Older People algorithm) need to be standardized and consistently applied before they can be deemed worthy of comparison. Unless this is done, diagnosis and prevalence rates of sarcopenia are difficult to compare and do not hold credibility. We also explored the rationale behind measuring muscle mass to predict the onset of disability in older adults. The result was that muscle mass and derived indices of sarcopenia were not related to measures of physical function. It seemed that an appropriate and standardized functional ability test battery might be better suited to detect changes in physical function and, consequently, reveal the onset of disability.

This study showed that the prevalence of sarcopenia (low muscle mass and performance) among 70–80-year-old home-dwelling Finnish women is very low, while every third woman has WHO-based osteopenia (low bone mass). Muscle mass and derived indices of sarcopenia were not significantly related to measures of functional ability. This study aims to determine the prevalence of sarcopenia and osteopenia among four hundred nine 70–80-year-old independently living Finnish women. The study compared consensus diagnostic criteria for age-related sarcopenia recently published by the European Working Group on Sarcopenia in Older People (EWGSOP) and the International Working Group on Sarcopenia (IWG) and assessed their associations with functional ability. Femoral bone mineral density and body composition were measured with dual-energy X-ray absorptiometry. Skeletal muscle mass index (SMI), gait speed, and handgrip strength were used for sarcopenia diagnosis. Independent samples t tests determined group differences in body composition and functional ability according to recommended diagnostic cutpoints. Scatter plots were used to illustrate the correlations between the outcome measures used for diagnosis. Prevalence of sarcopenia was 0.9 and 2.7 % according to the EWGSOP and IWG, respectively. Thirty-six percent of the women had WHO-based osteopenia. Women with higher gait speed had significantly lower body weight and fat mass percentage, higher lean mass percentage, and better functional ability. Women with a low SMI weighed significantly less, with no significant differences in other outcome measures. SMI, gait speed, and grip strength were significantly correlated. Our study suggests that when using consensus definitions, sarcopenia is infrequent among older home-dwelling women while every third woman has osteopenia. In clinical practice, attention should be paid to the decline in functional ability rather than focusing on low muscle mass alone.

Background Falls are the leading cause of unintentional injury and injury-related death among older people. In addition to physical activity, vitamin D also may affect balance and neuromuscular function. Low serum 25-hydroksivitamin D level increases the risk of bone loss, falls and fractures. Thus, an appropriate exercise program and sufficient vitamin D intake may significantly improve not only functional balance, but also balance confidence. Balance represents a complex motor skill determined by reaction time, muscle strength, and speed and coordination of movement. Methods/Design A 2-year randomized double-blind placebo-controlled vitamin D and open exercise trial of 409 home-dwelling women 70 to 80 years of age comprising four study arms: 1) exercise + vitamin D (800 IU/d), 2) exercise + placebo, 3) no exercise + vitamin D (800 IU/d), 4) no exercise + placebo. In addition to monthly fall diaries, general health status, life style, bone health, physical functioning, and vitamin D metabolism will be assessed. The primary outcomes are the rate of falls and fall-related injuries. Secondary outcomes include changes in neuromuscular functioning (e.g. body balance, muscle strength), ADL- and mobility functions, bone density and structure, cardiovascular risk factors, quality of life and fear of falling. Discussion The successful completion of this trial will provide evidence on the effectiveness of exercise and vitamin D for falls reduction. Trial Registration ClinicalTrial.gov -register (NCT00986466).

Background Exercise is widely recommended to reduce osteoporosis, falls and related fragility fractures, but its effect on whole bone strength has remained inconclusive. The primary purpose of this systematic review and meta-analysis was to evaluate the effects of long-term supervised exercise (≥6 months) on estimates of lower-extremity bone strength from childhood to older age. Methods We searched four databases (PubMed, Sport Discus, Physical Education Index, and Embase) up to October 2009 and included 10 randomised controlled trials (RCTs) that assessed the effects of exercise training on whole bone strength. We analysed the results by age groups (childhood, adolescence, and young and older adulthood) and compared the changes to habitually active or sedentary controls. To calculate standardized mean differences (SMD; effect size), we used the follow-up values of bone strength measures adjusted for baseline bone values. An inverse variance-weighted random-effects model was used to pool the results across studies. Results Our quality analysis revealed that exercise regimens were heterogeneous; some trials were short in duration and small in sample size, and the weekly training doses varied considerably between trials. We found a small and significant exercise effect among pre- and early pubertal boys [SMD, effect size, 0.17 (95% CI, 0.02-0.32)], but not among pubertal girls [-0.01 (-0.18 to 0.17)], adolescent boys [0.10 (-0.75 to 0.95)], adolescent girls [0.21 (-0.53 to 0.97)], premenopausal women [0.00 (-0.43 to 0.44)] or postmenopausal women [0.00 (-0.15 to 0.15)]. Evidence based on per-protocol analyses of individual trials in children and adolescents indicated that programmes incorporating regular weight-bearing exercise can result in 1% to8% improvements in bone strength at the loaded skeletal sites. In premenopausal women with high exercise compliance, improvements ranging from 0.5% to 2.5% have been reported. Conclusions The findings from our meta-analysis of RCTs indicate that exercise can significantly enhance bone strength at loaded sites in children but not in adults. Since few RCTs were conducted to investigate exercise effects on bone strength, there is still a need for further well-designed, long-term RCTs with adequate sample sizes to quantify the effects of exercise on whole bone strength and its structural determinants throughout life.