P Kannus

University of Tampere, Tammerfors, Pirkanmaa, Finland

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Publications (232)806.16 Total impact

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    ABSTRACT: Poor knee alignment is associated with increased loading of the joints, ligaments and tendons, and may increase the risk of injury. The study purpose was to compare differences in knee kinematics between basketball and floorball players during a vertical drop jump (VDJ) task. We wanted to investigate whether basketball players, whose sport includes frequent jump-landings, exhibited better knee control compared with floorball players, whose sport involves less jumping. Complete data was obtained from 173 basketball and 141 floorball players. Peak knee valgus and flexion angles during the VDJ were analyzed by 3D motion analysis.Larger knee valgus angles were observed among basketball players (- 3.2°, 95%CI -4.5 to - 2.0) compared with floorball players (- 0.9°, 95%CI -2.3 to 0.6) (P=0.022). Basketball players landed with a decreased peak knee flexion angle (83.1°, 95%CI 81.4 to 84.8) compared with floorball players (86.5°, 95%CI 84.6 to 88.4) (P=0.016). There were no significant differences in height, weight or BMI between basketball and floorball players. Female athletes exhibited significantly greater valgus angles than males. This study revealed that proper knee control during jump-landing does not seem to develop in young athletes simply by playing the sport, despite the fact that jump-landings occur frequently in practice and games.
    No preview · Article · Dec 2015 · International Journal of Sports Medicine
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    ABSTRACT: 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.
    Full-text · Article · Jul 2015 · Osteoporosis International
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    ABSTRACT: Purpose: This randomized controlled study was designed to investigate the effects of a 4-month whole body vibration-intervention on muscle performance and body balance in young, healthy, nonathletic adults. Methods: Fifty-six volunteers (21 men and 35 women, aged 19-38 yr) were randomized to either the vibration group or control group. The vibration-intervention consisted of a 4-month whole body vibration training (4 min?d(sup-1), 3-5 times a week) employed by standing on a vertically vibrating platform. Five performance tests (vertical jump, isometric extension strength of the lower extremities, grip strength, shuttle run, and postural sway on a stability platform) were performed initially and at 2 and 4 months. Results: Four-month vibration intervention induced an 8.5% (95% CI, 3.7-13.5%, P = 0.001) net improvement in the jump height. Lower-limb extension strength increased after the 2-month vibration-intervention resulting in a 3.7% (95% CI, 0.3-7.2%, P = 0.034) net benefit for the vibration. This benefit, however, diminished by the end of the 4-month intervention. In the grip strength, shuttle run, or balance tests, the vibration-intervention showed no effect. Conclusion: The 4-month whole body vibration-intervention enhanced jumping power in young adults, suggesting neuromuscular adaptation to the vibration stimulus. On the other hand, the vibration-intervention showed no effect on dynamic or static balance of the subjects. Future studies should focus on comparing the performance-enhancing effects of a whole body vibration to those of conventional resistance training and, as a broader objective, on investigating the possible effects of vibration on structure and strength of bones, and perhaps, incidence of falls of elderly people.
    Full-text · Article · Jul 2015
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    Full-text · Article · Apr 2015 · Scandinavian Journal of Medicine and Science in Sports
  • J Parkkari · Am Jussila · R Oksanen · K Pasanen · P Kannus
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    ABSTRACT: Number of sports injuries has increased in Finland during the past decades. Today sports injuries are the most common injury type. Especially children and youth are at high risk. The purpose of the LiVE program is to increase safety of sports and exercise in a nationwide setting. Sports specific injury incidence, risk factors and mechanisms were studied. Two prevention RCT's have been carried out, one among female athletes (Pasanen et al. BMJ 2008) and another among army recruits (Parkkari et al. BMC Medicine 2011), and finally a systematic review and meta-analysis was conducted in September 2013 on all randomised controlled intervention trials aiming at the prevention of sports injuries (Leppänen et al. submitted). The effectiveness of following interventions was studied: insoles, external joint supports, training programmes, stretching, protective head equipment, modified shoes, and injury prevention videos. Implementation of the findings of the above noted studies is now conducted in two nationwide projects; Healthy Athlete (2006-) and Safety in Schools (2010-). The primary target groups are young athletes, their coaches and parents, elementary school pupils and their teachers. Programs main communication channels are websites: www.terveurheilija.fi and www.tervekoululainen.fi. So far, the prevention program has educated over 80 tutors who work in different organisations (e.g. Finnish Ice Hockey Association and Finnish Gymnastic Federation), built up sport safety networks, introduced itself to projects target groups in numerous events, and organized several seminars to improve safety in sports. LiVE websites have attracted 6000-9000 visitors per month each. RE-AIM analyses will be presented during the conference. Successful development and implementation of preventive strategies against sports injuries are likely to result in reduction in the absolute number of health problems in sports, decrease in training, work and school absenteeism, and reduction in medical costs.
    No preview · Article · Apr 2014 · British Journal of Sports Medicine
  • K Pasanen · M Rossi · A Heinonen · J Parkkari · P Kannus
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    ABSTRACT: Low back pain (LBP) is a common complaint in general population affecting both genders and almost all age-groups. LBP is a common problem in sports as well, even in younger populations. LBP is prone to recur, thus there is a need for studies on the early phases of the problem in different sports. To investigate the prevalence, nature, severity and risk factors of self-reported LBP in young team sport players. A retrospective cross-sectional study. Finnish female and male basketball, floorball, ice hockey and volleyball teams. This study is a part of an ongoing cohort study exploring risk factors for sports injuries. Players from 22 teams, a total of 464 young players (16±1.9 years), have been included. Players' gender, age, sport and family LBP history were assessed as risk factors. Prevalence of LBP provided by a standardized Nordic questionnaire. LBP was defined: ache, pain or discomfort of lumbar region with or without radiation to one or both legs. 255 (54.9 %) of all players had suffered LBP during the previous year. 73 (15.7 %) had received medical attention for LBP. 51 players (11.0 %) had suffered over 4 weeks' total duration of pain symptoms during the previous year. 80 (17.2 %) reported missing training because of LBP. Male players had more time-loss from training due to LBP than females. Family history of LBP and higher age were associated with LBP in players. Low back pain is a relatively common complaint in young team sport players. Preventive measures are needed to reduce low back pain in youth sports.
    No preview · Article · Apr 2014 · British Journal of Sports Medicine
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    ABSTRACT: We determined the current trend in the number and incidence of hip fracture among persons 50 years of age or older in Finland between 1970 and 2010. After a clear rise until the late 1990s, the incidence of hip fracture has continuously declined. INTRODUCTION: Hip fractures are a major public health issue associated with excess morbidity and mortality. We determined the current trend in the number and incidence (per 100,000 persons) of hip fracture among older adults in Finland, an EU country with a well-defined Caucasian population of 5.4 million people. METHODS: We took into account all persons 50 years of age or older who were admitted to hospitals for primary treatment of hip fracture between 1970 and 2010. RESULTS: The number of hip fractures rose sharply till the end of 1990s (from 1,857 in 1970 to 7,122 in 1997), but since then, the rise has leveled off (7,594 fractures in 2010). Similarly, the age-adjusted incidence of hip fracture increased until 1997 but declined thereafter. The decline was especially clear in women whose age-adjusted incidence was 515.7 (per 100,000 persons) in 1997 but only 382.6 in 2010. In men, the corresponding incidence was 245.3 in 1997 and 210.7 in 2010. The number of hip fractures will increase 1.8-fold by 2030 even with the current 2010 incidence rates because the size of the 50-year-old or older population is likely to increase sharply in the near future. CONCLUSIONS: The declining trend in the incidence of hip fracture in Finland has continued through the entire first decade of the new millennium. Reasons for this development are uncertain, but possible explanations include increased average body weight, improved functional ability among elderly Finns, and specific measures to prevent bone loss and reduce the risk of falling.
    Full-text · Article · Oct 2012 · Osteoporosis International
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    Full-text · Article · Sep 2012 · Osteoporosis International
  • P. Kannus · S. Niemi
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    ABSTRACT: Although fall-induced injuries among older adults are said to be a major publichealth concern in modern societies with aging populations, reliable epidemiologicinformation on their secular trends is limited.We assessed the secular trend in the number and incidence (per 100 000 persons) offall-induced severe cervical spine injuries (fracture, cord injury, or both) of older adultsin Finland, an EU-country with a well-defined white population of 5.3 million, by takinginto account all persons 60 years of age or older who were admitted to Finnish hospitalsfor primary treatment of such injuries in 1970-2009. Similar patients aged 20 through 49years served as a reference group.The number and raw incidence of fall-induced cervical spine injury among Finns 60years of age or older rose considerably between the years 1970 and 2009, from 37(number) and 5.7 (incidence) in 1970 to 280 and 21.7 in 2009. The relative increaseswere 657% and 280%, respectively. Throughout the study period, the age-adjustedincidence of injury was higher in men than women and showed a clear increase in bothsexes in 1970-2009: from 9.7 to 30.0 in men, and from 3.0 to 13.2 in women. A similarfinding was observed in the age-specific incidences of the study group. In the referencegroup, the annual number and incidence of injury decreased somewhat over time.Assuming that the observed increase in the age-adjusted or age-specific injury incidencecontinues in the 60-year-old or older Finns and the size of this population increases as predicted, the annual number of fall-induced cervical spine injuries in this population willbe almost two-times higher in the year 2030 than it was in 2009.In Finnish persons aged 60 years or older, the number of fall-induced severe cervicalspine injuries seems to show an alarming rise with a rate that cannot be explained merelyby demographic changes. The finding underscores an increasing influence of falls andsubsequent injuries on health and well-being of our older adults, and therefore, widescalefall-prevention measures should be urgently adopted to control this development.
    No preview · Article · Sep 2012
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    Full-text · Article · Aug 2012 · Osteoporosis International
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    ABSTRACT: Background Sports injuries are the most common injury type in Finland. The Sports and Exercise Safety in Finland (LiVE) program started in 2006, and is financially supported by the Ministry of Education and Culture and the Ministry of Social Affairs and Health. Objectives The aim of the program is to increase safety of sports and exercise in a nationwide setting. Methods LiVE research projects are carried out in Tampere Research Centre of Sports Medicine. Epidemiology and prevention of sports injuries are in focus on the studies. Results are spread to the field by two campaigns, Healthy Athlete (TU) and Safety in School Sports (TEKO). The target group of the TU is young athletes, their coaches and parents. The target group of the TEKO is secondary school students, their teachers and parents. LiVE program educates annually LiVE-instructors who work in different operational environments. The 1-year education is directed for coaches, physical therapists, PE teachers and PE instructors. Educated LiVE-instructors uses a four-step-approach to prevent injuries: 1) Survey in a target group, 2) Analyses and planning, 3) Implementation, and 4) Evaluation. Results Two large randomised controlled trials have been carried through. Also, numerous original studies of sports injury epidemiology have been published. Results have been spread to the field by education and communication. Today, overall 55 LiVE-instructors work in different organisations (eg, sports federations, sports clubs, schools). In addition, the program has appeared annually in about 30 different sports and school events. LiVE website has attracted 4000-6000 visitors and 40,000-60,000 hits per month. Conclusion Implementation of preventive strategies against sports injuries will result in a reduction of the number of health problems and work or school absenteeism, as well as a clear decrease in the medical costs. Essential results of the LiVE program will be expressed within five to 10 years.
    No preview · Article · Apr 2011 · British Journal of Sports Medicine
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    ABSTRACT: Objective To investigate whether a neuromuscular training programme and educational counselling are effective in preventing acute lower limb injuries in young men during military service. Design Cluster randomised controlled study. Setting Two successive cohorts of male conscripts in four companies of one brigade (Pori Brigade, Säkylä) in the Finnish Defence Forces were first followed prospectively for one 6-month term (pre-study period). After this, two new successive cohorts in the same four companies were randomised into two groups and followed prospectively for one term (6 months) comprising data during the intervention (study period). Participants 944 conscripts participated in the study during the pre-study period. The randomised controlled trial included 968 conscripts (mean age 19 years): 501 conscripts in the intervention group and 467 conscripts in the control group. Intervention A neuromuscular training programme was used to enhance conscripts' motor skills and body control, and an educational counselling programme was used to increase knowledge and awareness of acute injuries during compulsory military service. Main outcome measures Acute injuries of the lower limbs. Results In the intervention companies, the risk for acute ankle injuries decreased significantly compared to control companies (adjusted Hazard ratio (HR)=0.34; 95% CI 0.15 to 0.78, p=0.011). This risk decline was observed in conscripts with low, as well as medium-to-high, baseline fitness. In addition, the intervention companies tended to have fewer severe injuries (adjusted HR=0.42; 95% CI 0.17 to 1.06). On the other hand, among men with low baseline fitness, intervention-induced additional training was associated with an increased risk for overuse injuries (adjusted HR=1.81; 95% CI 1.16 to 2.84, p=0.009). Conclusion A neuromuscular training programme was effective in preventing acute ankle injuries in young Finnish men during compulsory military service. Among conscripts with low baseline fitness, the amount and intensity of neuromuscular training requires careful planning and execution to avoid overuse injuries.
    No preview · Article · Apr 2011 · British Journal of Sports Medicine
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    ABSTRACT: The operating principle of the load-driven feedback system responsible for the mechanical integrity of bones was introduced over a century ago and has become an axiom in skeletal biology - form follows function. The primary endocrine regulator of female bones, oestrogen, has been suggested to exert its influence on skeletal homeostasis by both increasing the sensitivity of this mechanical control system for skeletal integrity and acting directly on bone surfaces. In our series of experiments, we have shown that the anabolic skeletal effects of oestrogen are mainly restricted to accrual of bone mass, whereas the alleged hormonal modulation of the mechanosensitivity and geometry of bones is not direct but rather a consequence of oestrogen-induced increase in mineral mass and the resulting increase in bone rigidity. Our findings also imply that the effects of mechanical loading and oestrogen on bone structure are independent and distinct and, from an evolutionary perspective, in accordance with their respective roles in the evolutionary functions of locomotion and reproduction.
    No preview · Article · Feb 2011 · European Musculoskeletal Review
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    ABSTRACT: The risk of falls increases in elderly patients receiving treatment with antidepressants. The increased risk is probably attributable to the adverse effects (e.g. sedation, sleep disturbances and subsequent daytime drowsiness, balance problems, orthostatic hypotension and cardiac rhythm disorders) associated with antidepressants.
    No preview · Article · Jan 2010 · Drugs & Therapy Perspectives
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    ABSTRACT: Three hundred and thirty healthy Finnish girls and premenopausal women, aged 7-47 years, were examined to evaluate the natural development of bone mineral mass and density from early childhood to menopause. Bone mineral content (BMC,g) and areal density (BMD, g/cm2) were measured from the spine (L2-L4), femoral neck, trochanter region of the femur, and distal radius using dual-energy X-ray absorptiometry (DXA). In addition, the bone mineral apparent density (BMAD, g/cm3) was assessed from the above described skeletal sites, and the mechanical competence of the femoral neck was estimated. Special attention was paid to the timing of the peak values of these bone parameters as well as to the evidence of premenopausal bone loss. The BMC, BMD, and BMAD of the spine, femoral neck, and trochanter region of the femur achieved peak values around the age of 20, and the bone loss seemed to start soon thereafter. In contrast, the bone mass of the distal radius slightly increased between the ages of 20 and 47. In the femoral neck, the estimated bending strength achieved its peak value around the age of 20 and showed a slight decrease during the following decades. The highest body weight and neck-length adjusted strength values of the femoral neck were, however, found in early childhood, with the values decreasing linearly thereafter. In conclusion, this study supports previous findings of rapid bone mineral accumulation in late adolescence, and occurrence of the peak bone mass and density around the age of 20. Premenopausal bone loss seems to occur in the proximal femur and lumbar spine. Our observations of femur strength development imply that from childhood to menopause the mechanical strength of the femoral neck is well adjusted to the biomechanical loading requirements of the body.
    No preview · Article · Nov 2009 · Journal of Bone and Mineral Research
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    ABSTRACT: 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% (p < 0.05) greater cortical area (CoA) than the referents. At the tibial shaft, these three impact groups had approximately 15% to 20% (p < 0.05) greater total area (ToA) and approximately 15% to 30% (p < 0.05) 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.
    Full-text · Article · Nov 2009 · Osteoporosis International
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    ABSTRACT: Hip protectors represent a promising strategy for preventing fall-related hip fractures. However, clinical trials have yielded conflicting results due, in part, to lack of agreement on techniques for measuring and optimizing the biomechanical performance of hip protectors as a prerequisite to clinical trials. In November 2007, the International Hip Protector Research Group met in Copenhagen to address barriers to the clinical effectiveness of hip protectors. This paper represents an evidence-based consensus statement from the group on recommended methods for evaluating the biomechanical performance of hip protectors. The primary outcome of testing should be the percent reduction (compared with the unpadded condition) in peak value of the axial compressive force applied to the femoral neck during a simulated fall on the greater trochanter. To provide reasonable results, the test system should accurately simulate the pelvic anatomy, and the impact velocity (3.4 m/s), pelvic stiffness (acceptable range: 39-55 kN/m), and effective mass of the body (acceptable range: 22-33 kg) during impact. Given the current lack of clear evidence regarding the clinical efficacy of specific hip protectors, the primary value of biomechanical testing at present is to compare the protective value of different products, as opposed to rejecting or accepting specific devices for market use.
    Full-text · Article · Oct 2009 · Osteoporosis International
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    ABSTRACT: While hip protectors are effective in some clinical trials, many, including all in community settings, have been unable to demonstrate effectiveness. This is due partly to differences in the design and analysis. The aim of this report is to develop recommendations for subsequent clinical research. In November of 2007, the International Hip Protector Research Group met to address barriers to the clinical effectiveness of hip protectors. This paper represents a consensus statement from the group on recommended methods for conducting future clinical trials of hip protectors. Consensus recommendations include the following: the use of a hip protector that has undergone adequate biomechanical testing, the use of sham hip protectors, the conduct of clinical trials in populations with annual hip fracture incidence of at least 3%, a run-in period with demonstration of adequate adherence, surveillance of falls and adherence, and the inclusion of economic analyses. Larger and more costly clinical trials are required to definitively investigate effectiveness of hip protectors.
    No preview · Article · Oct 2009 · Osteoporosis International
  • K Pasanen · J Parkkari · M Pasanen · P Kannus
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    ABSTRACT: To investigate whether a 6-month neuromuscular warm-up programme could improve muscle power, balance, speed and agility. Cluster randomised controlled study. 27 top level female floorball teams in Finland. 222 players (mean age 24 years); 119 in the intervention group and 103 in the control group were followed-up for one league season (6 months). A neuromuscular warm-up programme included sports-specific running technique, balance, jumping and strengthening exercises. The teams were advised to use the programme 1-3 times per week through the league season. One training session took approximately 25 min. Performance tests were assessed before and after the 6-month intervention and included static jump, countermovement jump, jumping over a bar, standing on a bar and figure-of-eight running. At 6 months, significant between-group differences were found in two outcome measures: jumping over a bar (number of jumps in 15 s) and standing on a bar (number of balance losses in 60 s). These differences were 2.3 jumps (95% CI 0.8 to 3.8, p = 0.003), favouring the intervention group, and -0.4 balance losses (95% CI -0.8 to 0.0, p = 0.050), again in favour of the intervention group. A neuromuscular warm-up programme improved the floorball players' sideways jumping speed and static balance. The exercises were also safe to perform and can thus be recommended for weekly training of floorball players. ISRCTN26550281.
    No preview · Article · Aug 2009 · British Journal of Sports Medicine
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    ABSTRACT: Muscle performance, body composition and bone mass at the lumbar spine and proximal femur with DXA, structural traits at the tibia and radius with pQCT, and biomarkers of bone metabolism were assessed at baseline and after a three-month weight reduction in obese premenopausal women. Associations between changes in weight loss and bone traits were analyzed by linear regression analysis. The mean (SD) weight loss was 4.3 (4.5) kg ranging from 14.8 kg loss to 2.1 kg gain. Muscle performance was well maintained, while no signs of bone loss or structural deterioration were observed. Changes in bone resorption were significantly associated with weight change (for CTX, r=-0.34; p=0.043, and for TRACP5b, r=-0.35; p=0.032). There were borderline (p<0.1) negative correlations between changes in biomarkers and bone traits. Reduced fat mass was associated with slight mean increase in cortical density of the radial shaft. Also total body BMC increased slightly. Changes in both fat and lean mass were associated with a change in BMC. Our findings suggest that mild-to-moderate weight reduction modulated bone turnover slightly, but they do not support the common notion that such a weight reduction would compromise bone rigidity, possibly partly due to well maintained muscle performance.
    Full-text · Article · Jun 2009 · Journal of musculoskeletal & neuronal interactions

Publication Stats

11k Citations
806.16 Total Impact Points

Institutions

  • 1985-2015
    • University of Tampere
      • • Medical School
      • • Department of Surgery
      Tammerfors, Pirkanmaa, Finland
  • 1991-2009
    • UKK Institute
      Tammerfors, Province of Western Finland, Finland
    • University of Turku
      • Paavo Nurmi Center
      Turku, Western Finland, Finland
  • 1991-2004
    • Tampere University Hospital (TAUH)
      Tammerfors, Province of Western Finland, Finland
  • 2002
    • La Trobe University
      Melbourne, Victoria, Australia
  • 2000
    • University of British Columbia - Vancouver
      • Department of Family Practice
      Vancouver, British Columbia, Canada
  • 1991-1992
    • University of Vermont
      • Department of Orthopaedics and Rehabilitation
      Burlington, Vermont, United States
  • 1988
    • Central Hospital Central Finland
      Jyväskylä, Province of Western Finland, Finland
    • Helsinki University Central Hospital
      • Department of Surgery
      Helsinki, Uusimaa, Finland