René Rizzoli

University of Geneva, Genève, Geneva, Switzerland

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Publications (154)641.85 Total impact

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    ABSTRACT: Prospective controlled evidence supporting the efficacy of long-term exercise to prevent physical decline and reduce falls in old age is lacking. The present study aimed to assess the effects of long-term music-based multitask exercise (i.e., Jaques-Dalcroze eurhythmics) on physical function and fall risk in older adults. A 3-year follow-up extension of a 1-year randomized controlled trial (NCT01107288) was conducted in Geneva (Switzerland), in which 134 community-dwellers aged ≥65 years at increased risk of falls received a 6-month music-based multitask exercise program. Four years following original trial enrolment, 52 subjects (baseline mean ± SD age, 75 ± 8 years) who (i) have maintained exercise program participation through the 4-year follow-up visit ("long-term intervention group", n = 23) or (ii) have discontinued participation following original trial completion ("control group", n = 29) were studied. They were reassessed in a blind fashion, using the same procedures as at baseline. At 4 years, linear mixed-effects models showed significant gait (gait speed, P = 0.006) and balance (one-legged stance time, P = 0.015) improvements in the long-term intervention group, compared with the control group. Also, long-term intervention subjects did better on Timed Up & Go, Five-Times-Sit-to-Stand and handgrip strength tests, than controls (P < 0.05, for all comparisons). Furthermore, the exercise program reduced the risk of falling (relative risk, 0.69; 95 % confidence interval, 0.5-0.9; P = 0.008). These findings suggest that long-term maintenance of a music-based multitask exercise program is a promising strategy to prevent age-related physical decline in older adults. They also highlight the efficacy of sustained long-term adherence to exercise for falls prevention.
    Calcified Tissue International 08/2014; · 2.50 Impact Factor
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    ABSTRACT: General recommendations for a reference case for economic studies in rheumatic diseases were published in 2002 in an initiative to improve the comparability of cost-effectiveness studies in the field. Since then, economic evaluations in osteoarthritis (OA) continue to show considerable heterogeneity in methodological approach.
    Seminars in arthritis and rheumatism. 06/2014;
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    ABSTRACT: High protein (> median:Hprot) vs. moderate (< median:MProt) intake was shown to enhance the positive impact of high physical activity (HPA) on proximal femur BMC/aBMD/Area in healthy prepubertal boys. We tested the hypothesis that this synergistic effect would track and influence bone structure and strength until mid-adolescence. BMC/aBMD/Area was measured at femoral neck (FN) and total hip (TotHip) by DXA in 176 boys at 7.4 ± 0.4 and 15.2 ± 0.5 years (± SD). Distal tibia (DistTib) microstructure and strength were also assessed at 15.2 years by high-resolution peripheral computerized tomography (HR-pQCT) and micro-finite element analysis (µFEA). The positive impact of HProt vs. MProt on FN and TotHip BMC/aBMD/Area, recorded at 7.4 years remained unabated at 15.2 years. At this age, at DistTib, HProt-HPA vs. MProt-HPA was associated (P < 0.001) with larger cross-sectional area (CSA, mm2), trabecular number (Tb.N, mm−1) and lower trabecular separation (Tb.Sp, µm). The interaction between physical activity and protein intake was significant for CSA (P = 0.012) and Tb.N (P = 0.043). Under MProt (38.0 ± 6.9 g.d−1), a difference in PA from 168 ± 40 to 303 ± 54 kcal.d−1 was associated with greater stiffness (kN/mm) and failure load (N) of +0.16 and +0.14 Z-score, respectively. In contrast, under HProt (56.2 ± 9.5 g.d−1), a difference in PA of similar magnitude, from 167 ± 33 to 324 ± 80 kcal.d−1, was associated with a larger difference in stiffness and failure load of +0.50 and +0.57 Z-score, respectively. In conclusion, the positive influence of relatively HProt on the impact of HPA on proximal femur macrostructure tracks from prepuberty to mid-late puberty. At this stage, the impact of HProt on HPA is also associated with microstructural changes that should confer greater mechanical resistance to weight-bearing bones. These results underscore the importance of protein intake and exercise synergistic interaction in the early prevention of adult osteoporosis. © 2014 American Society for Bone and Mineral Research
    Journal of bone and mineral research: the official journal of the American Society for Bone and Mineral Research 04/2014; · 6.04 Impact Factor
  • Calcified Tissue International 04/2014; · 2.50 Impact Factor
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    ABSTRACT: Obesity has been associated with increased bone mass, but the mechanisms involved are still poorly understood. We aimed to explore the relationship between bone mineral density and factors known to influence bone formation, in obese and lean adolescents. We recruited 24 obese and 25 lean adolescents in a case-control study. Total body bone mineral density (TB-BMD) z-scores and body composition were determined using DXA. We measured vitamin D (25-OH-D), glucose, insulin and leptin concentrations. Physical activity (PA) level was quantified using accelerometer. TB-BMD z-score was higher, while 25-OH-D and PA levels were lower in obese compared to lean subjects (TB-BMD z-score: 1.06 ± 0.96 vs. 0.26 ± 0.91, p = .004; 25-OH-D: 9.9 ± 6.4 vs. 18.5 ± 7.4 ng.ml, p < 0.001; PA level: 308.3 ± 22.1 vs. 406.8 ± 29.2 count.min, p = .01). TB-BMD z-score was not related with 25-OH-D or PA levels, but positively with leptin concentration and fat mass (p < .05). Vitamin D concentration was negatively correlated with fat mass (p < .001). Despite lower serum vitamin D and physical activity levels, BMD was higher in obese adolescents and associated with higher serum leptin concentrations. Furthermore, obese adolescents have lower vitamin D serum concentrations than lean controls, probably owing to its distribution in adipose tissue.
    Journal of pediatric gastroenterology and nutrition 01/2014; · 2.18 Impact Factor
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    ABSTRACT: Osteoporosis is complicated by the occurrence of fragility fractures. Over past years, various treatment options have become available, mostly potent antiresorptive agents such as bisphosphonates and denosumab. However, antiresorptive therapy cannot fully and rapidly restore bone mass and structure that has been lost because of increased remodelling. Alternatively recombinant human parathyroid hormone (rhPTH) analogues do increase the formation of new bone material. The bone formation stimulated by intermittent PTH analogues not only increases bone mineral density (BMD) and bone mass but also improves the microarchitecture of the skeleton, thereby reducing incidence of vertebral and nonvertebral fractures. Teriparatide, a recombinant human PTH fragment available in Switzerland, is reimbursed as second-line treatment in postmenopausal women and men with increased fracture risk, specifically in patients with incident fractures under antiresorptive therapy or patients with glucocorticoid-induced osteoporosis and intolerance to antiresorptives. This position paper focuses on practical aspects in the management of patients on teriparatide treatment. Potential first-line indications for osteoanabolic treatment as well as the benefits and limitations of sequential and combination therapy with antiresorptive drugs are discussed.
    Swiss medical weekly. 01/2014; 144:w13952.
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    ABSTRACT: Low protein intake is associated with an alteration of bone microstructure and material level properties. However, it remains unknown whether these alterations of bone tissue could influence the response to repeated mechanical loading. The authors investigated the in vitro effect of repeated loading on bone strength in humeri collected from 20 6-month-old female rats pair-fed with a control (15% casein) or an isocaloric low protein (2.5% casein) diet for 10 weeks. Bone specimens were cyclically loaded in three-point bending under load control for 2000 cycles. Humeri were then monotonically loaded to failure. The load-displacement curve of the in vitro cyclically loaded humerus was compared to the contralateral noncyclically loaded humerus and the influence of both protein diets. Material level properties were also evaluated through a nanoindentation test. Cyclic loading decreased postyield load and plastic deflection in rats fed a low protein diet, but not in those on a regular diet. Bone material level properties were altered in rats fed a low protein diet. This suggests that bone biomechanical alterations consequent to cyclic loading are more likely to occur in rats fed a low protein diet than in control animals subjected to the same in vitro cyclic loading regimen.
    BioMed Research International 01/2014; 2014:185075. · 2.88 Impact Factor
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    ABSTRACT: Objectives Existing practice guidelines for osteoarthritis (OA) analyze the evidence behind each proposed treatment but do not prioritize the interventions in a given sequence. The objective was to develop a treatment algorithm recommendation that is easier to interpret for the prescribing physician, based on the available evidence and applicable in Europe and internationally. The knee was used as the model OA joint. Methods ESCEO assembled a task force of 13 international experts (rheumatologists, clinical epidemiologists, clinical scientists). Existing guidelines were reviewed, all interventions listed and recent evidence retrieved using established databases. A first schematic flow chart with treatment prioritization was discussed in a one-day meeting and shaped to the treatment algorithm. Fine tuning occurred by electronic communication and three consultation rounds until consensus. Results Basic principles consist of the need of combined pharmacological and non-pharmacological treatment, with a core set of initial measures including information access/education, weight loss if overweight and an appropriate exercise program. Four multimodal steps are then established. Step 1 consists of background therapy, either non-pharmacological (referral to a physical therapist for re-alignment treatment if needed and sequential introduction of further physical interventions initially and at any time thereafter) and pharmacological. The latter consists of chronic Symptomatic Slow Acting Drugs for OA (e.g. prescription glucosamine sulfate and/or chondroitin sulfate) with paracetamol at-need; topical NSAIDs are added in the still symptomatic patient. Step 2 consists of the advanced pharmacological management in the persistent symptomatic patient and is centered on the use of oral COX-2 selective or non-selective NSAIDs, chosen based on concomitant risk factors, with intra-articular corticosteroids or hyaluronate for further symptom relief if insufficient. In Step 3, the last pharmacological attempts before surgery are represented by weak opioids and other central analgesics. Finally, Step 4 consists of end-stage disease management and surgery, with classical opioids as a difficult to manage alternative when surgery is contraindicated. Conclusions The proposed treatment algorithm may represent a new framework for the development of future guidelines for the management of OA, more easily accessible to physicians.
    Seminars in Arthritis and Rheumatism. 01/2014;
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    ABSTRACT: From 50 years of age, postmenopausal women are at an increased risk of developing sarcopenia and osteoporosis as a result of deterioration of musculoskeletal health. Both disorders increase the risk of falls and fractures. The risk of developing sarcopenia and osteoporosis may be attenuated through healthy lifestyle changes, which include adequate dietary protein, calcium and vitamin D intakes, and regular physical activity/exercise, besides hormone replacement therapy when appropriate. Protein intake and physical activity are the main anabolic stimuli for muscle protein synthesis. Exercise training leads to increased muscle mass and strength, and the combination of optimal protein intake and exercise produces a greater degree of muscle protein accretion than either intervention alone. Similarly, adequate dietary protein intake and resistance exercise are important contributors to the maintenance of bone strength. Vitamin D helps to maintain muscle mass and strength as well as bone health. These findings suggest that healthy lifestyle measures in women aged >50 years are essential to allow healthy aging. The European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) recommends optimal dietary protein intake of 1.0–1.2 g/kg body weight/d with at least 20–25 g of high-quality protein at each main meal, with adequate vitamin D intake at 800 IU/d to maintain serum 25-hydroxyvitamin D levels >50 nmol/L as well as calcium intake of 1000 mg/d, alongside regular physical activity/exercise 3–5 times/week combined with protein intake in close proximity to exercise, in postmenopausal women for prevention of age-related deterioration of musculoskeletal health.
    Maturitas 01/2014; · 2.84 Impact Factor
  • René Rizzoli
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    ABSTRACT: Bone mass, geometry and microstructure, and bony tissue material level properties determine bone strength, hence the resistance to fracture. At a given age, all these variables are the consequence of the amount accumulated and of the structure developed during growth, up to the so-called peak bone mass, and of the bone loss and microstructure degradation occurring later in life. Genetic factors primarly contribute to the variance of the determinants of bone strength. Nutritional intakes are environmental factors that influence both processes, either directly by modifying modeling and remodeling, or indirectly through changes in calcitropic hormone secretion and action. Some effects of nutrition on the offspring bone could take place during fetal life. There are interplays between genetic factors, nutritional intakes and physical exercise. Among the nutrients, sufficient dietary intakes of calcium and protein are necessary for bone health in childhood and adolescence as well as later in life.
    Best Practice & Research: Clinical Endocrinology & Metabolism 01/2014; · 4.91 Impact Factor
  • Calcified Tissue International 12/2013; · 2.50 Impact Factor
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    ABSTRACT: To investigate the efficacy and safety of oral fixed-dose combination strontium ranelate 2 g/vitamin D3 1,000 IU daily vs. strontium ranelate 2 g daily for correction of vitamin D insufficiency in osteoporosis. A 6-month international, randomized, double-blind, parallel-group, phase 3 study. 518 men and postmenopausal women aged ≥50 years with primary osteoporosis (T-score ≤-2.5 SD) and 25-hydroxyvitamin D [25(OH)D] >22.5 nmol/L were included. Patients were allocated to strontium ranelate 2 g/vitamin D3 1,000 IU daily (n=413) or strontium ranelate 2 g daily (n=105). Participants received calcium 1 g daily. The primary endpoint was serum 25(OH)D at last post-baseline evaluation during 3 months. Both groups were comparable at baseline. Mean baseline 25(OH)D was 44.1±14.6 nmol/L. After 3 months, the percentage of patients with 25(OH)D ≥50 nmol/L was higher with strontium ranelate/vitamin D3 vs. strontium ranelate (84% vs. 44%, P<0.001) (adjusted between-group odds ratio=6.7; 95% CI, 4.2-10.9). The efficacy on 25(OH)D of the combination was maintained at 6 months (86% vs. 40%, P<0.001). Mean 25(OH)D was 65.1 and 49.5 nmol/L, respectively, after 3 months and 66.9 and 45.4 nmol/L after 6 months. Physical performance improved in both groups. Falls were 17% and 20% in the strontium ranelate/vitamin D3 and strontium ranelate groups, respectively. Parathyroid hormone levels were inversely correlated with 25(OH)D. No clinically relevant differences in safety were observed. This study confirms the efficacy and safety of fixed-dose combination strontium ranelate 2 g/vitamin D3 1,000 IU for correction of vitamin D insufficiency in osteoporotic patients.
    European Journal of Endocrinology 12/2013; · 3.14 Impact Factor
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    ABSTRACT: Background: in a secondary analysis of a randomised controlled trial, we investigated whether 6 months of music-based multitask training had beneficial effects on cognitive functioning and mood in older adults.Methods: 134 community-dwellers aged ≥65 years at increased risk for falling were randomly assigned to either an intervention group (n = 66) who attended once weekly 1-h supervised group classes of multitask exercises, executed to the rhythm of piano music, or a control group with delayed intervention (n = 68) who maintained usual lifestyle habits, for 6 months. A short neuropsychological test battery was administered by an intervention-blinded neuropsychologist at baseline and Month 6, including the mini-mental state examination (MMSE), the clock-drawing test, the frontal assessment battery (FAB) and the hospital anxiety (HADS-A) and depression scale.Results: intention-to-treat analysis showed an improvement in the sensitivity to interference subtest of the FAB (adjusted between-group mean difference (AMD), 0.12; 95% CI, 0.00 to 0.25; P = 0.047) and a reduction in anxiety level (HADS-A; AMD, -0.88; 95% CI, -1.73 to -0.05; P = 0.039) in intervention participants, as compared with the controls. Within-group analysis revealed an increase in MMSE score (P = 0.004) and a reduction in the number of participants with impaired global cognitive performance (i.e., MMSE score ≤23; P = 0.003) with intervention.Conclusion: six months of once weekly music-based multitask training was associated with improved cognitive function and decreased anxiety in community-dwelling older adults, compared with non-exercising controls. Studies designed to further delineate whether training-induced changes in cognitive function could contribute to dual-task gait improvements and falls reduction, remain to be conducted.
    Age and Ageing 11/2013; · 3.82 Impact Factor
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    ABSTRACT: There is an important need to evaluate therapeutic approaches for osteoarthritis (OA) in terms of cost-effectiveness as well as efficacy. The ESCEO expert working group met to discuss the epidemiological and economic evidence that justifies the increasing concern of the impact of this disease and reviewed the current state-of-the-art in health economic studies in this field. OA is a debilitating disease; it is increasing in frequency and is associated with a substantial and growing burden on society, in terms of both burden of illness and cost of illness. Economic evaluations in this field are relatively rare, and those that do exist, show considerable heterogeneity of methodological approach (such as indicated population, comparator, decision context and perspective, time horizon, modeling and outcome measures used). This heterogeneity makes comparisons between studies problematic. Better adherence to guidelines for economic evaluations is needed. There was strong support for the definition of a reference case and for what might constitute "standard optimal care" in terms of best clinical practice, for the control arms of interventional studies.
    Seminars in arthritis and rheumatism 08/2013; · 4.72 Impact Factor
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    ABSTRACT: Context:Sclerostin inhibits bone formation and is involved in the bone response to mechanical loading, but the role and significance of circulating sclerostin is poorly understood.Objective:We assessed the association between serum sclerostin and calcitropic hormones, bone turnover marker levels, bone mineral content/density (BMC/BMD), and microstructure using three different immunoassays.Design, Setting, and Participants:In a cross-sectional study, serum sclerostin was measured in a cohort of 187 healthy subjects (98 women; 89 men) aged 65±1 (x±SD) years.Results:Overall, mean sclerostin (95% CI) was 37.3 (18.0-69.2) ng/l, 1165.8 (464.0-2296.4) ng/l, and 513.5 (250.7-950.9) ng/l with assays I, II and III, respectively. Serum sclerostin was higher in men with assays II and III. In all three assays, sclerostin and PTH were inversely correlated, only after adjustment for whole-body BMC (WB-BMC). After adjustment for sex and WB-BMC, the bone turnover markers P1NP and CTX negatively correlated, only with assay II. In all three assays, sclerostin positively correlated to WB-BMC, distal radius and distal tibia cortical area, cancellous bone volume (BV/TV) and trabecular number, and lumbar spine and proximal femur areal BMD following adjustment for sex.Conclusion:Sclerostin levels are markedly different according to the immunoassay used. Detection of an association with calcitropic hormones or turnover markers relies on the epitope recognized by the immunoassay and adjustment for bone mass.
    The Journal of clinical endocrinology and metabolism 07/2013; · 6.50 Impact Factor
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    ABSTRACT: The reduced muscle mass and impaired muscle performance that define sarcopenia in older individuals are associated with increased risk of physical limitation and a variety of chronic diseases. They may also contribute to clinical frailty. A gradual erosion of quality of life (QoL) has been evidenced in these individuals, although much of this research has been done using generic QoL instruments, particularly the SF-36, which may not be ideal in older populations with significant comorbidities. This review and report of an expert meeting presents the current definitions of these geriatric syndromes (sarcopenia and frailty). It then briefly summarizes QoL concepts and specificities in older populations and examines the relevant domains of QoL and what is known concerning QoL decline with these conditions. It calls for a clearer definition of the construct of disability, argues that a disease-specific QoL instrument for sarcopenia/frailty would be an asset for future research, and discusses whether there are available and validated components that could be used to this end and whether the psychometric properties of these instruments are sufficiently tested. It calls also for an approach using utility weighting to provide some cost estimates and suggests that a time trade-off study could be appropriate.
    Calcified Tissue International 07/2013; · 2.50 Impact Factor
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    ABSTRACT: Loss of bone mineral mass, muscle atrophy, and functional limitations are predictable consequences of immobilization and subsequent weight-bearing restriction due to leg or ankle fractures. The aim of this study was to prospectively determine whether decreased bone mineral mass following lower-limb fractures recovers at follow-up durations of six and eighteen months in adolescents. In the present study, we included fifty adolescents who underwent cast immobilization for a leg or ankle fracture. Dual x-ray absorptiometry scans of four different sites (total hip, femoral neck, entire lower limb, and calcaneus) were performed at the time of the fracture, at cast removal, and at follow-ups of six and eighteen months. Patients with fractures were paired with healthy controls according to sex, age, and ethnicity. Dual x-ray absorptiometry values were compared between groups and between injured and non-injured legs in adolescents with fractures. Among those with fractures, lower-limb bone mineral variables were significantly lower at the injured side compared with the non-injured side at cast removal, with differences ranging from 6.2% to 31.7% (p < 0.0001). Similarly, injured adolescents had significantly lower bone mineral values at the level of the injured lower limb compared with healthy controls (p < 0.0001). At the six-month follow-up, there were still significant residual differences between injured and non-injured legs in adolescents with fractures (p < 0.0001). However, a significant residual difference between healthy controls and injured adolescents was present only for femoral neck bone mineral density (p = 0.011). At the eighteen-month follow-up, no significant difference was observed at any lower-limb site. Bone mineral loss following a fracture of the lower limb in adolescents is highly significant and affects the lower limb both proximal to and distal to the fracture site. In contrast to observations in adults, a rapid bone mass reversal occurs with full bone recovery by eighteen months. Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.
    The Journal of Bone and Joint Surgery 06/2013; 95(11):1037-43. · 3.23 Impact Factor
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    ABSTRACT: Abstract Background: Osteoarthritis is a clinical syndrome of failure of the joint accompanied by varying degrees of joint pain, functional limitation, and reduced quality of life due to deterioration of articular cartilage and involvement of other joint structures. Scope: Regulatory agencies require relevant clinical benefit on symptoms and structure modification for registration of a new therapy as a disease-modifying osteoarthritis drug (DMOAD). An international Working Group of the European Society on Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) and International Osteoporosis Foundation was convened to explore the current burden of osteoarthritis, review current regulatory guidelines for the conduct of clinical trials, and examine the concept of responder analyses for improving drug evaluation in osteoarthritis. Findings: The ESCEO considers that the major challenges in DMOAD development are the absence of a precise definition of the disease, particularly in the early stages, and the lack of consensus on how to detect structural changes and link them to clinically meaningful endpoints. Responder criteria should help identify progression of disease and be clinically meaningful. The ideal criterion should be sensitive to change over time and should predict disease progression and outcomes such as joint replacement. Conclusion: The ESCEO considers that, for knee osteoarthritis, clinical trial data indicate that radiographic joint space narrowing >0.5 mm over 2 or 3 years might be a reliable surrogate measure for total joint replacement. On-going research using techniques such as magnetic resonance imaging and biochemical markers may allow the identification of these patients earlier in the disease process.
    Current Medical Research and Opinion 04/2013; · 2.37 Impact Factor
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    ABSTRACT: BACKGROUND: As an important modifiable lifestyle factor in osteoporosis prevention, physical activity has been shown to positively influence bone mass accrual during growth. We have previously shown that a nine month general school based physical activity intervention increased bone mineral content (BMC) and density (aBMD) in primary school children. From a public health perspective, a major key issue is whether these effects persist during adolescence. We therefore measured BMC and aBMD three years after cessation of the intervention to investigate whether the beneficial short-term effects persisted. METHODS: All children from 28 randomly selected first and fifth grade classes (Intervention group (INT): 16 classes, n=297; control group (CON): 12 classes, n=205) who had participated in KISS (Kinder- und Jugendsportstudie) were contacted three years after cessation of the intervention program. The intervention included daily physical education with daily impact loading activities over nine months. Measurements included anthropometry, vigorous physical activity (VPA) by accelerometers, and BMC/aBMD for total body, femoral neck, total hip, and lumbar spine by dual-energy X-ray absorptiometry (DXA). Sex- and age-adjusted Z-scores of BMC or aBMD at follow-up were regressed on intervention (1 vs 0), the respective Z-score at baseline, gender, follow-up height and weight, pubertal stage at follow-up, previous and current VPA, adjusting for clustering within schools. RESULTS: 377 of 502 (75%) children participated in baseline DXA measurements and of those, 214 (57%) participated to follow-up. At follow-up INT showed significantly higher Z-scores of BMC at total body (adjusted group difference: 0.157 units (0.031 - 0.283); p=0.015), femoral neck (0.205 (0.007 - 0.402); p=0.042) and at total hip (0.195 (0.036 to 0.353); p=0.016) and higher Z-scores of aBMD for total body (0.167 (0.016 to 0.317); p=0.030) compared to CON, representing 6-8% higher values for children in the INT. No differences could be found for the remaining bone parameters. For the subpopulation with baseline VPA (n=163), effect sizes became stronger after baseline VPA adjustment. After adjustment for baseline and current VPA (n=101), intervention effects were no longer significant, while effect sizes remained the same as without adjustment for VPA. CONCLUSION: Beneficial effects on BMC of a nine month general physical activity intervention appeared to persist over three years. Part of the maintained effects may be explained by current physical activity.
    Bone 03/2013; · 3.82 Impact Factor

Publication Stats

3k Citations
641.85 Total Impact Points

Institutions

  • 1998–2014
    • University of Geneva
      • • Faculty of Medicine
      • • Division of Transplantation
      • • Department of Rehabilitation and Geriatrics
      • • Division of Bone Diseases
      Genève, Geneva, Switzerland
  • 2009–2013
    • University of Liège
      • Department of Public Health, Epidemiology and Health Economics
      Luik, Walloon Region, Belgium
  • 2011
    • Ghent University
      • Department of Internal Medicine
      Gent, VLG, Belgium
    • University Hospital of Lausanne
      Lausanne, Vaud, Switzerland
  • 2008
    • Schulthess Klinik, Zürich
      Zürich, Zurich, Switzerland
  • 2006
    • University of Maryland, Baltimore
      • Department of Medicine
      Baltimore, MD, United States
  • 2005
    • Hôpitaux Universitaires de Genève
      Genève, Geneva, Switzerland
  • 2004
    • CHU de Lyon - Groupement Hospitalier Edouard Herriot
      Lyons, Rhône-Alpes, France
    • University of Pittsburgh
      • School of Medicine
      Pittsburgh, PA, United States