Paid expenditures and productivity costs associated with permanent disability pensions in patients with spinal disorders: Nationwide Finnish Register-based Study, 1990-2010.

PURPOSE: The objective of this study is to present the paid expenditures and productivity costs of disability pensions (DP) due to spinal disorders (SD) in Finland during 1990-2010. METHODS: This study is a register-based national study. All new cases aged 20-64 that were granted a DP due to SD were identified from the nationwide register maintained by the Finnish Centre of Pensions. The data included sex, age group, year of the DP decision, main cause of incapacity (diagnosis) leading to permanent DP and yearly paid expenditures for DPs. Annual productivity costs were estimated based on labour force participation rate and the employment rate adjusted gross domestic product. RESULTS: A total of 39,107 individuals (18,072 females, 21,035 males) received DPs during the study period. SDs generated 9,372 million euros extra cost during this period due to DP (females 3.5 billion, males 5.9 billion). The total DP expenditures paid increased during the first half of 1990s but decreased during the second half of 1990s (-44.8 %). For degenerative SD cases, the DP expenditure was 5.1 billion €, disc disease 3.5 billion € and for other SDs 0.7 billion €. Males, compared to females, were expected to have a rate 1.22 times greater costs due to DPs. The estimated total annual productivity costs due to SDs have been over six times higher than expenditures paid for DPs per year. The costs of DPs are different compared to occurrence rates due to salary and early retirement age differences between genders. CONCLUSION: Despite a significant decrease in DP-associated expenditures due to SDs after 1993, the annual expenditures have stayed on a high level in Finland.

Individualized methods for the diagnosis and treatment of nonspecific lower back pain.

Lower back pain is globally the most common problem interfering with functional capacity, and the recognition of causes that are serious and require specific therapy is essential in its diagnosis. Provision of information for a person suffering from lower back pain is essential. In some patients psychosocial factors prolong the back pain and potential incapacity for work. For their evaluation several internationally validated surveys have been developed, which can be used to facilitate the identification of higher-risk patients. By using electronic data, our aim is to develop in Finland the assessment of individual risk of patients with lower back pain and their appropriate treatment.

[Update on current care guidelines. Pain]. / KÄYPÄ HOITO -SUOSITUS (Tiivistelmä). Kipu.

Management of patients suffering from chronic pain is based on long-term therapeutic relationship. The main objectives of the treatment are pain relief, restoration of function and improvement of quality of life. Interventions for treatment and rehabilitation need to be planned in agreement with the patient. Non-pharmaceutical interventions form the basics of the treatment. If medication is needed, it should be tailored to meet the individual needs of the patient according to the etiology and intensity of pain, comorbidities and psychosocial situation.

No increased cardiovascular mortality among early rheumatoid arthritis patients: a nationwide register study in 2000-2008.

OBJECTIVES: To assess cardiovascular (CV) mortality in early rheumatoid arthritis (RA), and the impact of RA medications on CV mortality. METHODS: We identified all incident RA patients over 18 years of age diagnosed between 2000 and 2007 in Finland. Causes of death were analysed until the end of the year 2008. We used competing-risks regression models to assess the impact of different variables such as RA medications on CV mortality. CV mortality was compared with that of the age- and sex-specific general population. RESULTS: We identified 14,878 incident RA patients (68% women, 63% rheumatoid factor (RF) positive, mean age 55.8/57.5 years in men/women), of whom more than 80% received RA medications for longer than 90% of their individual patient-years. By the end of 2008, 1,157 patients died, 501 (43%) of whom of CV causes. The standardised mortality ratio (SMR) for CV deaths in the entire RA cohort was 0.57 (95% CI 0.52 to 0.62). Along with traditional CV risk factors, the presence of RF and the use of glucocorticoids was associated with a higher risk of CV death, whereas the use of methotrexate was associated with a lower risk. CONCLUSIONS: These nationwide results suggest that patients with recent-onset RA who receive consistent RA medication have no increased risk for CV mortality compared to the general population, at least in the early years of the disease. The use of methotrexate is associated with lower CV mortality, whereas the use of glucocorticoids is associated with a higher than average CV mortality.

[Update on Current Care Guideline: Low back pain]. / Alaselkäkipu.

Classification to severe diseases, sciatic symptoms or non-specific back pain is recommended. Radiography in acute or subacute non-specific back pain is not recommended in the primary health care. In specialized care magnetic resonance imaging is the main imaging modality. Importance of patient information is emphasized. In acute non-specific pain avoidance of bed rest, advice and paracetamol are recommended. Indications for an emergency referral should be considered. In disabling pain for 6 weeks, multidisciplinary measures are needed. Pain over 3 months indicates intensive multidisciplinary rehabilitation, and also surgery may be considered.

Incidence of systemic lupus erythematosus in Finland, 2000-2007, a nationwide study.

OBJECTIVES: To determine the age- and sex-specific incidence rates of systemic lupus erythematosus (SLE) in Finland. METHODS: The incident cases were identified through diagnostic register searches for SLE on the nationwide database of the Social Insurance Institution. RESULTS: During the 8-year study period 599 incident cases occurred (518 females, 81 males). The mean annual incidence rate of SLE for adults was 1.69 per 100,000 (95% CI 1.56-1.84) and was highest among females aged 40-59 years. The gender incidence rate ratio was 6.43 (95% CI 5.06-8.26). The incidence for children was 0.39 (95% CI 0.27-0.55). CONCLUSIONS: The incidence of SLE was lower compared to the countries at the same latitudes. SLE in children remained a rarity.

Decline in work disability caused by early rheumatoid arthritis: results from a nationwide Finnish register, 2000-8.

OBJECTIVES: To study whether the work disability (WD) rates in early rheumatoid arthritis (RA) have changed in Finland, where the treatment of RA has long been active but has intensified further since 2000. METHODS: All incident non-retired patients with RA of working age (18-64 years) in a nationwide register maintained by the Finnish Social Insurance Institution from 1 January 2000 to 31 December 2007 were identified. Patient cohorts were analysed in 2-year time periods (2000-1, 2002-3, 2004-5, 2006-7) and initial disease-modifying antirheumatic drugs (DMARDs) were elucidated from the drug purchase register. The incidence of continuous WD in the RA cohorts as well as in the entire Finnish population up to 31 December 2008 was analysed. RESULTS: A total of 7831 patients were identified (71% women, 61% rheumatoid factor-positive). Throughout the follow-up period the use of methotrexate and combination DMARDs as the initial treatment of early RA increased. During the first 2 years the incidence of RA-related continuous WD was 8.9%, 9.4%, 7.2% and 4.8% in the year cohorts, respectively (p<0.001 for linearity). Compared with the entire Finnish population, the age- and sex-stratified standardised incidence ratio of a WD pension due to any cause was 3.69, 3.34, 2.77 and 2.80 in the year cohorts, respectively (p<0.001 for linearity). CONCLUSIONS: Since 2000 the frequency of continuous WD in early RA has declined in Finland. The present data allow no explanatory analysis but, at the same time, increasingly active treatment strategies have been introduced.

[Update on current care guidelines: spinal cord injury]. / Selkäydinvamma.

Traumatic spinal cord injury is most common among men between 16 and 30 years. Prevention should be targeted both on traffic safety and individual behaviour Key issues in patient care are safe transfer from the place of injury to a hospital, diagnostic imaging (primarily CT, MRI if needed) and assessment of neurological injury by AIS-questionnaire, early surgical decompression and stabilisation for most cases, and treatment and rehabilitation starting from the emergency room and extending to life-long care carried out by a multi-professional team.

Use of osteoporosis drugs in patients with recent-onset rheumatoid arthritis in Finland.

OBJECTIVES: We investigated the implementation of pharmaceutical osteoporosis (OP) prevention in early rheumatoid arthritis (RA) in Finland. METHODS: All incident RA cases from 2000 to 2007 were identified using the national register of the Social Insurance Institution (SII) as the sole source. The use of calcium and vitamin D preparations and OP drugs during the first year was evaluated. RESULTS: A total of 14,878 incident RA patients were found. They had a mean age of 56 (SD 15) and 68% were female. Nine per cent of the total number, which equated to 11% for women and to 5% men, had purchased OP drugs. The use of OP drugs increased over time: in the 2006-2007 period, relative risk (RR) for purchase was 1.62 (95% CI 1.38-1.92) for women and 2.1 (1.34-3.30) for men compared to the 2000-2001 period. Over the 2000-2005 period, 49% of females and 52% of males used glucocorticoids (GCs) during the first year. Among the GC-users, 38% of women and 24% of men also received calcium and vitamin D preparations by prescription, and 14% of women and 6% of men also used OP drugs. For GC users, the female sex, and older age increased the risk for OP use: the respective RRs were 1.45 (95% CI 1.31-1.61), 2.54 (95% CI 2.21-2.91), and 1.060 (95% CI 1.057-1.065). CONCLUSIONS: Patients with early RA are increasingly receiving OP drugs, and the use is more frequent among patients with known risk factors.

First-year purchases of disease-modifying drugs of incident patients with chronic juvenile arthritis in Finland.

OBJECTIVES: To establish a nationwide overview on drug treatment of juvenile idiopathic arthritis (JIA), which is the most frequent form of chronic arthritis (JA) in children and adolescents. The emphasis is on the first 12 months after diagnosis, and any changes in medication practices during the early years of the present millennium are registered. METHODS: The Social Insurance Institution (SII) in Finland keeps a national register on individuals granted with a special reimbursement for medication of defined chronic diseases. From that register, we identified by the ICD-code of M08 all JA patients aged 16 years or under with an index day from 2000 through 2007. The prescription register of the SII showed the medication purchased for the patients. The register does not cover infused medications given in hospitals. We evaluated the first disease year's medication and the treatment strategy of the very first three months. RESULTS: Within our study period 2000-2007, the proportion of patients using methotrexate during the first year of treatment increased from 54 to 72% (p<0.001). The combination of two or more DMARDs became more popular (increased from 16 to 21%) as the initial treatment strategy. These changes parallel a decrease in per oral glucocorticoids. The proportion of JA patients receiving TNFα-blockers during the first year after diagnose reached the level of about 5% during the years 2004 to 007. CONCLUSIONS: The drug treatment of patients with recent onset JA has become more intensive during the course of the new millennium in Finland, a fact expected to improve the disease outcome.

Network-based geriatric rehabilitation for frail elderly people: feasibility and effects on subjective health and pain at one year.

OBJECTIVE: To study the feasibility and 1-year effects on subjective health and symptoms of a network-based geriatric rehabilitation intervention for frail elderly people. DESIGN: A randomized, controlled trial. SUBJECTS: A total of 741 frail elderly people who lived at home, aged > 65 years, without severe cognitive impairment (Mini Mental State Examination < 18), and eligible to receive Pensioners' Care Allowance (a benefit that is independent of personal income or insurance). The setting included 41 municipalities and 7 rehabilitation centres in Finland. METHODS: Over a period of 8 months the intervention group received network-based rehabilitation for 3 in-patient periods (totalling 21 days) at rehabilitation centres and a home visit by a professional. Both groups received standard social and health services locally. Functional Independence Measure, subjective health, common symptoms and pain were assessed at baseline and 1-year follow-up. RESULTS: After baseline measurements, 33 of those allocated to rehabilitation withdrew from the study. Of the 343 intervention subjects, 276 attended all 3 in-patient periods. At one year, there were no differences in symptoms between the groups. Subjective health was improved in the intervention group and impaired in the control group (p < 0.01). CONCLUSION: The network-based geriatric rehabilitation programme was feasible for use among the frail elderly people and improved their subjective health.

The effect of two physiotherapy approaches on physical and cognitive functions and independent coping at home in stroke rehabilitation. A preliminary follow-up study.

PURPOSE: Activating physiotherapy was used to support the principle of post stroke functional recovery as a learning process which requires both cognitive and physical actions. The purpose of the present preliminary study was to examine the influence of activating physiotherapy on stroke patients' cognitive and physical functions and independent living at home compared with traditional treatment over a 12-month follow-up. METHODS: The 40 patients who received activating physiotherapy were compared with 40 patients receiving traditional therapy. Patients' physical functional capacity was measured one week and 12 months post stroke with the Barthel Index (BI), 10-m gait speed, the Postural Control and Balance for Stroke (PCBS) test, walking distances and patients' abilities to cope without outside help. Cognitive capacity was measured with specific neuropsychological tests: language, visuospatial functions, visual inattention and memory. RESULTS: Physical functional capacity improved significantly (p = 0.001) in both groups at the 12-month follow-up, but no significant differences were found between groups. However, the patients in the activating therapy group coped better without outside help (p = 0.042) and covered longer distances outdoors (p = 0.012). At follow-up all the measured cognitive functions had improved significantly in the activating therapy group and the change in memory in the same group differed significantly from that in the traditional therapy group (p < 0.001), where no significant improvement was observed. CONCLUSIONS: Activating therapy advanced stroke patients' cognitive and physical functional recovery and supported their return to independent life at home more than did traditional physiotherapy. In this respect activating therapy seems to have a beneficial influence on long-term stroke rehabilitation.

Manipulation under anesthesia with home exercises versus home exercises alone in the treatment of frozen shoulder: a randomized, controlled trial with 125 patients.

We aimed to determine the effect of manipulation under anesthesia in frozen shoulder patients. A blinded randomized trial with a 1-year follow-up was performed at 3 referral hospitals in Southern Finland. We randomly assigned 125 patients with clinically verified frozen shoulder to the manipulation group (n = 65) or control group (n = 60). Both the intervention group and the control group were instructed in specific therapeutic exercises by physiotherapists. Clinical data were gathered at baseline and at 6 weeks and 3, 6, and 12 months after randomization. The 2 groups did not differ at any time of the follow-up in terms of shoulder pain or working ability. Small differences in the range of movement were detected in favor of the manipulation group. Perceived shoulder pain decreased during follow-up equally in the 2 groups, and at 1 year after randomization, only slight pain remained. Manipulation under anesthesia does not add effectiveness to an exercise program carried out by the patient after instruction.

Effectiveness of a home exercise programme in low back pain: a randomized five-year follow-up study.

BACKGROUND AND PURPOSE: Therapeutic exercise has been shown to be beneficial in decreasing pain and in increasing functioning in patients with chronic low back pain. However, longitudinal follow-up studies are small in number, and often limited in the numbers of subjects due to drop-outs. In addition there is a shortage of real control groups in most cases. The purpose of the present study was to describe long-term changes in intensity of low back pain and in functioning for two study groups five years after undertaking a home exercise programme. METHOD: This was a randomized follow-up study over five years. Fifty-seven subjects were reassessed with questionnaires five years after their initial recruitment for an intervention study. A home exercise group (n = 29), with training once a day, and a control group (n = 28), without exercise, were included in the present study protocol. The primary outcome measurements included a questionnaire on the intensity of low back pain (Borg CR-10 scale) and on functioning (Oswestry Disability Index; ODI). The confounding physical activity was controlled with metabolic unit (MET) values. RESULTS: The CR-10 and ODI scores decreased during the first three months in both study groups. During the follow-ups, the corresponding indicators of the home exercise group remained below baseline values. The CR-10 score was significantly lower in the home exercise group (p = 0.01) during the last five-year follow-up session compared with the control group. Overall physical activity decreased slightly during the five-year follow-up, but there were no differences between the two study groups. CONCLUSIONS: The present randomized study indicates that supervised, controlled home exercises lead to reduced low back pain, and that positive effects were preserved over five years.

Validity of the Postural Control and Balance for Stroke test.

BACKGROUND AND PURPOSE: To determine the construct and predictive validity and sensitivity of the sub-scale items for postural changes, sitting balance and standing balance of the Postural Control and Balance for Stroke (PCBS) test over a 90-day follow-up. METHOD: In the initial phase of stroke the PCBS test scores were compared with values obtained for the Barthel Index (BI) and the four neuropsychological domains most widely studied in the literature: memory; language; visuo-spatial functions; and visual inattention. The ability of the PCBS test at an early stage to predict functional status, as measured by the BI, and tendency to falls at 90 days after stroke was studied. The sensitivity of the PCBS test in evaluating postural control was studied by comparing the changes between the initial and 90 days' measures, and by examining the ability of the test to discriminate between healthy people and stroke patients. Forty stroke patients (aged 51-89 years), measured 7 and 90 days post-stroke, and 35 healthy control subjects (aged 50-90 years) participated in the study. RESULTS: Moderate correlations were found between the initial PCBS test and the BI (Spearman's r = 0.56-0.79) and a negative correlation between the sum variables for visual inattention and postural changes (Spearman's r = -0.39) and sitting balance (Spearman's r = -0.55). The score for postural changes predicted functional capacity (p < 0.002) and standing balance predicted falls at the three-month follow-up (p < 0.007). The PCBS test proved to be sensitive to change: the median change in the PCBS test scores during the three-month follow-up was 6.06. The control subjects mostly obtained maximum scores, indicating that the PCBS test was able to discriminate between healthy individuals and those with stroke. CONCLUSIONS: The results confirm that the PCBS test has good construct validity, good ability to predict functional capacity and safe moving, and it is sensitive to changes in balance control after stroke.

Effect of long-term neck muscle training on pressure pain threshold: a randomized controlled trial.

Muscle tenderness has been measured in several studies to evaluate effectiveness of treatment methods, but only short-term results have been reported so far. The aim of the present study was to evaluate the long-term effects of two different muscle training methods on the pressure pain threshold of neck muscles in women with neck pain. Altogether 180 woman with chronic, non-specific neck pain were randomized into three groups: neck muscle endurance training, neck muscle strength training and control groups. The main outcome measures included pressure pain threshold measurement at six muscle sites and on the sternum. Neck pain was assessed by a visual analogue scale (VAS). At the 12-month follow-up statistically significantly higher pressure pain threshold values were obtained in both training groups at all muscle sites compared to the baseline, while no significant change occurred in the controls. Significantly higher changes in pressure pain threshold were detected at all six sites in the strength training group and at four out of six sites in the endurance training group compared to the control group. This is the first study to show an increase in pressure pain thresholds as a result of long-term muscle training. A decrease in neck pain was associated with reduced pressure pain sensitivity in neck muscles, showing that the pressure pain threshold may be a useful outcome measure of the effectiveness of neck muscle rehabilitation.

Finnish version of the Tampa Scale of Kinesiophobia: Reference values in the Finnish general population and associations with leisure-time physical activity.

OBJECTIVES: To create reference values for the general Finnish population using the Tampa Scale of Kinesiophobia (TSK-FIN), to study gender differences in the TSK-FIN, to assess the internal consistency of the TSK-FIN, to estimate the prevalence of high levels of kinesiophobia in Finnish men and women, and to examine the association between kinesiophobia and leisure-time physical activity and the impact of co-morbidities on kinesiophobia. METHODS: The study population comprised 455 men and 579 women. Participants completed a self-administered questionnaire about their socio-demographic factors, leisure-time physical activity, co-morbidities and kinesiophobia. RESULTS: The mean TSK-FIN score was significantly higher for men (mean 34.2, standard deviation (SD) 6.9) compared with women (mean 32.9, SD 6.5), with an age-adjusted p = 0.004 for the difference between men and women. Cronbach's alpha was 0.72, indicating substantial internal consistency. Men over 55 years of age and women over 65 years of age had a higher (p < 0.001) TSK score compared with younger people. There was a significant (p < 0.001) inverse association between kinesiophobia and leisure-time physical activity among both sexes. The presence of cardiovascular disease, musculoskeletal disease or a mental disorder was associated with a higher TSK-FIN score compared with the absence of the aforementioned disorders. CONCLUSION: We present here the reference values for the TSK-FIN. The reference values and prevalence among the general population may help clinicians to define the level of kinesiophobia among patients. Disorders other than musculoskeletal diseases were associated with kinesiophobia, which should be noted in daily practice.

Association of neck pain, disability and neck pain during maximal effort with neck muscle strength and range of movement in women with chronic non-specific neck pain.

Several studies have reported lower neck muscle strength in patients with chronic neck pain compared to healthy controls. The aim of the present study was to evaluate the association between the severity of neck pain and disability with neck strength and range of movement in women suffering from chronic neck pain. One hundred and seventy-nine female office workers with chronic neck pain were selected to the study. The outcome was assessed by the self-rating questionnaires on neck pain (visual analogue scale, Vernon's disability index, Neck pain and disability index) and by measures of the passive range of movement (ROM) and maximal isometric neck muscle strength. No statistically significant correlation was found between perceived neck pain and the disability indices and the maximal isometric neck strength and ROM measures. However, the pain values reported during the strength tests were inversely correlated with the results of strength tests (r=-0.24 to -0.46), showing that pain was associated with decreased force production. About two-thirds of the patients felt pain during test efforts. Pain may prevent full effort during strength tests and hence the production of maximal force. Thus in patients with chronic neck pain the results do not always describe true maximal strength, but rather the patients' ability to bear strain, which may be considerably influenced by their painful condition. The results of the present study suggest that rehabilitation in cases of chronic neck pain should aim at raising tolerance to mechanical strain.

Disability pensions due to spinal disorders: nationwide Finnish register-based study, 1990-2010.

STUDY DESIGN: A register-based national study. OBJECTIVE: To describe the occurrence of spinal disorders (SDs) resulting in disability pension (DP) in Finland during 1990-2010. SUMMARY OF BACKGROUND DATA: The indirect cost of SD is excessive. The most significant indirect cost is due to DP. There are no nationwide long-term studies of DP trends caused by SDs. METHODS: The study setting consisted of Finnish working population (20-64 yr). All new cases were identified from the nationwide register maintained by the Finnish Centre of Pensions from the beginning of 1990 to the end of 2010. The data included sex, age group, year of the DP decision, and the main cause of incapacity (diagnosis) leading to DP. Main outcome measure was DPs due to SDs. RESULTS: A total of 84,375 individuals (40,415 females; 43,960 males) received DP during the study period. Age- and sex-adjusted incidence rate ratio was 0.45 (95% CI: 0.44-0.46) between time periods of 1990-1994 and 2005-2010. In males, crude incidence in 1990-1994 was 21.0 (95% CI: 20.6-21.3) per 10,000 person-years and in 2005-2010, it was 11.1 (10.9 to 11.3). In females, it was 18.8 (95% CI: 18.5-19.1) and 11.4 (95% CI: 11.1-11.6). During the study period, the overall DP rate also decreased. Age- and sex-adjusted incidence rate ratio was 0.66 (95% CI: 0.65-0.67) between the time periods 1990-1994 and 2005-2010. However, the proportion of DPs due to the SDs of all new DPs was higher in the first half of 1990s than in 2005-2010 (adjusted proportion 19.6% [95% CI: 19.4-19.8] vs. 14.4% [95% CI: 14.2-14.6]). CONCLUSION: The occurrence of DPs due to SDs has decreased significantly during the period of 1990-2010 in Finland. On the basis of the register data, nonmedical factors and legislative reforms may explain the decrease of DPs more than treatments provided by health care. LEVEL OF EVIDENCE: 3.