Layout 1 Thematic Section: Advances in Musculoskeletal and Neuromuscular Rehabilitation | Maccarone & Masiero Eur J Transl Myol 34 (4) 13021, 2024 doi: 10.4081/ejtm.2024.13021 Downhill (alpine) skiing is the most popular winter sport, exceeding 400 million skier days yearly, recorded in more than 2000 downhill ski areas worldwide.1 This sport is practiced by recreational skiers of a wide age range (about 3 to 90+ years) of both sexes.2 Downhill skiing at an older age, i.e., >60 years, requires the maintenance of appropriate muscle strength, which can be achieved through a generally physically active lifestyle and/or specific preparatory training.3 The biomechanical characteristics of downhill skiing are challenging for older people and include the coordinated performance of repetitive (primarily eccentric and static) loading of the leg muscles across a broad range of intensities.4 Insufficient muscle strength makes skiing down steep slopes and getting up after a fall more difficult and increases the risk of injury.5 High values of leg muscle strength are characteristic for downhill skiers and may represent a crucial pre-requisite for good skiing performance and the prevention of injury.6-8 Thus, being still able to ski at a higher age could be an indication of appropriate muscular power and healthy aging. As hand- grip strength is an acceptable indicator of overall muscle strength,9 including of lower limb strength,10 the present study was aimed at evaluating hand-grip strength in a large population of downhill skiers and comparing these values to the normal population, considering age and sex. We hypothesized that muscle strength, i.e., hand-grip strength (as an easy-to-use test) of active downhill skiers is higher at all ages and declines more slowly with age than in the normal population. Materials and Methods The full methods of the study have been reported elsewhere.11 Briefly, the characteristics of skiers (by inter- view) and grip strength (by hand dynamometry) have been recorded/assessed in six large ski resorts in Tyrol, Austria. Participants Recreational downhill skiers (N=757, from various na- tions) of both sexes aged from 18 to 69 years were in- cluded. Data were collected throughout all days of the week for one winter season in 2014: during rest periods on the slope, at ski huts, or the ski lifts/cable cars. Skiers were randomly selected with no in- or exclusion criteria other than age. Participants completed a brief survey in- cluding questions about basic anthropometric data, i.e., age, height, weight, and lifestyle characteristics, i.e., smoking, alcohol drinking, and physical activity. The re- Abstract Hand-grip strength was evaluated in 757 recreational downhill skiers and compared to 1021 community-dwellers. Findings are reported for age and sex categories consistent with community- dwelling norms. Effect size (Cohen’s d) was calculated to estimate the clinical relevance of strength differences between populations. Most male and half of the female age categories of downhill skiers demonstrated higher grip strength of the dominant hand (moderate to large effect size) compared to the reference population. Hand-grip strength in skiers declined with age at a similar rate as in the reference population. Relative grip strength (per kg body mass) was significantly and positively correlated with physical activity (hours/week), and with the number of ski days per year, and negatively with body mass. Thus, hand-grip strength may be related to the type, volume and intensity of exercise regularly performed. These results can help to assess whether the individual hand-grip strength is above or below average with regard to the normal population and the skier population as well and will support advice for training and/or rehabilitation. Key Words: downhill skiing, muscle strength, aging, sex. Eur J Transl Myol 34 (4) 13021, 2024 doi: 10.4081/ejtm.2024.13021 Hand-grip strength in recreational downhill skiers: a comparison to normative reference values Johannes Burtscher,1* Barbara Strasser,2,3* Gerhard Ruedl,1 Elena Pocecco,1 Verena Menz,1 Marc Philippe,4 Martin Kopp,1 Martin Burtscher1 1Department of Sport Science, University of Innsbruck, Innsbruck, Austria; 2Ludwig Boltzmann Institute for Rehabilitation Research, Vienna, Austria; 3Faculty of Medicine, Sigmund Freud Private University, Vienna, Austria; 4Olympiazentrum Vorarlberg GmbH, Dornbirn, Austria. *shared first-authorship, equal contribution. This article is distributed under the terms of the Creative Commons Attribution Noncommercial License (CC BY-NC 4.0) which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited. - 58 - Non -co mmerc ial us e o nly Hand-grip strength in recreational downhill skiers: a comparison to normative reference values Eur J Transl Myol 34 (4) 13021, 2024 doi: 10.4081/ejtm.2024.13021 jection rate was below 3% and the reasons for rejections were “no interest” or “no time to participate”. Hand-grip strength testing A calibrated electronic hand dynamometer (Camry, EH101, Camry Scale, CA, USA) was used. Skiers were instructed to squeeze the dynamometer as hard as possible standing upright, with arms by their sides, elbows flexed to 90°, and forearms in a neutral position. A single submaximal practice trial was done for each (right and left) hand, and after one- minute rest, a single maximal trial of 3 to 5 seconds was performed for each hand (the results of which were recorded and analyzed). Ethics The study was performed according to the Declaration of Helsinki and was approved by the Institutional Review Board of the Department of Sport Science (University of Innsbruck);11 informed consent was received and the rights of the subjects were protected. Statistics Data are presented as means ± standard deviation (SD). Normal distribution of data was tested by the Kolmogorov– Smirnov test. Depending on the normality distribution, in- dependent t-tests or Mann-Whitney U tests were used to compare differences between age groups, and Pearson’s or Spearman’s correlation coefficients were applied to eval- uate relationships between hand grip strength and other variables. Cohen’s d was calculated for effect size (ES) of all comparisons between skiers and the normal population of the same age group. Clinical relevance of differences is indicated by the value of ES, i.e., ES <0.2 are negligible, 0.2 <0.5 small, 0.5 <0.8 moderate and ≥ are 0.8 large. Mean differences in the decline of hand-grip strength (percentage decline from the age group with the highest value to that of the oldest age group) have been calculated and 95% con- fidence intervals are reported for men and women of both populations (alpine skiers and the normal population). Dif- ferences were considered statistically significant at p <0.05. Data analyses were conducted with the SPSS statistical software package (Version 24.0). Results Anthropometric and physical activity data for 10 age groups of male and female skiers are shown in Tables 1 and 2 and the results of hand-grip testing in Table 3 and 4. Hand-grip data were compared with normative reference values of hand grip strength for the same 10 age groups of both sexes obtained from a previous study.9 Figure 1 visualizes age- dependent changes in hand grip strength for skiers and the normal population. The absolute hand-grip strength values of the dominant and non-dominant hand were closely correlated in male skiers (r=0.82, p <0.05) and female skiers (r=0.83, p <0.05) as well. These absolute hand-grip strength values were signif- icantly correlated with body mass (r=0.25, p <0.05, in male skiers and r=0.22, p <0.05, in female skiers). The relative hand-grip strength (grip strength/kg) of the dominant hand was significantly and positively correlated with physical ac- tivity (hours/week) (r=0.21, p <0.05), and with ski days per year (r=0.23 , p <0.05), and negatively with body mass (r= -0.44, p <0.05); similar correlations were found between relative hand-grip strength of the non-dominant hand and physical activity (hours/week) (r=0.26, p <0.05), and with ski days per year (r=0.26, p <0.05), and negatively with body mass (r=-0.42, p <0.05). The decline in hand-grip strength (dominant hand) from the age group with the highest values to that of the oldest age group (64 – 69 years) was 28% (95% CI: 19.4% - 35.4%) in male skiers compared to 26% (95% CI: 13.6% - 38.0%) in men of the normal population. In contrast, this decline - 59 - Table 1. Characteristics of male skiers Age group N Height Weight BMI Exercise Skiing (years) (cm) (kg) (hours/week) (days/year) 18-24 56 179.5 (6.4) 74.7 (10.1) 23.2 (2.7) 6.2 (4.0) 13.0 (11.9) 25-29 57 181.8 (6.6) 78.6 (8.8) 23.8 (2.4) 7.5 (8.2) 21.7 (19.4) 30-34 43 180.9 (5.2) 80.8 (8.2) 24.7 (2.6) 6.5 (5.0) 19.8 (25.4) 35-39 19 181.6 (7.6) 81.1 (10.4) 24.5 (2.0) 6.1 (5.7) 20.4 (25.2) 40-44 37 179.9 (7.1) 83.6 (12.1) 25.9 (3.4) 5.7 (5.1) 19.4 (21.7) 45-49 47 179.9 (7.3) 83.0 (10.6) 25.6 (2.7) 4.8 (4.7) 12.0 (8.7) 50-54 73 180.7 (6.8) 85.1 (12.2) 26.0 (2.9) 5.2 (5.4) 15.7 (18.7) 55-59 33 179.4 (6.9) 82.3 (11.1) 25.5 (2.4) 5.9 (8.1) 16.1 (13.6) 60-64 29 179.2 (9.3) 83.0 (11.7) 25.8 (2.7) 5.6 (4.5) 19.8 (30.4) 65-69 15 176.0 (6.3) 81.6 (12.0) 26.3 (3.4) 4.4 (3.4) 17.0 (10.7) Non -co mmerc ial us e o nly Hand-grip strength in recreational downhill skiers: a comparison to normative reference values Eur J Transl Myol 34 (4) 13021, 2024 doi: 10.4081/ejtm.2024.13021 was only 14% (95% CI: 0.6% - 28.8%) in female skiers compared to 26% (95% CI: 16.1% - 36.4%) in women of the normal population. Discussion The majority of age categories of male (8 out of 10) and half of female downhill skiers demonstrated higher grip strength of the dominant hand (statistical significance and moderate or large effect size) compared to the normal pop- ulation evaluated by Wang et al.9 However, the expectedly less-pronounced age-related decline in hand-grip strength in skiers was not confirmed. The higher hand-grip strength values in some age categories of skiers, compared to the normal population, may be re- lated to higher physical fitness levels and associated muscle strength,12,13 which is necessary to perform downhill skiing but also promoted by general engagement in winter outdoor activities.14 The favorable impact of physical activity and skiing practice is emphasized by the positive relationship between these factors and the measured hand-grip strength in the present study. The negative relationship between rel- ative hand-grip strength and body mass in skiers may indi- cate unfavorable effects of increasing fat mass (and reduced lean body mass),15 which is characteristic of older people not sufficiently engaged in regular physical activity.16 Ho- wever, besides physical activity, ethnic differences between the compared populations could have contributed to the hand-grip strength differences observed.17 Although the skier population of the present study consisted of various nationalities, the proportion of Caucasian people may be dominant.18 Günther and colleagues reported reference values for healthy Caucasian people (region Munich, Ger- many) also of a wide age range of both sexes (403 women and 366 men).19 These authors report hand-grip strength values similar to those of the skiers in the present study, e.g., 54 kg (right hand) in men aged 30-39 years, and 33 kg in the same age group of women.19 Also, the decline with age was similar but slightly steeper (from 33 to 26 kg for the right hand in the age group 60 – 69 years) when com- pared to female skiers (from 33.1 to 28.4 kg). A significant proportion of the cohort evaluated by Günther et al. likely practice downhill skiing or other alpine sports activities be- cause those people live close to the Alps.19 A study reporting hand-grip strength of senior athletes drawing comparisons to some age groups (50 – 69 years) of the same normal populations as in the present study showed similar or larger strength values of senior athletes compared to alpine skiers.20 These findings are not surpris- ing as these athletes were still competing in one of a Na- tional Senior Games event. Thus, hand-grip strength values of skiers are somewhere between those of the normal pop- ulation and (still active) senior athletes. Similar hand-grip strength values as measured in skiers of the present study have been reported in male and female ath- letes participating in the 2022 World Master Weightlifting Championships (considering ages from 40 to 69 years), while comparisons to community-dwelling adults revealed signif- icantly higher and to Senior Games athletes lower grip- strength values.21 Again, the rate of decline was similar across different populations (weightlifters, other athletes, com- munity-dwelling adults).21 This observation is in line with the findings from a systematic review and meta-analyses which revealed that chronic exercise training does not prevent age- related declines in muscular strength.22 However, higher ab- solute levels of strength provide skiers with a greater strength reserve, thus delaying the onset of impaired function. Several markers of muscular strength, including hand-grip strength, are improved by regular physical activity in older adults but inevitably decline with aging.9,19,23 Our hypothesis that older skiers will better maintain hand-grip strength has to be rejected. However, both male and female skiers of the oldest age group exceeded a proposed threshold value of hand-grip strength (28 kg for men and 18 kg for women) - 60 - Table 2. Characteristics of female skiers Age group N Height Weight BMI Exercise Skiing (years) (cm) (kg) (hours/week) (days/year) 18-24 59 168.5 (6.3) 61.0 (7.2) 21.5 (2.0) 5.1 (3.3) 13.4 (11.9) 25-29 40 168.3 (6.3) 60.4 (7.0) 21.4 (2.7) 5.7 (3.9) 15.7 (18.3) 30-34 50 169.1 (6.7) 63.0 (8.4) 22.0 (2.6) 5.2 (3.1) 13.2 (14.5) 35-39 19 166.8 (5.3) 61.3 (7.2) 22.0 (2.1) 4.6 (3.3) 8.9 (8.0) 40-44 38 169.6 (5.9) 62.7 (8.9) 21.8 (2.7) 3.9 (2.3) 14.4 (11.5) 45-49 50 167.1 (5.6) 64.2 (8.7) 22.9 (2.3) 5.6 (6.4) 13.6 (11.6) 50-54 46 168.0 (6.5) 66.5 (11.9) 23.5 (3.6) 4.4 (3.4) 12.9 (10.0) 55-59 21 164.6 (5.9) 63.1 (8.9) 23.3 (2.7) 4.8 (3.2) 18.8 (19.4) 60-64 17 164.6 (5.2) 65.7 (8.9) 24.3 (3.6) 3.6 (2.5) 13.7 (8.4) 65-69 8 165.1 (7.6) 66.1 (13.0) 24.2 (4.4) 4.4 (3.4) 14.2 (8.9) Non -co mmerc ial us e o nly Hand-grip strength in recreational downhill skiers: a comparison to normative reference values Eur J Transl Myol 34 (4) 13021, 2024 doi: 10.4081/ejtm.2024.13021 clearly, indicative for above average muscle strength and physical fitness.24 These observations provide a clue for hand-grip strength necessary for being able to perform (safely and enjoyable) usual downhill skiing activities.4 Furthermore, the maintenance of muscle power is critical to preserve sports performance and functionality in ad- - 61 - Table 3. Results of the hand-grip tests (dominant and non-dominant hand) of 409 male alpine skiers in 10 age groups from 18 to 69 years compared to data from the normal male US population (Reference; 348 men).9 Age group Population N Mean (kg) SD Cohen’s d Men, dominant hand 18-24 Skiers 56 50.7* 8.1 0.5 Reference 36 47.0 8.1 25-29 Skiers 57 54.2 9.9 0.4 Reference 35 49.7 11.6 30-34 Skiers 43 54.8* 8.3 0.8 Reference 29 46.5 12.1 35-39 Skiers 19 53.5* 8.4 0.6 Reference 41 47.1 11.9 40-44 Skiers 37 54.9* 8.3 0.8 Reference 47 46.7 11.7 45-49 Skiers 47 50.9* 9.2 0.8 Reference 32 42.8 10.9 50-54 Skiers 73 50.6* 8.4 0.7 Reference 46 44.0 10.3 55-59 Skiers 33 47.8* 8.3 0.8 Reference 27 40.7 10.4 60-64 Skiers 29 47.1* 7.8 1.0 Reference 33 38.4 10.3 65-69 Skiers 15 39.4 5.6 0.3 Reference 22 36.8 10.5 Men, non-dominant hand 18-24 Skiers 56 48.2 9.5 0.4 Reference 36 44.9 7.8 25-29 Skiers 57 50.8* 8.6 0.5 Reference 35 46.5 9.6 30-34 Skiers 43 52.3* 8.3 0.7 Reference 29 45.8 11.3 35-39 Skiers 19 52.1* 7.7 0.7 Reference 41 45.5 11.0 40-44 Skiers 37 51.4* 8.5 0.6 Reference 47 44.9 11.7 45-49 Skiers 47 47.8* 8.8 0.7 Reference 32 41.2 10.0 50-54 Skiers 73 48.8* 7.7 0.7 Reference 46 42.3 10.6 55-59 Skiers 33 45.1* 7.9 0.8 Reference 27 38.5 9.6 60-64 Skiers 29 44.3* 9.0 0.8 Reference 33 37.2 9.1 65-69 Skiers 15 38.3 6.5 0.3 Reference 22 35.4 10.3 *Indicates significant statistical difference between skiers and the normal population, p<0.05. Non -co mmerc ial us e o nly Hand-grip strength in recreational downhill skiers: a comparison to normative reference values Eur J Transl Myol 34 (4) 13021, 2024 doi: 10.4081/ejtm.2024.13021 vanced age. Current evidence indicates that the age-related decline in muscle power better predicts health outcomes than muscle strength.25,26 The Longevity Check-up 7+ (Lookup 7+) project recently provided normative values of lower extremity muscle power, estimated according to five- repetition sit-to-stand equations.27 Absolute muscle power - 62 - Table 4. Results of the hand-grip tests (dominant and non-dominant hand) of 348 female alpine skiers in 10 age groups from 18 to 69 years compared to data from the normal female US population (Reference; 673 women).9 Age group Population N Mean (kg) SD Cohen’s d Women, dominant hand 18-24 Skiers 59 30.7* 5.2 0.4 Reference 54 28.1 7.1 25-29 Skiers 40 31.2 5.8 0.2 Reference 102 29.6 7.0 30-34 Skiers 50 32.5* 4.7 0.6 Reference 105 28.9 6.2 35-39 Skiers 19 31.8 4.5 0.4 Reference 90 29.2 6.2 40-44 Skiers 38 33.1* 6.3 0.5 Reference 88 29.9 6.2 45-49 Skiers 50 29.3 5.3 0.1 Reference 52 28.8 7.2 50-54 Skiers 46 30.4 5.3 0.4 Reference 65 28.2 6.3 55-59 Skiers 21 27.2 4.2 0.4 Reference 30 25.1 6.2 60-64 Skiers 17 28.9* 7.8 0.7 Reference 58 23.6 6.5 65-69 Skiers 8 28.4* 5.6 1.0 Reference 29 22.1 6.6 Women, non-dominant hand 18-24 Skiers 59 28.6 5.1 0.3 Reference 54 26.6 6.4 25-29 Skiers 40 29.5 5.0 0.3 Reference 102 27.9 6.6 30-34 Skiers 50 30.1* 4.2 0.5 Reference 105 27.7 5.9 35-39 Skiers 19 30.7 5.6 0.5 Reference 90 28.0 6.0 40-44 Skiers 38 31.4* 6.4 0.4 Reference 88 28.9 6.4 45-49 Skiers 50 27.9 5.8 0.1 Reference 52 27.4 7.2 50-54 Skiers 46 28.0 6.0 0.2 Reference 65 26.5 6.6 55-59 Skiers 21 26.2 3.1 0.5 Reference 30 23.6 6.4 60-64 Skiers 17 26.1 4.2 0.6 Reference 58 22.9 6.3 65-69 Skiers 8 25.5 4.0 0.8 Reference 29 21.0 6.6 *Indicates significant difference between skiers and the normal population, p<0.05. Non -co mmerc ial us e o nly Hand-grip strength in recreational downhill skiers: a comparison to normative reference values Eur J Transl Myol 34 (4) 13021, 2024 doi: 10.4081/ejtm.2024.13021 peaked at 41–50 and 31–40 years in men and women, re- spectively. Subsequently, a rate of decline of approximately 12% per decade was observed, regardless of sex. This is in agreement with data from World Records of Master ath- letes, demonstrating an absence of sex differences in the de- cline of performance with aging.28 Low values of hand-grip strength may not only provide in- formation on the fitness status of downhill skiers but are also closely related to morbidity and mortality of various causes,29-31 and this association tended to be stronger in women.32 Thus, the overall health effects in regular long- term downhill skiers are not surprising.2 On the other hand, the injury risk during downhill skiing should not be under- estimated,33,34 but higher muscular strength has been sug- gested as a preventive factor, particularly considering the relatively high risk of an anterior cruciate ligament (ACL) injury in female skiers.35 This risk is about three times greater in women than men, which may, besides neuromus- cular factors, be attributed to hormonal and anatomical, but also environmental and equipment-related factors.34,36 Furthermore, increased hand-grip strength is associated with a reduced risk of falls in older age, but is partly mediated by balance problems.37 Generally, the maintenance of appropri- ate musculoskeletal fitness with aging is a long-known measure for the prevention of injury in sports.38 As demon- strated by the association between lower hand-grip strength with higher all-cause, cardiovascular, and cancer mortality risk,29 as well as a higher risk of falls, grip strength meas- urements in skiers may provide possible clues about the abil- ity to ski and the associated injury risk in older people. Hand-grip strength values are markers for the strength of knee extensor muscles,10 which are predominantly used in downhill skiing.39 Both appropriate strength training and performing regular downhill skiing improve lower leg strength and consequently also hand-grip strength.39 Ho- wever, it must be noted that muscle strength is only one fac- tor contributing to skiing performance and other parameters, e.g., aerobic and anaerobic endurance, agility, balance ca- pability, and technical skills are also crucial.8,40 Limitations First, besides age and sex, multiple factors such as height, body mass, type, volume, and intensity of phys- ical activity, pre-existing diseases, and dietary behavior may all influence hand-grip strength, all of them have not been sufficiently considered in the present study. Second, the sample size of some age groups is small likely provoking a type II error. Third, no detailed infor- mation was collected, e.g., on geographic, sociocultural and economic characteristics of participants. Hence, po- tential selection biases cannot be ruled out. Finally, re- finements of hand-grip strength measurement protocols are needed41 for a deeper understanding of age-depen- dent trajectories of muscle strength in downhill skiers. In conclusion, this study provides average values of hand-grip strength for 5-year age categories of male and female skiers from 18 to 69 years and draws compari- sons to a normal population. On average, recreational al- pine skiers have greater hand-grip strength than individuals of the normal population but may have lower strength values than competitive athletes of both sexes across all age groups considered. Differences may be a consequence of the volume and intensity of exercise reg- ularly performed. These results can help to assess whether the individual hand-grip strength is above or below average with regard to the normal population and the skier population as well and will support advice for training and/or rehabilitation. Future studies should de- termine more precisely the potential impact of hand-grip strength on the age-related skiing ability and the associ- ated risk of injury. List of abbreviations ACL, Anterior cruciate ligament CI, Confidence Interval ES, Effect size SD, Standard deviation - 63 - Figure 1. Visualization of age-dependent grip strength values in skiers compared to reference values of a normal population. Non -co mmerc ial us e o nly Hand-grip strength in recreational downhill skiers: a comparison to normative reference values Eur J Transl Myol 34 (4) 13021, 2024 doi: 10.4081/ejtm.2024.13021 Contributions MB was responsible for the conception and design of the study; EP, VM, GR and MP were involved in data collection; MB, JB, and BS were involved in the processing and statis- tical analysis of data; MB, JB, BS, and MK were involved in the drafting of the manuscript; and all authors contributed to the interpretation of the data for the work and revising it critically for important intellectual content. All the authors finally approved the manuscript. MB was responsible for obtaining project funding and takes responsibility for the in- tegrity of the work as a whole. All authors have read and agreed to the published version of the manuscript. Conflict of interest None of the authors report any conflict of interest related to this study. Ethics approval and consent to participate The study was performed according to the Declaration of Helsinki and was approved by the Institutional Review Board of the Department of Sport Science (University of Innsbruck); informed consent was received and the rights of the subjects were protected. Availability of data and materials All data generated or analyzed during this study are in- cluded in this published article. Acknowledgements We thank to the Austrian Ski Federation for the valuable support of this study. Corresponding author Prof. Martin Burtscher, MD, PhD, University of Innsbruck, A-6020 Innsbruck. ORCID ID: 0000-0002-5232-3632 E-mail: martin.burtscher@uibk.ac.at Johannes Burtscher ORCID ID: 0000-0002-2889-0151 E-mail: Johannes.burtsscher@uibk.ac.at Barbara Strasser ORCID ID: 0000-0002-4318-5629 E-mail: Barbara.strasser@med.sfu.ac.at Gerhard Ruedl ORCID ID: 0000-0001-5036-7984 E-mail: Gerhard.ruedl@uibk.ac.at Elena Pocecco ORCID ID: 0000-0002-3730-1961 E-mail: Elena.pocecco@uibk.ac.at Verena Menz ORCID ID: 0000-0003-1833-6568 E-mail: Verena.menz@uibk.ac.at Marc Philippe ORCID ID: 0009-0005-3868-9880 E-mail: Marc.philippe@olympiazentrum-vorarlberg.at Martin Kopp ORCID ID: 0000-0002-3011-387X E-mail: Martin.kopp@uibk.ac.at References 1. Vanat L. 2018 International Report on Snow & Moun- tain Tourism. June 2018. 2. Burtscher M, Bodner T, Burtscher J, et al. Life-style characteristics and cardiovascular risk factors in regular downhill skiers: an observational study. BMC Public Health 2013;13:788. 3. Pötzelsberger B, Kösters A, Finkenzeller T, Müller E. 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