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Physical Activity During GrowthEffects on Bone, Muscle, Fracture Risk and Academic PerformanceJesper Fritzcenter349948500DOCTORAL DISSERTATIONby due permission of the Faculty of Medicine, Lund University, Sweden.To be defended at Ortopedens F?rel?sningssal, Inga Marie Nilssons gata 22, Malm?, January 13, 2017, at 09.00.Faculty opponentProfessor Mats B?rjessonGymnastik och Idrottsh?gskolan Stockholm and Sahlgrenska akademin G?teborgOrganizationLUND UNIVERSITYClinical and Molecular Osteoporosis Research Unit Department of Clinical Sciences Document nameDOCTORAL DISSERTATIONDate of issueJanuary 13, 2017Author(s)Jesper FritzSponsoring organizationTitle and subtitlePhysical Activity During Growth – Effects on Bone, Muscle, Fracture Risk and Academic PerformanceAbstractPhysical activity (PA) enhances bone mass, bone structure and muscle strength, traits associated with low fall and fracture risk. Since the greatest effect of PA on musculoskeletal health occurs during childhood, increased PA for all children could be a strategy to improve these traits. Since PA may also influence brain development, cognition and concentration, it has been postulated that physical activity may enhance academic performance.The Pediatric Osteoporosis Prevention (POP) study is a population-based prospective controlled exercise intervention study with one school as intervention school and three other schools as control schools. In the intervention school we increased the amount of physical education (PE) per week from the Swedish standard of 60 minutes to 200 minutes. Meanwhile, the control schools continued with 60 minutes of PE per school week.We included all children (aged 6–8 years) who started first grade in these schools from 1998 to 2012 and followed them for seven years regarding fractures, using our digital radiographic archive (cohort A – 3,534 children). Children starting school between 1998 and 2000 were invited to musculoskeletal evaluations during seven years, using dual-energy X-ray absorptiometry (DXA) for bone parameters such as areal bone mineral density (aBMD), peripheral quantitative computed tomography (pQCT) for bone structure such as cortical thickness, and computerized dynamometer (Biodex) for muscle strength (evaluated by isokinetic peak torque) (cohort B – 261 to 264 children depending on evaluated trait). To evaluate academic performance, we included all children who finished 9th grade from 2003 to 2012 in all of Sweden (cohort C – 1,161,807 children) and in the intervention school (cohort D – 633 children) and evaluated the grade scores and eligibility for upper secondary school programs in both cohorts. We could thus compare the academic results within and between the groups before the intervention was initiated (finished school in year 2003 to 2006) and with the intervention (finished school in year 2007 to 2012).The incidence rate ratio (IRR) of fractures in the intervention group compared to the control group decreased with each year of the intervention (r=–0.79; p=0.036). Girls in the intervention group gained more spine aBMD during the seven-year study period (p<0.05) and had higher cortical thickness (p<0.05) after seven years intervention than girls in the control group. Both girls and boys in the intervention group gained more muscle strength than their respective control group (p ranging from <0.05 to <0.01). With the intervention, the proportion of boys eligible for upper secondary school increased by 7.3 (1.4, 13.2) percentage points (pp) and the overall grade points increased by 13.3 (3.1, 23.5) points among boys. This thesis concludes that a long-term PA intervention program initiated in pre-pubertal children reduces the fracture risk with each year of intervention, and improves skeletal traits in girls, muscle strength in both genders and academic performance in boys. Key words Academic performance, Children, Fracture risk, Muskuloskeletal traits, Physical activityClassification system and/or index terms (if any)Supplementary bibliographical informationLanguageEnglishISSN and key title1652-8220 ISBN978-91-7619-384-6Recipient’s notesNumber of pages 85PriceSecurity classificationI, the undersigned, being the copyright owner of the abstract of the above-mentioned dissertation, hereby grant to all reference sources permission to publish and disseminate the abstract of the above-mentioned dissertation.Signature Date Physical Activity During GrowthEffects on Bone, Muscle, Fracture Risk and Academic PerformanceJesper Fritzcenter349948500Financial support for this study was received from ALF, Region Sk?ne FoUU, Centre for Athletic Research (CIF), Herman J?rnhardt Foundation, Greta och Johan Kock’s Foundation, Maggie Stephen’s Foundation, Sk?ne University Hospital (SUS) Foundations and Clinical Osteoporosis Research School (CORS).Copyright Jesper FritzClinical and Molecular Osteoporosis Research UnitDepartment of Clinical Sciences and OrthopedicsSk?ne University Hospital, Malm?Faculty of Medicine, Lund University, SwedenISBN 978-91-7619-384-6ISSN 1652-8220Lund University, Faculty of Medicine Doctoral Dissertation Series 2017:3Printed in Sweden by Media-Tryck, Lund UniversityLund 2017Content TOC \o "1-3" \u Abstract7Abbreviations9Original Papers10Glossary11Introduction13Fractures13Skeleton15Physiology15Growth, peak and decline18Bone strength19Risk factors20Measurements20Muscle24Physiology24Muscle strength25Measurements25Academic School Performance26Physiology26Measurements28Physical activity29Falls and Fractures29Skeleton30Muscle31Academic School Performance31Adverse effects32Aims37General37Specific37Hypothesis39Research questions41Material and methods43The Pediatric Osteoporosis Prevention (POP) study43Fracture registration44Measurements45Academic performance51Statistical methods52Summary of papers53Paper I53Paper II54Paper III55Paper IV56General discussion57Osteoporosis and fracture risk57Musculoskeletal traits60Academic performance61Strengths of the studies63Limitations of the studies64Conclusions65Future perspectives67Summary in Swedish – Popul?rvetenskaplig sammanfattning69Acknowledgements71References73AbstractPhysical activity (PA) enhances bone mass, bone structure and muscle strength, traits associated with low fall and fracture risk. Therefore PA has been suggested as a strategy to improve musculoskeletal health in the population to decrease the incidence of one of the largest and most costly health problems in the world, osteoporosis and related fractures. Since the greatest effect of PA on musculoskeletal health occurs during childhood, and since there is no clinically useful way of knowing who will develop osteoporosis later in life, increased PA for all children could be a strategy to decrease osteoporosis in the population of future generations. Speaking of future generations, since PA may also influence brain development, cognition and concentration, it has been postulated that physical activity may enhance academic performance. Since the proportion of Swedish children who finish the 9th and final year of compulsory school without eligibility for upper secondary school programs has increased during recent decades, increased PA in school could also be a strategy to reverse this negative trend. Previous prospective pediatric PA intervention studies are short-term, use specific training programs and only use surrogate endpoints both for fractures and academic performance. The Pediatric Osteoporosis Prevention (POP) study is a population-based prospective controlled exercise intervention study, designed to evaluate the effect of PA on musculoskeletal development, fracture risk and academic performance in children. This thesis presents the outcome after 7–9 years of the program. In the POP study, one school was chosen as intervention school and three other schools in the same area with the same socioeconomic background were chosen as control schools. In the intervention school we increased the amount of physical education (PE) per week from the Swedish standard of 60 minutes to 200 minutes, given as one lesson of 40 minutes for each of the five school days per week. Meanwhile, the control schools continued with 60 minutes of PE per school week.We included all children (aged 6–8 years) who started first grade in these schools from 1998 to 2012 and followed them for seven years regarding fractures, using our digital radiographic archive (cohort A – 3,534 children). Children starting school between 1998 and 2000 were invited to annual lifestyle and musculoskeletal evaluations during seven years, using questionnaire for lifestyle factors, dual-energy X-ray absorptiometry (DXA) for bone parameters such as areal bone mineral density (aBMD), peripheral quantitative computed tomography (pQCT) for bone structure such as cortical thickness, polar strength strain index (SSI) and cortical bone mineral mass distribution in several tibial sites, and computerized dynamometer (Biodex) for muscle strength (evaluated by isokinetic peak torque) (cohort B – 261 to 264 children depending on evaluated trait). To evaluate academic performance, we included all children who finished 9th grade from 2003 to 2012 in all of Sweden (cohort C – 1,161,807 children) and in the intervention school (cohort D – 633 children) and evaluated grade scores and eligibility for upper secondary school programs in both cohorts. We could thus compare the academic results within and between the schools before the intervention was initiated (finished school in year 2003 to 2006) and with the intervention (finished school in year 2007 to 2012).The incidence rate ratio (IRR) of fractures in the intervention group compared to the control group decreased with each year of the intervention (r=–0.79; p=0.036) and during the seventh year it was almost halved (IRR 0.52 95% CI 0.27, 1.01). Girls in the intervention group gained more spine aBMD during the seven-year study period (p<0.05) and had higher cortical thickness (p<0.05) and greater SSI (p<0.05) at the 66% tibia site after seven years intervention than girls in the control group. In girls in the intervention group these enhancements were accompanied by greater mineral mass in the lateral, anterior-medial and medial sectors of the tibia both at the 66% and the 38% sites (p ranging from <0.05 to <0.001) than controls. We found no skeletal differences between intervention and control boys. Both girls and boys in the intervention group gained more muscle strength than their respective control group (p ranging from <0.05 to <0.01). With the intervention, the proportion of boys eligible for upper secondary school increased by 7.3 (1.4, 13.2) percentage points (pp) and the overall grade points increased by 13.3 (3.1, 23.5) points among boys. This resulted in both higher eligibility rate (+8.3 pp) and higher overall grade points (+12.6 points) in the intervention school compared to all other Swedish boys. Among girls, the academic school performance did not change with the intervention. This thesis concludes that a long-term PA intervention program initiated in pre-pubertal children reduces the fracture risk with each year of intervention, and improves skeletal traits in girls, muscle strength in both genders and academic performance in boys. AbbreviationsaBMDAreal bone mineral density (g/cm2)ANCOVA Analysis of covarianceBMC Bone mineral content (g)BMDBone mineral density (g/cm2)BMIBody mass index (kg/m2)CIConfidence intervalCVCoefficient of variation (%)DPADual-photon absorptiometryDXADual-energy X-ray absorptiometryExExtensionFlFlexionFNFemoral neckIRRIncidence rate ratioLSLumbar spinePAPhysical activityPBMPeak bone massPEPhysical educationPOPPediatric Osteoporosis Prevention (study)pQCTPeripheral quantitative computed tomographyRCTRandomized controlled trialSDStandard deviationSPASingle-photon absorptiometrySSIPolar strength strain indexTBTotal bodyvBMDVolumetric bone mineral density (g/cm3)WHOWorld Health OrganizationOriginal PapersThe Associations of Physical Activity with Fracture Risk – a 7 year Prospective Controlled Intervention Study in 3 534 ChildrenFritz J, C?ster ME, Nilsson J-?, Rosengren BE, Dencker M, Karlsson MK.Osteoporosis International 2016, 27:915–922A Seven-year Physical Activity Intervention for Children Increased Gains in Bone Mass and Muscle StrengthFritz J, Rosengren BE, Dencker M, Karlsson C, Karlsson MK.Acta Paediatrica 2016, 105:1216–1224Influence of a School-Based Physical Activity Intervention on Cortical Bone Mass Distribution: A 7-year Intervention StudyFritz J, Duckham RL, Rantalainen T, Rosengren BE, Karlsson MK, Daly RM. Calcified Tissue 2016, 99:443–453Daily School Physical Activity Improves the Academic School Performance in Boys but not Girls – a Nine-year Nationwide Prospective Controlled Intervention StudyFritz J, C?ster ME, Rosengren BE, Karlsson C, Karlsson MK. In manuscriptGlossaryAccuracyIn this context means how well a measured value corresponds to the true valueConcentric contractionA contraction during shortening of the muscleEccentric contractionA contraction during lengthening of the muscleExercisePhysical activity that is planned, structured with repetitive bodily movement performed to improve or maintain one or more components of physical fitnessIsokineticMovement at a constant angular velocity around the axis of rotationIsometric contractionA contraction during which the muscle length remains unchangedMuscle strengthThe amount of force that can be produced by a muscle in a single contractionPeak torqueMaximum force applied around a pivot pointPhysical activityAny bodily movement produced by the contraction of skeletal muscles that result in energy expenditurePolar distributionSubdivision of the cortex into sectors around its center of mass with the average bone mass estimated for each sectorPre-pubertal children Children in Tanner stage 1 or 2Radial distributionSubdivision of the cortex into concentric rings with the average bone density estimated for each ring ReliabilityRefers to the consistency of measurementsValidityThe extent to which an instrument or method actually measures what it is intended to measureIntroductionFracturesThe rising number of fractures in elderly is a large health problem worldwide, especially in populations with a high incidence of osteoporosisPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5HZW5hbnQ8L0F1dGhvcj48WWVhcj4xOTk5PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA 4. With the projected increase in life expectancy, especially in developing countriesPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5HZW5hbnQ8L0F1dGhvcj48WWVhcj4xOTk5PC9ZZWFyPjxS
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ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5HZW5hbnQ8L0F1dGhvcj48WWVhcj4xOTk5PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA 1, the problem of fractures in elderly will grow even bigger in the futurePEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Sb3NlbmdyZW48L0F1dGhvcj48WWVhcj4yMDE0PC9ZZWFy
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ADDIN EN.CITE.DATA 7,8. Furthermore, it has recently been shown that the distal forearm fracture rate in children is currently 50% higher than in the 1950s, and it still appears to be increasing ADDIN EN.CITE <EndNote><Cite><Author>Jerrhag</Author><Year>2016</Year><RecNum>452</RecNum><DisplayText><style face="superscript">9</style></DisplayText><record><rec-number>452</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1475334575">452</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Jerrhag, D.</author><author>Englund, M.</author><author>Petersson, I.</author><author>Lempesis, V.</author><author>Landin, L.</author><author>Karlsson, M. K.</author><author>Rosengren, B. E.</author></authors></contributors><auth-address>a Clinical and Molecular Osteoporosis Research Unit, Departments of Clinical Sciences and Orthopedics Malmo , Skane University Hospital, Lund University .
b Clinical Epidemiology Unit, Orthopedics, Department of Clinical Sciences Lund , Lund University , Lund , Sweden .
c Clinical Epidemiology Research and Training Unit , Boston University School of Medicine , Boston , MA , USA.</auth-address><titles><title>Increasing wrist fracture rates in children may have major implications for future adult fracture burden</title><secondary-title>Acta Orthop</secondary-title><alt-title>Acta orthopaedica</alt-title></titles><periodical><full-title>Acta Orthop</full-title><abbr-1>Acta orthopaedica</abbr-1></periodical><alt-periodical><full-title>Acta Orthop</full-title><abbr-1>Acta orthopaedica</abbr-1></alt-periodical><pages>296-300</pages><volume>87</volume><number>3</number><dates><year>2016</year><pub-dates><date>Jun</date></pub-dates></dates><isbn>1745-3682 (Electronic)
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ADDIN EN.CITE.DATA 12.Fractures are also a great problem in magnitude during childhood, since 10–25% of all pediatric injuries include fractures ADDIN EN.CITE <EndNote><Cite><Author>Nathorst Westfelt</Author><Year>1982</Year><RecNum>192</RecNum><DisplayText><style face="superscript">13</style></DisplayText><record><rec-number>192</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1433057692">192</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Nathorst Westfelt, J. A.</author></authors></contributors><titles><title>Environmental factors in childhood accidents. A prospective study in Goteborg, Sweden</title><secondary-title>Acta Paediatr Scand Suppl</secondary-title><alt-title>Acta paediatrica Scandinavica. Supplement</alt-title></titles><periodical><full-title>Acta Paediatr Scand Suppl</full-title><abbr-1>Acta paediatrica Scandinavica. Supplement</abbr-1></periodical><alt-periodical><full-title>Acta Paediatr Scand Suppl</full-title><abbr-1>Acta paediatrica Scandinavica. Supplement</abbr-1></alt-periodical><pages>1-75</pages><volume>291</volume><keywords><keyword>*Accidents</keyword><keyword>Adolescent</keyword><keyword>Age Factors</keyword><keyword>Athletic Injuries/epidemiology</keyword><keyword>Child</keyword><keyword>Child, Preschool</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Infant</keyword><keyword>Infant, Newborn</keyword><keyword>Male</keyword><keyword>Prospective Studies</keyword><keyword>Sex Factors</keyword><keyword>*Social Environment</keyword><keyword>Sweden</keyword><keyword>Wounds and Injuries/*epidemiology</keyword></keywords><dates><year>1982</year></dates><isbn>0300-8843 (Print)
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ADDIN EN.CITE.DATA 14,15. Pediatric fracture incidence has also been shown with time trends, indicating that there has been an increase in fracture risk from 1998 to 2007 ADDIN EN.CITE <EndNote><Cite><Author>Hedstrom</Author><Year>2010</Year><RecNum>135</RecNum><DisplayText><style face="superscript">16</style></DisplayText><record><rec-number>135</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1420802103">135</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Hedstrom, E. M.</author><author>Svensson, O.</author><author>Bergstrom, U.</author><author>Michno, P.</author></authors></contributors><auth-address>Division of Surgery and Perioperative Science, Umea University Hospital, Umea, Sweden. erik.hedstrom@orthop.umu.se</auth-address><titles><title>Epidemiology of fractures in children and adolescents</title><secondary-title>Acta Orthop</secondary-title><alt-title>Acta orthopaedica</alt-title></titles><periodical><full-title>Acta Orthop</full-title><abbr-1>Acta orthopaedica</abbr-1></periodical><alt-periodical><full-title>Acta Orthop</full-title><abbr-1>Acta orthopaedica</abbr-1></alt-periodical><pages>148-53</pages><volume>81</volume><number>1</number><keywords><keyword>Accidental Falls/statistics & numerical data</keyword><keyword>Accidents, Traffic/statistics & numerical data</keyword><keyword>Adolescent</keyword><keyword>Athletic Injuries/epidemiology</keyword><keyword>Child</keyword><keyword>Child, Preschool</keyword><keyword>Female</keyword><keyword>Fractures, Bone/*epidemiology/etiology/prevention & control</keyword><keyword>Humans</keyword><keyword>Incidence</keyword><keyword>Infant</keyword><keyword>Male</keyword><keyword>Registries</keyword><keyword>Sweden/epidemiology</keyword></keywords><dates><year>2010</year><pub-dates><date>Feb</date></pub-dates></dates><isbn>1745-3682 (Electronic)
1745-3674 (Linking)</isbn><accession-num>20175744</accession-num><urls><related-urls><url> (Figure 1). Figure 1. Pediatric fracture incidence from 1993 to 2007 ADDIN EN.CITE <EndNote><Cite><Author>Hedstrom</Author><Year>2010</Year><RecNum>135</RecNum><DisplayText><style face="superscript">16</style></DisplayText><record><rec-number>135</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1420802103">135</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Hedstrom, E. M.</author><author>Svensson, O.</author><author>Bergstrom, U.</author><author>Michno, P.</author></authors></contributors><auth-address>Division of Surgery and Perioperative Science, Umea University Hospital, Umea, Sweden. erik.hedstrom@orthop.umu.se</auth-address><titles><title>Epidemiology of fractures in children and adolescents</title><secondary-title>Acta Orthop</secondary-title><alt-title>Acta orthopaedica</alt-title></titles><periodical><full-title>Acta Orthop</full-title><abbr-1>Acta orthopaedica</abbr-1></periodical><alt-periodical><full-title>Acta Orthop</full-title><abbr-1>Acta orthopaedica</abbr-1></alt-periodical><pages>148-53</pages><volume>81</volume><number>1</number><keywords><keyword>Accidental Falls/statistics & numerical data</keyword><keyword>Accidents, Traffic/statistics & numerical data</keyword><keyword>Adolescent</keyword><keyword>Athletic Injuries/epidemiology</keyword><keyword>Child</keyword><keyword>Child, Preschool</keyword><keyword>Female</keyword><keyword>Fractures, Bone/*epidemiology/etiology/prevention & control</keyword><keyword>Humans</keyword><keyword>Incidence</keyword><keyword>Infant</keyword><keyword>Male</keyword><keyword>Registries</keyword><keyword>Sweden/epidemiology</keyword></keywords><dates><year>2010</year><pub-dates><date>Feb</date></pub-dates></dates><isbn>1745-3682 (Electronic)
1745-3674 (Linking)</isbn><accession-num>20175744</accession-num><urls><related-urls><url> risk in children peaks during early puberty, possibly due to high bone turnover, with a large gain in bone size but slower bone mineral accrual, temporarily leaving the bone more fragile ADDIN EN.CITE <EndNote><Cite><Author>Goulding</Author><Year>2007</Year><RecNum>297</RecNum><DisplayText><style face="superscript">17</style></DisplayText><record><rec-number>297</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1468142477">297</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Goulding, A.</author></authors></contributors><auth-address>Department of Medical and Surgical Sciences, University of Otago, Dunedin, New Zealand. ailsa.goulding@stonebow.otago.ac.nz</auth-address><titles><title>Risk factors for fractures in normally active children and adolescents</title><secondary-title>Med Sport Sci</secondary-title><alt-title>Medicine and sport science</alt-title></titles><periodical><full-title>Med Sport Sci</full-title><abbr-1>Medicine and sport science</abbr-1></periodical><alt-periodical><full-title>Med Sport Sci</full-title><abbr-1>Medicine and sport science</abbr-1></alt-periodical><pages>102-20</pages><volume>51</volume><keywords><keyword>Adolescent</keyword><keyword>Bone Density/physiology</keyword><keyword>Child</keyword><keyword>Chronic Disease</keyword><keyword>Diet</keyword><keyword>Fractures, Bone/epidemiology/*etiology/prevention & control</keyword><keyword>Genetic Predisposition to Disease</keyword><keyword>*Health Behavior</keyword><keyword>Humans</keyword><keyword>Obesity/complications</keyword><keyword>Risk Factors</keyword></keywords><dates><year>2007</year></dates><isbn>0254-5020 (Print)
0076-6070 (Linking)</isbn><accession-num>17505122</accession-num><urls><related-urls><url>. The most common fracture sites in children and adolescents are the distal forearm, followed by the hand ADDIN EN.CITE <EndNote><Cite><Author>Landin</Author><Year>1983</Year><RecNum>60</RecNum><DisplayText><style face="superscript">14</style></DisplayText><record><rec-number>60</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1383041180">60</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Landin, L. A.</author></authors></contributors><titles><title>Fracture patterns in children. Analysis of 8,682 fractures with special reference to incidence, etiology and secular changes in a Swedish urban population 1950-1979</title><secondary-title>Acta Orthop Scand Suppl</secondary-title><alt-title>Acta orthopaedica Scandinavica. Supplementum</alt-title></titles><periodical><full-title>Acta Orthop Scand Suppl</full-title><abbr-1>Acta orthopaedica Scandinavica. Supplementum</abbr-1></periodical><alt-periodical><full-title>Acta Orthop Scand Suppl</full-title><abbr-1>Acta orthopaedica Scandinavica. Supplementum</abbr-1></alt-periodical><pages>1-109</pages><volume>202</volume><keywords><keyword>Accidents</keyword><keyword>Age Factors</keyword><keyword>Athletic Injuries/epidemiology</keyword><keyword>Child</keyword><keyword>Child, Preschool</keyword><keyword>Female</keyword><keyword>Fractures, Bone/classification/*epidemiology/etiology</keyword><keyword>Humans</keyword><keyword>Infant</keyword><keyword>Infant, Newborn</keyword><keyword>Male</keyword><keyword>Recurrence</keyword><keyword>Risk</keyword><keyword>Seasons</keyword><keyword>Sex Factors</keyword><keyword>Sweden</keyword></keywords><dates><year>1983</year></dates><isbn>0300-8827 (Print)
0300-8827 (Linking)</isbn><accession-num>6574687</accession-num><urls><related-urls><url>. Some risk factors for fracture in children are the same as for elderly, e.g. low bone mass ADDIN EN.CITE <EndNote><Cite><Author>Clark</Author><Year>2006</Year><RecNum>63</RecNum><DisplayText><style face="superscript">18</style></DisplayText><record><rec-number>63</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1383041472">63</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Clark, E. M.</author><author>Tobias, J. H.</author><author>Ness, A. R.</author></authors></contributors><auth-address>Department of Community Based Medicine, University of Bristol, Bristol, United Kingdom. emma.clark@bristol.ac.uk</auth-address><titles><title>Association between bone density and fractures in children: a systematic review and meta-analysis</title><secondary-title>Pediatrics</secondary-title><alt-title>Pediatrics</alt-title></titles><periodical><full-title>Pediatrics</full-title><abbr-1>Pediatrics</abbr-1></periodical><alt-periodical><full-title>Pediatrics</full-title><abbr-1>Pediatrics</abbr-1></alt-periodical><pages>e291-7</pages><volume>117</volume><number>2</number><keywords><keyword>*Bone Density</keyword><keyword>Case-Control Studies</keyword><keyword>Child</keyword><keyword>Fractures, Bone/etiology/*metabolism</keyword><keyword>Humans</keyword><keyword>Risk Factors</keyword></keywords><dates><year>2006</year><pub-dates><date>Feb</date></pub-dates></dates><isbn>1098-4275 (Electronic)
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ADDIN EN.CITE.DATA 20.With this in mind, any intervention or treatment leading to a decreased number of fractures mediated through increased bone mass, bone strength, muscle strength or other factors should be of profound interest both now and in the future.SkeletonPhysiologyBone is a tissue with vascularization and innervation that constantly remodels to adapt to the needs of the skeleton. The hard building block of the skeleton consists of the hydroxyapatite molecule, Ca5(PO4)3(OH)2, while the triple helix protein of collagen type 1 together with several glucosaminoglycans make up the extracellular matrix that surrounds the cellular components of the bone. There are three main types of bone cells, osteoblasts, osteoclasts and osteocytes. They work in units called basic multicellular units (BMU), where the osteoblasts produce new bone and the osteoclasts resorb bone ADDIN EN.CITE <EndNote><Cite><Author>Kular</Author><Year>2012</Year><RecNum>299</RecNum><DisplayText><style face="superscript">21</style></DisplayText><record><rec-number>299</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1468144370">299</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Kular, J.</author><author>Tickner, J.</author><author>Chim, S. M.</author><author>Xu, J.</author></authors></contributors><auth-address>School of Pathology and Laboratory Medicine, The University of Western Australia, Western Australia, Australia.</auth-address><titles><title>An overview of the regulation of bone remodelling at the cellular level</title><secondary-title>Clin Biochem</secondary-title><alt-title>Clinical biochemistry</alt-title></titles><periodical><full-title>Clin Biochem</full-title><abbr-1>Clinical biochemistry</abbr-1></periodical><alt-periodical><full-title>Clin Biochem</full-title><abbr-1>Clinical biochemistry</abbr-1></alt-periodical><pages>863-73</pages><volume>45</volume><number>12</number><keywords><keyword>Animals</keyword><keyword>Bone Diseases, Metabolic/metabolism/pathology/physiopathology</keyword><keyword>*Bone Remodeling</keyword><keyword>Bone and Bones/metabolism/*pathology/physiopathology</keyword><keyword>Endothelial Cells/metabolism/physiology</keyword><keyword>Humans</keyword><keyword>Lymphocytes/metabolism/physiology</keyword><keyword>Macrophages/metabolism/physiology</keyword><keyword>Osteoblasts/metabolism/physiology</keyword><keyword>Osteoclasts/metabolism/physiology</keyword></keywords><dates><year>2012</year><pub-dates><date>Aug</date></pub-dates></dates><isbn>1873-2933 (Electronic)
0009-9120 (Linking)</isbn><accession-num>22465238</accession-num><urls><related-urls><url>. The third cell type, the osteocytes, are embedded in bone matrix during new bone formation, connected to each other with long dendrites and make up roughly 90% of all skeletal cells in adults ADDIN EN.CITE <EndNote><Cite><Author>Knothe Tate</Author><Year>2004</Year><RecNum>300</RecNum><DisplayText><style face="superscript">22</style></DisplayText><record><rec-number>300</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1468144666">300</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Knothe Tate, M. L.</author><author>Adamson, J. R.</author><author>Tami, A. E.</author><author>Bauer, T. W.</author></authors></contributors><auth-address>Orthopaedic Research Center, The Cleveland Clinic, 44195, Cleveland, OH, USA. tatem@bme.</auth-address><titles><title>The osteocyte</title><secondary-title>Int J Biochem Cell Biol</secondary-title><alt-title>The international journal of biochemistry & cell biology</alt-title></titles><periodical><full-title>Int J Biochem Cell Biol</full-title><abbr-1>The international journal of biochemistry & cell biology</abbr-1></periodical><alt-periodical><full-title>Int J Biochem Cell Biol</full-title><abbr-1>The international journal of biochemistry & cell biology</abbr-1></alt-periodical><pages>1-8</pages><volume>36</volume><number>1</number><keywords><keyword>Animals</keyword><keyword>Bone Diseases/pathology</keyword><keyword>Bone Matrix/cytology</keyword><keyword>Cell Cycle</keyword><keyword>Cell Differentiation</keyword><keyword>Humans</keyword><keyword>Osteocytes/*cytology/pathology/*physiology</keyword></keywords><dates><year>2004</year><pub-dates><date>Jan</date></pub-dates></dates><isbn>1357-2725 (Print)
1357-2725 (Linking)</isbn><accession-num>14592527</accession-num><urls><related-urls><url>. The function of osteocytes is not completely understood, but they are believed to be mechanosensible, capable of transducting mechanical stimuli to a biological response in bone ADDIN EN.CITE <EndNote><Cite><Author>Duncan</Author><Year>1995</Year><RecNum>301</RecNum><DisplayText><style face="superscript">23</style></DisplayText><record><rec-number>301</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1468145127">301</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Duncan, R. L.</author><author>Turner, C. H.</author></authors></contributors><auth-address>Biomechanics and Biomaterials Research Center, Indiana University Medical Center, Indianapolis 46202, USA.</auth-address><titles><title>Mechanotransduction and the functional response of bone to mechanical strain</title><secondary-title>Calcif Tissue Int</secondary-title><alt-title>Calcified tissue international</alt-title></titles><periodical><full-title>Calcif Tissue Int</full-title><abbr-1>Calcified tissue international</abbr-1></periodical><alt-periodical><full-title>Calcif Tissue Int</full-title><abbr-1>Calcified tissue international</abbr-1></alt-periodical><pages>344-58</pages><volume>57</volume><number>5</number><keywords><keyword>Bone Density/*physiology</keyword><keyword>Bone Remodeling/*physiology</keyword><keyword>Bone and Bones/*physiology</keyword><keyword>Humans</keyword><keyword>Signal Transduction/*physiology</keyword><keyword>*Stress, Mechanical</keyword></keywords><dates><year>1995</year><pub-dates><date>Nov</date></pub-dates></dates><isbn>0171-967X (Print)
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ADDIN EN.CITE.DATA 24.There are two types of bone tissue: compact (cortical) and cancellous (spongy) bone. In compact bone, the bone matrix and osteocytes are histologically organized in onion-shaped rings called osteons with a central canal, called the Haversian canal, containing blood vessels, lymphatic tissue and sometimes nerves. Osteocytes lie in small cavities, called lacunae, and are connected to each other by small tunnels called canaliculi ADDIN EN.CITE <EndNote><Cite><Author>Kular</Author><Year>2012</Year><RecNum>299</RecNum><DisplayText><style face="superscript">21</style></DisplayText><record><rec-number>299</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1468144370">299</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Kular, J.</author><author>Tickner, J.</author><author>Chim, S. M.</author><author>Xu, J.</author></authors></contributors><auth-address>School of Pathology and Laboratory Medicine, The University of Western Australia, Western Australia, Australia.</auth-address><titles><title>An overview of the regulation of bone remodelling at the cellular level</title><secondary-title>Clin Biochem</secondary-title><alt-title>Clinical biochemistry</alt-title></titles><periodical><full-title>Clin Biochem</full-title><abbr-1>Clinical biochemistry</abbr-1></periodical><alt-periodical><full-title>Clin Biochem</full-title><abbr-1>Clinical biochemistry</abbr-1></alt-periodical><pages>863-73</pages><volume>45</volume><number>12</number><keywords><keyword>Animals</keyword><keyword>Bone Diseases, Metabolic/metabolism/pathology/physiopathology</keyword><keyword>*Bone Remodeling</keyword><keyword>Bone and Bones/metabolism/*pathology/physiopathology</keyword><keyword>Endothelial Cells/metabolism/physiology</keyword><keyword>Humans</keyword><keyword>Lymphocytes/metabolism/physiology</keyword><keyword>Macrophages/metabolism/physiology</keyword><keyword>Osteoblasts/metabolism/physiology</keyword><keyword>Osteoclasts/metabolism/physiology</keyword></keywords><dates><year>2012</year><pub-dates><date>Aug</date></pub-dates></dates><isbn>1873-2933 (Electronic)
0009-9120 (Linking)</isbn><accession-num>22465238</accession-num><urls><related-urls><url> (Figure 2). In compact bone, the Haversian systems are packed tightly together, almost as a solid mass while the cancellous bone is lighter and less dense. Cancellous bone consists of plates (trabeculae) and bars of bone adjacent to small, irregular cavities that contain red bone marrow. The canaliculi connect to the adjacent cavities, instead of a central Haversian canal, to receive their blood supply.Figure 2. The anatomy of bone tissue ADDIN EN.CITE <EndNote><Cite><Author>Chao Le Meng Bao</Author><Year>2013</Year><RecNum>460</RecNum><DisplayText><style face="superscript">25</style></DisplayText><record><rec-number>460</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1477125969">460</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Chao Le Meng Bao, Erin Y. Teo, Mark S.K. Chong, Yuchun Liu,</author><author>Mahesh Choolani and Jerry K.Y. Chan</author></authors></contributors><titles><title>Advances in Bone Tissue Engineering</title><secondary-title>Regenerative Medicine and Tissue Engineering, InTech. Available from: Medicine and Tissue Engineering, InTech. Available from: bones of the body come in a variety of sizes and shapes. The four principal types of bones are long, short, flat and irregular. Long bones consist of a long shaft (diaphysis) with two bulky ends (epiphysis). They are primarily compact bone but may have a large amount of cancellous bone in the epiphysis (Figure 3). Long bones include bones of the thigh, leg, arm, and forearm. Short bones are roughly cube shaped and consist primarily of spongy bone, which is covered by a thin layer of compact bone. The bones of the wrist and ankle are short bones. Flat bones are thin, flattened, and usually curved, and the cranium consists primarily of flat bones. Bones that are not in any of the above three categories are classified as irregular bones. They are primarily spongy bone that is covered with a thin layer of compact bone, e.g. the vertebrae.Figure 3. The anatomy of a long bone.There are two types of metabolic processes in bone tissue, bone modeling and bone remodeling. Bone modeling is when the metabolism changes the shape and size of the skeleton and takes place during growth, but can also be seen later in life in response to mechanical loading or during fracture repair. Bone remodeling is when old bone is substituted for new bone without changing the shape and size of the bone and is an ongoing process in adult life ADDIN EN.CITE <EndNote><Cite><Author>Lanyon</Author><Year>1993</Year><RecNum>303</RecNum><DisplayText><style face="superscript">26</style></DisplayText><record><rec-number>303</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1468146563">303</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Lanyon, L. E.</author></authors></contributors><auth-address>Royal Veterinary College, London, UK.</auth-address><titles><title>Osteocytes, strain detection, bone modeling and remodeling</title><secondary-title>Calcif Tissue Int</secondary-title><alt-title>Calcified tissue international</alt-title></titles><periodical><full-title>Calcif Tissue Int</full-title><abbr-1>Calcified tissue international</abbr-1></periodical><alt-periodical><full-title>Calcif Tissue Int</full-title><abbr-1>Calcified tissue international</abbr-1></alt-periodical><pages>S102-6; discussion S106-7</pages><volume>53 Suppl 1</volume><keywords><keyword>Animals</keyword><keyword>Birds</keyword><keyword>Bone Remodeling/drug effects/*physiology</keyword><keyword>Bone Resorption/metabolism/pathology</keyword><keyword>Calcitriol/pharmacology</keyword><keyword>Cell Communication</keyword><keyword>Cell Division/drug effects/physiology</keyword><keyword>Glucosephosphate Dehydrogenase/metabolism</keyword><keyword>Mammals</keyword><keyword>Osteocytes/cytology/drug effects/*physiology</keyword><keyword>Parathyroid Hormone/pharmacology</keyword></keywords><dates><year>1993</year></dates><isbn>0171-967X (Print)
0171-967X (Linking)</isbn><accession-num>8275362</accession-num><urls><related-urls><url>, replacing approximately 25% of the cancellous bone and 3% of the cortical bone each year ADDIN EN.CITE <EndNote><Cite><Author>Watts</Author><Year>1999</Year><RecNum>304</RecNum><DisplayText><style face="superscript">27</style></DisplayText><record><rec-number>304</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1468146646">304</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Watts, N. B.</author></authors></contributors><auth-address>Emory University School of Medicine, Atlanta, GA 30322, USA. nwatts@emory.edu</auth-address><titles><title>Clinical utility of biochemical markers of bone remodeling</title><secondary-title>Clin Chem</secondary-title><alt-title>Clinical chemistry</alt-title></titles><periodical><full-title>Clin Chem</full-title><abbr-1>Clinical chemistry</abbr-1></periodical><alt-periodical><full-title>Clin Chem</full-title><abbr-1>Clinical chemistry</abbr-1></alt-periodical><pages>1359-68</pages><volume>45</volume><number>8 Pt 2</number><keywords><keyword>Biomarkers/blood/urine</keyword><keyword>Bone Diseases/blood/diagnosis/urine</keyword><keyword>*Bone Remodeling</keyword><keyword>Bone Resorption/blood/urine</keyword><keyword>Bone and Bones/enzymology/*metabolism</keyword><keyword>Clinical Laboratory Techniques</keyword><keyword>Humans</keyword></keywords><dates><year>1999</year><pub-dates><date>Aug</date></pub-dates></dates><isbn>0009-9147 (Print)
0009-9147 (Linking)</isbn><accession-num>10430819</accession-num><urls><related-urls><url> is one of several main functions of the skeleton. Some bones, such as the rib cage and skull, protect vital organs from injury, while others, such as the femur, protect the bone marrow. Another main function of the skeleton is mechanical support, whereby bones provide a framework for the attachment of muscles and other tissues. Within this framework, some bones act as levers enabling movement as a result of muscle contraction. Storing calcium is yet another purpose of bone. The calcium levels are of most importance for the bone-building capacity and are closely linked to the parathyroid hormone (PTH), calcitonin and vitamin D levels. PTH increases the blood calcium levels by increasing bone resorption (through increased osteoclastic activity) and also increases reabsorption of calcium in the kidneys. Calcitonin counteracts these effects. PTH also increases the enzymatic activation of vitamin D in the kidneys, which increases calcium absorption from the intestines, tubular reabsorption in the kidneys and skeletal calcium release ADDIN EN.CITE <EndNote><Cite><Author>Arnaud</Author><Year>1990</Year><RecNum>306</RecNum><DisplayText><style face="superscript">28</style></DisplayText><record><rec-number>306</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1468147614">306</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Arnaud, C. D.</author></authors></contributors><auth-address>Department of Medicine, University of California, San Francisco.</auth-address><titles><title>Role of dietary calcium in osteoporosis</title><secondary-title>Adv Intern Med</secondary-title><alt-title>Advances in internal medicine</alt-title></titles><periodical><full-title>Adv Intern Med</full-title><abbr-1>Advances in internal medicine</abbr-1></periodical><alt-periodical><full-title>Adv Intern Med</full-title><abbr-1>Advances in internal medicine</abbr-1></alt-periodical><pages>93-106</pages><volume>35</volume><keywords><keyword>Aged</keyword><keyword>Animals</keyword><keyword>*Calcium, Dietary/administration & dosage/therapeutic use</keyword><keyword>Female</keyword><keyword>Fractures, Spontaneous/prevention & control</keyword><keyword>Humans</keyword><keyword>Incidence</keyword><keyword>Male</keyword><keyword>Menopause</keyword><keyword>Osteoporosis/epidemiology/*prevention & control</keyword></keywords><dates><year>1990</year></dates><isbn>0065-2822 (Print)
0065-2822 (Linking)</isbn><accession-num>2405603</accession-num><urls><related-urls><url>. This means that over-production of PTH in the parathyroid glands leads to elevated bone remodeling and thereby decalcification of the skeleton, while elevated calcium levels in the blood have the opposite effectPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5XYXN0bmV5PC9BdXRob3I+PFllYXI+MjAwMDwvWWVhcj48
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ADDIN EN.CITE.DATA 29. Vitamin D is essential for calcium uptake in the intestines and calcium resorption from bone and it increases both the osteoblastic and ostoclastic activity, leaving the skeleton intactPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Ib2xpY2s8L0F1dGhvcj48WWVhcj4yMDA3PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA 30. Vitamin D is converted from 7-dehydrocholesterol to metabolically active vitamin D3 (cholecalciferol) when our skin is exposed to sunlight and it can also be ingested. Since vitamin D has a positive effect on bone and also seems to have a direct effect on skeletal muscle to reduce the risk of falling, at least in elderly people, vitamin D may have the potential to reduce fracture riskPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CaXNjaG9mZi1GZXJyYXJpPC9BdXRob3I+PFllYXI+MjAw
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ADDIN EN.CITE.DATA 32. Up until puberty the gain in BMC is linear in both girls and boys ADDIN EN.CITE <EndNote><Cite><Author>Seeman</Author><Year>2003</Year><RecNum>312</RecNum><DisplayText><style face="superscript">33</style></DisplayText><record><rec-number>312</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1468409971">312</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Seeman, E.</author></authors></contributors><titles><title>Bone quality</title><secondary-title>Osteoporos Int</secondary-title><alt-title>Osteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA</alt-title></titles><periodical><full-title>Osteoporos Int</full-title><abbr-1>Osteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA</abbr-1></periodical><alt-periodical><full-title>Osteoporos Int</full-title><abbr-1>Osteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA</abbr-1></alt-periodical><pages>S3-7</pages><volume>14 Suppl 5</volume><keywords><keyword>Aging/physiology</keyword><keyword>Biomechanical Phenomena</keyword><keyword>Bone Density/physiology</keyword><keyword>Bone Remodeling/physiology</keyword><keyword>Bone and Bones/*physiology</keyword><keyword>Humans</keyword><keyword>Osteoporosis/physiopathology</keyword><keyword>Terminology as Topic</keyword></keywords><dates><year>2003</year><pub-dates><date>Sep</date></pub-dates></dates><isbn>1433-2965 (Electronic)
0937-941X (Linking)</isbn><accession-num>14504698</accession-num><urls><related-urls><url>. At puberty the levels of sex steroids increase, raising the levels of GH and IGF-1, and all three of these hormones have an anabolic effect on bone and muscle tissue ADDIN EN.CITE <EndNote><Cite><Author>Mauras</Author><Year>1996</Year><RecNum>314</RecNum><DisplayText><style face="superscript">34</style></DisplayText><record><rec-number>314</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1468411065">314</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Mauras, N.</author><author>Rogol, A. D.</author><author>Haymond, M. W.</author><author>Veldhuis, J. D.</author></authors></contributors><auth-address>Nemours Children's Clinic, Jacksonville, Fla, USA.</auth-address><titles><title>Sex steroids, growth hormone, insulin-like growth factor-1: neuroendocrine and metabolic regulation in puberty</title><secondary-title>Horm Res</secondary-title><alt-title>Hormone research</alt-title></titles><periodical><full-title>Horm Res</full-title><abbr-1>Hormone research</abbr-1></periodical><alt-periodical><full-title>Horm Res</full-title><abbr-1>Hormone research</abbr-1></alt-periodical><pages>74-80</pages><volume>45</volume><number>1-2</number><keywords><keyword>Adolescent</keyword><keyword>Androgens/physiology</keyword><keyword>Bone Development</keyword><keyword>Child</keyword><keyword>Estrogens/physiology</keyword><keyword>Female</keyword><keyword>Gonadal Steroid Hormones/*physiology</keyword><keyword>Gonadotropin-Releasing Hormone/physiology</keyword><keyword>Growth Hormone/*physiology</keyword><keyword>Homeostasis</keyword><keyword>Humans</keyword><keyword>Insulin-Like Growth Factor I/*physiology</keyword><keyword>Luteinizing Hormone/secretion</keyword><keyword>Male</keyword><keyword>Neurosecretory Systems/*physiology</keyword><keyword>*Puberty</keyword><keyword>Sexual Maturation</keyword></keywords><dates><year>1996</year></dates><isbn>0301-0163 (Print)
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ADDIN EN.CITE.DATA 35,36. Hence, puberty is an important period in life when it comes to bone growth, probably as a result of the skeleton being maximally responsive to stimuli during periods with fast skeletal apposition ADDIN EN.CITE <EndNote><Cite><Author>Kannus</Author><Year>1995</Year><RecNum>38</RecNum><DisplayText><style face="superscript">37</style></DisplayText><record><rec-number>38</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1380716883">38</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Kannus, P.</author><author>Haapasalo, H.</author><author>Sankelo, M.</author><author>Sievanen, H.</author><author>Pasanen, M.</author><author>Heinonen, A.</author><author>Oja, P.</author><author>Vuori, I.</author></authors></contributors><auth-address>UKK Institute for Health Promotion Research, Tampere, Finland.</auth-address><titles><title>Effect of starting age of physical activity on bone mass in the dominant arm of tennis and squash players</title><secondary-title>Ann Intern Med</secondary-title><alt-title>Annals of internal medicine</alt-title></titles><periodical><full-title>Ann Intern Med</full-title><abbr-1>Annals of internal medicine</abbr-1></periodical><alt-periodical><full-title>Ann Intern Med</full-title><abbr-1>Annals of internal medicine</abbr-1></alt-periodical><pages>27-31</pages><volume>123</volume><number>1</number><keywords><keyword>Age Factors</keyword><keyword>Anthropometry</keyword><keyword>*Bone Density</keyword><keyword>Confounding Factors (Epidemiology)</keyword><keyword>Cross-Sectional Studies</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Interviews as Topic</keyword><keyword>Menarche</keyword><keyword>Racquet Sports/*physiology</keyword><keyword>Tennis/*physiology</keyword></keywords><dates><year>1995</year><pub-dates><date>Jul 1</date></pub-dates></dates><isbn>0003-4819 (Print)
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ADDIN EN.CITE.DATA 39.Peak bone mass (PBM) is the highest bone mass a person reaches during lifetime, and is usually reached in the early twenties and varies depending on gender, genetic background and skeletal regionPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5IZWFuZXk8L0F1dGhvcj48WWVhcj4yMDAwPC9ZZWFyPjxS
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ADDIN EN.CITE.DATA 40, being as early as age 17–18 years in the hip ADDIN EN.CITE <EndNote><Cite><Author>Alwis</Author><Year>2010</Year><RecNum>321</RecNum><DisplayText><style face="superscript">41</style></DisplayText><record><rec-number>321</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1468415731">321</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Alwis, G.</author><author>Rosengren, B.</author><author>Stenevi-Lundgren, S.</author><author>Duppe, H.</author><author>Sernbo, I.</author><author>Karlsson, M. K.</author></authors></contributors><auth-address>Clinical and Molecular Osteoporosis Research Unit, Department of Clinical Sciences, Lund University, Lund, Sweden.</auth-address><titles><title>Normative dual energy X-ray absorptiometry data in Swedish children and adolescents</title><secondary-title>Acta Paediatr</secondary-title><alt-title>Acta paediatrica</alt-title></titles><periodical><full-title>Acta Paediatr</full-title><abbr-1>Acta paediatrica</abbr-1></periodical><alt-periodical><full-title>Acta Paediatr</full-title><abbr-1>Acta paediatrica</abbr-1></alt-periodical><pages>1091-9</pages><volume>99</volume><number>7</number><keywords><keyword>*Absorptiometry, Photon</keyword><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>*Body Composition</keyword><keyword>Bone Density/*physiology</keyword><keyword>Canada</keyword><keyword>Child</keyword><keyword>Cross-Sectional Studies</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Korea</keyword><keyword>Male</keyword><keyword>Netherlands</keyword><keyword>Reference Values</keyword><keyword>Sweden</keyword><keyword>Young Adult</keyword></keywords><dates><year>2010</year><pub-dates><date>Jul</date></pub-dates></dates><isbn>1651-2227 (Electronic)
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ADDIN EN.CITE.DATA 42. Genetic factors regulate 50–85% of the variance in PBM ADDIN EN.CITE <EndNote><Cite><Author>Eisman</Author><Year>1999</Year><RecNum>323</RecNum><DisplayText><style face="superscript">43</style></DisplayText><record><rec-number>323</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1468416506">323</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Eisman, J. A.</author></authors></contributors><auth-address>Bone and Mineral Research Program, St. Vincent's Hospital, Sydney, New South Wales, Australia. j.eisman@garvan.unsw.edu.au</auth-address><titles><title>Genetics of osteoporosis</title><secondary-title>Endocr Rev</secondary-title><alt-title>Endocrine reviews</alt-title></titles><periodical><full-title>Endocr Rev</full-title><abbr-1>Endocrine reviews</abbr-1></periodical><alt-periodical><full-title>Endocr Rev</full-title><abbr-1>Endocrine reviews</abbr-1></alt-periodical><pages>788-804</pages><volume>20</volume><number>6</number><keywords><keyword>Animals</keyword><keyword>Bone and Bones/anatomy & histology</keyword><keyword>Collagen/genetics</keyword><keyword>Genetic Predisposition to Disease</keyword><keyword>Humans</keyword><keyword>Osteoporosis/*genetics</keyword><keyword>Phenotype</keyword><keyword>Receptors, Calcitriol/genetics</keyword></keywords><dates><year>1999</year><pub-dates><date>Dec</date></pub-dates></dates><isbn>0163-769X (Print)
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ADDIN EN.CITE.DATA 44,45.After PBM, the skeleton gets weaker with agePEVuZE5vdGU+PENpdGU+PEF1dGhvcj5BaGxib3JnPC9BdXRob3I+PFllYXI+MjAwMzwvWWVhcj48
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ADDIN EN.CITE.DATA 42, resulting in an exponentially increased fracture riskPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5GYXVsa25lcjwvQXV0aG9yPjxZZWFyPjIwMDA8L1llYXI+
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ADDIN EN.CITE.DATA 48, this point has been defined by the World Health Organization, (WHO), as 2.5 or more standard deviations (SD) lower BMD (bone mineral density) than the mean value of young healthy adults of the same gender, also referred to as T-score –2.5 (Table 1). Since bone fragility and greatly increased fracture risk is the major clinical manifestation, osteoporosis is also “a systemic skeletal disorder characterized by low bone mass and micro-architectural deterioration of bone tissue” according to WHO ADDIN EN.CITE <EndNote><Cite><Year>1994</Year><RecNum>451</RecNum><DisplayText><style face="superscript">49</style></DisplayText><record><rec-number>451</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1475329296">451</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors></contributors><titles><title>Assessment of fracture risk and its application to screening for postmenopausal osteoporosis. Report of a WHO Study Group</title><secondary-title>World Health Organ Tech Rep Ser</secondary-title><alt-title>World Health Organization technical report series</alt-title></titles><periodical><full-title>World Health Organ Tech Rep Ser</full-title><abbr-1>World Health Organization technical report series</abbr-1></periodical><alt-periodical><full-title>World Health Organ Tech Rep Ser</full-title><abbr-1>World Health Organization technical report series</abbr-1></alt-periodical><pages>1-129</pages><volume>843</volume><keywords><keyword>Aged</keyword><keyword>Bone Density</keyword><keyword>Female</keyword><keyword>Fractures, Bone/*epidemiology/etiology/prevention & control</keyword><keyword>Humans</keyword><keyword>Mass Screening/*methods</keyword><keyword>Middle Aged</keyword><keyword>Osteoporosis, Postmenopausal/*complications/diagnosis/prevention &</keyword><keyword>control/therapy</keyword><keyword>Risk Factors</keyword><keyword>World Health Organization</keyword></keywords><dates><year>1994</year></dates><isbn>0512-3054 (Print)
0512-3054 (Linking)</isbn><accession-num>7941614</accession-num><urls><related-urls><url>. Primary osteoporosis is the result of aging, menopause and/or lifestyle factors without any underlying disease, while secondary osteoporosis is, at least partly, due to an underlying disease ADDIN EN.CITE <EndNote><Cite><Author>SBU</Author><Year>2003</Year><RecNum>333</RecNum><DisplayText><style face="superscript">50</style></DisplayText><record><rec-number>333</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1468497585">333</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>SBU</author></authors></contributors><titles><title>The Swedish Council on Technology Assessment in Health Care. Oesoporos-prevention, diagnostik och behandling.</title></titles><pages>377</pages><volume>1</volume><dates><year>2003</year></dates><urls></urls></record></Cite></EndNote>50.PBM has been suggested as the single most important factor in the development of osteoporosisPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5IZWFuZXk8L0F1dGhvcj48WWVhcj4yMDAwPC9ZZWFyPjxS
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ADDIN EN.CITE.DATA 51 and up to half of the variance in bone mass at age 70 is estimated to be predicted by PBM ADDIN EN.CITE <EndNote><Cite><Author>Hui</Author><Year>1990</Year><RecNum>80</RecNum><DisplayText><style face="superscript">52</style></DisplayText><record><rec-number>80</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1392362927">80</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Hui, S. L.</author><author>Slemenda, C. W.</author><author>Johnston, C. C., Jr.</author></authors></contributors><auth-address>Department of Medicine, Indiana University School of Medicine, Indianapolis.</auth-address><titles><title>The contribution of bone loss to postmenopausal osteoporosis</title><secondary-title>Osteoporos Int</secondary-title><alt-title>Osteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA</alt-title></titles><periodical><full-title>Osteoporos Int</full-title><abbr-1>Osteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA</abbr-1></periodical><alt-periodical><full-title>Osteoporos Int</full-title><abbr-1>Osteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA</abbr-1></alt-periodical><pages>30-4</pages><volume>1</volume><number>1</number><keywords><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>*Bone Density</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Middle Aged</keyword><keyword>Osteoporosis, Postmenopausal/*physiopathology</keyword></keywords><dates><year>1990</year><pub-dates><date>Oct</date></pub-dates></dates><isbn>0937-941X (Print)
0937-941X (Linking)</isbn><accession-num>2133638</accession-num><urls><related-urls><url>, this does not seem farfetched. Table 1. The WHO definition of osteoporosis by use of T-score ADDIN EN.CITE <EndNote><Cite><Year>1994</Year><RecNum>451</RecNum><DisplayText><style face="superscript">49</style></DisplayText><record><rec-number>451</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1475329296">451</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors></contributors><titles><title>Assessment of fracture risk and its application to screening for postmenopausal osteoporosis. Report of a WHO Study Group</title><secondary-title>World Health Organ Tech Rep Ser</secondary-title><alt-title>World Health Organization technical report series</alt-title></titles><periodical><full-title>World Health Organ Tech Rep Ser</full-title><abbr-1>World Health Organization technical report series</abbr-1></periodical><alt-periodical><full-title>World Health Organ Tech Rep Ser</full-title><abbr-1>World Health Organization technical report series</abbr-1></alt-periodical><pages>1-129</pages><volume>843</volume><keywords><keyword>Aged</keyword><keyword>Bone Density</keyword><keyword>Female</keyword><keyword>Fractures, Bone/*epidemiology/etiology/prevention & control</keyword><keyword>Humans</keyword><keyword>Mass Screening/*methods</keyword><keyword>Middle Aged</keyword><keyword>Osteoporosis, Postmenopausal/*complications/diagnosis/prevention &</keyword><keyword>control/therapy</keyword><keyword>Risk Factors</keyword><keyword>World Health Organization</keyword></keywords><dates><year>1994</year></dates><isbn>0512-3054 (Print)
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ADDIN EN.CITE.DATA 53 and depends on both the mechanical and structural properties of the bone ADDIN EN.CITE <EndNote><Cite><Author>Seeman</Author><Year>2008</Year><RecNum>338</RecNum><DisplayText><style face="superscript">54</style></DisplayText><record><rec-number>338</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1468855616">338</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Seeman, E.</author></authors></contributors><auth-address>Department of Endocrinology and Medicine, Austin Hospital, Austin Health, Heidelberg 3084, Melbourne, Australia. egos@unimelb.edu.au</auth-address><titles><title>Bone quality: the material and structural basis of bone strength</title><secondary-title>J Bone Miner Metab</secondary-title><alt-title>Journal of bone and mineral metabolism</alt-title></titles><periodical><full-title>J Bone Miner Metab</full-title><abbr-1>Journal of bone and mineral metabolism</abbr-1></periodical><alt-periodical><full-title>J Bone Miner Metab</full-title><abbr-1>Journal of bone and mineral metabolism</abbr-1></alt-periodical><pages>1-8</pages><volume>26</volume><number>1</number><keywords><keyword>Adult</keyword><keyword>Aging</keyword><keyword>Animals</keyword><keyword>Bone Density</keyword><keyword>Bone Remodeling</keyword><keyword>Bone and Bones/*anatomy & histology/*physiology</keyword><keyword>Female</keyword><keyword>Femur Neck/anatomy & histology</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Sex Characteristics</keyword><keyword>Spine/growth & development</keyword></keywords><dates><year>2008</year></dates><isbn>0914-8779 (Print)
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ADDIN EN.CITE.DATA 58,59. During growth, bone modeling is the primary factor associated with exercise-induced changes in cortical bone geometry and mass distribution around the center of mass or neutral axis (polar distribution) ADDIN EN.CITE <EndNote><Cite><Author>Seeman</Author><Year>2008</Year><RecNum>269</RecNum><DisplayText><style face="superscript">60</style></DisplayText><record><rec-number>269</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1462459383">269</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Seeman, E.</author></authors></contributors><auth-address>Department of Endocrinology and Medicine, Austin Health, University ofMelbourne, Melbourne, Australia. egos@unimelb.edu.au</auth-address><titles><title>Structural basis of growth-related gain and age-related loss of bone strength</title><secondary-title>Rheumatology (Oxford)</secondary-title><alt-title>Rheumatology</alt-title></titles><periodical><full-title>Rheumatology (Oxford)</full-title><abbr-1>Rheumatology</abbr-1></periodical><alt-periodical><full-title>Rheumatology (Oxford)</full-title><abbr-1>Rheumatology</abbr-1></alt-periodical><pages>iv2-8</pages><volume>47 Suppl 4</volume><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Aged</keyword><keyword>*Bone Density</keyword><keyword>Bone Development/*physiology</keyword><keyword>Bone Remodeling/physiology</keyword><keyword>Bone and Bones/*physiopathology</keyword><keyword>Child</keyword><keyword>Child, Preschool</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Infant</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Osteoporosis/*physiopathology</keyword><keyword>Sex Factors</keyword></keywords><dates><year>2008</year><pub-dates><date>Jul</date></pub-dates></dates><isbn>1462-0332 (Electronic)
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ADDIN EN.CITE.DATA 61,62.Risk factorsThe most important risk factor for osteoporosis is natural aging, an unalterable risk factor that over time leads to an increasing fracture risk independent of the level of BMD. Other similar risk factors are gender, ethnicity and age at menopause, all of which are also risk factors for fracture and falls. Since hereditary and lifestyle factors influence the level of BMD, several other risk factors have been found through research within these areas, including genetic variance that explains the diseasePEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Ib3dhcmQ8L0F1dGhvcj48WWVhcj4xOTk4PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA 66. For example, an increase in bone size with unchanged amount of mineral would result in an unchanged BMC while aBMD would decrease. When the accrual of mineral and gain in bone size are similar, the BMC increases and the aBMD remains unchanged. Only when the relative accrual of mineral is greater than the gain in bone size does the aBMD increase. Most methods for estimating the mineralization of bone use ionizing radiation while others are non-ionizing (Table 2). Magnetic Resonance Imaging (MRI) and ultrasound are examples of non-ionizing methods. The techniques utilizing ionizing radiation depend on either gamma radiation or X-rays ADDIN EN.CITE <EndNote><Cite><Year>1997</Year><RecNum>343</RecNum><DisplayText><style face="superscript">67</style></DisplayText><record><rec-number>343</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1469022706">343</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors></contributors><titles><title>Bone density measurement--a systematic review. A report from SBU, the Swedish Council on Technology Assessment in Health Care</title><secondary-title>J Intern Med Suppl</secondary-title><alt-title>Journal of internal medicine. Supplement</alt-title></titles><periodical><full-title>J Intern Med Suppl</full-title><abbr-1>Journal of internal medicine. Supplement</abbr-1></periodical><alt-periodical><full-title>J Intern Med Suppl</full-title><abbr-1>Journal of internal medicine. Supplement</abbr-1></alt-periodical><pages>1-60</pages><volume>739</volume><keywords><keyword>*Bone Density</keyword><keyword>Case-Control Studies</keyword><keyword>*Densitometry/economics/methods</keyword><keyword>Female</keyword><keyword>Fractures, Bone/physiopathology</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Mass Screening/*methods</keyword><keyword>Meta-Analysis as Topic</keyword><keyword>Osteoporosis/*diagnosis/*physiopathology/radiography/ultrasonography</keyword><keyword>Research Design</keyword><keyword>Risk</keyword><keyword>*Tomography, X-Ray Computed/economics</keyword></keywords><dates><year>1997</year></dates><isbn>0955-7873 (Print)
0955-7873 (Linking)</isbn><accession-num>9104441</accession-num><urls><related-urls><url> but all use the amount of ionizing radiation absorbed by the bone to estimate the amount of mineral. Dual-energy X-ray absorptiometry (DXA) and peripheral quantitative computed tomography (pQCT) are the most common techniques in this group today.Table 2. Examples of methods for measuring bone mineral. Non-IonizingIonizingGamma RadiationX-rayQuantitative Ultrasound(QUS)Single Photon Absorptiometry (SPA)Single X-ray absorptiometry(SXA)Magnetic Resonance Imaging (MRI)Dual Photon Absorptiometry (DPA)Dual-Energy X-ray Absorptiometry (DXA)Peripheral Computed Tomography (pQCT)Dual-energy X-ray absorptiometry (DXA)DXA (Figure 4) uses an X-ray generator as radiation source and a filter to send out two different energy levels ADDIN EN.CITE <EndNote><Cite><Author>Laskey</Author><Year>1996</Year><RecNum>344</RecNum><DisplayText><style face="superscript">68</style></DisplayText><record><rec-number>344</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1469343092">344</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Laskey, M. A.</author></authors></contributors><auth-address>MRC Dunn Nutritional Laboratory, Cambridge, UK.</auth-address><titles><title>Dual-energy X-ray absorptiometry and body composition</title><secondary-title>Nutrition</secondary-title><alt-title>Nutrition</alt-title></titles><periodical><full-title>Nutrition</full-title><abbr-1>Nutrition</abbr-1></periodical><alt-periodical><full-title>Nutrition</full-title><abbr-1>Nutrition</abbr-1></alt-periodical><pages>45-51</pages><volume>12</volume><number>1</number><keywords><keyword>*Absorptiometry, Photon/statistics & numerical data</keyword><keyword>*Body Composition</keyword><keyword>Bone Density</keyword><keyword>Humans</keyword><keyword>Radiation Dosage</keyword><keyword>Sensitivity and Specificity</keyword></keywords><dates><year>1996</year><pub-dates><date>Jan</date></pub-dates></dates><isbn>0899-9007 (Print)
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ADDIN EN.CITE.DATA 69,70. DXA can measure any body part and uses a relatively low radiation dose (1–8 ?Sv), which corresponds to 1/1000 of the yearly background radiation dose ADDIN EN.CITE <EndNote><Cite><Author>Damilakis</Author><Year>2010</Year><RecNum>349</RecNum><DisplayText><style face="superscript">71</style></DisplayText><record><rec-number>349</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1469344292">349</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Damilakis, J.</author><author>Adams, J. E.</author><author>Guglielmi, G.</author><author>Link, T. M.</author></authors></contributors><auth-address>Department of Medical Physics, Faculty of Medicine, University of Crete, PO Box 2208, 71003 Iraklion, Crete, Greece. damilaki@med.uoc.gr</auth-address><titles><title>Radiation exposure in X-ray-based imaging techniques used in osteoporosis</title><secondary-title>Eur Radiol</secondary-title><alt-title>European radiology</alt-title></titles><periodical><full-title>Eur Radiol</full-title><abbr-1>European radiology</abbr-1></periodical><alt-periodical><full-title>Eur Radiol</full-title><abbr-1>European radiology</abbr-1></alt-periodical><pages>2707-14</pages><volume>20</volume><number>11</number><keywords><keyword>*Absorptiometry, Photon</keyword><keyword>Bone Density</keyword><keyword>Bone and Bones/radiation effects</keyword><keyword>Humans</keyword><keyword>Osteoporosis/*radiography</keyword><keyword>Osteoporotic Fractures/radiography</keyword><keyword>Radiation Dosage</keyword><keyword>*Tomography, X-Ray Computed</keyword></keywords><dates><year>2010</year><pub-dates><date>Nov</date></pub-dates></dates><isbn>1432-1084 (Electronic)
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ADDIN EN.CITE.DATA 73.Figure 4. Dual energy X-ray absorptiometry (DXA) scanner. Photo by Nick Smith photography (ALSPAC). Peripheral quantitative computed tomography (pQCT)Quantitative computed tomography (Figure 5) uses a higher radiation dose than DXA ADDIN EN.CITE <EndNote><Cite><Author>Damilakis</Author><Year>2010</Year><RecNum>349</RecNum><DisplayText><style face="superscript">71</style></DisplayText><record><rec-number>349</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1469344292">349</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Damilakis, J.</author><author>Adams, J. E.</author><author>Guglielmi, G.</author><author>Link, T. M.</author></authors></contributors><auth-address>Department of Medical Physics, Faculty of Medicine, University of Crete, PO Box 2208, 71003 Iraklion, Crete, Greece. damilaki@med.uoc.gr</auth-address><titles><title>Radiation exposure in X-ray-based imaging techniques used in osteoporosis</title><secondary-title>Eur Radiol</secondary-title><alt-title>European radiology</alt-title></titles><periodical><full-title>Eur Radiol</full-title><abbr-1>European radiology</abbr-1></periodical><alt-periodical><full-title>Eur Radiol</full-title><abbr-1>European radiology</abbr-1></alt-periodical><pages>2707-14</pages><volume>20</volume><number>11</number><keywords><keyword>*Absorptiometry, Photon</keyword><keyword>Bone Density</keyword><keyword>Bone and Bones/radiation effects</keyword><keyword>Humans</keyword><keyword>Osteoporosis/*radiography</keyword><keyword>Osteoporotic Fractures/radiography</keyword><keyword>Radiation Dosage</keyword><keyword>*Tomography, X-Ray Computed</keyword></keywords><dates><year>2010</year><pub-dates><date>Nov</date></pub-dates></dates><isbn>1432-1084 (Electronic)
0938-7994 (Linking)</isbn><accession-num>20559834</accession-num><urls><related-urls><url>. In children, only peripheral images, usually at the tibia or radius, are acceptable, as the radiation dose in these parts remains under 10 ?SvPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5EYW1pbGFraXM8L0F1dGhvcj48WWVhcj4yMDEwPC9ZZWFy
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ADDIN EN.CITE.DATA 71,74. This technique creates a virtual three-dimensional image, enabling visualization of the microarchitecture and distribution of bone and soft tissue. This also enables calculation of bone parameters such as mineral mass, vBMD, cortical thickness and strength strain index (SSI), supplying even more information regarding bone strength and resistance to fracture.Figure 5. A peripheral quantitative computed tomography (pQCT) apparatus, (XCT 2000 Stratec? Pforzheim).MusclePhysiologyMuscular tissue is built from muscle fibers, where each fiber contains thousands of thin strands, called myofibrils. Two overlapping protein filaments, actin and myosin, constitute myofibrils, and it is the interaction between actin and myosin that produces muscular contraction ADDIN EN.CITE <EndNote><Cite><Author>Huxley</Author><Year>1974</Year><RecNum>354</RecNum><DisplayText><style face="superscript">75</style></DisplayText><record><rec-number>354</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1469546718">354</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Huxley, A. F.</author></authors></contributors><titles><title>Muscular contraction</title><secondary-title>J Physiol</secondary-title><alt-title>The Journal of physiology</alt-title></titles><periodical><full-title>J Physiol</full-title><abbr-1>The Journal of physiology</abbr-1></periodical><alt-periodical><full-title>J Physiol</full-title><abbr-1>The Journal of physiology</abbr-1></alt-periodical><pages>1-43</pages><volume>243</volume><number>1</number><keywords><keyword>Actins/metabolism</keyword><keyword>Action Potentials</keyword><keyword>Adenosine Triphosphate/metabolism</keyword><keyword>Animals</keyword><keyword>Anura</keyword><keyword>Biomechanical Phenomena</keyword><keyword>Calcium/metabolism</keyword><keyword>Creatine/metabolism</keyword><keyword>Elasticity</keyword><keyword>Electric Stimulation</keyword><keyword>In Vitro Techniques</keyword><keyword>Membrane Potentials</keyword><keyword>Models, Biological</keyword><keyword>*Muscle Contraction</keyword><keyword>Muscles/metabolism/physiology</keyword><keyword>Myofibrils/metabolism/physiology</keyword><keyword>Myosins/metabolism</keyword></keywords><dates><year>1974</year><pub-dates><date>Nov</date></pub-dates></dates><isbn>0022-3751 (Print)
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ADDIN EN.CITE.DATA 77,78. Genetics largely determines the distribution of the two muscle fiber types, and conversion between type I and type II fibers is rare ADDIN EN.CITE <EndNote><Cite><Author>Ingalls</Author><Year>2004</Year><RecNum>383</RecNum><DisplayText><style face="superscript">79</style></DisplayText><record><rec-number>383</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1471093277">383</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Ingalls, C. P.</author></authors></contributors><titles><title>Nature vs. nurture: can exercise really alter fiber type composition in human skeletal muscle?</title><secondary-title>J Appl Physiol (1985)</secondary-title><alt-title>Journal of applied physiology</alt-title></titles><periodical><full-title>J Appl Physiol (1985)</full-title><abbr-1>Journal of applied physiology</abbr-1></periodical><alt-periodical><full-title>J Appl Physiol (1985)</full-title><abbr-1>Journal of applied physiology</abbr-1></alt-periodical><pages>1591-2</pages><volume>97</volume><number>5</number><keywords><keyword>*Exercise/physiology</keyword><keyword>History, 20th Century</keyword><keyword>Humans</keyword><keyword>*Muscle Fibers, Skeletal/physiology</keyword><keyword>*Muscle, Skeletal/physiology</keyword><keyword>Physiology/*history</keyword><keyword>United States</keyword></keywords><dates><year>2004</year><pub-dates><date>Nov</date></pub-dates></dates><isbn>8750-7587 (Print)
0161-7567 (Linking)</isbn><accession-num>15475545</accession-num><urls><related-urls><url> 6. The anatomy of a muscle fiber. There are three types of muscle contractions, concentric, eccentric and isometric. Concentric contraction is a contraction during shortening of the muscle, eccentric contraction is a contraction during elongation of the muscle and isometric contraction is a contraction during which the muscle maintains its length. During any motion all three types of contractions usually occur simultaneously in different muscle groups ADDIN EN.CITE <EndNote><Cite><Author>Rowland</Author><Year>1996</Year><RecNum>356</RecNum><DisplayText><style face="superscript">80</style></DisplayText><record><rec-number>356</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1469548090">356</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Rowland, TW</author></authors></contributors><titles><title>Developmental exercise physiology</title></titles><pages>215-230</pages><dates><year>1996</year></dates><urls></urls></record></Cite></EndNote>80.Muscle strengthDefined as “the amount of force that can be produced by a muscle in a single contraction”, muscle strength reflects the tension created when actin slides past myosin filaments within the muscle fibrils ADDIN EN.CITE <EndNote><Cite><Author>Rowland</Author><Year>1996</Year><RecNum>356</RecNum><DisplayText><style face="superscript">80</style></DisplayText><record><rec-number>356</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1469548090">356</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Rowland, TW</author></authors></contributors><titles><title>Developmental exercise physiology</title></titles><pages>215-230</pages><dates><year>1996</year></dates><urls></urls></record></Cite></EndNote>80. In children, muscle strength is associated with age, height and/or body stature, weight, gender and sexual maturityPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5EYWx5PC9BdXRob3I+PFllYXI+MjAxMzwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA 84. There is however a need for further research to determine the validity of this much-used method in children ADDIN EN.CITE <EndNote><Cite><Author>Jones</Author><Year>2000</Year><RecNum>365</RecNum><DisplayText><style face="superscript">85</style></DisplayText><record><rec-number>365</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1469618494">365</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Jones,</author><author>Stratton, G.</author></authors></contributors><auth-address>Department of Movement Science and Physical Education, University of Liverpool, England, UK. maj501@liverpool.ac.uk</auth-address><titles><title>Muscle function assessment in children</title><secondary-title>Acta Paediatr</secondary-title><alt-title>Acta paediatrica</alt-title></titles><periodical><full-title>Acta Paediatr</full-title><abbr-1>Acta paediatrica</abbr-1></periodical><alt-periodical><full-title>Acta Paediatr</full-title><abbr-1>Acta paediatrica</abbr-1></alt-periodical><pages>753-61</pages><volume>89</volume><number>7</number><keywords><keyword>Adolescent</keyword><keyword>Biomechanical Phenomena</keyword><keyword>Child</keyword><keyword>Diagnostic Techniques and Procedures/instrumentation</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Isometric Contraction</keyword><keyword>Male</keyword><keyword>Muscle Weakness/diagnosis</keyword><keyword>Muscles/*physiology</keyword><keyword>Muscular Diseases/*diagnosis</keyword><keyword>Reproducibility of Results</keyword></keywords><dates><year>2000</year><pub-dates><date>Jul</date></pub-dates></dates><isbn>0803-5253 (Print)
0803-5253 (Linking)</isbn><accession-num>10943949</accession-num><urls><related-urls><url>. Another method with high specificity is to utilize standardized weights during isotonic strength measurement, but this method is limited as it measures the maximum strength at the weakest point in the motion range ADDIN EN.CITE <EndNote><Cite><Author>Baker</Author><Year>1994</Year><RecNum>366</RecNum><DisplayText><style face="superscript">86</style></DisplayText><record><rec-number>366</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1469618838">366</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Baker, D.</author><author>Wilson, G.</author><author>Carlyon, B.</author></authors></contributors><auth-address>Centre for Human Movement Science and Sports Management, University of New England-Northern Rivers, NSW, Australia.</auth-address><titles><title>Generality versus specificity: a comparison of dynamic and isometric measures of strength and speed-strength</title><secondary-title>Eur J Appl Physiol Occup Physiol</secondary-title><alt-title>European journal of applied physiology and occupational physiology</alt-title></titles><periodical><full-title>Eur J Appl Physiol Occup Physiol</full-title><abbr-1>European journal of applied physiology and occupational physiology</abbr-1></periodical><alt-periodical><full-title>Eur J Appl Physiol Occup Physiol</full-title><abbr-1>European journal of applied physiology and occupational physiology</abbr-1></alt-periodical><pages>350-5</pages><volume>68</volume><number>4</number><keywords><keyword>Adult</keyword><keyword>Humans</keyword><keyword>*Isometric Contraction</keyword><keyword>Male</keyword><keyword>*Muscle Contraction</keyword><keyword>Muscles/*physiology</keyword><keyword>Physical Education and Training</keyword><keyword>Time Factors</keyword></keywords><dates><year>1994</year></dates><isbn>0301-5548 (Print)
0301-5548 (Linking)</isbn><accession-num>8055895</accession-num><urls><related-urls><url> School PerformancePhysiologyThe brain and the spinal cord constitute the central nervous system (CNS). Together with the peripheral nervous system (PNS) it can relay information to and from the brain to different parts of the body, thus allowing movement and sensory input. The brain is the body’s control center, constantly receiving and interpreting nerve signals from the body, and it responds based on this information ADDIN EN.CITE <EndNote><Cite><Author>Society</Author><Year>2010</Year><RecNum>367</RecNum><DisplayText><style face="superscript">87</style></DisplayText><record><rec-number>367</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1470127467">367</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>American Cancer Society</author></authors></contributors><titles><title>Brain and Spinal Cord Tumors in Adults</title></titles><dates><year>2010</year></dates><urls></urls></record></Cite></EndNote>87. The largest part of the brain, the cerebrum, is divided into two hemispheres, where the right hemisphere controls the left side of the body and the left hemisphere controls the right side of the body. The outer surface of the cerebrum is called the cerebral cortex or gray matter. It is the area of the brain where nerve cells (neurons) make connections, called synapses. Neurons might not be replaced or repaired if they are damaged. The inner area of the cerebrum, called the white matter, contains the insulated (myelinated) bodies of the nerve cells (axons) that relay information between the brain and spinal cord (Figure 7). Figure 7. Cross section visualisation of the brain, with its gray (cortex) and white matter. Figure by NIH Medline. The cerebrum is further divided into 4 sections on each side, called the frontal, parietal, temporal and occipital lobes (Figure 8). The frontal lobe is thought to control movement, speech, behavior, memory, emotions and intellectual functioning, such as thought processes, reasoning, problem solving, decision making and planning. The parietal lobes on the other hand seem to control sensations, such as touch, pressure, pain and temperature, and also spatial orientation (understanding of size, shape and direction). The temporal lobes are responsible for hearing, memory and emotions and the left temporal lobe also most often controls the speech. Vision has been found to be represented mainly in the occipital lobes ADDIN EN.CITE <EndNote><Cite><Author>Society</Author><Year>2010</Year><RecNum>367</RecNum><DisplayText><style face="superscript">87</style></DisplayText><record><rec-number>367</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1470127467">367</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>American Cancer Society</author></authors></contributors><titles><title>Brain and Spinal Cord Tumors in Adults</title></titles><dates><year>2010</year></dates><urls></urls></record></Cite></EndNote>87.Figure 8. The lobes of the brain. Concentration is an overall control of thoughts and actions through focus, endurance and attention of the mind ADDIN EN.CITE <EndNote><Cite><Author>Barkley</Author><Year>1997</Year><RecNum>368</RecNum><DisplayText><style face="superscript">88,89</style></DisplayText><record><rec-number>368</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1470129013">368</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Barkley, R</author></authors></contributors><titles><title>ADHD and the nature of self-control. </title><secondary-title>The Guilford Press</secondary-title></titles><periodical><full-title>The Guilford Press</full-title></periodical><dates><year>1997</year></dates><urls></urls></record></Cite><Cite><Author>Duvner</Author><Year>1997</Year><RecNum>369</RecNum><record><rec-number>369</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1470129059">369</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Duvner, T</author></authors></contributors><titles><title>ADHD</title><secondary-title>Liber</secondary-title></titles><periodical><full-title>Liber</full-title></periodical><dates><year>1997</year></dates><urls></urls></record></Cite></EndNote>88,89. Learning ability is closely connected to concentration, and neither has a specific anatomical location in the brain or body. Several factors have been postulated to affect concentration and academic performance, such as the support and availability of the parents, socio-economic level, parental education and PAPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5GYXJvb3E8L0F1dGhvcj48WWVhcj4yMDExPC9ZZWFyPjxS
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ADDIN EN.CITE.DATA 90-92. During recent decades there has been a trend of decreasing school results in several western countries ADDIN EN.CITE <EndNote><Cite><Year>2010</Year><RecNum>273</RecNum><DisplayText><style face="superscript">93</style></DisplayText><record><rec-number>273</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1462948287">273</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors></contributors><titles><title>Organisation for Co-operation and Development. PISA 2009</title><secondary-title>Results: Learning trends: Changes in Student Performance Since 2000. OECD Publishing, Paris. Available from: : Learning trends: Changes in Student Performance Since 2000. OECD Publishing, Paris. Available from: and therefore it should be considered an international issue.MeasurementsThe most common way to evaluate academic performance is through grades or grade point average (GPA). Within this system, different countries use different grading systems, some use numbers (e.g. 1–6) and others use letters (e.g. A–F) ADDIN EN.CITE <EndNote><Cite><Author>York</Author><Year>2015</Year><RecNum>385</RecNum><DisplayText><style face="superscript">94</style></DisplayText><record><rec-number>385</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1471094921">385</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>York, TT. </author><author>Gibson, C. </author><author>Rankin, S. </author></authors></contributors><titles><title>Defining and Measuring Academic Success</title><secondary-title>Practical Assessment, Research & Evaluation.</secondary-title></titles><periodical><full-title>Practical Assessment, Research & Evaluation.</full-title></periodical><volume>20</volume><number>5</number><dates><year>2015</year></dates><isbn>1531-7714</isbn><urls></urls></record></Cite></EndNote>94. In Sweden there have been several different grading systems in use just during the last century. From 1897 to 1962 there was a seven-step grading system utilizing capital and small letters from a to c, either as single letters and as combinations. Then there was a five-step system using the numbers 1 to 5. In 1994, Sweden changed to a four-step system including the grades; Failed (0 points), Passed (10 points), Passed with Distinction (15 points) and Passed with Special Distinction (20 points), as a combined name- and points-system. Finally, in 2013 Sweden switched back to a letter-based grading system, this time running from A to F in six steps ADDIN EN.CITE <EndNote><Cite><Year>2014</Year><RecNum>370</RecNum><DisplayText><style face="superscript">95</style></DisplayText><record><rec-number>370</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1470164780">370</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors></contributors><titles><title>Swedish National Agency for Education. </title><secondary-title>Grading systems. Available from: systems. Available from: measurement for academic performance on a general level is the proportion of children with eligibility for upper secondary school programs. To qualify for national upper secondary school programs in Sweden the grade Passed in each of the subjects Swedish, English and Mathematics was required from 1994–2012. During recent decades the proportion of Swedish children who finished the 9th and final year of the compulsory school with eligibility for upper secondary school programs has decreased ADDIN EN.CITE <EndNote><Cite><Year>2015</Year><RecNum>272</RecNum><DisplayText><style face="superscript">96,97</style></DisplayText><record><rec-number>272</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1462948210">272</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors></contributors><titles><title>Swedish National Agency for Education. </title><secondary-title>Final Grades in Mandatory School, Spring 2015. Available from: Grades in Mandatory School, Spring 2015. Available from: app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1462948124">271</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors></contributors><titles><title>Organisation for Co-operation and Development. </title><secondary-title>Improving schools in Sweden: an OECD perspective. OECD Publishing, Paris. Available from: schools in Sweden: an OECD perspective. OECD Publishing, Paris. Available from: . The proportion of eligible students was only 86% in 2015, the lowest proportion since 1998 ADDIN EN.CITE <EndNote><Cite><Year>2015</Year><RecNum>272</RecNum><DisplayText><style face="superscript">96</style></DisplayText><record><rec-number>272</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1462948210">272</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors></contributors><titles><title>Swedish National Agency for Education. </title><secondary-title>Final Grades in Mandatory School, Spring 2015. Available from: Grades in Mandatory School, Spring 2015. Available from: . The decrease is a paradox since researchers claim that 100% of Swedish pupils have the potential and capacity to reach the goals for a pass grade in all school subjects ADDIN EN.CITE <EndNote><Cite><Author>Ekman</Author><Year>2010</Year><RecNum>235</RecNum><DisplayText><style face="superscript">98</style></DisplayText><record><rec-number>235</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1456100678">235</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Ekman, R. </author><author>Dolan, T.</author></authors></contributors><titles><title>Kunskap om hj?rnan kan ge b?ttre skola [Knowledge about the brain can lead to a better school].</title><secondary-title>Sydsvenska Dagbladet 21 October 2010: A5.</secondary-title></titles><periodical><full-title>Sydsvenska Dagbladet 21 October 2010: A5.</full-title></periodical><dates><year>2010</year></dates><urls></urls></record></Cite></EndNote>98.Physical activityThe most commonly used definition of physical activity is “any bodily movement produced by the contraction of muscle that results in energy expenditure” ADDIN EN.CITE <EndNote><Cite><Author>Caspersen</Author><Year>1985</Year><RecNum>445</RecNum><DisplayText><style face="superscript">99</style></DisplayText><record><rec-number>445</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1472028253">445</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Caspersen, C. J.</author><author>Powell, K. E.</author><author>Christenson, G. M.</author></authors></contributors><titles><title>Physical activity, exercise, and physical fitness: definitions and distinctions for health-related research</title><secondary-title>Public Health Rep</secondary-title><alt-title>Public health reports</alt-title></titles><periodical><full-title>Public Health Rep</full-title><abbr-1>Public health reports</abbr-1></periodical><alt-periodical><full-title>Public Health Rep</full-title><abbr-1>Public health reports</abbr-1></alt-periodical><pages>126-31</pages><volume>100</volume><number>2</number><keywords><keyword>Energy Metabolism</keyword><keyword>Humans</keyword><keyword>*Physical Exertion</keyword><keyword>*Physical Fitness</keyword><keyword>Research</keyword><keyword>*Terminology as Topic</keyword></keywords><dates><year>1985</year><pub-dates><date>Mar-Apr</date></pub-dates></dates><isbn>0033-3549 (Print)
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ADDIN EN.CITE.DATA 104,105 with the obvious limitation of subjectivity but with the advantage of low-cost and ease to administer. Doubly labeled water (DLW), heart rate monitors (HRM), pedometers and accelerometers are all objective measurements but have different limitations including high cost and no information about intensity, duration or frequency for the DLW ADDIN EN.CITE <EndNote><Cite><Author>Schoeller</Author><Year>1982</Year><RecNum>396</RecNum><DisplayText><style face="superscript">106</style></DisplayText><record><rec-number>396</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1471165811">396</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Schoeller, D. A.</author><author>van Santen, E.</author></authors></contributors><titles><title>Measurement of energy expenditure in humans by doubly labeled water method</title><secondary-title>J Appl Physiol Respir Environ Exerc Physiol</secondary-title><alt-title>Journal of applied physiology: respiratory, environmental and exercise physiology</alt-title></titles><periodical><full-title>J Appl Physiol Respir Environ Exerc Physiol</full-title><abbr-1>Journal of applied physiology: respiratory, environmental and exercise physiology</abbr-1></periodical><alt-periodical><full-title>J Appl Physiol Respir Environ Exerc Physiol</full-title><abbr-1>Journal of applied physiology: respiratory, environmental and exercise physiology</abbr-1></alt-periodical><pages>955-9</pages><volume>53</volume><number>4</number><keywords><keyword>Body Water/metabolism</keyword><keyword>Deuterium</keyword><keyword>*Energy Metabolism</keyword><keyword>Humans</keyword><keyword>Oxygen Isotopes</keyword><keyword>*Radioisotope Dilution Technique</keyword><keyword>Water/*metabolism</keyword></keywords><dates><year>1982</year><pub-dates><date>Oct</date></pub-dates></dates><isbn>0161-7567 (Print)
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ADDIN EN.CITE.DATA 107, no information about intensity and duration for pedometers ADDIN EN.CITE <EndNote><Cite><Author>Tudor-Locke</Author><Year>2004</Year><RecNum>398</RecNum><DisplayText><style face="superscript">108</style></DisplayText><record><rec-number>398</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1471165938">398</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Tudor-Locke, C.</author><author>Williams, J. E.</author><author>Reis, J. P.</author><author>Pluto, D.</author></authors></contributors><auth-address>Department of Exercise and Wellness, Arizona State University East, Mesa, Arizona 85212, USA.</auth-address><titles><title>Utility of pedometers for assessing physical activity: construct validity</title><secondary-title>Sports Med</secondary-title><alt-title>Sports medicine</alt-title></titles><periodical><full-title>Sports Med</full-title><abbr-1>Sports medicine</abbr-1></periodical><alt-periodical><full-title>Sports Med</full-title><abbr-1>Sports medicine</abbr-1></alt-periodical><pages>281-91</pages><volume>34</volume><number>5</number><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Age Factors</keyword><keyword>Aged</keyword><keyword>Anthropometry</keyword><keyword>Child</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Monitoring, Ambulatory/*instrumentation</keyword><keyword>Motor Activity/*physiology</keyword><keyword>Physical Fitness/physiology</keyword><keyword>Physiology/*instrumentation</keyword><keyword>Reproducibility of Results</keyword></keywords><dates><year>2004</year></dates><isbn>0112-1642 (Print)
0112-1642 (Linking)</isbn><accession-num>15107007</accession-num><urls><related-urls><url> and lack of registration in water and with activities without relative positional change, such as cycling, for accelerometers. During recent decades there has been a reduction in physical education (PE) in school in favor of academic subjects ADDIN EN.CITE <EndNote><Cite><RecNum>275</RecNum><DisplayText><style face="superscript">109</style></DisplayText><record><rec-number>275</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1462949505">275</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors></contributors><titles><title>Committee on Physical Activity and Physical Education in the School Environment</title><secondary-title>Food and Nutrition Board; Institute of Medicine; Kohl HW III, Cook HD, editors. Educating the Student Body: Taking Physical Activity and Physical Education to School. Washington (DC): National Academies Press (US); 2013 Oct 30. Available from: doi: 10.17226/18314</secondary-title></titles><dates><year>2013</year></dates><urls></urls></record></Cite></EndNote>109. In Sweden PE has been reduced from 20% to 7.5% during the most recent three decades ADDIN EN.CITE <EndNote><Cite><Author>Ericsson</Author><Year>2003</Year><RecNum>252</RecNum><DisplayText><style face="superscript">110</style></DisplayText><record><rec-number>252</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1458629337">252</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Ericsson, I.</author></authors></contributors><titles><title>Thesis: Motor skills, attention and academic achievements - An intervention study in school year 1-3.</title><secondary-title>School of Education, Malm? University</secondary-title></titles><periodical><full-title>School of Education, Malm? University</full-title></periodical><dates><year>2003</year></dates><urls></urls></record></Cite></EndNote>110. Also, only six out of 28 countries in Europe offered at least 180 min/week of PE in school ADDIN EN.CITE <EndNote><Cite><Year>2013</Year><RecNum>371</RecNum><DisplayText><style face="superscript">111</style></DisplayText><record><rec-number>371</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1470226881">371</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors></contributors><titles><title>European Commision E, Eurodyce. </title><secondary-title>Physical Education and Sport at School in Europe. </secondary-title></titles><periodical><full-title>Physical Education and Sport at School in Europe.</full-title></periodical><dates><year>2013</year></dates><urls></urls></record></Cite></EndNote>111. PA pattern during adulthood, however, seems moderately reflected by PA behavior during childhoodPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5UYW1tZWxpbjwvQXV0aG9yPjxZZWFyPjIwMDU8L1llYXI+
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ADDIN EN.CITE.DATA 115-118, including programs with different approaches such as physical exercise, home hazard modifications, adjustment of psychotropic medication, modification of multi-pharmacy and anti-slip shoe devices. Falls account for about 15% of vertebral fractures and 90% of hip fracturesPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Db3V0aW5obzwvQXV0aG9yPjxZZWFyPjIwMDg8L1llYXI+
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ADDIN EN.CITE.DATA 121,122. If presenting one or more risk factors, women should be screened at a younger agePEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MaW08L0F1dGhvcj48WWVhcj4yMDA5PC9ZZWFyPjxSZWNO
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ADDIN EN.CITE.DATA 123, while the benefits of screening men are still debatedPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MaW08L0F1dGhvcj48WWVhcj4yMDA5PC9ZZWFyPjxSZWNO
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ADDIN EN.CITE.DATA 126, leaving an open debate between increased short-term fracture risk and long-term musculoskeletal benefits. SkeletonIn 1987, Dr. Harold Frost proposed the idea that bone adapts to the mechanical stress it is exposed to ADDIN EN.CITE <EndNote><Cite><Author>Frost</Author><Year>1987</Year><RecNum>413</RecNum><DisplayText><style face="superscript">127</style></DisplayText><record><rec-number>413</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1471167091">413</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Frost, H. M.</author></authors></contributors><auth-address>Southern Colorado Clinic, Pueblo 81004.</auth-address><titles><title>Bone "mass" and the "mechanostat": a proposal</title><secondary-title>Anat Rec</secondary-title><alt-title>The Anatomical record</alt-title></titles><periodical><full-title>Anat Rec</full-title><abbr-1>The Anatomical record</abbr-1></periodical><alt-periodical><full-title>Anat Rec</full-title><abbr-1>The Anatomical record</abbr-1></alt-periodical><pages>1-9</pages><volume>219</volume><number>1</number><keywords><keyword>Animals</keyword><keyword>Biomechanical Phenomena</keyword><keyword>Bone Development</keyword><keyword>Bone and Bones/*physiology</keyword><keyword>Female</keyword><keyword>Fluorides/pharmacology</keyword><keyword>Genetics</keyword><keyword>Humans</keyword><keyword>Menopause</keyword><keyword>*Models, Biological</keyword><keyword>Osteoporosis/etiology</keyword><keyword>Space Flight</keyword></keywords><dates><year>1987</year><pub-dates><date>Sep</date></pub-dates></dates><isbn>0003-276X (Print)
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ADDIN EN.CITE.DATA 129,130, such as weight lifting, tennis, hockey and soccer ADDIN EN.CITE <EndNote><Cite><Author>Leigey</Author><Year>2009</Year><RecNum>418</RecNum><DisplayText><style face="superscript">131</style></DisplayText><record><rec-number>418</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1471167520">418</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Leigey, D.</author><author>Irrgang, J.</author><author>Francis, K.</author><author>Cohen, P.</author><author>Wright, V.</author></authors></contributors><auth-address>University of Pittsburgh, Pittsburgh, Pennsylvania.</auth-address><titles><title>Participation in high-impact sports predicts bone mineral density in senior olympic athletes</title><secondary-title>Sports Health</secondary-title><alt-title>Sports health</alt-title></titles><periodical><full-title>Sports Health</full-title><abbr-1>Sports health</abbr-1></periodical><alt-periodical><full-title>Sports Health</full-title><abbr-1>Sports health</abbr-1></alt-periodical><pages>508-13</pages><volume>1</volume><number>6</number><dates><year>2009</year><pub-dates><date>Nov</date></pub-dates></dates><isbn>1941-7381 (Print)
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ADDIN EN.CITE.DATA 132,133 whereas no or minimal effects have been shown in endurance sports without weight bearing, such as swimming and cycling ADDIN EN.CITE <EndNote><Cite><Author>Nikander</Author><Year>2005</Year><RecNum>109</RecNum><DisplayText><style face="superscript">133</style></DisplayText><record><rec-number>109</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1392364243">109</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Nikander, R.</author><author>Sievanen, H.</author><author>Heinonen, A.</author><author>Kannus, P.</author></authors></contributors><auth-address>Bone Research Group, UKK Institute for Health Promotion Research, Tampere, Finland. rinikand@cc.jyu.fi</auth-address><titles><title>Femoral neck structure in adult female athletes subjected to different loading modalities</title><secondary-title>J Bone Miner Res</secondary-title><alt-title>Journal of bone and mineral research : the official journal of the American Society for Bone and Mineral Research</alt-title></titles><periodical><full-title>J Bone Miner Res</full-title><abbr-1>Journal of bone and mineral research : the official journal of the American Society for Bone and Mineral Research</abbr-1></periodical><alt-periodical><full-title>J Bone Miner Res</full-title><abbr-1>Journal of bone and mineral research : the official journal of the American Society for Bone and Mineral Research</abbr-1></alt-periodical><pages>520-8</pages><volume>20</volume><number>3</number><keywords><keyword>Adult</keyword><keyword>Bone Density/*physiology</keyword><keyword>Female</keyword><keyword>Femur Neck/*physiology/radiography</keyword><keyword>Humans</keyword><keyword>Physical Fitness/physiology</keyword><keyword>Sports/*physiology</keyword></keywords><dates><year>2005</year><pub-dates><date>Mar</date></pub-dates></dates><isbn>0884-0431 (Print)
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ADDIN EN.CITE.DATA 37,134. Muscles are responsible for a large portion of the load and strains on bone, and it has been demonstrated that the increase in bone parameters during growth and in response to exercise is to a large extent mediated through muscle tissue ADDIN EN.CITE <EndNote><Cite><Author>Schoenau</Author><Year>2002</Year><RecNum>424</RecNum><DisplayText><style face="superscript">135</style></DisplayText><record><rec-number>424</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1471167963">424</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Schoenau, E.</author><author>Frost, H. M.</author></authors></contributors><auth-address>Children's Hospital, University of Cologne, 50924 Cologne, Germany.</auth-address><titles><title>The "muscle-bone unit" in children and adolescents</title><secondary-title>Calcif Tissue Int</secondary-title><alt-title>Calcified tissue international</alt-title></titles><periodical><full-title>Calcif Tissue Int</full-title><abbr-1>Calcified tissue international</abbr-1></periodical><alt-periodical><full-title>Calcif Tissue Int</full-title><abbr-1>Calcified tissue international</abbr-1></alt-periodical><pages>405-7</pages><volume>70</volume><number>5</number><keywords><keyword>Adolescent</keyword><keyword>Biomechanical Phenomena</keyword><keyword>Bone and Bones/*physiology</keyword><keyword>Child</keyword><keyword>Endocrine System/metabolism</keyword><keyword>Exercise/physiology</keyword><keyword>Humans</keyword><keyword>Models, Biological</keyword><keyword>Muscles/*physiology</keyword></keywords><dates><year>2002</year><pub-dates><date>May</date></pub-dates></dates><isbn>0171-967X (Print)
0171-967X (Linking)</isbn><accession-num>11960207</accession-num><urls><related-urls><url>, even though muscle area could explain only 12–16% of the variance in bone mass, size and bending strength ADDIN EN.CITE <EndNote><Cite><Author>Daly</Author><Year>2004</Year><RecNum>55</RecNum><DisplayText><style face="superscript">136</style></DisplayText><record><rec-number>55</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1381909550">55</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Daly, R. M.</author><author>Saxon, L.</author><author>Turner, C. H.</author><author>Robling, A. G.</author><author>Bass, S. L.</author></authors></contributors><auth-address>Centre for Physical Activity and Nutrition, School of Health Sciences, Deakin University, Melbourne, Australia. rmdaly@deakin.edu.au</auth-address><titles><title>The relationship between muscle size and bone geometry during growth and in response to exercise</title><secondary-title>Bone</secondary-title><alt-title>Bone</alt-title></titles><periodical><full-title>Bone</full-title><abbr-1>Bone</abbr-1></periodical><alt-periodical><full-title>Bone</full-title><abbr-1>Bone</abbr-1></alt-periodical><pages>281-7</pages><volume>34</volume><number>2</number><keywords><keyword>Adolescent</keyword><keyword>Bone and Bones/*anatomy & histology/*physiology</keyword><keyword>Child</keyword><keyword>Exercise/*physiology</keyword><keyword>Female</keyword><keyword>Functional Laterality</keyword><keyword>Humans</keyword><keyword>Infant, Newborn</keyword><keyword>Magnetic Resonance Imaging</keyword><keyword>Muscle, Skeletal/*anatomy & histology/*growth & development</keyword><keyword>Puberty/physiology</keyword><keyword>Tennis</keyword></keywords><dates><year>2004</year><pub-dates><date>Feb</date></pub-dates></dates><isbn>8756-3282 (Print)
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ADDIN EN.CITE.DATA 112-114.MusclePA does not only stimulate cross-sectional growth of the muscle fibers, mitochondrial biogenesis, synthesis of oxidative enzymes and excitation-contraction coupling improvements, but also stimulates increased recruitment of muscle units, neoangiogenesis and coordination benefits ADDIN EN.CITE <EndNote><Cite><Author>Marini</Author><Year>2010</Year><RecNum>427</RecNum><DisplayText><style face="superscript">140</style></DisplayText><record><rec-number>427</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1471168428">427</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Marini, M.</author></authors></contributors><titles><title>The Exercised Skeletal Muscle: A review. </title><secondary-title>European Translational Myology - Myology reviews. </secondary-title></titles><periodical><full-title>European Translational Myology - Myology reviews.</full-title></periodical><dates><year>2010</year></dates><urls></urls></record></Cite></EndNote>140. In line with the type I fibers using aerobic metabolism and type II fibers using anaerobic metabolism, endurance training with multiple repetition with low loads improves the type I fibers through increased mitochondrial oxidative chain capacity, whereas resistance training with low repetition frequency and increased loads has a greater impact on type II fibers and muscle strength through muscle cross-section hypertrophyPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5HYXJjaWEtUGFsbGFyZXM8L0F1dGhvcj48WWVhcj4yMDEx
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ADDIN EN.CITE.DATA 144,145, a meta-analysis evaluating the effects of resistance training on muscle strength in children and adolescents showed that the possibility to gain muscle strength seems to increase with maturation and age, but without a clear boost during puberty ADDIN EN.CITE <EndNote><Cite><Author>Behringer</Author><Year>2010</Year><RecNum>363</RecNum><DisplayText><style face="superscript">146</style></DisplayText><record><rec-number>363</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1469550018">363</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Behringer, M.</author><author>Vom Heede, A.</author><author>Yue, Z.</author><author>Mester, J.</author></authors></contributors><auth-address>Institute of Training Science and Sport Informatics, German Sport University Cologne, Cologne, Germany. behringer@dshs-koeln.de</auth-address><titles><title>Effects of resistance training in children and adolescents: a meta-analysis</title><secondary-title>Pediatrics</secondary-title><alt-title>Pediatrics</alt-title></titles><periodical><full-title>Pediatrics</full-title><abbr-1>Pediatrics</abbr-1></periodical><alt-periodical><full-title>Pediatrics</full-title><abbr-1>Pediatrics</abbr-1></alt-periodical><pages>e1199-210</pages><volume>126</volume><number>5</number><keywords><keyword>Adolescent</keyword><keyword>Adolescent Development/*physiology</keyword><keyword>Age Factors</keyword><keyword>Athletic Performance/physiology</keyword><keyword>Child</keyword><keyword>Child Development/*physiology</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Muscle Strength/*physiology</keyword><keyword>Physical Endurance/physiology</keyword><keyword>Puberty/physiology</keyword><keyword>*Resistance Training</keyword><keyword>Treatment Outcome</keyword></keywords><dates><year>2010</year><pub-dates><date>Nov</date></pub-dates></dates><isbn>1098-4275 (Electronic)
0031-4005 (Linking)</isbn><accession-num>20974785</accession-num><urls><related-urls><url>. Whether there is a “window of opportunity” to gain muscle strength during puberty is therefore still debated.Academic School PerformanceHigh level of PA has been associated with better intellectual performancePEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CdW5rZXRvcnAgS2FsbDwvQXV0aG9yPjxZZWFyPjIwMTU8
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ADDIN EN.CITE.DATA 147-150. Other studies suggest that PA has positive effects on psychological parameters such as self-esteem, motivation, social engagement and communication, all of importance for learning outcomes ADDIN EN.CITE <EndNote><Cite><RecNum>275</RecNum><DisplayText><style face="superscript">109</style></DisplayText><record><rec-number>275</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1462949505">275</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors></contributors><titles><title>Committee on Physical Activity and Physical Education in the School Environment</title><secondary-title>Food and Nutrition Board; Institute of Medicine; Kohl HW III, Cook HD, editors. Educating the Student Body: Taking Physical Activity and Physical Education to School. Washington (DC): National Academies Press (US); 2013 Oct 30. Available from: doi: 10.17226/18314</secondary-title></titles><dates><year>2013</year></dates><urls></urls></record></Cite></EndNote>109. There are even studies suggesting that inferior motor skills might lead to negative effects in these psychological parameters and delay cognitive development ADDIN EN.CITE <EndNote><Cite><Author>Cratty</Author><Year>1997</Year><RecNum>248</RecNum><DisplayText><style face="superscript">151,152</style></DisplayText><record><rec-number>248</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1456889578">248</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Cratty, B. </author></authors></contributors><titles><title>Coordination Problems Among Learning Disabled, In B. Cratty & R. Goldman (Eds.)</title><secondary-title>Learning Disabilities, Contemporary Viewpoints. Amsterdam: Harwood Academic Publishers.</secondary-title></titles><periodical><full-title>Learning Disabilities, Contemporary Viewpoints. Amsterdam: Harwood Academic Publishers.</full-title></periodical><dates><year>1997</year></dates><urls></urls></record></Cite><Cite><Author>Gjesing</Author><Year>1997</Year><RecNum>246</RecNum><record><rec-number>246</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1456889408">246</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Gjesing, G. </author></authors></contributors><titles><title>Kropumulige Unger. </title><secondary-title>K?penhamn: DHLs f?rlag.</secondary-title></titles><periodical><full-title>K?penhamn: DHLs f?rlag.</full-title></periodical><dates><year>1997</year></dates><urls></urls></record></Cite></EndNote>151,152. Furthermore, reports also show an association between PA and attention and academic test resultsPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5IaWxsbWFuPC9BdXRob3I+PFllYXI+MjAwODwvWWVhcj48
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ZT4A
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ADDIN EN.CITE.DATA 20.Another possible adverse effect of increased PA is the female athlete triad, defined as the combination of disordered eating, amenorrhea and osteoporosis, possibly resulting in premature osteoporotic fractures and permanent loss of aBMD ADDIN EN.CITE <EndNote><Cite><Author>Hobart</Author><Year>2000</Year><RecNum>449</RecNum><DisplayText><style face="superscript">158</style></DisplayText><record><rec-number>449</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1473249787">449</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Hobart, J. A.</author><author>Smucker, D. R.</author></authors></contributors><auth-address>University of Cincinnati, Family Medicine Residency Program, Ohio 45239, USA.</auth-address><titles><title>The female athlete triad</title><secondary-title>Am Fam Physician</secondary-title><alt-title>American family physician</alt-title></titles><periodical><full-title>Am Fam Physician</full-title><abbr-1>American family physician</abbr-1></periodical><alt-periodical><full-title>Am Fam Physician</full-title><abbr-1>American family physician</abbr-1></alt-periodical><pages>3357-64, 3367</pages><volume>61</volume><number>11</number><keywords><keyword>*Amenorrhea/diagnosis/etiology/therapy</keyword><keyword>*Anorexia Nervosa/diagnosis/etiology/therapy</keyword><keyword>*Bulimia/diagnosis/etiology/therapy</keyword><keyword>Diagnosis, Differential</keyword><keyword>*Exercise</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Life Style</keyword><keyword>Patient Education as Topic</keyword><keyword>Prognosis</keyword><keyword>Risk Factors</keyword><keyword>*Sports</keyword><keyword>Teaching Materials</keyword></keywords><dates><year>2000</year><pub-dates><date>Jun 1</date></pub-dates></dates><isbn>0002-838X (Print)
0002-838X (Linking)</isbn><accession-num>10865930</accession-num><urls><related-urls><url> 3. Exercise intervention trials and their effect on skeletal traits in children. ReferenceAge and Number of ParticipantsType of Exercise/PAStudy DurationEffects on Bone Increase, higher in Cases vs. ControlsTanner stage 1 – Pre-pubertalGunter et al. 200822 girls34 boys7–8 yearsHigh-moderate impact jumps 20 min ×3/week7 monthsBMC: FNWiebe et al.200842 girls6–10 yearsHigh-moderate impact jumps 50 min ×3/week7 monthsaBMD: No effectsBradney et al.199838 boys10.4±0.4 yearsWeight bearing 30 min ×3/week8 monthsaBMD: TB, LS, LegsCT: LegsMacKay et al.2000144 children6.9–10.2 yearsHigh-moderate impact 10–30 min ×3/week8 monthsaBMD: TrFuchs et al.200099 children7.6±0.2 yearsHigh impact jumping7 monthsBMC: FN, LSaBMD; LS, BW: FNPetit et al200268 children10.0±0.6 yearsHigh impact 10–12 min ×3/week7 monthsNo effectsVan Langendonck et al.200342 children8.7±0.7 yearsHigh impact ×3/week9 monthsBMC: PF, FNSpecker et al. 2003178 girls3.9±0.6 yearsHigh impact30 min ×5/week12 monthsBMC: LegsMacKelvie et al. 200464 boys10.2±0.2 yearsHigh impact10–12 min ×5/week20 monthsBMC: FNHSA: ZLaing et al.2005143 girls10.2±0.2 yearsGymnastics60 min /week24 monthsBMC: TB, LS, PFaBMD: TB, PFBA: TB, PFValdimarsson et al. 2005103 girls7.7±0.6 yearsPE classes40 min ×5/week12 monthsBMS: Tr, LSLinden et al. 200699 girls7.6±0.6PE classes40 min ×5/week24 monthsBMC: LS, Legs, aBMD: TB, LS, LegsBW: LSLinden et al. 2007138 boys7.8±0.6 yearsPE classes40 min ×5/week24 monthsBMC: LS, Legs, aBMD: TB, LS, LegsBW: LSAlwis et al. 2008137 boys7.8±0.6 yearsPE classes40 min ×5/week24 monthsBMC: LSBW: LSAlwis et al. 200899 girls7.6±0.6 yearsPE classes40 min ×5/week24 monthsHSA: No effectsHasselstr?m et al. 2008349 children6.8±0.4 yearsPE classes45 min ×2/week36 monthsGirlsBMC: Distal forearmBA: Distal forearmBoysNo effectsGreene et al. 200942 girls6–10 yearsHigh-moderate impact jumps50 min ×3/week7 monthsHSA: No effectsMeyer et al. 2011158 children8.7±2.1 yearsPE classes45 min including 10 min of jumping ×2/week9 monthsBMC: TB, LS, FNTanner stage 2–3 – Early pubertalMorris et al.199771 girls8.7±2.1 yearsModerate impact30 min ×3/week10 monthsBMC: TB; LS, FN, PFaBMD: TB, LS, FNHeinonen et al. 200058 girls11.0±0.9 yearsHigh impact20 min ×2/week9 monthsBMC: LS, FNMacKelvie et al. 2001107 girls11.0±0.9 yearsHigh impact10–12 min ×3/week7 monthsBMC: LSaBMD: LS, FNPetit et al. 2002106 girls10.5±0.6 yearsHigh impact10–12 min ×3/week7 monthsaBMD: Tr, FNHSA: ZCT: FNIuliano-Burns et al. 200364 girls8.8±0.1 yearsModerate impact20 min ×3/week9 monthsBMC: LS, Lower legMacKelvie et al. 200375 girls9.9±0.6 yearsHigh impact10–12 min ×3/week20 monthsBMC: FN, LSMcKay et al. 2005122 children10.1±0.5 yearsJumping3×3 min ×3/week8 monthsBMC: PF, Tr, BA: PFHSA: No effectsCourteix et al. 2005113 girls8–13 yearsExercised mean 7.2?hours /week vs. 1.2?hours /week12 monthsaBMD: TB, LS, FNMacdonald et al. 2008197 girls213 boys10.2±0.6 yearsHigh impact15 min ×5/week11 monthsGirlsBMC: FNBoysBMC: LS, TBHSA: ZL?fgren et al. 201192 girls131 boys7.8±0.6 yearsPE classes40 min ×5/week36 monthsGirlsBMC: LS, FNBW: LSHSA: CSABoysBMC: LSBW: LSHSA: No effectsMeyer et al. 2011133 children11.1±0.6 yearsPE classes45 min including 10 min of jumping ×2/week9 monthsBMC: TB, LS, FNL?fgren et al. 201296 girls125 boys7.8±0.6 yearsPE classes40 min ×5/week36 monthsGirlsBMC: TB, LS, FN, TrBW: LS, FNHSA: CSA, Z, CSMIBoysBMC: LSBW: FNHSA: No effectsTanner stage 4–5 – Late pubertalBlimkie et al.199636 girls16.3±0.3 yearsWeight training×3/week7 monthsNo effectsWitzke et al. 200053 girls14.6±0.5 yearsResistance training30–45 min ×3/week9 monthsNo effectsHeinonen et al. 200068 girls13.3±0.9 yearsHigh impact20 min ×2/week9 monthsNo effectsNichols et al. 200167 girls15.9±0.1 yearsResistance training30–45 min ×3/week15 monthsaBMD: FNSundberg et al. 2001104 girls122 boys16.0±0.3 yearsPE classes40 min ×4/week48 monthsGirlsNo effectsBoysBMC: FN, SpineaBMD: FNStear et al. 2003144 girls17.3±0.3 yearsModerate impact45 min ×3/week± calcium16 monthsBMC: LS, TB, PF, TrWeeks et al.200344 girls37 boys13.8±0.4 yearsHigh impact jumping10 min ×2/week8 monthsGirlsBMC: FN, LSBoysBMC: TB, LS, TrQUS: BUADetter et al. 201396 girls125 boys7.9±0.6 yearsPE classes40 min ×5/week60 monthsGirlsBMC: FNaBMD: SpineSize: FN areaBoysaBMD: SpineDetter et al. 2014130 girls165 boys7.9±0.6 yearsPE classes40 min ×5/week72 monthsGirlsBMC: FNaBMD: SpineSize: FN areaBoysaBMD: SpineFritz et al. 2016117 girls147 boys7.7±0.6 yearsPE classes40 min ×5/week84 monthsGirlsaBMD: SpineCT: TCTBoysNo effectsFritz et al. 2016116 girls145 boys7.7±0.6 yearsPE classes40 min ×5/week84 monthsGirlsCT: SSI, MM, vBMDBoysNo effectsSignificant increase in intervention compared to controls seen in the parameters/sites: Bone area (BA), Bone width (BW), Broadband ultrasound attenuation (BUA), Cross-sectional area (CSA), Cross-sectional moment of inertia (CSMI), Computed tomography (CT), Distal forearm, Femoral neck (FN), Hip structure analysis (HSA), Lumbar spine (LS), Mineral mass distribution (MM), Proximal femur (PF), Stress strain index (SSI), Total body (TB), Tibial cortical thickness (TCT), Trochanter (Tr), Volumetric bone mineral distribution (vBMD), Section modulus (Z). AimsGeneralTo prospectively evaluate the effect of physical activity on fracture risk, bone, muscle and academic performance. SpecificPapers I and IITo evaluate the effect of increased school-based physical activity during 7 years on fracture risk and musculoskeletal traits in children aged 6–9 years at study start.Paper IIITo evaluate the effect of increased school-based physical activity during 7 years on cortical bone mass distribution in children aged 6–9 years at study start.Paper IVTo evaluate the effect of increased school-based physical activity during 9 years on academic performance in children aged 6–9 years at study start.HypothesesWe hypothesized that daily school-based PA in children would lead to gradually lower fracture risk due to benefits gained in bone mass and muscle strength. 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ADDIN EN.CITE.DATA 110,159-161.The POP study is a population-based, prospective, controlled exercise intervention study that evaluates the effects of increased school-based PA in growing children aged 6–9 years at study start. Four community-based government-funded schools located in the same geographic area with homogenous socioeconomic and ethnic structure and with the children allocated to schools according to their residential address were invited to participate in the study. Before the study, all schools had the standard duration of school-based PA in the Swedish school curriculum of 60 minutes’ PE per week, given in one to two lessons. One school was then invited to intervention. The school accepted and increased the amount of school PE from 60 minutes per week to 40 minutes per school day (200 minutes per week). The 3 remaining schools continued with 60 minutes per week. All lessons were led by regular teachers and included standard curriculum activities such as ball games, running, jumping and climbing, were conducted within the resources of the schools. Since physical education (PE) is a compulsory subject, all children had to participate (Figure 9).The study has been approved by the Ethics Committee of Lund University, Sweden (LU 453-98; September 15, 1998) and has been conducted according to the Declaration of Helsinki. Before the study start we obtained informed written consent from parents or guardians of all participating children.Figure 9. Children in the POP-study during a class of physical education. Photo presented by courtesy of Christian Lindén.Fracture registrationFracture identification was objectively done through our hospital, the only emergency hospital in the city. We identified incident fractures through repeated evaluations of the regional radiographic database that covers the referrals of most non-private health care facilities in the region and all radiographs taken irrespective of the reason for the exam, and all fractures in the studied population were confirmed and classified by one of the co-authors, a senior consultant in orthopedic surgery. If fractures occurred in other regions of the country (about 14%), the majority of these were registered when they were referred to our hospital for a follow-up visit. This method has previously been extensively used and validated at our research center and has been proven valid since it misses less than 3% of the fractures ADDIN EN.CITE <EndNote><Cite><Author>Jonsson</Author><Year>1994</Year><RecNum>36</RecNum><DisplayText><style face="superscript">162</style></DisplayText><record><rec-number>36</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1380716823">36</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Jonsson, B.</author><author>Gardsell, P.</author><author>Johnell, O.</author><author>Redlund-Johnell, I.</author><author>Sernbo, I.</author></authors></contributors><auth-address>Department of Orthopedics, Malmo General Hospital, Sweden.</auth-address><titles><title>Remembering fractures: fracture registration and proband recall in southern Sweden</title><secondary-title>J Epidemiol Community Health</secondary-title><alt-title>Journal of epidemiology and community health</alt-title></titles><periodical><full-title>J Epidemiol Community Health</full-title><abbr-1>Journal of epidemiology and community health</abbr-1></periodical><alt-periodical><full-title>J Epidemiol Community Health</full-title><abbr-1>Journal of epidemiology and community health</abbr-1></alt-periodical><pages>489-90</pages><volume>48</volume><number>5</number><keywords><keyword>Data Collection/methods</keyword><keyword>Female</keyword><keyword>Fractures, Bone/*epidemiology</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>*Mental Recall</keyword><keyword>*Registries</keyword><keyword>Rural Health</keyword><keyword>Sweden/epidemiology</keyword><keyword>Urban Health</keyword></keywords><dates><year>1994</year><pub-dates><date>Oct</date></pub-dates></dates><isbn>0143-005X (Print)
0143-005X (Linking)</isbn><accession-num>7964361</accession-num><urls><related-urls><url>. We also registered fracture site and trauma level according to the Landin classification ADDIN EN.CITE <EndNote><Cite><Author>Landin</Author><Year>1983</Year><RecNum>60</RecNum><DisplayText><style face="superscript">14</style></DisplayText><record><rec-number>60</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1383041180">60</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Landin, L. A.</author></authors></contributors><titles><title>Fracture patterns in children. Analysis of 8,682 fractures with special reference to incidence, etiology and secular changes in a Swedish urban population 1950-1979</title><secondary-title>Acta Orthop Scand Suppl</secondary-title><alt-title>Acta orthopaedica Scandinavica. Supplementum</alt-title></titles><periodical><full-title>Acta Orthop Scand Suppl</full-title><abbr-1>Acta orthopaedica Scandinavica. Supplementum</abbr-1></periodical><alt-periodical><full-title>Acta Orthop Scand Suppl</full-title><abbr-1>Acta orthopaedica Scandinavica. Supplementum</abbr-1></alt-periodical><pages>1-109</pages><volume>202</volume><keywords><keyword>Accidents</keyword><keyword>Age Factors</keyword><keyword>Athletic Injuries/epidemiology</keyword><keyword>Child</keyword><keyword>Child, Preschool</keyword><keyword>Female</keyword><keyword>Fractures, Bone/classification/*epidemiology/etiology</keyword><keyword>Humans</keyword><keyword>Infant</keyword><keyword>Infant, Newborn</keyword><keyword>Male</keyword><keyword>Recurrence</keyword><keyword>Risk</keyword><keyword>Seasons</keyword><keyword>Sex Factors</keyword><keyword>Sweden</keyword></keywords><dates><year>1983</year></dates><isbn>0300-8827 (Print)
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ADDIN EN.CITE.DATA 20,163. All children starting first grade in the four schools in 1998 were included and followed in the study. The inclusion of children in the first grade continued until 2013. Children who moved out of the region or changed school from the intervention to another school were followed until this event (n=179). This resulted in 1,339 children in the intervention (53.8% boys and 46.2% girls) and 2,195 children in the control group (51.3% boys and 48.7% girls) (Paper I). Children with school start 1998 to 2006 (n=1936) were hence followed for seven years, while those with school start 2007 and later (n=1598) were followed until 2013 and thus for a shorter duration than 7 years. This explains why the numbers of participants in paper 1, table 1 were larger during the first evaluated years. This study design resulted in the inclusion of 3,462 individuals in the fracture evaluation in the 1st school year, 3,179 in the 2nd year, 2,856 in the 3rd year, 2,554 in the 4th year, 2,301 in the 5th year, 2,113 in the 6th year and 1,864 in the 7th year. Since only objectively verified fractures were included and this was done through our radiographic archives (and not through questionnaires provided to the children), we were able to include all of the children, that is, no children were excluded from this evaluation.MeasurementsStudy subjectsFor the in-depth evaluations, including lifestyle factors, anthropometry and musculoskeletal traits, we invited a sub-cohort that included all children in the intervention school with school start 1998 to 2000 and all children in the control schools with school start 1999 to 2000 to participate. In the intervention group 94 of the 105 invited girls and 123 of the 132 invited boys agreed to participate. For the current analyses we excluded two girls and four boys due to diseases or medication that could affect growth, bone health or muscle development and 20 girls and 19 boys as their baseline or follow-up data were inadequate. The corresponding baseline attendance rate in the control group was 64 of the 157 invited girls and 68 of the 170 invited boys and the exclusion rate was one girl due to medication that could affect growth and 18 girls and 21 boys with inadequate follow-up data. This resulted in a sub-cohort of 264 children, 72 girls and 100 boys in the intervention group and 45 girls and 47 boys in the control group (Papers I–II) (Figure 10). Another two boys in the intervention group and one girl in the control group were excluded in the bone distribution analysis due to too poor pQCT image quality, rendering 261 children, 72 girls and 98 boys in the intervention group and 44 girls and 47 boys in the control group for that specific analysis (Paper III) (Figure 10). Figure 10. Flow chart describing number of participants included and dropouts for the sub-cohort in Papers I and II and the cohort in Paper III.Dropout analysis revealed that there were no differences in baseline age, weight or body mass index (BMI) when comparing the girls who completed the measurements with those who only attended the baseline measurements (Paper II). However, girls who dropped out were taller, had higher BMC and aBMD in the femoral neck, had larger muscle mass (lean mass) and had higher muscle strength in one out of four tests (peak torque 180o/sec). Among boys, no such differences were found. Furthermore, there were no differences in age, height, weight or BMI when data from the grade one compulsory school health examination were analyzed for comparison between the children who participated in the baseline measurements with those who declinedPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5MaW5kZW48L0F1dGhvcj48WWVhcj4yMDA2PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA 164,165. This strengthens the view that the data are generalizable. AnthropometryHeight (Holtan stadiometer) and weight (Avery Berkel HL120 electric scale) were measured repeatedly in all children in the sub-cohort when wearing light clothes but no shoes. Body mass index (BMI) was calculated as weight/height2. Pubertal maturation, as Tanner staging, was assessed by our research nurse at baseline and self-assessed with the assistance of our research nurse if questions arose at follow-up, a validated method ADDIN EN.CITE <EndNote><Cite><Author>Duke</Author><Year>1980</Year><RecNum>30</RecNum><DisplayText><style face="superscript">166</style></DisplayText><record><rec-number>30</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1380716618">30</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Duke, P. M.</author><author>Litt, I. F.</author><author>Gross, R. T.</author></authors></contributors><titles><title>Adolescents' self-assessment of sexual maturation</title><secondary-title>Pediatrics</secondary-title><alt-title>Pediatrics</alt-title></titles><periodical><full-title>Pediatrics</full-title><abbr-1>Pediatrics</abbr-1></periodical><alt-periodical><full-title>Pediatrics</full-title><abbr-1>Pediatrics</abbr-1></alt-periodical><pages>918-20</pages><volume>66</volume><number>6</number><keywords><keyword>Adolescent</keyword><keyword>*Adolescent Psychology</keyword><keyword>Child</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>*Self-Assessment</keyword><keyword>*Sexual Maturation</keyword></keywords><dates><year>1980</year><pub-dates><date>Dec</date></pub-dates></dates><isbn>0031-4005 (Print)
0031-4005 (Linking)</isbn><accession-num>7454482</accession-num><urls><related-urls><url> factorsLifestyle factors, including current and previous medication, current and previous disease, dietary intake of dairy products, smoking status, alcohol use and organized leisure time physical activity (PA), were assessed through a questionnaire that the children in the sub-cohort answered annually. Total duration of PA was calculated as duration of school physical education together with stated organized leisure time activity (hours/week). Dual-X-Ray Absorptiometry (DXA)DXA (DPX-L? version 1.3z Lunar, Madison, WI) measurements were used to evaluate bone mass and bone composition (Figure 11). Lean mass and total body and total spine BMC and aBMD were derived from a total body scan, while a hip scan provided BMC and aBMD in the femoral neck. The equipment was calibrated daily with the Lunar Phantom by our research technicians, who also conducted all measurements and software analyses. The precision, estimated as the coefficients of variation (CV) by duplicate measurements in 13 healthy children aged 7–15 years (mean age 10 years) were 1.4–5.2% for BMC, 2.4–2.6% for aBMD and 1.5% for total body lean mass. Figure 11. A girl in the POP-study is measured by DXA (The Lunar? DPX-L). Photo presented by courtesy of Bjarne L?fgren. Peripheral Quantitative Computed Tomography (pQCT)pQCT (XCT 2000?; Stratec, Pforzheim, Germany) evaluated the appendicular skeletal properties at the seven-year follow-up (Paper II and III). A left leg scout scan was performed to determine the 14%, 38% and 66% of the tibia length from the distal end of the medial malleolus, after which each site was scanned. The voxel size was set to 0.5 mm, the slice thickness to 2 mm and the scanning speed to 20 mm/second. The manufacturer’s software package (Stratec Medical, Pforzheim, Germany, version 6) in conjunction with edge detection and thresholding steps was used to acquire densitometric and structural parameters of bone and soft tissue. The periosteal surface of the tibia diaphysis was found by using a contour algorithm based on a threshold of 280 mg/cm3 from which total bone area (mm2) was estimated. The polar stress-strain index (SSI, mm3) was derived to estimate diaphyseal bone resistance to torsional loadingPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TY2hvZW5hdTwvQXV0aG9yPjxZZWFyPjIwMDE8L1llYXI+
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ADDIN EN.CITE.DATA 167. Cortical bone was selected by thresholding at 550 mg/cm3 for the 14% site and 710 mg/cm3 for the 38% and 66% sites, from which cortical area (mm2), cortical density (mg/cm3), and cortical thickness (mm) were derived. Subcutaneous fat cross-sectional area (CSA; cm2) was obtained by selecting the area with thresholds –40 to 40 mg/cm3 hydroxyapatite density. Muscle CSA (cm2) was obtained by subtracting fat CSA and total bone area from the CSA of the total limb. As we measured precision, CV evaluated as duplicate measurements in 13 healthy children aged 7–15 years (mean age 10 years), was 1.7% for trabecular vBMD and 0.5% for cortical vBMD. Polar distribution (cortical bone mineral mass; mg) and radial distribution (radial vBMD; mg/cm3) of the tibia were estimated using Image J. A threshold of 550 mg/cm3 for the 14% site and 710 mg/cm3 for the 38% and 66% sites with a 3×3 median filtering of the image was used to differentiate the cortical bone from the surrounding soft-tissue and bone marrow. To eliminate partial volume effects, the outermost and innermost layers of cortical pixels were excluded from the analysis. We aligned the bones between individuals according to tibia and fibula marrow center and calculated polar distribution by subdividing the tibia cortex into six sectors around its center of mass with the average bone mass estimated for each sector (Figure 12). Radial distribution was estimated by subdividing the cortex into three concentric rings by first removing all pixels below the threshold of each site from the image and subdividing the remaining cortical bone into three concentric circles with the same thickness. The thickness of the rings varied around the cortex according to the anatomy. The innermost ring is referred to as endocortical, the mid ring as midcortical and the outermost ring as the pericortical (Figure 12).Figure 12. Polar (left) and radial (right) bone mass distribution ADDIN EN.CITE <EndNote><Cite><Author>Fritz</Author><Year>2016</Year><RecNum>459</RecNum><DisplayText><style face="superscript">168</style></DisplayText><record><rec-number>459</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1476179538">459</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Fritz, J.</author><author>Duckham, R. L.</author><author>Rantalainen, T.</author><author>Rosengren, B. E.</author><author>Karlsson, M. K.</author><author>Daly, R. M.</author></authors></contributors><auth-address>Clinical and Molecular Osteoporosis Research Unit, Department of Orthopedics, Institution of Clinical Research, Lund University, Skane University Hospital, 205 02, Malmo, Sweden. jesper.fritz@med.lu.se.
Institute for Physical Activity and Nutrition, Deakin University, Geelong, Australia.
Clinical and Molecular Osteoporosis Research Unit, Department of Orthopedics, Institution of Clinical Research, Lund University, Skane University Hospital, 205 02, Malmo, Sweden.</auth-address><titles><title>Influence of a School-based Physical Activity Intervention on Cortical Bone Mass Distribution: A 7-year Intervention Study</title><secondary-title>Calcif Tissue Int</secondary-title><alt-title>Calcified tissue international</alt-title></titles><periodical><full-title>Calcif Tissue Int</full-title><abbr-1>Calcified tissue international</abbr-1></periodical><alt-periodical><full-title>Calcif Tissue Int</full-title><abbr-1>Calcified tissue international</abbr-1></alt-periodical><pages>443-453</pages><volume>99</volume><number>5</number><dates><year>2016</year><pub-dates><date>Nov</date></pub-dates></dates><isbn>1432-0827 (Electronic)
0171-967X (Linking)</isbn><accession-num>27406102</accession-num><urls><related-urls><url> strengthA computerized dynamometer, Biodex (Biodex system III Pro?, with Biodex advantage software), measured the strength of the quadriceps and hamstrings muscles during concentric isokinetic contractions (Figure 13). The participant was seated in the testing chair with the hips flexed to 85° from the anatomical position and the axis of the right knee aligned with the axis of rotation. The participant was secured in the chair according to standard procedure using three belts, crossing the thigh, pelvis and upper torso, as stabilization. If the participant’s upper leg was shorter than the seat, or the lower leg was shorter than the lever arm of the Biodex, pads were used to adjust for the difference to give the correct angle and positioning of the limb. All participants were instructed to place their arms across their chest during the testing. The knee was positioned at 90° of flexion and went through a 75° range of motion, stopping at 15° flexion. Concentric isokinetic knee extension and flexion peak torque were tested at an angular velocity of extension (ex) and flexion (fl) at 60°/second (60°/sec) and 180°/second (180°/sec). Five maximal repetitions at 60°/sec were performed, including both extension and flexion. After 30 seconds’ rest, 10 maximal repetitions at 180°/sec were performed in the same way. The highest peak torque for each of the extension and flexion variables (PTex60, PTfl60, PTex180, PTfl180) were recorded (Nm). All participants received both visual and verbal encouragement during the test ADDIN EN.CITE <EndNote><Cite><Author>De Ste Croix</Author><Year>2003</Year><RecNum>29</RecNum><DisplayText><style face="superscript">82</style></DisplayText><record><rec-number>29</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1380716589">29</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>De Ste Croix, M.</author><author>Deighan, M.</author><author>Armstrong, N.</author></authors></contributors><auth-address>Children's Health and Exercise Research Centre, School of Sport and Health Sciences, University of Exeter, Exeter, UK. m.b.a.de-ste-croix@exeter.ac.uk</auth-address><titles><title>Assessment and interpretation of isokinetic muscle strength during growth and maturation</title><secondary-title>Sports Med</secondary-title><alt-title>Sports medicine</alt-title></titles><periodical><full-title>Sports Med</full-title><abbr-1>Sports medicine</abbr-1></periodical><alt-periodical><full-title>Sports Med</full-title><abbr-1>Sports medicine</abbr-1></alt-periodical><pages>727-43</pages><volume>33</volume><number>10</number><keywords><keyword>Biomechanics/methods</keyword><keyword>Child</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Movement/physiology</keyword><keyword>Muscle Contraction/physiology</keyword><keyword>Muscle Development/*physiology</keyword><keyword>Muscle, Skeletal/*growth & development</keyword></keywords><dates><year>2003</year></dates><isbn>0112-1642 (Print)
0112-1642 (Linking)</isbn><accession-num>12895130</accession-num><urls><related-urls><url>. The precision, evaluated as CV for repeated measurements in 21 children, was 6.6% for PTex60, 12.1% for PTfl60, 12.3% for PTex180 and 9.1% for PTfl180.Figure 13. A girl in the POP-study is measured by Biodex? (System III Pro) apparatus. Photo presented by courtesy of Susanna Stenevi Lundgren. Academic performanceAll schools in Sweden have to retain grade data for all students for at least 15 years. To evaluate the effect of the intervention on academic performance we collected elementary grade scorecard data from 9th grade through the archive of the intervention school. Among the 234 boys and 190 girls starting the intervention school from 1998 to 2003, 49 boys and 37 girls were excluded since they left the intervention school during the study period (and did not have all nine years of intervention), rendering 185 boys and 153 girls finishing the same school from 2007 to 2012 (Paper IV).To be able to identify any changes within the intervention school from the period before the intervention was initiated until after the intervention was initiated, we collected the final grade scorecard data from the 9th grade in all children who started 1st grade in the intervention school from 1994 to 1997 (175 boys and 181 girls). We excluded 20 boys and 41 girls who left the intervention school before graduation in 2003–2006, rendering 155 boys and 140 girls (Paper IV).During these years the 9th and final elementary school grades in Sweden included 16 compulsory school subjects where every subject was graded with the grades Failed (0 points), Passed (10 points), Passed with Distinction (15 points) or Passed with Special Distinction (20 points). The final grade points of these 16 subjects may thus vary from 0 points (p) (no subject with an accepted grade) to 320 p (the highest grade in all subjects). To qualify for national upper secondary school programs the grade Passed in each of the subjects Swedish, English and Mathematics is required. We then registered final grade points and eligibility for upper secondary school programs in all these children in the intervention school. The same endpoint data for all other Swedish students were retrieved from the Swedish National Agency of Education (Skolverket) ADDIN EN.CITE <EndNote><Cite><Year>2009</Year><RecNum>220</RecNum><DisplayText><style face="superscript">169</style></DisplayText><record><rec-number>220</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1455510791">220</key></foreign-keys><ref-type name="Dataset">59</ref-type><contributors></contributors><titles><title>Swedish National Agency for Education</title></titles><dates><year>2009</year></dates><pub-location> siris.skolverket.se</pub-location><urls></urls></record></Cite></EndNote>169 from 2003 to 2006 (241,089 boys and 230,837 girls) and from 2007 to 2012 (353,439 boys and 336,442 girls) (Paper IV).Statistical methodsSPSS Statistics for Macintosh, version 20.0 (IBM Corp. Armonk, New York, USA) was used for all statistical analyses. P<0.05 was regarded as statistically significant. Papers I–IIIData are presented as absolute numbers, means ± standard deviations (SD) or means with 95% confidence intervals (95% CI). Annual fracture incidence was estimated and annual incidence rate ratio (IRR) with 95% CI was calculated using Poisson distribution. Spearman’s test was used for correlation between years of intervention and IRR. Lifestyle factors were compared using cross-tabulation with either chi-2 or Fisher’s exact test. Tanner stage distribution between groups was compared using Mann-Whitney U test at both baseline and follow-up. Two-tailed Student’s t-test was used to compare group differences in anthropometrics, PA and baseline musculoskeletal traits. Changes in musculoskeletal traits were estimated as the changes from baseline to follow-up. When comparing musculoskeletal changes between groups, analysis of covariance (ANCOVA) was used with adjustments for age at baseline and absolute baseline value for evaluated trait (Papers I–II). ANCOVA was also used for tibia composition comparisons between groups at follow-up, adjusting for age at follow-up, and for bone distribution parameter comparisons between groups at follow-up, adjusting for age at baseline (Paper III). Fracture-free survival curves were estimated by Kaplan Meier analyses (Paper II). Paper IVData are presented as absolute numbers (n), percentages (%), percentage points (pp) or means with 95% confidence intervals (95% CI). No measurement of dispersion is given for national data as these are not drawn from a sample but include all Swedish children (true values). Group differences were evaluated by Pearson’s chi-square test for the eligibility rate and student’s t-test between means for grade points.Summary of papersPaper IIntroduction: Physical activity (PA) in childhood is associated with high bone mass and beneficial neuromuscular function. We investigated whether increased PA is also associated with fracture risk. Methods: Physical education was increased in school for seven years from 60 min/week to 200 min/week in the intervention group, while remaining at 60 min/week in the control group. We registered fractures in all children and measured areal bone mineral density (aBMD; g/cm2) with DXA (femoral neck and total spine) and muscle strength (peak torque for knee extension and flexion; Nm) with computerized dynamometer at baseline and after 7 years. We estimated annual fracture incidence rate ratios (IRR) in the intervention group compared to the control group as well as changes in bone mass and muscle strength. Data are given as mean (95% CI).Subjects: We registered fractures in 3,534 children aged six to eight years at study start, 1,339 in the intervention group and 2,195 in the control group. In a sub-sample of 264 children, 172 in the intervention group and 92 in the control group, we measured musculoskeletal traits.Results: The IRR of fractures decreased with each year of the PA intervention (r=–0.79; p=0.04). During the seventh year IRR was almost halved [IRR 0.52 (0.27, 1.01)]. The intervention group had a statistically significant greater gain in total spine aBMD with a mean group difference of 0.03 (0.00, 0.05) g/cm2 and peak flexion torque 180°/sec with a mean group difference of 5.0 (1.5, 8.6) Nm.Conclusion: Increased PA is associated with decreased fracture risk, probably due in part to beneficial gains in aBMD and muscle strength. Paper IIIntroduction: Physical activity (PA) is associated with high bone mass and beneficial muscle strength in children, but whether the musculoskeletal influence is different in girls and boys is debated. We therefore investigated gender-specific musculoskeletal effects of increased physical activity in children.Methods: In one school we increased the physical education of 72 girls and 100 boys to 200 minutes per week over seven years. In three other schools, 45 girls and 47 boys continued to receive 60 minutes per week. We measured aBMD with DXA and muscle strength with computerized dynamometer at baseline and after seven years and tibial cortical thickness with peripheral quantitative computed tomography (pQCT) after seven years. Data are given as mean (95% CI).Subjects: We assessed musculoskeletal traits in 72 girls and 100 boys in the intervention group and 45 girls and 47 boys in the control group. Results: Girls in the intervention group gained 0.04g/cm2 (0.01–0.08) more total spine aBMD (p<0.05) and 6.2 Nm (1.6, 10.7) more knee flexion strength (p<0.01) than control group girls and had a 0.1 mm (0.0, 0.3) higher tibial cortical thickness at follow-up (p<0.05). Boys in the intervention group gained 7.3 Nm (0.4, 14.2) more knee extension strength (p<0.05) and 7.4 Nm (2.3, 12.4) more knee flexion strength (p<0.01) than the control group boys, but their aBMD was no higher than the control group. Conclusion: A seven-year, population-based moderately intense exercise intervention enhanced gains in spine bone mass in girls and knee muscle strength in both genders. Paper IIIIntroduction: Cortical bone mass and density varies across a bone’s length and cross-section, and may be influenced by physical activity. This study evaluated the long-term effects of a pediatric school-based physical activity intervention on tibial cortical bone mass distribution. Methods: Children from one school were provided with 200 minutes of physical education per week (intervention group). Three other schools continued with the standard of 60 minutes per week (control group). Tibial total and cortical area, cortical density, polar stress-strain index (SSI), and the mass and density distribution around the center of mass (polar distribution, mg) and through the bone’s cortex (radial distribution subdivided into endo-, mid-, and pericortical volumetric BMD: mg/cm3) at three sites (14%, 38% and 66%) were assessed using pQCT after 7 years.Subjects: In 72 girls and 98 boys in the intervention group and 44 girls and 47 boys in the control group we assessed cortical bone parameters and distribution.Results: Girls in the intervention group had 2.5% greater cortical thickness and 6.9% greater SSI at the 66% tibia, which was accompanied by significantly greater pericortical volumetric BMD compared to controls (all p<0.05). Region-specific differences in cortical mass were also detected in the anterior, medial and lateral sectors at the 38% and 66% tibial sites. There were no group differences at the 14% tibia site in girls, and no group differences in any of the bone parameters in boys. Conclusion: Additional school-based physical education over seven years was associated with greater tibial structure, strength and region-specific adaptations in cortical bone mass and density distribution in girls, but not in boys.Paper IVIntroduction: Physical activity (PA) may improve brain development, cognition and concentration and may therefore also improve academic performance.Methods: In the intervention school the level of physical education (PE) was increased from 60 min/week to 200 min/week for students starting first grade in 1998–2003, thus graduating in 2007–2012 after 9 years with the increased level of PE. All other Swedish children continued with the average of 60 min/week of PE during this period. Children graduating in 2003–2006 (before the intervention was initiated), both those in the intervention school and all other Swedish children, had the Swedish standard of 60 min/week of PE. At graduation we registered the proportion of students eligible for upper secondary school and the final grade score (from 0 to 320 grade points). Data are reported as means with 95% confidence intervals for the intervention school but only as means for the all other Swedish children (since this is not a sample).Subjects: We registered academic results in 185 boys and 153 girls in the intervention group graduating in 2007–2012. As controls served all other 353,439 Swedish boys and 336,442 Swedish girls graduating during the same years. We also registered academic results in 155 boys and 140 girls in the same school and in all other 241,089 Swedish boys and 230,837 Swedish girls graduating in 2003–2006 to evaluate academic performance before the intervention was initiated.Results: Before the intervention was initiated, academic performance was similar in the intervention school and all other Swedish boys and girls. With the intervention, the eligibility rate increased in the intervention school for boys by 7.3 (1.4, 13.2) percentage points (pp) and the grades by 13.3 (3.1, 23.5) points, while there was a decrease of 0.8 pp in eligibility rate and an increase by 2.7 points in all other Swedish boys. 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ADDIN EN.CITE.DATA 10,42.During growthThe POP study is the only prospective PA intervention study with fracture as endpoint, and we have previously found similar fracture risks in the intervention and the control cohorts over the entire study period ADDIN EN.CITE <EndNote><Cite><Author>Detter</Author><Year>2014</Year><RecNum>114</RecNum><DisplayText><style face="superscript">175</style></DisplayText><record><rec-number>114</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1392365129">114</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Detter, F.</author><author>Rosengren, B. E.</author><author>Dencker, M.</author><author>Lorentzon, M.</author><author>Nilsson, J. A.</author><author>Karlsson, M. K.</author></authors></contributors><auth-address>Clinical and Molecular Osteoporosis Research Unit, Department of Clinical Sciences and Orthopedics, Lund University, Skane University Hospital, SE-205 02, Malmo, Sweden.</auth-address><titles><title>A Six-Year Exercise Program Improves Skeletal Traits without Affecting Fracture Risk - a Prospective Controlled Study in 2621 Children</title><secondary-title>J Bone Miner Res</secondary-title><alt-title>Journal of bone and mineral research : the official journal of the American Society for Bone and Mineral Research</alt-title></titles><periodical><full-title>J Bone Miner Res</full-title><abbr-1>Journal of bone and mineral research : the official journal of the American Society for Bone and Mineral Research</abbr-1></periodical><alt-periodical><full-title>J Bone Miner Res</full-title><abbr-1>Journal of bone and mineral research : the official journal of the American Society for Bone and Mineral Research</abbr-1></alt-periodical><dates><year>2014</year><pub-dates><date>Jan 6</date></pub-dates></dates><isbn>1523-4681 (Electronic)
0884-0431 (Linking)</isbn><accession-num>24390777</accession-num><urls><related-urls><url>. Since no PA exposure-time dependent fracture risk was provided in previous reports, a transient increased initial fracture risk due to more falls and traumas in children not used to PA could therefore have obscured long-term fracture-preventive effects. This hypothesis was supported in this thesis and after seven years the fracture risk was halved in the intervention compared to the control cohort. Furthermore, the inverse correlation between IRR to sustain a fracture and number of years of intervention that we found seems explained by the fact that the higher fracture incidence with each year closer to puberty usually seen ADDIN EN.CITE <EndNote><Cite><Author>Hedstrom</Author><Year>2010</Year><RecNum>135</RecNum><DisplayText><style face="superscript">16</style></DisplayText><record><rec-number>135</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1420802103">135</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Hedstrom, E. M.</author><author>Svensson, O.</author><author>Bergstrom, U.</author><author>Michno, P.</author></authors></contributors><auth-address>Division of Surgery and Perioperative Science, Umea University Hospital, Umea, Sweden. erik.hedstrom@orthop.umu.se</auth-address><titles><title>Epidemiology of fractures in children and adolescents</title><secondary-title>Acta Orthop</secondary-title><alt-title>Acta orthopaedica</alt-title></titles><periodical><full-title>Acta Orthop</full-title><abbr-1>Acta orthopaedica</abbr-1></periodical><alt-periodical><full-title>Acta Orthop</full-title><abbr-1>Acta orthopaedica</abbr-1></alt-periodical><pages>148-53</pages><volume>81</volume><number>1</number><keywords><keyword>Accidental Falls/statistics & numerical data</keyword><keyword>Accidents, Traffic/statistics & numerical data</keyword><keyword>Adolescent</keyword><keyword>Athletic Injuries/epidemiology</keyword><keyword>Child</keyword><keyword>Child, Preschool</keyword><keyword>Female</keyword><keyword>Fractures, Bone/*epidemiology/etiology/prevention & control</keyword><keyword>Humans</keyword><keyword>Incidence</keyword><keyword>Infant</keyword><keyword>Male</keyword><keyword>Registries</keyword><keyword>Sweden/epidemiology</keyword></keywords><dates><year>2010</year><pub-dates><date>Feb</date></pub-dates></dates><isbn>1745-3682 (Electronic)
1745-3674 (Linking)</isbn><accession-num>20175744</accession-num><urls><related-urls><url>, and seen in our control cohort, did not occur in the intervention group (Paper I, Table 1).Gender specific fracture analyses would have been preferable, but are not meaningful in our cohort due to low power. However, when gender specifically observing data, the same trend of decreasing IRR for every year of PA intervention as for all individuals (Figure 14) seems to occur for both girls and boys separately (Figure 15 and 16). This strengthens the view that the PA intervention program influences the fracture risk in a positive way, regardless of gender.Figure 14. Fracture incidence rate ratio (IRR) during 7 years in the 3534 children in the fracture study (Paper I). Figure 15. Fracture incidence rate ratio (IRR) during 7 years in the 1688 girls in the fracture study (Paper I). Figure 16. Fracture incidence rate ratio (IRR) during 7 years in the 1846 boys in the fracture study (Paper I). In adulthoodProspective studies have also shown that PA-induced skeletal benefits, at least partly, are retained long-term after reduced activity levelPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5UdmVpdDwvQXV0aG9yPjxZZWFyPjIwMTM8L1llYXI+PFJl
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ADDIN EN.CITE.DATA 126. With this in mind, this thesis shows benefits of PA regarding both bone mass and muscle strength as well as for the primary outcome, fractures. This indicates that PA intervention is a feasible strategy to prevent fractures both during childhood and later in life, and possibly also osteoporosis later in life, thereby decreasing the economic burden on society as well as the individual suffering.Musculoskeletal traitsAbout 20–40% of the variance in bone mass can be explained by environmental factors, the rest is thought to be constituted by genetic factorsPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5FaXNtYW48L0F1dGhvcj48WWVhcj4xOTk5PC9ZZWFyPjxS
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0937-941X (Linking)</isbn><accession-num>2133638</accession-num><urls><related-urls><url> and 50% of the bone mass at age 70 years is predicted by PBM ADDIN EN.CITE <EndNote><Cite><Author>Hui</Author><Year>1990</Year><RecNum>80</RecNum><DisplayText><style face="superscript">52</style></DisplayText><record><rec-number>80</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1392362927">80</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Hui, S. L.</author><author>Slemenda, C. W.</author><author>Johnston, C. C., Jr.</author></authors></contributors><auth-address>Department of Medicine, Indiana University School of Medicine, Indianapolis.</auth-address><titles><title>The contribution of bone loss to postmenopausal osteoporosis</title><secondary-title>Osteoporos Int</secondary-title><alt-title>Osteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA</alt-title></titles><periodical><full-title>Osteoporos Int</full-title><abbr-1>Osteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA</abbr-1></periodical><alt-periodical><full-title>Osteoporos Int</full-title><abbr-1>Osteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA</abbr-1></alt-periodical><pages>30-4</pages><volume>1</volume><number>1</number><keywords><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>*Bone Density</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Middle Aged</keyword><keyword>Osteoporosis, Postmenopausal/*physiopathology</keyword></keywords><dates><year>1990</year><pub-dates><date>Oct</date></pub-dates></dates><isbn>0937-941X (Print)
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ADDIN EN.CITE.DATA 178, the growth period may be the most important period in life to influence the skeleton. It is common knowledge today that the most potent osteogenic activities include fast novel dynamic loads with high magnitude and high frequency. The skeleton however becomes saturated quite fast with these activities and endurance activities are thereby less effective in this sense ADDIN EN.CITE <EndNote><Cite><Author>Rubin</Author><Year>1987</Year><RecNum>111</RecNum><DisplayText><style face="superscript">179</style></DisplayText><record><rec-number>111</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1392364258">111</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Rubin, C. T.</author><author>Lanyon, L. E.</author></authors></contributors><titles><title>Kappa Delta Award paper. Osteoregulatory nature of mechanical stimuli: function as a determinant for adaptive remodeling in bone</title><secondary-title>J Orthop Res</secondary-title><alt-title>Journal of orthopaedic research : official publication of the Orthopaedic Research Society</alt-title></titles><periodical><full-title>J Orthop Res</full-title><abbr-1>Journal of orthopaedic research : official publication of the Orthopaedic Research Society</abbr-1></periodical><alt-periodical><full-title>J Orthop Res</full-title><abbr-1>Journal of orthopaedic research : official publication of the Orthopaedic Research Society</abbr-1></alt-periodical><pages>300-10</pages><volume>5</volume><number>2</number><keywords><keyword>*Adaptation, Physiological</keyword><keyword>Animals</keyword><keyword>Bone Resorption</keyword><keyword>Bone and Bones/analysis/*physiology</keyword><keyword>Male</keyword><keyword>Microradiography</keyword><keyword>Minerals/analysis</keyword><keyword>*Osteogenesis</keyword><keyword>Stress, Mechanical</keyword><keyword>Turkeys</keyword><keyword>Ulna/physiology</keyword></keywords><dates><year>1987</year></dates><isbn>0736-0266 (Print)
0736-0266 (Linking)</isbn><accession-num>3572599</accession-num><urls><related-urls><url>. The activities alter the mechanostat balance system ADDIN EN.CITE <EndNote><Cite><Author>Frost</Author><Year>1998</Year><RecNum>210</RecNum><DisplayText><style face="superscript">180</style></DisplayText><record><rec-number>210</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1453696603">210</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Frost, H. M.</author><author>Ferretti, J. L.</author><author>Jee, W. S.</author></authors></contributors><titles><title>Perspectives: some roles of mechanical usage, muscle strength, and the mechanostat in skeletal physiology, disease, and research</title><secondary-title>Calcif Tissue Int</secondary-title><alt-title>Calcified tissue international</alt-title></titles><periodical><full-title>Calcif Tissue Int</full-title><abbr-1>Calcified tissue international</abbr-1></periodical><alt-periodical><full-title>Calcif Tissue Int</full-title><abbr-1>Calcified tissue international</abbr-1></alt-periodical><pages>1-7</pages><volume>62</volume><number>1</number><keywords><keyword>Biomechanical Phenomena</keyword><keyword>Bone Diseases, Metabolic/*physiopathology</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Muscle, Skeletal/*physiology</keyword><keyword>*Musculoskeletal Physiological Phenomena</keyword><keyword>Physical Endurance/physiology</keyword><keyword>Research</keyword></keywords><dates><year>1998</year><pub-dates><date>Jan</date></pub-dates></dates><isbn>0171-967X (Print)
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ADDIN EN.CITE.DATA 182. Improved muscle strength is known to reduce fall frequency ADDIN EN.CITE <EndNote><Cite><Author>Yau</Author><Year>2013</Year><RecNum>444</RecNum><DisplayText><style face="superscript">183</style></DisplayText><record><rec-number>444</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1471954881">444</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Yau, D. T.</author><author>Chung, R. C.</author><author>Pang, M. Y.</author></authors></contributors><auth-address>Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong.</auth-address><titles><title>Knee muscle strength and visual acuity are the most important modifiable predictors of falls in patients after hip fracture surgery: a prospective study</title><secondary-title>Calcif Tissue Int</secondary-title><alt-title>Calcified tissue international</alt-title></titles><periodical><full-title>Calcif Tissue Int</full-title><abbr-1>Calcified tissue international</abbr-1></periodical><alt-periodical><full-title>Calcif Tissue Int</full-title><abbr-1>Calcified tissue international</abbr-1></alt-periodical><pages>287-95</pages><volume>92</volume><number>3</number><keywords><keyword>*Accidental Falls</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Female</keyword><keyword>Hip Fractures/*complications</keyword><keyword>Humans</keyword><keyword>Incidence</keyword><keyword>Knee</keyword><keyword>Male</keyword><keyword>Multivariate Analysis</keyword><keyword>*Muscle Strength</keyword><keyword>Postural Balance</keyword><keyword>Risk Factors</keyword><keyword>*Visual Acuity</keyword></keywords><dates><year>2013</year><pub-dates><date>Mar</date></pub-dates></dates><isbn>1432-0827 (Electronic)
0171-967X (Linking)</isbn><accession-num>23239261</accession-num><urls><related-urls><url> and contributes to fewer injurious falls, probably due to improved sensorimotor function ADDIN EN.CITE <EndNote><Cite><Author>Lord</Author><Year>1995</Year><RecNum>137</RecNum><DisplayText><style face="superscript">116</style></DisplayText><record><rec-number>137</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1420802179">137</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Lord, S. R.</author><author>Ward, J. A.</author><author>Williams, P.</author><author>Strudwick, M.</author></authors></contributors><auth-address>Prince of Wales Medical Research Institute, Randwick, New South Wales, Australia.</auth-address><titles><title>The effect of a 12-month exercise trial on balance, strength, and falls in older women: a randomized controlled trial</title><secondary-title>J Am Geriatr Soc</secondary-title><alt-title>Journal of the American Geriatrics Society</alt-title></titles><periodical><full-title>J Am Geriatr Soc</full-title><abbr-1>Journal of the American Geriatrics Society</abbr-1></periodical><alt-periodical><full-title>J Am Geriatr Soc</full-title><abbr-1>Journal of the American Geriatrics Society</abbr-1></alt-periodical><pages>1198-206</pages><volume>43</volume><number>11</number><keywords><keyword>Accidental Falls/*prevention & control</keyword><keyword>Aged</keyword><keyword>Aged, 80 and over</keyword><keyword>Exercise/*physiology</keyword><keyword>Female</keyword><keyword>Follow-Up Studies</keyword><keyword>Humans</keyword><keyword>Middle Aged</keyword><keyword>*Postural Balance</keyword><keyword>Posture</keyword><keyword>Psychomotor Performance</keyword><keyword>Reaction Time</keyword></keywords><dates><year>1995</year><pub-dates><date>Nov</date></pub-dates></dates><isbn>0002-8614 (Print)
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ADDIN EN.CITE.DATA 62,190 and young athletes ADDIN EN.CITE <EndNote><Cite><Author>Rantalainen</Author><Year>2011</Year><RecNum>249</RecNum><DisplayText><style face="superscript">191</style></DisplayText><record><rec-number>249</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1458275880">249</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Rantalainen, T.</author><author>Nikander, R.</author><author>Daly, R. M.</author><author>Heinonen, A.</author><author>Sievanen, H.</author></authors></contributors><auth-address>Department of Mechanical Engineering, Lappeenranta University of Technology, Finland. timo.j.rantalainen@jyu.fi</auth-address><titles><title>Exercise loading and cortical bone distribution at the tibial shaft</title><secondary-title>Bone</secondary-title><alt-title>Bone</alt-title></titles><periodical><full-title>Bone</full-title><abbr-1>Bone</abbr-1></periodical><alt-periodical><full-title>Bone</full-title><abbr-1>Bone</abbr-1></alt-periodical><pages>786-91</pages><volume>48</volume><number>4</number><keywords><keyword>Adolescent</keyword><keyword>Adult</keyword><keyword>Analysis of Variance</keyword><keyword>Bone Density</keyword><keyword>*Exercise</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Tibia/anatomy & histology/*physiology</keyword><keyword>Young Adult</keyword></keywords><dates><year>2011</year><pub-dates><date>Apr 1</date></pub-dates></dates><isbn>1873-2763 (Electronic)
1873-2763 (Linking)</isbn><accession-num>21122824</accession-num><urls><related-urls><url> have reported that higher levels of weight-bearing impact activities were associated with localized cortical adaptations, particularly in the anterior-posterior plane of the mid and proximal tibia. This is in line with other evidence that suggests that the mid-tibial shafts primary loading mode is bending in anterior-posterior plane ADDIN EN.CITE <EndNote><Cite><Author>Peterman</Author><Year>2001</Year><RecNum>214</RecNum><DisplayText><style face="superscript">192</style></DisplayText><record><rec-number>214</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1454544555">214</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Peterman, M. M.</author><author>Hamel, A. J.</author><author>Cavanagh, P. R.</author><author>Piazza, S. J.</author><author>Sharkey, N. A.</author></authors></contributors><auth-address>Center for Locomotion Studies, 29 Recreation Building, Pennsylvania State University, University Park, PA 16802-5702, USA.</auth-address><titles><title>In vitro modeling of human tibial strains during exercise in micro-gravity</title><secondary-title>J Biomech</secondary-title><alt-title>Journal of biomechanics</alt-title></titles><periodical><full-title>J Biomech</full-title><abbr-1>Journal of biomechanics</abbr-1></periodical><alt-periodical><full-title>J Biomech</full-title><abbr-1>Journal of biomechanics</abbr-1></alt-periodical><pages>693-8</pages><volume>34</volume><number>5</number><keywords><keyword>Aged</keyword><keyword>Biomechanical Phenomena</keyword><keyword>Exercise/*physiology</keyword><keyword>Gait/physiology</keyword><keyword>Humans</keyword><keyword>In Vitro Techniques</keyword><keyword>Middle Aged</keyword><keyword>*Models, Biological</keyword><keyword>Tibia/*physiology</keyword><keyword>Walking/physiology</keyword><keyword>Weightlessness Countermeasures</keyword><keyword>*Weightlessness Simulation</keyword></keywords><dates><year>2001</year><pub-dates><date>May</date></pub-dates></dates><isbn>0021-9290 (Print)
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ADDIN EN.CITE.DATA 116,183. This thesis also shows that girls receiving the intervention had greater cortical strength (SSI) and higher mineral mass at the lateral, anterior and anterior-medial sectors of the tibia compared to controls, which may also contribute in decreasing the fracture risk. The region-specific adaptations in the medial and lateral planes may be explained by the fact that our generalized PE intervention included a wide range of activities, such as ball games, running, jumping, and playing, that could have created bending forces in the medial and lateral planes of the tibia. This thesis supports previous short-term studies that indicate that PA programs improve musculoskeletal development in both genders, but extend the knowledge as we found that girls seemed to benefit more when the program was continued long-term into puberty. This could be because girls in general are less active in their spare time generally and in puberty reduce their PA level to a greater extent than boys ADDIN EN.CITE <EndNote><Cite><Author>Goran</Author><Year>1998</Year><RecNum>70</RecNum><DisplayText><style face="superscript">194</style></DisplayText><record><rec-number>70</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1383573189">70</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Goran, M. I.</author><author>Gower, B. A.</author><author>Nagy, T. R.</author><author>Johnson, R. K.</author></authors></contributors><auth-address>Division of Physiology and Metabolism, Department of Nutrition Sciences, and the Obesity Research Center, School of Health Related Professions, University of Alabama at Birmingham, Birmingham, Alabama, USA.</auth-address><titles><title>Developmental changes in energy expenditure and physical activity in children: evidence for a decline in physical activity in girls before puberty</title><secondary-title>Pediatrics</secondary-title><alt-title>Pediatrics</alt-title></titles><periodical><full-title>Pediatrics</full-title><abbr-1>Pediatrics</abbr-1></periodical><alt-periodical><full-title>Pediatrics</full-title><abbr-1>Pediatrics</abbr-1></alt-periodical><pages>887-91</pages><volume>101</volume><number>5</number><keywords><keyword>Basal Metabolism</keyword><keyword>Child</keyword><keyword>Child Development/*physiology</keyword><keyword>Child, Preschool</keyword><keyword>Energy Intake</keyword><keyword>*Energy Metabolism</keyword><keyword>Exercise</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Longitudinal Studies</keyword><keyword>Male</keyword><keyword>*Physical Exertion</keyword><keyword>Puberty</keyword><keyword>Sex Factors</keyword></keywords><dates><year>1998</year><pub-dates><date>May</date></pub-dates></dates><isbn>1098-4275 (Electronic)
0031-4005 (Linking)</isbn><accession-num>9565420</accession-num><urls><related-urls><url>. Indeed, boys in our study were already undertaking a mean of >3 hours per week of physical activity prior to the start of the intervention, hence the additional physical activity may not have been not enough to elicit further bone adaptation. The extra school-based PE would therefore have contributed relatively more to the total duration of PA in girls than in boys. Academic performancePA has been associated with beneficial cognitive achievementPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CdXJyb3dzPC9BdXRob3I+PFllYXI+MjAxNDwvWWVhcj48
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ADDIN EN.CITE.DATA 92,195-198. This thesis supports this view by showing that increased PA results in increased grades and increased qualification rate to upper secondary school for boys. Furthermore, the increase by 7.3 percentage points should be regarded as an improvement not only of statistical but also clinical relevance, especially since the eligibility rate in Swedish children has decreased during the same period. Since girls before the intervention already had a 95.0% qualification rate and 74.8% of the maximal grades, significantly higher than boys, the potential for them to improve was probably lower than in boys, for girls maybe even enough to be affected by ceiling effects ADDIN EN.CITE <EndNote><Cite><Author>Po</Author><Year>1998</Year><RecNum>446</RecNum><DisplayText><style face="superscript">199</style></DisplayText><record><rec-number>446</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1472029946">446</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Po, Alain Li Wan</author></authors></contributors><titles><title>Dictionary of Evidence-based Medicine</title><secondary-title>Radcliffe Publishing, ISBN 978-1-85775-305-9.</secondary-title></titles><periodical><full-title>Radcliffe Publishing, ISBN 978-1-85775-305-9.</full-title></periodical><pages>20</pages><dates><year>1998</year></dates><urls></urls></record></Cite></EndNote>199.To further analyze the effect of the PA intervention program on academic performance, we compared the intervention school with the control schools from Paper I-III (Table 4 and 5). The results are similar to those comparing the intervention school to all Swedish students (Paper IV). This strengthens our view that the intervention program is the main factor for the positive development in academic performance. However, the fact that the control schools had significantly higher grades and qualification rates before the intervention was initiated is a limitation. Since we had data for all Swedish students, we thus consider the primary analysis included in Paper IV to be of higher interest and research value. Table 4. Eligibility for upper secondary school and summarized grades for boys in the index school (n=155) and the control school (n=358) during years 2003 – 2006 (abefore the intervention was initiated in the index school) and for boys in the index school (n=185) and the control school (n=448) during years 2007 – 2012 (bwith intervention in the index school).BOYSStudents graduatingaStudents graduatingbMean difference between2003-20062007-2012the two periodsEligibility for upper secondary school (n (%))percentage pointsIndex school137 (88.4%)177 (95.7%)7.3 (1.4, 13.2)Control school344 (96.1%)432 (96.4%)0.3 (-2.3, 3.0)Summarized grades (mean points (95%CI))pointsIndex school197.7 (189.6, 205.7)211.0 (204.4, 217.5)13.3 (3.1, 23.5)Control school215.0 (208.9, 221.1)223,3 (218.3, 228.3)8.3 (0.5, 16.1)Data presented as absolute numbers (n), percentages (%), percentage points (pp) and means with 95% confidence intervals (95% CI). Statistically significant group differences are bolded. Table 5. Eligibility for upper secondary school and summarized grades for girls in the index school (n=140) and the control school (n=316) during years 2003 – 2006 (abefore the intervention was initiated in the index school) and for girls in the index school (n=153) and the control school (n=410) during years 2007 – 2012 (bwith intervention in the index school).GIRLSStudents graduatingaStudents graduatingbMean difference between2003-20062007-2012the two periodsEligibility for upper secondary school (n (%))percentage pointsIndex school133 (95.0%)146 (95.4%)0.4 (-4.5, 5.4)Control school306 (96.8%)397 (96.8%)0.0 (-2.6, 2.6)Summarized grades (mean points (95%CI))pointsIndex school239.2 (231.3, 247.1)233.6 (225.9, 241.3) -5.6 (-16.6, 5.4)Control school231.2 (224.9, 237.5)237.7 (232.3, 243.2)6.5 (-1.8, 14.8)Data presented as absolute numbers (n), percentages (%), percentage points (pp) and means with 95% confidence intervals (95% CI). Statistically significant group differences are bolded.The amount or intensity of the PA needed to improve cognitive achievement has been discussedPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Eb25uZWxseTwvQXV0aG9yPjxZZWFyPjIwMTE8L1llYXI+
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ADDIN EN.CITE.DATA 147,148,150. There are also studies suggesting PA to have positive effects on psychological parameters such as self-esteem, motivation, social engagement, and communication ADDIN EN.CITE <EndNote><Cite><RecNum>275</RecNum><DisplayText><style face="superscript">109</style></DisplayText><record><rec-number>275</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1462949505">275</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors></contributors><titles><title>Committee on Physical Activity and Physical Education in the School Environment</title><secondary-title>Food and Nutrition Board; Institute of Medicine; Kohl HW III, Cook HD, editors. Educating the Student Body: Taking Physical Activity and Physical Education to School. Washington (DC): National Academies Press (US); 2013 Oct 30. Available from: doi: 10.17226/18314</secondary-title></titles><dates><year>2013</year></dates><urls></urls></record></Cite></EndNote>109, all of importance for learning outcomes. Other studies suggest inferior motor skills to have negative effects in these psychological parameters and delay cognitive development ADDIN EN.CITE <EndNote><Cite><Author>Cratty</Author><Year>1997</Year><RecNum>248</RecNum><DisplayText><style face="superscript">151,152</style></DisplayText><record><rec-number>248</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1456889578">248</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Cratty, B. </author></authors></contributors><titles><title>Coordination Problems Among Learning Disabled, In B. Cratty & R. Goldman (Eds.)</title><secondary-title>Learning Disabilities, Contemporary Viewpoints. Amsterdam: Harwood Academic Publishers.</secondary-title></titles><periodical><full-title>Learning Disabilities, Contemporary Viewpoints. Amsterdam: Harwood Academic Publishers.</full-title></periodical><dates><year>1997</year></dates><urls></urls></record></Cite><Cite><Author>Gjesing</Author><Year>1997</Year><RecNum>246</RecNum><record><rec-number>246</rec-number><foreign-keys><key app="EN" db-id="d20efv2terewpwesp0epasxexsze5s2rwesx" timestamp="1456889408">246</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Gjesing, G. </author></authors></contributors><titles><title>Kropumulige Unger. </title><secondary-title>K?penhamn: DHLs f?rlag.</secondary-title></titles><periodical><full-title>K?penhamn: DHLs f?rlag.</full-title></periodical><dates><year>1997</year></dates><urls></urls></record></Cite></EndNote>151,152. Furthermore, an association has been shown between PA and attention and academic test resultsPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5IaWxsbWFuPC9BdXRob3I+PFllYXI+MjAwODwvWWVhcj48
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ADDIN EN.CITE.DATA 153,154, linking higher levels of PA to the ability to concentrate in the classroom, which also could influence academic performance.Strengths of the studiesThe strengths of the studies in this thesis include the longitudinal population-based case-control design, the large sample size in the fracture evaluation, the high participation rate in the fracture evaluation and the longest reported intervention follow-up period. It is advantageous that the level of PA in the intervention group was on a moderate level so that all children could participate. Also, the unique technique used to quantify cortical mass and density distribution and the use of the clinically relevant endpoints fractures, average grades and qualification rate to upper secondary school programs must be considered as strengths.Limitations of the studiesThe main weakness of the studies in this thesis is that they are not randomized controlled trials (RCT). No individual and no school randomization was done prior to study start, but since all schools had the Swedish standard of 60 min/week of PE before the study start and since the schools were community-based, located in the same geographic area with homogenous socioeconomic and ethnic structure and with the children allocated to each school according to their residential address, the risk of selection bias seems low. Other weaknesses include the lack of information regarding when and where the fractures occurred and the lack of registration of non-organized PA. Also, it would have been advantageous to have an objective measurement of the duration of PA throughout the study, e.g. continuous accelerometer-data. Since we only found positive effects in aBMD at the lumbar spine and not the hip and only two of four muscle strength tests in boys and one of four tests in girls, the concern that these positive effects may be related to other differences than the level of PA must be raised. The lower participation rate in the control group (28%) compared to the intervention group (73%) in the musculoskeletal evaluations is also a weakness. However, the view that the data are generalizable is strengthened by the dropout analyses revealing only slight differences between participants and dropouts at baseline in girls and none in boys, and no differences between participants and non-participants in the compulsory grade one school health examination.In the academic performance evaluation the relatively small intervention group and the absence of background data are limitations since other variables such as ethnicity, socioeconomic status and parental education may affect the outcome. To avoid the influence of any ceiling effect, we would have preferred to conduct the intervention in a school with lower academic achievements in girls, giving them the same potential for improvement as boys in our study.Other limitations that should be highlighted include the power problem for the fracture endpoint, especially in gender-specific sub-group analyses, the cross-sectional pQCT evaluation and the self-assessment of Tanner staging.ConclusionsThis thesis shows that increasing the amount of physical education in school from approximately 60 min/week to 40 min daily (200 min/week) from school start in children aged 6–9 years decreases the fracture risk with every year of extra physical education and enhances muscle strength.This program also improves bone mass and bone strength in girls, accompanied by region-specific gains in cortical bone mass distribution.Finally, the extra physical education during all nine compulsory school years improves grades and eligibility to higher education in boys.With these conclusions, we call on politicians and decision makers to strongly consider expansion of the physical education school curriculum to include daily physical activity in all Swedish schools to improve the musculoskeletal health and academic performance of future generations. Future perspectivesThe first three papers in this thesis examine the effect on fracture risk and musculoskeletal health during childhood and adolescence, and since there is a positive effect for the study subject the most intriguing question for the future is whether or not these benefits remain into adulthood and old age and thereby could affect the development of osteoporosis and fragility fractures. To answer this question the POP cohort must be followed further longitudinally into adulthood. However, a seven-year exercise intervention trial is a push forward regarding the field of school-based physical activity affecting bone mass, bone structure and muscle strength. One of the main findings, decreasing fracture risk with every year of intervention, provides new information about the main outcome from most studies involving bone mass and bone structure, fractures. Since this might be in part due to increased bone mass and muscle strength, fracture risk should be followed further to evaluate if this decrease continues and results in an absolute lower fracture risk with extension of the intervention. The bone mass distribution sheds light on how and where the increased bone mass is acquired and provides more insight into the physiology of skeletal response to general physical activity. Future studies should include more common fracture sites to evaluate the effect of physical activity on bone remodeling where the effect can be directly transferred to decreasing fractures. Two major concerns about increasing physical education in school have been the decreased time for other important school subjects and increased school resources needed for such a change in the curriculum. With this school-based intervention we now burst these concerning bubbles by showing that no decrease in grades accompanies such a program and no extra resources are needed. In fact, this thesis now provides strong evidence that increased physical education from school start and throughout elementary school increases grades and eligibility rate for upper secondary school programs in boys. To further investigate the effect of physical activity on academic performance the same cohort should be followed into adulthood to evaluate professional success. Summary in Swedish – Popul?rvetenskaplig sammanfattningFrakturer ?r ett stort och dessutom ?kande samh?llsproblem. Genom att st?rka skelettet och muskulaturen kan risken f?r frakturer minskas. H?g fysisk aktivitet ?r associerad med h?g benmassa, gynnsam skelettstruktur, god muskelfunktion och l?g risk att drabbas av frakturer. Fysisk aktivitet skulle d?rf?r kunna vara en m?jlig strategi f?r att minska antalet frakturer i samh?llet. Tidigare forskning har visat att den b?sta perioden i livet att p?verka sitt skelett genom fysisk aktivitet ?r pre- och peri-pubertalt. Tidigare studier ?r dock korta, innefattar sm? kohorter och baseras fr?mst p? inklusion av frivilliga idrottsintresserade barn. Detta g?r det sv?rt att uttala sig om eventuella l?ngtidseffekter samt populationsbaserade effekter, b?da viktiga sett ur ett samh?llsperspektiv. Skall fysisk aktivitet kunna anv?ndas s? effektivt som m?jligt som frakturprofylax b?r den inkludera s? m?nga barn som m?jligt, helst alla i befolkningen, och ge effekter ?ven vid en tr?ningsniv? som alla barn klarar av att genomf?ra. Det finns ut?ver detta ?ven studier som antyder att ?kad fysisk aktivitet ?r associerad med f?rb?ttrade kognitiva funktioner, s?som minne och inl?rning. D?rigenom skulle ?ven akademiska skolresultat kunna p?verkas. Detta ?r av stort intresse eftersom skolresultaten i svensk grundskola, enligt den ?terkommande PISA-rapporten, de senaste decennierna f?rs?mrats. Detta g?ller b?de betyg och andel barn som blir beh?riga till gymnasial utbildning. ?kad skolidrott skulle s?ledes kunna vara ett s?tt att v?nda denna trend. Mot denna bakgrund startades Bunkefloprojektet (p? engelska f?rkortad till POP-study), en populationsbaserad prospektiv kontrollerad interventionsstudie som innefattar barn fr?n fyra grundskolor i sydv?stra Malm?. En av skolorna ut?kade ?mnet idrott och h?lsa fr?n 60 min/vecka till 200 min/vecka (40 min/skoldag). Denna skola fungerade som interventionsskola. Resterande tre skolor fortsatte med 60 min/vecka idrottsundervisning (svensk standard) och fungerade d? som kontrollskolor. Vi inkluderade alla 3?534 barn (6–9 ?r gamla) som b?rjade ?rskurs 1 i n?gon av dessa skolor ?r 1998 till 2012 och f?ljde dem i 7 ?r avseende frakturer. De 264 barn som b?rjade ?r 1998 till 2000 erbj?ds vara med i en ut?kad del av studien d?r vi f?ljde utveckling av skelett, muskelstyrka och livsstilsfaktorer genom ?rliga m?tningar. F?r att utv?rdera akademiska skolresultat inkluderades alla individer som slutat ?rskurs 9 ?r 2003 till 2012 i interventionsskolan. Vi anv?nde ?ven Skolverkets statistikdatabas (Siris) f?r att inkludera alla individer som slutat ?rskurs 9 ?r 2003 till 2012 i hela Sverige som akademisk kontrollgrupp. P? detta s?tt kunde vi j?mf?ra skolresultaten mellan och inom skolorna f?re interventionen (skolslut 2003 till 2006) och efter interventionens inf?rande (skolslut 2007 till 2012).Barnen i interventionsskolan hade j?mf?rt med barnen i kontrollskolorna ?kad frakturrisk under det f?rsta ?ret efter p?b?rjad intervention, varefter den relativa frakturrisken sj?nk f?r varje ?r som interventionen p?gick. Vi s?g ?ven att flickorna i interventionsgruppen hade f?rb?ttrad utveckling av skelettet, i form av ?kad benmassa och f?r?ndrad struktur j?mf?rt med kontrollgruppen. N?gon s?dan effekt kunde inte registreras bland pojkarna. B?de flickor och pojkar i interventionsgruppen hade f?rb?ttrad utveckling av muskelstyrkan j?mf?rt med kontrollgruppen. Pojkarna med extra skolidrott f?rb?ttrade sina slutbetyg i nionde klass samt i denna grupp minskade ?ven andelen individer som inte klarade beh?righetskraven till gymnasial utbildning. Hos flickorna kunde inga akademiska gynnsamma effekter registreras bland dem med daglig fysisk aktivitet under grundskole?ren.?kad skolidrott f?refaller s?ledes vara en strategi som kan minska den relativa risken f?r fraktur, f?rb?ttra utvecklingen av skelett och muskelstyrka samt ?ka de akademiska skolprestationerna. Det finns st?d fr?n andra studier att en s?dan utveckling i ungdomen kan leda till starkare skelett och b?ttre muskulatur och d?rigenom f?rre frakturer ?ven i vuxenlivet och ?lderdomen. Detta g?r att vi nu har starkt vetenskapligt underlag att rekommendera daglig idrott i grundskolan f?r alla barn. AcknowledgementsMy first encounter with the project that was to be my PhD project was in the office of my supervisor, Professor Magnus Karlsson. I was pitching an idea for a research project I was going to do as part of my medical education. I had it all worked out. I had a plan.For the next months, Professor Karlsson guided me in my work towards an approved report for my education. He also inspired me to continue with the project and apply for an internship with research possibilities. After that there was no longer any doubt in my mind that this thesis would be completed. Professor Karlsson showed great enthusiasm and leadership over the following years when he inspired me through discussions at the office, email replies during the early hours of Sundays, travels to ?re, Houston, Seattle, Las Vegas and Melbourne and in the end finalizing this thesis.Back to the plan I had during that first meeting. Well, that was the first and most important thing Professor Karlsson did for me. He told me it was a crappy plan and instead presented a great research project including the schools I myself attended for 9 years to make it even more interesting. My most sincere thanks for that honesty and for all your tutelage.Research was never part of my plan when studying medicine. Therefore I have many people to thank for getting me started and even more people for helping along the way:Co-supervisor Dr. Bj?rn Rosengren. Thank you for your relentless endeavor for improvement in our work and our interesting and humorous discussions that really keep me on my toes.Co-author Professor Rob Daly. Thank you for hosting me in Melbourne and for filling in some of the gaps in knowledge I had concerning difficulties in creating a database and inclusion in a study.Co-author Dr. Marcus C?ster. Thank you for all the discussions at the office when we tried to outwit Magnus and Bj?rn with new takes on all the data and research questions. You had a great impact in the beginning of my research journey.Co-author Jan-?ke Nilsson. Thank you for your invaluable statistical advice and discussions.Co-authors Magnus Dencker, Caroline Karlsson. Thank you for your contributions to the publications.Co-authors Rachel Duckham and Timo Rantalainen. Thank you for guiding me in the field of cortical distribution, teaching me about study inclusion and taking time out of your schedules to support my research.Per G?rdsell and Christian Lindén. Thank you for your initiation and planning of the study.Susanne J?nsson, Christina Nilsson, Eva-Lena Forsberg, Karin Kristensson, Gunnel Nilsson, Karin ?nnby, Susanna Stenevi-Lundgren and Karin Ringsberg. Thank you for all you efforts with the measurements.Lise-Lott H?gg, Lisa Quensel and Lars Jehpsson. Thank you for your help with data management.Anette Rafsted, ?sa Almgren and Carin Holmberg. Thank you for collecting data, giving logistic support and helping out with organization of the study participants.All the children, parents, teachers and headmasters from the POP study. Thank you for making this project possible and for your enthusiasm doing so.My family. Thank you for your limitless support in every aspect of life.My wife Emma. Thank you for all your love and support, especially when I wander away in my own thoughts.References ADDIN EN.REFLIST 1.Genant HK, Cooper C, Poor G, et al. Interim report and recommendations of the World Health Organization Task-Force for Osteoporosis. Osteoporosis international 1999;10:259-64.2.Abrahamsen B, van Staa T, Ariely R, Olson M, Cooper C. Excess mortality following hip fracture: a systematic epidemiological review. Osteoporosis international 2009;20:1633-50.3.Johnell O, Kanis JA. An estimate of the worldwide prevalence and disability associated with osteoporotic fractures. 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