Per Aagaard

University of Southern Denmark, Odense, South Denmark, Denmark

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Publications (300)837.26 Total impact

  • [Show abstract] [Hide abstract] ABSTRACT: Purpose: A decline in physical capacity takes place with increasing age that negatively affects overall physical function including work ability and the ability to perform typical activities of daily living (ADL). The overall aim of the present study was to determine the neuromuscular adaptations to long-term (1 year) football and strength training in older untrained adults, and to assess the concurrent effect on functional ADL capacity. Methods: Twenty-seven healthy elderly males (68.2 ± 3.2 years) were randomly assigned to 12 months of either recreational football training (FT: n = 10), strength training (ST: n = 9) or served as inactive controls (CON: n = 8). Recreational football training consisted of small-sided training sessions whereas strength training consisted of high intensity exercises targeting the lower extremity and upper body. Maximal thigh muscle strength and rate of force development (RFD) were assessed with isokinetic dynamometry, while postural balance and vertical jumping performance were evaluated using force plate analysis. Furthermore, functional ability was evaluated by stair-ascent and chair-rising testing. Results: A total of nine, nine and seven participants from FT, ST and CON, respectively, were included in the analysis. Both exercise regimens led to substantial gains in functional ability, evidenced by 24 and 18 % reduced stair-ascent time, and 32 and 21 % increased chair-rising performance in FT and ST, respectively (all P < 0.05). Long-term strength training led to increased concentric (14 %; P < 0.01) and isometric (23 %; P < 0.001) quadriceps and isometric hamstring strength (44 %; P < 0.0001), whereas football training mainly resulted in enhanced hamstring strength (18 %, P < 0.05) and RFD (89 %, P < 0.0001). Conclusions: Long-term (1 year) strength training led to increased quadriceps and hamstring strength, whereas the adaptations to football training mainly included enhanced strength and rapid force capacity of the hamstring muscles. Gains in functional ability were observed in response to both training regimens, evidenced by reduced stair-ascent time and increased chair-rising performance. Long-term football exercise and strength training both appear to be effective interventional strategies to improve factors of importance for ADL by counteracting the age-related decline in lower limb strength and functional capacity among old male adults. This could potentially be a way to improve work ability of senior workers.
    No preview · Article · Apr 2016 · Arbeitsphysiologie
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    [Show abstract] [Hide abstract] ABSTRACT: Purpose: The aim of the study was to investigate the effects of low-intensity running performed immediately after lower-body power-training sessions on power development. Methods: Twenty young females participated in 6 weeks, 3/week, of either lower body power training (PT) or lower body power training followed by 30 min of low-intensity running (PET) eliciting 60-70 % of maximal heart rate. The following were measured before and after the training period: counter-movement jump, isometric leg press force and rate of force development (RFD), half squat 1-RM, vastus lateralis fiber type composition and cross sectional area, resting intramuscular fiber conduction velocity (MFCV), and heart rate during the modified Bruce treadmill test. Results: Counter-movement jump height and peak power increased after PT (10.7 ± 6.2 and 12.9 ± 18.7 %, p < 0.05) but not after PET (3.4 ± 7.6 and 5.11 ± 10.94 %, p > 0.05). Maximum isometric force, RFD, and half squat 1-RM increased similarly in both groups. Muscle fiber type composition was not altered in either group. Muscle fiber cross sectional area increased only after PT (17.5 ± 17.4, 14.5 ± 10.4, 20.36 ± 11.3 %, in type I, IIA, and IIX fibers, respectively, p < 0.05). Likewise, mean MFCV increased with PT only (before: 4.53 ± 0.38 m s(-1), after: 5.09 ± 0.39 m s(-1), p = 0.027). Submaximal heart rate during the Bruce treadmill test remained unchanged after PT but decreased after PET. Conclusion: These results suggest that low-intensity running performed after lower-body power training impairs the exercise-induced adaptation in stretch-shortening cycle jumping performance (vertical jump height, peak power), during the first 6 weeks of training, which may be partially linked to inhibited muscle fiber hypertrophy and muscle fiber conduction velocity.
    Full-text · Article · Apr 2016 · Arbeitsphysiologie
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    [Show abstract] [Hide abstract] ABSTRACT: The evaluation of rate of force development during rapid contractions has recently become quite popular for characterising explosive strength of athletes, elderly individuals and patients. The main aims of this narrative review are to describe the neuromuscular determinants of rate of force development and to discuss various methodological considerations inherent to its evaluation for research and clinical purposes. Rate of force development (1) seems to be mainly determined by the capacity to produce maximal voluntary activation in the early phase of an explosive contraction (first 50–75 ms), particularly as a result of increased motor unit discharge rate; (2) can be improved by both explosive-type and heavy-resistance strength training in different subject populations, mainly through an improvement in rapid muscle activation; (3) is quite difficult to evaluate in a valid and reliable way. Therefore, we provide evidence-based practical recommendations for rational quantification of rate of force development in both laboratory and clinical settings.
    Full-text · Article · Mar 2016 · Arbeitsphysiologie
  • [Show abstract] [Hide abstract] ABSTRACT: With this study we investigated the role of nonsteroidal anti-inflammatory drugs (NSAIDs) in human skeletal muscle regeneration. Young men ingested NSAID [1200 mg/d ibuprofen (IBU)] or placebo (PLA) daily for 2 wk before and 4 wk after an electrical stimulation-induced injury to the leg extensor muscles of one leg. Muscle biopsies were collected from the vastus lateralis muscles before and after stimulation (2.5 h and 2, 7, and 30 d) and were assessed for satellite cells and regeneration by immunohistochemistry and real-time RT-PCR, and we also measured telomere length. After injury, and compared with PLA, IBU was found to augment the proportion of ActiveNotch1(+) satellite cells at 2 d [IBU, 29 ± 3% vs. PLA, 19 ± 2% (means ± sem)], satellite cell content at 7 d [IBU, 0.16 ± 0.01 vs. PLA, 0.12 ± 0.01 (Pax7(+) cells/fiber)], and to expedite muscle repair at 30 d. The PLA group displayed a greater proportion of embryonic myosin(+) fibers and a residual ∼2-fold increase in mRNA levels of matrix proteins (all P < 0.05). Endomysial collagen was also elevated with PLA at 30 d. Minimum telomere length shortening was not observed. In conclusion, ingestion of NSAID has a potentiating effect on Notch activation of satellite cells and muscle remodeling during large-scale regeneration of injured human skeletal muscle.-Mackey, A. L., Rasmussen, L. K., Kadi, F., Schjerling, P., Helmark, I. C., Ponsot, E., Aagaard, P., Durigan, J. L. Q., Kjaer, M. Activation of satellite cells and the regeneration of human skeletal muscle are expedited by ingestion of nonsteroidal anti-inflammatory medication.
    No preview · Article · Mar 2016 · The FASEB Journal
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    [Show abstract] [Hide abstract] ABSTRACT: Reduced ability to activate the medial hamstring muscles during a sports-specific sidecutting movement has been found to be a potential risk factor for non-contact ACL injury. However, whether a reduced ability to activate the medial hamstring muscle is a general neuromuscular phenomenon and thereby observable independently of the type of clinical screening tests used is not known. This cross sectional study investigated the rank correlation of knee joint neuromuscular activity between three different ACL injury risk screening tests.
    Full-text · Article · Mar 2016 · The Knee
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    [Show abstract] [Hide abstract] ABSTRACT: Background: Knowledge of factors associated with chronic pain is necessary for preventive strategies. The present study investigates biopsychosocial differences, with specific focus on rate of force development (RFD) and work ability, between workers with and without chronic upper limb pain. Methods: Eighty-two male slaughterhouse workers, 49 with chronic upper limb pain and 33 pain-free controls participated in the study. Maximal muscle strength, RFD, and muscle activity was determined from fast and forceful maximal voluntary contractions for the shoulder and hand. Participants filled out a questionnaire on work ability (work ability index), work disability (Work module of DASH questionnaire), fear avoidance, and self-rated health. Additionally, pressure pain threshold (PPT) was measured in muscles of the arm, shoulder and lower leg. Results: Muscle strength and RFD (determined within time intervals of 30, 50, 100, and 200 ms relative to onset of contraction) was 28 % and 58-78 % lower, respectively, in workers with chronic pain compared with pain-free controls, and paralleled by reduced muscle activity (all p < 0.001). Workers with chronic pain had lower PPT of the arm, shoulder and lower leg (p < 0.01), and reported impaired work ability index score and general health along with higher work disability and fear avoidance compared with controls (all p < 0.0001). No differences were observed between the groups in regard to age, BMI, physical activity level, job position and duration of slaughterhouse work (all p > 0.4). Conclusions: Chronic upper limb pain was paralleled by reduced neuromuscular function of the shoulder and hand along with impaired work ability, work disability and general health. Future studies on chronic pain management at the workplace should carefully consider the biopsychosocial nature of pain when designing and implementing preventive strategies.
    Full-text · Article · Feb 2016 · BMC Musculoskeletal Disorders
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    [Show abstract] [Hide abstract] ABSTRACT: Background: Imbalance between individual resources and work demands can lead to musculoskeletal disorders and reduced work ability. The purpose of this study was to investigate the effect of workplace- versus home-based physical exercise on work ability among healthcare workers. Methods: Two hundred female healthcare workers (Age: 42.0, BMI: 24.1, work ability index [WAI]: 43.1) from 18 departments at three Danish hospitals participated (Copenhagen, Denmark, Aug 2013-Jan 2014). Participants were randomly allocated at the cluster level to 10 weeks of: 1) workplace physical exercise (WORK) performed during working hours for 5x10 min per week and up to 5 group-based coaching sessions on motivation for regular physical exercise, or 2) home-based physical exercise (HOME) performed during leisure time for 5x10 min per week. Both groups received ergonomic counseling on patient handling and use of lifting aides. The main outcome measure was the change from baseline to 10-week follow-up in WAI. Results: Significant group by time interaction was observed for WAI (p < 0.05). WAI at follow-up was 1.1 (0.3 to 1.8) higher in WORK compared with HOME corresponding to a small effect size (Cohens'd = 0.24). Within-group changes indicated that between-group differences were mainly caused by a reduction in WAI in HOME. Of the seven items of WAI, item 2 (work ability in relation to the demands of the job) and item 5 (sickness absence during the past year) were improved in WORK compared with HOME (P < 0.05). Conclusions: Performing physical exercise together with colleagues at the workplace prevents deterioration of work ability among female healthcare workers. Trial registration number: ClinicalTrials.gov NCT01921764 . Registered 10 August 2013.
    Full-text · Article · Nov 2015 · BMC Public Health
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    [Show abstract] [Hide abstract] ABSTRACT: Objectives . The present study investigates the effect of workplace- versus home-based physical exercise on muscle reflex response to sudden trunk perturbation among healthcare workers. Methods . Two hundred female healthcare workers (age: 42 [SD 11], BMI: 24 [SD 4], and pain intensity: 3.1 [SD 2.2] on a scale of 0–10) from 18 departments at three hospitals were randomized at the cluster level to 10 weeks of (1) workplace physical exercise (WORK) performed in groups during working hours for 5 × 10 minutes per week and up to 5 group-based coaching sessions on motivation for regular physical exercise, or (2) home-based physical exercise (HOME) performed during leisure time for 5 × 10 minutes per week. Mechanical and neuromuscular (EMG) response to randomly assigned unloading and loading trunk perturbations and questions of fear avoidance were assessed at baseline and 10-week follow-up. Results . No group by time interaction for the mechanical trunk response and EMG latency time was seen following the ten weeks ( P = 0.17–0.75). However, both groups demonstrated within-group changes ( P < 0.05 ) in stopping time during the loading and unloading perturbation and in stopping distance during the loading perturbation. Furthermore, EMG preactivation of the erector spinae and fear avoidance were reduced more following WORK than HOME (95% CI −2.7–−0.7 ( P < 0.05 ) and −0.14 (−0.30 to 0.02) ( P = 0.09 )), respectively. WORK and HOME performed 2.2 (SD: 1.1) and 1.0 (SD: 1.2) training sessions per week, respectively. Conclusions . Although training adherence was higher following WORK compared to HOME this additional training volume did not lead to significant between-group differences in the responses to sudden trunk perturbations. However, WORK led to reduced fear avoidance and reduced muscle preactivity prior to the perturbation onset, compared with HOME. This trial is registered with Clinicaltrials.gov ( NCT01921764 ).
    Full-text · Article · Nov 2015
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    [Show abstract] [Hide abstract] ABSTRACT: Diabetic patients have an increased risk of foot ulcers, and glycation of collagen may increase tissue stiffness. We hypothesized that the level of glycemic control (glycation) may affect Achilles tendon stiffness, which can influence gait pattern. We therefore investigated the relationship between collagen glycation, Achilles tendon stiffness parameters and plantar pressure in poorly (n = 22) and well (n = 22) controlled diabetic patients, including healthy age matched (45-70 yrs) controls (n = 11). There were no differences in any of outcome parameters (collagen cross-linking or tendon stiffness) between patients with well-controlled and poorly controlled diabetes. The overall effect of diabetes was explored by collapsing the diabetes groups (DB) compared to the controls. Skin collagen cross-linking lysylpyridinoline (LP), hydroxylysylpyridinoline (HP), (136%, 80%, P < 0.01) and pentosidine concentrations (55%, P < 0.05) were markedly greater in DB. Furthermore, Achilles tendon material stiffness was higher in DB (54%, P < 0.01). Notably, DB also demonstrated higher forefoot/ rearfoot peak plantar pressure (PPP)-ratio (33%, P < 0.01). Overall, Achilles tendon material stiffness and skin connective tissue cross-linking were greater in diabetic patients compared to controls. The higher foot pressure indicates that material stiffness of tendon and other tissue (e.g skin and joint capsule) may influence on foot gait. The difference in foot pressure distribution may contribute to the development of foot ulcers in diabetic patients.
    Full-text · Article · Nov 2015 · Journal of Applied Physiology
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    [Show abstract] [Hide abstract] ABSTRACT: Background Adolescent female football and handball players are among the athletes with the highest risk of sustaining anterior cruciate ligament (ACL) injuries. Aim This study evaluated the effects of evidence-based lower extremity injury prevention training on neuromuscular and biomechanical risk factors for non-contact ACL injury. Methods 40 adolescent female football and handball players (15–16 years) were randomly allocated to a control group (CON, n=20) or neuromuscular training group (NMT, n=20). The NMT group performed an injury prevention programme as a warm-up before their usual training 3 times weekly for 12 weeks. The CON group completed their regular warm-up exercise programme before training. Players were tested while performing a side cutting movement at baseline and 12-week follow-up, using surface electromyography (EMG) and three-dimensional movement analysis. We calculated: (1) EMG amplitude from vastus lateralis (VL), semitendinosus (ST) and biceps femoris 10 ms prior to initial contact (IC) normalised to peak EMG amplitude recorded during maximal voluntary isometric contraction and (2) VL-ST EMG preactivity difference during the 10 ms prior to foot contact (primary outcome). We measured maximal knee joint valgus moment and knee valgus angle at IC. Results There was a difference between groups at follow-up in VL-ST preactivity (43% between-group difference; 95% CI 32% to 55%). No between-group differences were observed for kinematic and kinetic variables. Conclusions A 12-week injury prevention programme in addition to training and match play in adolescent females altered the pattern of agonist-antagonist muscle preactivity during side cutting. This may represent a more ACL-protective motor strategy.
    Full-text · Article · Sep 2015 · British Journal of Sports Medicine
  • [Show abstract] [Hide abstract] ABSTRACT: This study evaluates the between-day reliability of a newly developed trunk perturbation test and compares mechanical response during known and unknown conditions. Mechanical trunk response were measured in seventeen female subjects during unloading and loading perturbations of the abdomen (A: preloaded-abdomen condition) and low-back (B: preloaded-back condition). The loading perturbation increased the preload from 5.5 kg to a 10 kg pull on the trunk whereas the unloading perturbation decreased the pull from 5.5 kg to 0.1 kg. A sequence of loading (known), unloading (known) and randomized loading/unloading (unknown) perturbations were performed for A and B. Between-day reliability of stopping time, trunk displacement and velocity was quantified using intraclass correlation coefficients (ICCs). ICCs were good to excellent for all loading and unloading measures during the known (0.70 - 0.98) and unknown (0.64 - 0.94) perturbations of A and B. In general, larger trunk displacements were seen after the unknown perturbations compared with the known perturbation. The method may be used as a diagnostic tool for screening workers who are in risk of future work related low back injuries.
    No preview · Article · Sep 2015 · Journal of applied biomechanics
  • [Show abstract] [Hide abstract] ABSTRACT: High physical exertion during work is a risk factor for musculoskeletal pain and long-term sickness absence. Physical exertion (RPE) reflects the balance between physical work demands and physical capacity of the individual. Thus, increasing the physical capacity through physical exercise may decrease physical exertion during work. This study investigates the effect of workplace-based versus home-based physical exercise on physical exertion during work (WRPE) among healthcare workers. 200 female healthcare workers (age: 42.0, body mass index: 24.1, average pain intensity: 3.1 on a scale of 0 to 10, average WRPE: 3.6 on a scale of 0 to 10) from 18 departments at three participating hospitals. Participants were randomly allocated at the cluster level to 10 weeks of: (1) workplace physical exercise (WORK) performed in groups during working hours for 5×10 minutes per week and up to five group-based coaching sessions on motivation for regular physical exercise, or (2) home-based physical exercise (HOME) performed during leisure time for 5×10 minutes per week. Physical exertion was assessed at baseline and at 10-week follow-up. 2.2 (SD: 1.1) and 1.0 (SD: 1.2) training sessions were performed per week in WORK and HOME, respectively. Physical exertion was reduced more in WORK than HOME (p<0.01). Between-group differences in physical exertion at follow-up (WORK vs. HOME) was -0.5 points (95% CI -0.8 to -0.2). Within-group effect size (Cohen's d) in WORK and HOME was 0.43 and 0.13, respectively. Physical exercise performed at the workplace appears more effective than home-based exercise in reducing physical exertion during daily work tasks in healthcare workers. © 2015 the Nordic Societies of Public Health.
    No preview · Article · Jul 2015 · Scandinavian Journal of Public Health
  • [Show abstract] [Hide abstract] ABSTRACT: Sporadic inclusion body myositis (sIBM) is a systemic disease that is characterized by substantial skeletal muscle weakness and muscle inflammation, leading to impaired physical function. The objective was to investigate the effect of low-load resistance exercise with concurrent partial blood flow restriction to the working muscles (blood-flow-restricted (BFR) training) in a patient with sIBM. The training consisted of 12 weeks of lower extremity BFR training with low training loads (~25-RM). The patient was tested for mechanical muscle function and functional capacity before and after 6 and 12 weeks of training. Maximal horizontal gait speed increased by 19%, which was accompanied by 38-92% improvements in mechanical muscle function (maximal isometric strength, rate of force development and muscle power). In conclusion, BFR training was well tolerated by the patient with sIBM and led to substantial improvements in mechanical muscle function and gait speed. © 2015 Scandinavian Society of Clinical Physiology and Nuclear Medicine. Published by John Wiley & Sons Ltd.
    No preview · Article · Jun 2015 · Clinical Physiology and Functional Imaging
  • No preview · Article · May 2015 · Physiotherapy
  • A. Holsgaard-Larsen · C. Jensen · P. Aagaard
    No preview · Article · Apr 2015 · Osteoarthritis and Cartilage
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    [Show abstract] [Hide abstract] ABSTRACT: This study examined whether short-term maximal resistance training employing fast-velocity eccentric knee extensor actions would induce improvements in maximal isometric torque and rate of force development (RFD) at early (<100 ms) and late phases (>100 ms) of rising torque. Twenty healthy men were assigned to two experimental groups: eccentric resistance training (TG) or control (CG). Participants on the TG trained three days a week for a total of eight weeks. Training consisted of maximal unilateral eccentric knee extensors actions performed at 180°s-1. Maximal isometric knee extensor torque (MVC) and incremental RFD in successive 50 ms time-windows from the onset contraction were analysed in absolute terms (RFDINC) or when normalised relative to MVC (RFDREL). After eight weeks, TG demonstrated increases in MVC (28%), RFDINC (0-50 ms: 30%; 50-100 ms: 31%) and RFDREL (0-50 ms: 29%; 50-100 ms: 32%). Moreover, no changes in the late phase of incremental RFD were observed in TG. No changes were found in the CG. In summary, we have demonstrated, in active individuals, that a short period of resistance training performed with eccentric fast-velocity isokinetic muscle contractions is able to enhance RFDINC and RFDREL obtained at the early phase of rising joint torque.
    Full-text · Article · Feb 2015 · European Journal of Sport Science
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    [Show abstract] [Hide abstract] ABSTRACT: Numerous studies has shown that regular physical exercise can reduce musculoskeletal pain, but the optimal setting to achieve high adherence and effectiveness remains unknown. This study investigated the effect of workplace versus home-based physical exercise on musculoskeletal pain among healthcare workers. The randomized controlled trial (RCT) comprised 200 female healthcare workers from 18 departments at 3 hospitals. Participants were randomly allocated at the cluster level to ten weeks of: (i) workplace physical exercise (WORK) performed during working hours for 5×10 minutes per week and up to 5 group-based coaching sessions on motivation for regular physical exercise, or (ii) home-based physical exercise (HOME) performed during leisure time for 5×10 minutes per week. Both groups received ergonomic counseling on patient handling and use of lifting aides. Average pain intensity (0-10 scale) in the low back and neck/shoulder was the primary outcome. Per week, 2.2 (SD 1.1) and 1.0 (SD 1.2) training sessions were performed in WORK and HOME groups, respectively. Pain intensity, back muscle strength and use of analgesics improved more following WORK than HOME (P<0.05). Between-group differences at follow-up (WORK versus HOME) was -0.7 points for pain intensity [95% confidence interval (95% CI) -1.0- -0.3], 5.5 Nm for back muscle strength (95% CI 2.0-9.0), and -0.4 days per week for use of analgesics (95% CI -0.7- -0.2). The effect size for between-group differences in pain intensity was small (Cohen's d=0.31). Workplace physical exercise is more effective than home-based exercise in reducing musculoskeletal pain, increasing muscle strength and reducing the use of analgesics among healthcare workers.
    Full-text · Article · Jan 2015 · Scandinavian Journal of Work, Environment & Health
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    L. B. Michalsik · P. Aagaard · K. Madsen
    Full-text · Article · Jan 2015
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    L. B. Michalsik · K. Madsen · P. Aagaard
    Full-text · Article · Jan 2015
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    [Show abstract] [Hide abstract] ABSTRACT: To determine the physical demands placed on female elite team handball players in relation to playing position and body anthropometry, female elite team handball primarily field players were monitored during match-play using video recording and subsequent computerized technical match analysis during five regular tournament match seasons. Technical match activities were distributed in 6 major types of playing actions (shots, breakthroughs, fast breaks, technical errors, defensive errors and tackles) and further divided into various subcategories (e.g., type of shot, hard or light tackles, claspings, screenings and blockings). Furthermore, anthropometric measurements were carried out.Each player had 28.3±11.0 (group means±SD) high-intense playing actions per match with a total effective playing time of 50.70±5.83 min. On average, each player made 2.8±2.6 fast breaks, gave 7.9±14.4 screenings, received 14.6±9.2 tackles in total and performed 7.7±3.7 shots while in offense, along with 3.5±3.8 blockings, 1.9±2.7 claspings and 6.2±3.8 hard tackles in defense. Mean body height, body mass and age in the Danish Premier Female Handball League were 175.4±6.1 cm, 69.5±6.5 kg and 25.4±3.7 years, respectively. Wing players were lighter (63.5±4.8 kg, p<0.001) and smaller (169.3±4.9 cm, p<0.001) than backcourt players (70.6±5.3 kg, 177.0±5.4 cm) and pivots (72.5±4.9 kg, 177.7±4.9 cm).In conclusion, the present match observations revealed that female elite team handball players during competitive games intermittently perform a high number of short-term, high-intense technical playing actions making modern female elite team handball a physically demanding team sport. No sign of technical fatigue were observed, since the amount of intense technical playing actions remained unchanged in the second half. Marked positional differences in the physical demands were demonstrated, with wing players performing more fast breaks and less physical confrontations than backcourt players and pivots. Body anthropometry differed substantially between different playing positions. Consequently, this should lead to an increase in physical training in modern female elite team handball directed at specific positions and individual physical capacity.
    Full-text · Article · Oct 2014 · The Journal of Strength and Conditioning Research

Publication Stats

12k Citations
837.26 Total Impact Points

Institutions

  • 2014
    • University of Southern Denmark
      • Institute of Sports Science and Clinical Biomechanics
      Odense, South Denmark, Denmark
  • 2012
    • Nordic Institute of Chiropractic and Clinical Biomechanics
      Odense, South Denmark, Denmark
  • 2007
    • Institute of Sports Medicine Copenhagen
      København, Capital Region, Denmark
  • 2004
    • IT University of Copenhagen
      København, Capital Region, Denmark