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Background Family caregivers often report high levels of distress, including depressive symptoms, anxiety, and reduced quality of life. There is a need for a greater understanding of the factors influencing, explaining, and maintaining psychological distress in family caregivers. Aim The aim of this study was to examine whether avoidance strategies such as thought suppression (WBSI), psychological inflexibility (AAQ-II), and, and caregiver experiential avoidance (EACQ) predict psychological distress (BDI-II, GAD-7) and quality of life (WHOQOL) in family caregivers aged 60 and over. We hypothesized that these avoidance strategies would explain elevated levels of psychological symptoms and lower quality of life. Method Altogether, 149 family caregivers completed self-report measures of depressive symptoms, anxiety, quality of life, thought suppression, psychological inflexibility and caregiver experiential avoidance. We conducted correlation and regression analyses to assess the associations and the predictive ability of these constructs. Results Together, psychological inflexibility and thought suppression accounted for between 40 and 46% of the variance in the depression and anxiety outcomes and 15% of the variance in the physical domain of quality of life. Unwanted thoughts, the subcomponent of thought suppression, was strongly associated with symptoms of depression and anxiety, and with physical and psychological quality of life. Conclusion Thought suppression and psychological inflexibility played a significant role in explaining family caregivers’ symptoms of depression and anxiety. In addition, psychological inflexibility was significantly related to quality of life. This suggests the need for acceptance-based strategies to handle thought suppression and psychological inflexibility.

Objectives: The objective of the present study was to investigate whether an acceptance and commitment therapy (ACT)-based web-intervention (Group 1, CareACT), or a standardized rehabilitation in a rehabilitation center (Group 2) was effective in enhancing the psychological well-being of family caregivers aged 60 and over compared to support provided by voluntary caregiver associations (Group 3). Methods: Altogether, 149 family caregivers participated in this quasi-experimental study. Primary outcome measure was depression. Secondary outcomes included anxiety, sense of coherence, quality of life, psychological flexibility, experiential avoidance, and thought suppression. The questionnaires were administered at baseline, and four, and 10 months post-measurement. We investigated differences in the changes between the groups using Mplus modeling techniques. Results: Regarding the main outcome of depression, the results suggest that the CareACT intervention was superior to standardized rehabilitation and to the support given by caregiver associations at four months, both showing a medium-sized difference between the groups. However, the change from four to 10 months post-intervention was not significantly different between these groups (d = 0.32–0.36). Thought suppression showed a significantly different change between the three groups from baseline to four months and to 10 months post-measurement (p = .038). Conclusions: Web-based ACT may have beneficial effects on depressive symptoms and thought suppression in older caregivers. Clinical implications: Web-based ACT could be a feasible alternative to institutional rehabilitation and support provided by voluntary caregiver associations. Web-based ACT responds flexibly to the needs of caregivers and provides them an opportunity for learning new skills to promote well-being. peerReviewed

Progressive resistance training (PRT) combined with weight-bearing impact exercise are recommended to optimize bone health, but the optimal frequency and dose of training remains uncertain. This study, which is a secondary analysis of an 18-month intervention in men aged 50–79 years, examined the association between exercise frequency and the volume of training with changes in DXA and QCT-derived femoral neck (FN) and lumbar spine (LS) bone outcomes, respectively. Men were allocated to either thrice-weekly PRT plus impact exercise training (n = 87) or a non-exercising (n = 85) group. Average weekly exercise frequency (ExFreq) and training volume per session [PRT volume (weight lifted, kg), number of weight-bearing impacts (jumps completed) and total training volume] over the 18-months were calculated from the participants' exercise cards. Regression analysis showed that average weekly ExFreq and training volume per session were positively associated with the 18-month changes in FN BMD and LS trabecular volumetric BMD. Men completing on average 1 to

Summary A 12-month exercise program reversibly prevented hip bone loss in premenopausal women with early breast cancer. The bone-protective effect was maintained for 2 years after the end of the program but was lost thereafter. Purpose Breast cancer survivors are at an increased risk for osteoporosis and fracture. This 5-year follow-up of a randomized impact exercise intervention trial evaluated the maintenance of training effects on bone among breast cancer patients. Methods Five hundred seventy-three early breast cancer patients aged 35–68 years and treated with adjuvant therapy were allocated into a 12-month exercise program or a control group. Four hundred forty-four patients (77%) were included in the 5-year analysis. The exercise intervention comprised weekly supervised step aerobics, circuit exercises, and home training. Areal bone mineral density (aBMD) was measured by dual-energy X-ray absorptiometry. Physical activity was estimated in metabolic equivalent (MET) hours per week and physical performance assessed by 2-km walking and figure-8 running tests. Results In premenopausal patients, the 12-month exercise program maintained femoral neck (FN) and total hip (TH) aBMD for 3 years, but the protective effect was lost thereafter. The mean FN aBMD change in the exercise and control groups was − 0.2% and − 1.5% 1 year, − 1.1% and − 2.1% 3 years and − 3.3% versus − 2.4% 5 years after the beginning of the intervention, respectively. Lumbar spine (LS) bone loss was not prevented in premenopausal women and no training effects on aBMD were seen in postmenopausal women. The main confounding element of the study was the unexpected rise in physical activity among patients in the control group. The physical performance improved among premenopausal women in the exercise group compared with the controls. Conclusion The 12-month exercise program prevented FN and TH bone loss in premenopausal breast cancer patients for 3 years. The bone-protective effect was reversible and lost thereafter. Electronic supplementary material The online version of this article (10.1007/s00198-020-05611-w) contains supplementary material, which is available to authorized users.

Background/Aim: This is a report of the 5-year quality of life (QoL) findings of the BREX-study (n=444). Patients and Methods: A 12-month exercise intervention was arranged shortly after adjuvant treatments. Physical activity (PA) was assessed by PA diary, physical performance by a 2- km walking test, QoL by the EORTC QLQC30 and BR-23 questionnaires, fatigue by the FACIT-Fatigue scale and depression by the Beck’s 13-item depression scale (BDI). Results: Participants who improved their PA from baseline to 5-year follow-up were more likely to improve their global health score (RRR=1.02, p=0.016), physical (RRR=1.02, p=0.009), social (RRR=1.03, p=0.013), role functioning (RRR=1.03, p=0.005), and fatigue (RRR=1.02, p=0.002). An improved 2-km walking test was associated to improved global health, physical and role functioning, body image, future perspectives, and fatigue (p=0.011, p

Background/Aim: As the number of breast cancer survivors is increasing, their long-term health-related quality of life (HRQoL) has become an important issue. The aim of the study is to follow up the HRQoL of breast cancer survivors (BCS) in a prospective randomized exercise intervention study and to compare HRQoL to that of the age-matched general female population. Patients and Methods: Following adjuvant treatment, 537 patients aged 35-68 and capable of exercise training were randomized to a 12-month exercise trial. In 182 of those patients, HRQoL was measured by the generic 15D at baseline and followed up for five years. Furthermore, the HRQoL of all BCS answering the 15D at five-year follow-up (n=390) was compared to that of a representative sample of the general population. Results: After five years, the BCS’ mean HRQoL demonstrated a statistically and clinically significant impairment compared to that of the general population (difference –0.023, p

Sideways falls impose high stress on the thin superolateral cortical bone of the femoral neck, the region regarded as a fracture-prone region of the hip. Exercise training is a natural mode of mechanical loading to make bone more robust. Exercise-induced adaptation of cortical bone along the femoral neck has been previously demonstrated. However, it is unknown whether this adaption modulates hip fracture behavior. The purpose of this study was to investigate the influence of specific exercise loading history on fall-induced hip fracture behavior by estimating fracture load and location with proximal femur finite element (FE) models created from magnetic resonance images (MRI) of 111 women with distinct exercise histories: 91 athletes (aged 24.7 ± 6.1 years, >8 years competitive career) and 20 women as controls (aged 23.7 ± 3.8 years). The athletes were divided into five groups based on typical loading patterns of their sports: high-impact (H-I: 9 triple-jumpers and 10 high jumpers), odd-impact (O-I: 9 soccer and 10 squash players), high-magnitude (H-M: 17 power-lifters), repetitive-impact (R-I: 18 endurance runners), and repetitive non-impact (R-NI: 18 swimmers). Compared to the controls, the H-I, O-I, and R-I groups had significantly higher (11–26%, p

Aims To identify what factors are associated with the caregiver burden of spouse caregivers, adult child caregivers, and parent caregivers. Background Caregivers often feel stressed and perceive caregiving as a burden. The caregiver burden has been little studied from the perspective of the personal relationship between caregiver and care recipient. Design Cross-sectional study. Methods A random sample of 4,000 caregivers in Finland was drawn in 2014 and those who remained either spouse, adult child, or parent caregivers at data collection were included in the analysis (N = 1,062). Data collection included recipients' characteristics. Caregivers' perceived burden was measured using the Caregivers of Older People in Europe index. General linear models were used to explain perceived caregiver burden. Results Care recipients' low level of cognitive function was associated with greater perceived burden. Higher quality of support was associated with lower perceived burden among female and male spouse caregivers, daughter caregivers, and mother caregivers. Low cognitive function explained 3-6% and high quality of support 2-5% of the total variation in the burden explained by the models, which ranged between 45-55%. Conclusion Because cognitive challenges of care recipient are associated with greater perceived burden and high quality of support with lower burden among most of the caregiver groups, high-quality tailored nursing interventions will be needed especially for the caregivers of the most frail care recipients.

Objectives To investigate the effect of a yearlong multicomponent rehabilitation program on the level of physical activity (PA) and the maintenance of the level of PA over 1-year follow-up among older people recovering from a recent hip fracture. Design Secondary analysis of a randomized, controlled, parallel-group trial. Setting Home-based rehabilitation; measurements in university laboratory. Participants Community-dwelling people (N=81) aged ≥60 years recovering from a hip fracture. Participants were randomly assigned to an intervention (n=40) or a control (n=41) group, on average, 42±23 days after discharge from the hospital. Intervention A yearlong intervention included evaluation and modification of environmental hazards, guidance for safe walking, nonpharmacologic pain management, a progressive home exercise program, PA counseling, and standard care. Main Outcome Measures The outcome was the level of PA, which was assessed with the questionnaire (a modified Grimby scale) at baseline, and 3, 6, 12, and 24 months after baseline. Three PA categories were defined: inactivity, light PA, and moderate to heavy PA. Physical function was assessed using the Short Physical Performance Battery (SPPB) at baseline. The effects of the intervention were analyzed with generalized estimating equations. Results In the intervention group, a significant increase was observed in the level of PA after the intervention (interaction P=.005) and after 1-year follow-up (P=.021) compared with the standard care only. The benefit was particularly evident among the participants with a baseline SPPB score of ≥7 (interaction P, final draft, peerReviewed

Objectives: The aim of this study is to evaluate the effects of multicomponent rehabilitation on physical activity, sedentary behavior, and mobility in older people recently discharged from hospital. Design: Randomized controlled trial. Setting: Home and community. Participants: Community-dwelling people aged ⩾60 years recovering from a lower limb or back musculoskeletal injury, surgery, or disorder were recruited from local health center hospitals and randomly assigned into an intervention ( n = 59) or a control (standard care, n = 58) group. Intervention: The six-month intervention consisted of a motivational interview, goal attainment process, guidance for safe walking, a progressive home exercise program, physical activity counseling, and standard care. Measurements: Physical activity and sedentary time were assessed using an accelerometer and a single question. Mobility was evaluated with the Short Physical Performance Battery, self-reported use of a walking aid, and ability to negotiate stairs and walk outdoors. Intervention effects were analyzed with generalized estimating equations. Results: Daily physical activity was 127 ± 78 minutes/day and 121 ± 70 at baseline and 167 ± 81 and 164 ± 72 at six months in the intervention and control group, respectively; mean difference of 3.4 minutes (95% confidence interval (CI) = −20.3 to 27.1). In addition, no significant between-group differences were shown in physical performance. Conclusion: The rehabilitation program was not superior to standard care for increasing physical activity or improving physical performance. Mobility-limited older people who had recently returned home from hospital would have needed a longer and more frequently monitored comprehensive geriatric intervention.

IntroductionThe most promising way to promote active life years in old age is to promote regular participation in physical activity (PA). Maintaining lower extremity muscle function with good balance has been associated with fewer falls and the need of help from others. This article describes the design and intervention of a randomised controlled trial (RCT) investigating the effectiveness of a health and PA counselling programme on life-space mobility and falls rates in community-dwelling older adults at the Health Kiosk and/or Service Centre.Methods and analysisCommunity-dwelling men and women (n=450) aged 65 years and over with early phase mobility limitation will be recruited to a 24-month RCT with a 24-month follow-up. Participants will be randomly allocated into either a health and PA counselling group (intervention) or relaxation group (control intervention). All participants will receive five group specific face-to-face counselling sessions and 11 phone calls. The counselling intervention will include individualised health counselling, strength and balance training, and guidance to regular PA. The control group will receive relaxation exercises. Outcomes will be assessed at baseline, 12, 24 and 48 months. Primary outcomes are average life-space mobility score and falls rates. Life-space mobility will be assessed by a validated questionnaire. Falls rates will be recorded from fall diaries. Secondary outcomes are data on fall-induced injuries and living arrangements, number of fallers, fracture risk, mean level of PA, physical performance, quality of life, mood, cognition, balance confidence and fear of falling. Data will be analysed using the intention-to-treat principle. Cost-effectiveness of the programme will be analysed. Ancillary analyses are planned in participants with greater adherence.Ethics and disseminationEthical approval was obtained from the Ethics Committee of the Tampere University Hospital (R15160). Outcomes will be disseminated through publication in peer-reviewed journals and presentations at international conferences.Trial registrationISRCTN65406039; Pre-results.

Objectives: The aim of this study was to investigate activity‐induced effects from bone geometric properties of the proximal femur in athletic vs nonathletic healthy females by statistically controlling for variation in body size, lower limb isometric, and dynamic muscle strength, and cross‐sectional area of Musculus gluteus maximus. Methods: The material consists of hip and proximal thigh magnetic resonance images of Finnish female athletes (N = 91) engaged in either high jump, triple jump, soccer, squash, powerlifting, endurance running or swimming, and a group of physically active nonathletic women (N = 20). Cross‐sectional bone geometric properties were calculated for the lesser trochanter, sub‐trochanter, and mid‐shaft of the femur regions. Bone geometric properties were analyzed using a general linear model that included body size, muscle size, and muscle strength as covariates. Results: Body size and isometric muscle strength were positively associated with bone geometric properties at all three cross‐sectional levels of the femur, while muscle size was positively associated with bone properties only at the femur mid‐shaft. When athletes were compared to nonathletic females, triple jump, soccer, and squash resulted in greater values in all studied cross‐sections; high jump and endurance running resulted in greater values at the femoral mid‐shaft cross‐section; and swimming resulted in lower values at sub‐trochanter and femur mid‐shaft cross‐sections. Conclusions: Activity effects from ground impact loading were associated with higher bone geometric values, especially at the femur mid‐shaft, but also at lesser and sub‐trochanter cross‐sections. Bone geometric properties along the femur can be used to assess the mechanical stimuli experienced, where ground impact loading seems to be more important than muscle loading.

Purpose: Setting meaningful goals for the rehabilitation process after acute illness is essential for rehabilitees recovery. The aim of this study was to understand the meanings of the goal setting situation with professionals from rehabilitees point of view. - Method: We included 20 acute stroke and back pain rehabilitees (mean age 66 y) who set goals with a multidisciplinary rehabilitation team. Data was collected by interviewing the rehabilitees after the goal setting situations. A qualitative analysis from a phenomenological perspective using Spiegelberg’s seven-phase meaning analysis was performed to reveal meanings. - Results: The five meanings were identified as: (i) “trust in the rehabilitation situation, professionals, oneself, and relatives;” (ii) “respectful presence;” (iii) “confusing awareness;” (iv) “disturbing pain;” and (v) “fear of unpredictability.” When professionals committed to working in a patient-centred manner, the rehabilitees felt respected and they trusted professionals and thus their self-efficacy was empowered. Moreover, relatives were an important support in the situation. However, disturbing pain and fear of the future limited patients level of participation in the situation. - Conclusion: Rehabilitee commitment to rehabilitation can be supported with equality in communication and presence of relatives, while pain and uncertainty because of changed health limit participation in a goal setting situation. peerReviewed

Over 90% of hip fractures are caused by falls. Due to a fall-induced impact on the greater trochanter, the posterior part of the thin superolateral cortex of the femoral neck is known to experience the highest stress, making it a fracture-prone region. Cortical geometry of the proximal femur, in turn, reflects a mechanically appropriate form with respect to habitual exercise loading. In this finite element (FE) modeling study, we investigated whether specific exercise loading history is associated with femoral neck structural strength and estimated fall-induced stresses along the femoral neck. One hundred and eleven three-dimensional (3D) proximal femur FE models for a sideways falling situation were constructed from magnetic resonance (MR) images of 91 female athletes (aged 24.7 ± 6.1 years, > 8 years competitive career) and 20 non-competitive habitually active women (aged 23.7 ± 3.8 years) that served as a control group. The athletes were divided into five distinct groups based on the typical loading pattern of their sports: high-impact (H-I: triple-jumpers and high-jumpers), odd-impact (O-I: soccer and squash players), high-magnitude (H-M: power-lifters), repetitive-impact (R-I: endurance runners), and repetitive non-impact (R-NI: swimmers). The von Mises stresses obtained from the FE models were used to estimate mean fall-induced stresses in eight anatomical octants of the cortical bone cross-sections at the proximal, middle, and distal sites along the femoral neck axis. Significantly (p < 0.05) lower stresses compared to the control group were observed: the H-I group — in the superoposterior (10%) and posterior (19%) octants at the middle site, and in the superoposterior (13%) and posterior (22%) octants at the distal site; the O-I group — in the superior (16%), superoposterior (16%), and posterior (12%) octants at the middle site, and in the superoposterior (14%) octant at the distal site; the H-M group — in the superior (13%) and superoposterior (15%) octants at the middle site, and a trend (p = 0.07, 9%) in the superoposterior octant at the distal site; the R-I group — in the superior (14%), superoposterior (23%) and posterior (22%) octants at the middle site, and in the superoposterior (19%) and posterior (20%) octants at the distal site. The R-NI group did not differ significantly from the control group. These results suggest that exercise loading history comprising various impacts in particular is associated with a stronger femoral neck in a falling situation and may have potential to reduce hip fragility. peerReviewed

We examined whether specific physical exercise loading is associated with texture parameters from hip muscles scanned with magnetic resonance imaging (MRI). Ninety-one female athletes representing five distinct exercise-loading groups (high-impact, odd-impact, low-impact, nonimpact and high-magnitude) and 20 nonathletic female controls underwent MRI of the hip. Texture parameters were computed from the MRI images of four hip muscles (gluteus maximus, gluteus medius, iliopsoas and obturator internus). Differences in muscle texture between the athlete groups and the controls were evaluated using Mann-Whitney U-test. Significant (P

Adaptation to exercise training can affect bone marrow adiposity; muscle-fat distribution; and muscle volume, strength and architecture. The objective of this study was to identify exercise-load-associated differences in magnetic resonance image textures of thigh soft tissues between various athlete groups and non-athletes. Ninety female athletes representing five differently loading sport types (high impact, odd impact, high magnitude, repetitive low impact and repetitive non-impact), and 20 non-athletic clinically healthy female controls underwent magnetic resonance imaging. Five thigh muscles, subcutaneous fat and femoral bone marrow were analysed with co-occurrence matrix-based quantitative texture analysis at two anatomical levels of the dominant leg. Compared with the controls thigh muscle textures differed especially in high-impact and odd-impact exercise-loading groups. However, all sports appeared to modulate muscle textures to some extent. Fat tissue was found different among the low-impact group, and bone marrow was different in the high-impact group when compared to the controls. Exercise loading was associated with textural variation in magnetic resonance images of thigh soft tissues. Texture analysis proved a potential method for detecting apparent structural differences in the muscle, fat and bone marrow.

Physical activity (PA) decreases during hospitalization. In particular, the amount of PA engaged in by older people who are hospitalized following musculoskeletal injury is likely to be limited for months after discharge home. Given the importance of an active lifestyle for their recovery and the prevention of future adverse outcomes, there is clearly a need for interventions to increase PA. This article describes the protocol of a randomized controlled trial set up to investigate the effects of a physical activity oriented home rehabilitation program (ProPA) on PA and the restoration of mobility in community-dwelling older people. Men and women aged 60 years or older hospitalized due to a musculoskeletal injury or disorder in the back or lower limbs are recruited. After discharge from hospital to home, participants are randomized into a six-month ProPA program or a standard care (control) group. The ProPA program consists of a motivational interview, goal attainment process, guidance for safe walking, a progressive home exercise program and physical activity counseling. In addition, frail participants who are not able to go outdoors alone receive support from volunteers. Primary outcomes are PA measured using a 3-dimentional accelerometer, and mobility assessed by the Short Physical Performance Battery and self-reports. Secondary outcomes are life space mobility, participation restriction, fear of falling, pain, mood, and grip strength. Information on barriers to and enablers of PA participation are also collected. Data on mortality and use of health services are collected from the national register. In this 6-month intervention, all participants are assessed in their homes at baseline and after three and six months, and at 12 months after randomization they will receive a follow-up questionnaire. This study investigates the effects of a rehabilitation program on PA and mobility among older people at risk for increased sedentary time and mobility problems. If positive effects are observed, the program can be considered for incorporation into the health care system and thereby contribute to the rehabilitation of older people who have recently been discharged from hospital. ISRCTN13461584 . Registered 27 January 2016.

Objective To obtain reference values for the isometric endurance test (IET) of the cervical flexor muscles, investigate its reproducibility, and compare the results with the maximal isometric strength test (MIST) of the cervical flexor muscles. Design Cross-sectional non-comparative study with single group repeated measurements. Methods Altogether 219 healthy females aged 20–59 years volunteered to participate in the study. The IET was performed in the supine position and MIST seated. The reproducibility was evaluated by the intraclass correlation coefficient (ICC) and an analysis described by Bland and Altman. The relationship between the two measuring methods was evaluated by Pearson's correlation coefficient. Results The mean (SD) IET time was 60 (33) seconds with no significant differences between the age groups of each decade. The ICC for intrarater repeatability was 0.80. However, the Bland-Altman analysis suggested moderate variation in repeated measurements. Pearson's correlation coefficient between the IET and MIST was 0.56. Conclusion Normative reference values for the IET are presented. Although the ICC showed good repeatability, one should consider that the change at follow-up visits has to be considerable to be clinically relevant. The correlation between the endurance time and maximal flexion strength was moderate. Thus IET of the cervical flexor muscles may be used in the clinic like the Biering-Sorenson test has been used to assess fatigue of the trunk extensor muscles.

OBJECTIVE To compare the efficacy of three 12-month training programmes on headache and upper extremity pain in patients with chronic neck pain. METHODS A total of 180 female office workers, with chronic, non-specific neck pain were randomly assigned to 3 groups. The strength group performed isometric, dynamic and stretching exercises. The endurance group performed dynamic muscle and stretching exercises. The control group performed stretching exercises. Pain was assessed with a visual analogue scale. Each group was divided into 3 subgroups according to headache intensity. RESULTS At the 12-month follow-up headache had decreased by 69% in the strength group, 58% in the endurance group and 37% in the control group compared with baseline. Neck pain diminished most in the strength group with the most severe headache (p < 0.001). In the dose analysis, one metabolic equivalent per hour of training per week accounted for a 0.6-mm decrease in headache on the visual analogue scale. Upper extremity pain decreased by 58% in the strength group, 70% in the endurance group and 21% in the control group. CONCLUSION All of the training methods decreased headache. However, stretching, which is often recommended for patients, was less effective alone than when combined with muscle endurance and strength training. Care must be taken in recommending the type of training to be undertaken by patients with severe cervicogenic headache.

Bone structure of weight-bearing proximal femur and tibia was examined among the Finnish world-class moguls skiers and slalom skiers. We hypothesized that these bones, during typical sport-specific performance, had been subjected not only to extreme loading but also to distinct loading in terms of rate and primary direction. Bone [dual-energy X-ray absorptiometry (DXA), peripheral quantitative computed tomography (pQCT), magnetic resonance imaging] and muscle performance data of the lower extremities were obtained from the five Finnish male moguls skiers and six slalom skiers competing at the World Cup level. Data (DXA, pQCT) from 12 age- and weight-matched normally active men were used for comparison. The ANCOVA with body height as a covariate was used for statistical analysis. The weight-bearing bones of the athletes were 10-60% stronger than those of the normally active men. Compared with the moguls skiers, the slalom skiers showed an average 43% thicker anterior cortex at the narrowest region of the femoral neck. This study suggests that the bone structure at skiers' heavily loaded lower extremities was very robust. A specific finding was the thick anterior cortex of the femoral neck among the slalom skiers. Apparently, the predominant loading type had modulated the site-specific skeletal response to physical exertion.

Background Cervicogenic headache and migraine are common causes of visits to physicians and physical therapists. Few randomized trials utilizing active physical therapy and progressive therapeutic exercise have been previously published. The existing evidence on active treatment methods supports a moderate effect on cervicogenic headache. Objective The aim of this study is to investigate whether a progressive, group-based therapeutic exercise program decreases the intensity and frequency of chronic headache among women compared with a control group receiving a sham dose of transcutaneous electrical nerve stimulation (TENS) and stretching exercises. Design A randomized controlled trial with 6-month intervention and follow-up was developed. The participants were randomly assigned to either a treatment group or a control group. Setting The study is being conducted at 2 study centers. Patients The participants are women aged 18 to 60 years with chronic cervicogenic headache or migraine. Intervention The treatment group's exercise program consisted of 6 progressive therapeutic exercise modules, including proprioceptive low-load progressive craniocervical and cervical exercises and high-load exercises for the neck muscles. The participants in the control group received 6 individually performed sham TENS treatment sessions. Measurements The primary outcome is the intensity of headache. The secondary outcomes are changes in frequency and duration of headache, neck muscle strength, neck and shoulder flexibility, impact of headache on daily life, neck disability, fear-avoidance beliefs, work ability, and quality of life. Between-group differences will be analyzed separately at 6, 12, and 24 months with generalized linear mixed models. In the case of count data (eg, frequency of headache), Poisson or negative binomial regression will be used. Limitations The therapists are not blinded. Conclusions The effects of specific therapeutic exercises on frequency, intensity, and duration of chronic headache and migraine will be reported.

Purpose: To examine the dose-response relationship of specific strength- and endurance-training regimes for the cervical muscles, which have been shown to be effective among women with chronic neck pain and disability. Methods: A total of 180 female office workers, aged 25 to 53 yr, with chronic neck pain and disability were randomized into a strength-training, an endurance-training, and a control group. The training groups participated in a 12-d rehabilitation period, in which instructions for the exercises were given by an experienced physical therapist. Both training groups continued with exercises at home for 12 months. Physical activity was measured with a training diary and a 1-month all-time recall questionnaire. All activities were registered and converted into metabolic equivalents (METs). Results: Specific neck, shoulder, and upper-extremity training for more than 8.75 MET·h·wk-1 was an effective training dose for decreasing neck pain. One MET-hour of training per week accounted for an 0.8-mm decrease of neck pain on a visual analog scale (VAS) and a 0.5-mm decrease on a disability index. Both strength and endurance training decreased perceived neck pain and disability. Declines in neck pain and disability correlated positively with the amount of specific training. Conclusion: This study revealed that the described specific exercise protocols were associated with decreases in chronic neck pain and disability. The effective dose of training was feasible and safe to perform among female office workers.

Loading modality is a strong external determinant of structure and concomitant strength of the femoral neck. Particularly effective seem to be loadings, which arise from high impacts or impacts from atypical loading directions. Introduction: Physical loading plays an important role, not only in the process of bone modeling and remodeling, but also in shaping a mechanically appropriate bone structure. This study aimed at testing the hypothesis that the type of loading partly determines the femoral neck structure. Materials and Methods: A total of 255 premenopausal female athletes representing volleyball, hurdling, squash-playing, soccer, speed skating, step aerobics, weight-lifting, orienteering, cross-country skiing, cycling, and swimming and their 30 nonathletic counterparts were measured with DXA. Besides the conventional areal BMD (aBMD) of the femoral neck, the hip structure analysis (HSA) was used to estimate the cross-sectional area (CSA), subperiosteal width (W), and section modulus (Z, an index of bone strength) at the narrowest section of the femoral neck. Also, training history, muscle strength, and calcium intake were assessed. The above-mentioned sports were classified according to the type of loading they apparently produce at the hip region; that is, high-impact loading (volleyball, hurdling), odd-impact loading (squash-playing, soccer, speed-skating, step aerobics), high-magnitude loading (weightlifting), low-impact loading (orienteering, cross-country skiing), and nonimpact loading (swimming, cycling). Results: High-impact and odd-impact loading sports were associated with the highest age-, weight-, and height-adjusted aBMD (23% and 29% higher values compared to nonathletic referents), CSA (22% and 27%), and Z (22% and 26%). In contrast, repetitive, nonimpact loading sports were not associated with any clear benefit in any bone value compared with the referents. The W at the narrowest femoral neck section was similar in all groups. Body height and weight accounted virtually for one-half of the variation in Z, whereas the type of loading predicted 13% of the total variation of this variable—clearly more than the 2% attributable to isometric leg extension strength. Both high-impact and odd-impact loading modalities were associated with a large benefit in Z, corresponding to >1 SD in the reference group, whereas repetitive, low-impact loading showed a benefit that was only one-half of that. Surprisingly, high-magnitude loading (weightlifting) was not associated with a statistically significant increase in Z. Conclusion: We conclude that mechanical loading and its modality are strong external determinants of structure and concomitant strength of the femoral neck. Particularly effective seem to be loadings, which arise from high impacts or impacts from atypical loading directions.

Greater size of the gluteus maximus muscle in humans compared to non-human primates has been considered an indication of its function in bipedal posture and gait, especially running capabilities. Our aim was to find out how the size of the gluteus maximus muscle varies according to sports while controlling for variation in muscle strength and body weight. Data on gluteus maximus muscle cross-sectional area (MCA) were acquired from magnetic resonance images of the hip region of female athletes (N=91), and physically active controls (N=20). Dynamic muscle force was measured as counter movement jump and isometric knee extension force as leg press. Five exercise loading groups were created: high impact (triple-jumpers and high-jumpers), odd impact (soccer and squash players), high magnitude (power-lifters), repetitive impact (endurance runners) and repetitive non-impact (swimmers) loadings. Individuals in high impact, odd impact or high-magnitude loading groups had greater MCA compared to those of controls, requiring powerful hip extension, trunk stabilization in rapid directional change and high explosive muscle force. Larger body size and greater muscle strength were associated with larger MCA. An increase in dynamic force was associated with larger MCA, but the strength of this relationship varied with body weight. Thus, gluteal adaptation in humans promotes powerful lower limb movements required in sprinting and rapid changes in direction, as well as maintenance and stabilization of an erect trunk which also provides a platform for powerful motions of the upper limbs. These movements have likely evolved to facilitate food acquisition, including hunting.

Objectives We investigated the relationship between loading history and bone biomechanical properties used in physical activity reconstructions. These bone properties included bone bending and torsional strength (J), cortical area (CA), the direction of the major axis (theta angle), and element shape ratios determined from cross sections of standardized bone length. In addition, we explored the applicability of anatomically determined cross sections. Methods Our material consisted of hip and proximal thigh magnetic resonance images of Finnish female athletes (N = 91) engaged in high-jump, triple-jump, endurance running, swimming, power-lifting, soccer and squash; along with a group of active non-athlete individuals (N = 20). We used regression analysis for size-adjustment, and the extracted residuals were then used to compare differences in the bone properties between groups. Results We found that triple-jumpers, soccer players, and squash players had the greatest values in CA and J, swimmers and non-athletes had the smallest, whereas high-jumpers, power-lifters, and endurance runners exhibited interim values. No between-the-group differences in element shape ratios or theta angles were found. We found that influences of activity were similar regardless of whether standardized length or anatomically determined cross sections were used. Conclusions Extreme (triple-jump) and directionally inconsistent loading (soccer and squash) necessitate a more robust skeleton compared to directionally consistent loading (high-jump, power-lifting, and endurance running) or non-impact loading (swimming and non-athletes). However, not all of these relationships were statistically significant. Thus, information gained about physical activity using bone properties is informative but limited. Accounting for the limitations, the method is applicable on fragmented skeletal material as anatomically determined cross sections can be used.

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.

The aim of this study was to examine the association between different types of exercise loading and femoral neck cross-sectional geometry. Our data comprised proximal femur magnetic resonance (MR) images obtained from 91 female athletes and their 20 age-matched controls. The athletes were categorized according to typical training activity - high impact (high and triple jumping), odd impact (racket and soccer playing), high magnitude (power lifting), repetitive low impact (endurance running) and repetitive non-impact (swimming). Segmented MR images at two locations, narrowest cross-section of the femoral neck (narrowFN) and the cross-section at insertion of articular capsule (distalFN), were investigated to detect between group differences in shape, curvature and buckling ratio derived using image and signal analysis tools. The narrowFN results indicated that the high-impact group had weaker antero-superior (33% larger buckling ratio than controls) but stronger inferior weight-bearing region (32% smaller than controls), while the odd-impact group had stronger superior, posterior and anterior region (21% smaller buckling ratio than controls). The distalFN results indicated that the high-impact group had stronger inferior region (37% smaller buckling ratio), but the odd-impact group had stronger superior region (22% smaller buckling ratio) than the controls. Overall, the results point towards odd-impact exercise loading, with inherently varying directions of impact, associated with more robust cross-sectional geometry along the femoral neck. In conclusion, our one-dimensional polar treatment for geometrical traits and intuitive presentation of differences in trends between exercise groups and controls provides a basis for analysis with high angular accuracy.

The ability of combined step aerobic- and circuit-training to prevent bone loss after breast cancer treatments was related to skeletal site and patients’ menopausal status. Among premenopausal breast cancer survivors, a 12-month exercise intervention completely prevented bone loss at the femoral neck, whereas no exercise effect was seen at lumbar spine or at neither site in postmenopausal women. The primary objective of this randomised clinical trial was to determine the preventive effect of supervised weight-bearing jumping exercises and circuit training on bone loss among breast cancer patients. Of 573 breast cancer survivors aged 35–68 years randomly allocated into exercise or control group after adjuvant treatments, 498 (87%) were included in the final analysis. The 12-month exercise intervention comprised weekly supervised step aerobic- and circuit-exercises and similar home training. Bone mineral density (BMD) at lumbar spine and femoral neck were measured by dual-energy X-ray absorptiometry. Physical performance was assessed by 2-km walking and figure-8 running tests, and the amount of physical activity was estimated in metabolic equivalent-hours/week. In premenopausal women, bone loss at the femoral neck was prevented by exercise, the mean BMD changes being −0.2% among the trainees vs. −1.4% among the controls (p = 0.01). Lumbar bone loss could not be prevented (−1.9% vs. −2.2%). In postmenopausal women, no significant exercise-effect on BMD was found either at the lumbar spine (−1.6% vs. −2.1%) or femoral neck (−1.1% vs. −1.1%). This 12-month aerobic jumping and circuit training intervention completely prevented femoral neck bone loss in premenopausal breast cancer patients, whereas no effect on BMD was seen in postmenopausal women.

The strong association between body mass and skeletal robusticity has been attributed to increasing skeletal loading with increasing mass. However, it is unclear whether body mass is merely a coarse substitute for bone loading rather than a true independent predictor of bone strength. As indices of neuromuscular performance, impulse and peak power were determined from vertical ground reaction force during a maximal counter movement jump test in 221 premenopausal and 82 postmenopausal women. Bone compressive (BSI(d) g(2)/cm(4)) and bending (SSImax(mid) mm(3)) strength indices were measured with peripheral quantitative computed tomography (pQCT) at the distal ((d)) and midshaft ((mid)) sites of the tibia. A two-step forced regression model for predicting bone strength indices was constructed. Age, height and body mass were entered first, followed by impulse as an indicator of skeletal loading. The basic model explained 14% (P0.001) of the variance in BSI(d) in the premenopausal group and 16% (P=0.004) in the postmenopausal group, and 32% (P0.001) and 25% (P0.001) of the variance in SSImax(nud) respectively. Entering impulse into the model increased the explanatory power by 9% (P0.001) and 7% (P0.001) for BSI(d) and by 8% (P0.001) and 12% (P0.001) for SSImax(mid). Furthermore, impulse replaced body mass as an independent significant factor explaining the variance in bone strength. These results indicate that neuromuscular performance should be measured and preferred over body mass in models predicting skeletal robusticity.

This randomized, controlled pilot trial was carried out to assess the feasibility and efficacy of an aerobic exercise in enhancing physical performance of breast cancer patients after adjuvant treatments. The potential of the training regimen to prevent accompanying bone loss was also assessed. Thirty patients, 41-65 years of age, were randomly assigned into training or control groups shortly after adjuvant chemo- or radiotherapy. The 12-week training included a guided aerobic exercise session once a week (the effective part being either step aerobic- or circuit-training in alternate weeks) and similar home exercise sessions twice a week. Adherence to the guided sessions was 78%, while home training was performed an average 2.1 times per week. Agility assessed with figure-8 running test and peak jumping power showed significant between-group treatment-effects (approximately 5% and approximately 10%, respectively). Judged from the accelerometer data, reaction forces up to six times body weight occurred during the training, which implies that the training could also have potential to affect bone mass. The present exercise regimen turned out to be feasible and effective among breast cancer patients in terms of physical performance. Large controlled trials are necessary to confirm these findings.

This cross-sectional study of adult female athletes assessed whether the apparent loading-related differences in bone structure are primarily associated with the loading type or the muscle performance-related joint moments. Several structural variables at shaft sites of the tibia, radius and humerus, and distal sites of the tibia and radius were measured with peripheral quantitative computed tomography (pQCT) among 113 female national level athletes (representing hurdling, volleyball, soccer, racket-sports and swimming) and their 30 nonathletic referents. For the weight-bearing lower extremities, the loading modalities of the above sports were classified into high-impact (hurdling, volleyball), odd-impact (soccer, racket-sports) and repetitive, nonimpact (swimming) loadings; and for the nonweight-bearing upper extremities into high magnitude (functional weightlifting in hurdling and soccer), impact (volleyball, racket-sports) and repetitive, nonimpact (swimming) loadings. As expected, athletes' bone mass was substantially higher at loaded bone sites compared with the nonathletic referents, but more pertinently to the locomotive perspective, the loading-induced additional bone mass seemed to be used to build mechanically strong and appropriate bone structures. Compared with controls, the weight-bearing bone structures of female athletes (swimmers excluded) were characterized by larger diaphysis, thicker cortices and somewhat denser trabecular bone. The athletes' bones at the nonweight-bearing upper extremity were generally larger in cross-sectional area. The estimated indices of joint moment (muscle force x estimated lever arm) were explained from 29% to 50%, and the loading modalities from 8% to 25%, of the variance in most bone variables (P < 0.05) of the tibia (shaft and distal site). In contrast to the weight-bearing tibia, only the estimated joint moment was positively associated (P < 0.05) with the structural characteristics of the radius and humerus, accounting for 6% to 26% of the variance in bone variables of the shafts of these bones. Such association was not observed at the distal radius. In conclusion, at the weight-bearing lower extremity, the strong bone structure of the female athletes was attributable to muscle performance-related estimated joint moments and impact loading modality. At the shaft sites of the nonweight-bearing upper extremity, the strong bone structure was mainly attributable to the estimated joint moments. Thus, different loading history and other features of loading seemed to govern the skeletal adaptation at the upper and lower extremity.

The BREX study is the largest randomised prospective study to investigate the effect of physical exercise in rehabilitation of breast cancer survivors shortly after adjuvant treatments.Patients: 537 Finnish breast cancer patients(aged 35-68 years) were enrolled into the 1-year aerobic exercise intervention study (BREX) between 2005 and 2007. Patients were randomly allocated into exercise or control group. Methods: The exercise intervention consisted of weekly supervised step aerobics and home training. The physical performance was tested by a 2-km walking test and figure-8 running. The intensity of physical activity was measured by a two-week diary (METs) and Quality of life (QoL)by the EORTC QLQ-C30 and BR-23, FACIT-F and BDI before the intervention and after 6 and 12 mo's. Results: 500/537 patients were included in the final analyses (263 exercise and 237 control group). Patients participated in the supervised weekly exercise training median 32/52 times, vigorous home training 1.6 and endurance 1.4 times per week. Results are shown in table 1 and 2. Conclusions: Supervised aerobic exercise training improved significantly physical performance, even though physical activity increased in both groups. Physical activity correlated positively to QoL during the intervention irrespectively of the study group. However, the intervention itself did not influence on QoL. Table 1. Table 2. Factors association to QoL change from baseline. Change versus change. Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr PD08-07.