Incidence of traumatic spinal cord injuries in Finland over a 30-year period.

STUDY DESIGN: Register survey. OBJECTIVE: To provide national Finnish data on the incidence of traumatic spinal cord injury (TSCI) over a 30-year period. SETTING: Käpylä Rehabilitation Centre, Helsinki, Finland. METHODS: Patients aged 16 years and older who sustained a TSCI between 1976 and 2005 were identified using the registers of the Käpylä Rehabilitation Centre. RESULTS: The medical records of a total of 1647 patients (1362 men and 285 women) were analyzed. The mean annual incidence rate for the entire population was 13.8/1 000 000. Age-adjusted incidence did not change among men or women during the three decades, but the mean age at injury of both men (from 34.7 to 42.4 years) and women (from 35.8 to 40.4 years) increased. The annual incidence of new TSCI rose significantly in persons 55 years and older. The proportion of tetraplegia and of incomplete injuries increased, too. CONCLUSION: Although TSCI is predominantly present in young men, more attention for primary prevention, medical care and rehabilitation in men and women aged 55 years and older is needed. An international uniformity in methodology to collect epidemiological data of TSCI is needed.

Snuff use and smoking in Finnish olympic athletes.

This study aimed to assess the prevalence of smoking and snuff use in Finnish elite athletes. Of all the athletes (n = 494) financially supported by the National Olympic Committee, 446 completed a structured questionnaire (response rate 90.3 %) in 2002. A control group (n = 1504, response rate 80.2 %) comprised an age-matched sample from the population-based sample collected by the National Public Health Institute. Any smoking was reported by 11.4 % of the athletes (3.6 % daily and 7.8 % occasionally) and by 38.3 % of the controls (28.1 % and 10.2 %). After adjusting for age, sex, and education, OR (95 % CI) for any smoking was highest 0.42 (0.23 - 0.77) for athletes in skill-based events and lowest 0.06 (0.02 - 0.17) for endurance athletes as compared with controls. Snuff use was reported by 24.6 % of the athletes (9.6 % daily and 15.0 % occasionally) and by 3.7 % of the controls (1.8 % and 1.9 %). The adjusted OR (95 % CI) for any snuff use was highest 15.6 (9.55 - 25.6) for team-sport athletes and lowest 3.33 (1.54 - 7.21) for endurance athletes as compared with controls. Although snuff use in the general female population is rare, also female athletes did use snuff. Though prevalence of daily smoking among athletes was one-seventh of the respective figure for the general population, prevalence of daily snuff use was five-fold that of controls. Tobacco free elite athletes are valuable in health counselling because athletes are considered role models influencing their peers and the sport. Sport associations are challenged to ban all forms of tobacco.

Self-reported attitudes of elite athletes towards doping: differences between type of sport.

Although athletes' beliefs and values are known to influence whether or not an athlete will use banned drugs, little is known about the athletes' beliefs and attitudes in different sports. The aim of this study was to clarify the beliefs and attitudes of elite athletes towards banned substances and methods in sports. A total of 446 athletes (response rate 90.3 %; 446/494) financially supported by the National Finnish Olympic Committee completed a structured questionnaire during their national team camps in 2002. More than 90 % of the athletes reported to believe that banned substances and methods have performance enhancing effects, and 30 % reported that they personally know an athlete who uses banned substances. Of the male athletes 35 %, and 23 % of females reported they personally know an athlete using banned substances. A total of 15 % of the athletes reported that they had been offered banned substances: 21 % of the speed and power athletes, 14 % of the team sport athletes and of the athletes in motor skills demanding events, and 10 % of the endurance athletes. Stimulants were the most often offered substance group (to 7 % of all the athletes) followed by anabolic steroids (4 %). Subjects who regarded doping as a minor health risk seemed to be more often associated with doping users than those regarding doping as a significant health risk. Athletes in different sports have a different approach to doping. Risk of doping appears to be highest in speed and power sports and lowest in motor skills demanding sports. Males are at higher risk than females. Controlling doping only by tests is not sufficient. A profound change in the attitudes is needed, which should be monitored repeatedly.

Ample use of physician-prescribed medications in Finnish elite athletes.

The present study aimed at determining the use of physician-prescribed medication in a large number of elite athletes compared with a representative control sample of the general population. Of all the athletes (N = 494) financially supported by the National Olympic Committee, 446 completed a structured questionnaire (response rate 90.3 %) in 2002. A control group (N = 1503, response rate 80.1 %) comprised an age-matched sample from the population-based study collected by the National Public Health Institute. Any prescribed medication was used by 34.5 % of the athletes and 24.9 % of the controls during the past seven days. The most frequently reported physician-prescribed medications among athletes during the previous seven days were anti-allergic medicines (12.6 % of the respondents), non-steroidal anti-inflammatory drugs (NSAIDs; 8.1 %), anti-asthmatic medicines (7.0 %), and oral antibiotics (2.7 %). The adjusted odds ratios (95 % CI) for the physician-prescribed medications used during the previous seven days was 2.42 (1.69 - 3.46), 3.63 (2.25 - 5.84), 3.42 (2.05 - 5.70), and 2.15 (1.03 - 4.45) for use of anti-allergic medication, NSAIDs, anti-asthmatic medication, and oral antibiotics, respectively, in the athletes compared with controls. Every fifth athlete reported some NSAID-related adverse effect. In conclusion, the athletes used NSAIDs, antibiotics, anti-asthmatic and anti-allergic medication significantly more often than a representative sample of age-matched controls. All these medicines have potential adverse effects that may have a deleterious impact on the maximum exercise performance of elite athletes. Adverse effects were commonly reported in connection with NSAID use.

Prevalence of spinal cord injury in Helsinki.

STUDY DESIGN: Retrospective register-based epidemiological study. OBJECTIVE: To estimate the prevalence rate of persons with spinal cord injury (SCI) with special reference to ASIA Impairment Grade A-D. SETTING: Helsinki, Finland. METHODS: Cases were identified using the registers of the Kapyla Rehabilitation Centre, Helsinki University Central Hospital and the local organization for the disabled. Local health centres were informed about the study, residential service houses were contacted, and announcements were published in patient magazines. RESULTS: A regional population was found to have a prevalence rate of 28/100,000 inhabitants with SCI (ASIA Impairment Scale A-D). CONCLUSION: The prevalence rate in this study is consistent with the data published in other Nordic countries. SPONSORSHIP: The Finnish Cultural Foundation.

Traumatic spinal cord injury as a complication to ankylosing spondylitis. An extended report.

OBJECTIVE: Käpylä Rehabilitation Centre is in Finland the only unit taking care of the subacute rehabilitation activities of patients with spinal cord injury (SCI). The annual incidence of new patients with SCI is 55 (1.1 per 100,000 inhabitants). The ankylosed spine (AS) is reported to be at greater risk for fracture and SCI. The aim of the study was to clarify if this higher risk of ankylosing spondylitis (AS) could also be detected among patients with traumatic SCI rehabilitated at Käpylä Rehabilitation Centre. Further, the aim was to evaluate the characteristics of patients with traumatic SCI as a complication to AS in order to develop prevention of SCI in patients with AS. METHODS: Patient data was gathered from the patient register covering all Finnish patients with traumatic SCI (n = 1,103) rehabilitated at Käpylä Rehabilitation Centre from the year 1979 to 1998. The patient journals were subjected to a detailed and systematic analysis. Data about patients with a history of AS (n = 19; 18 men, 1 woman) was then compared to the data about all the patients with SCI (n = 1,103; 902 men, 201 women). RESULTS: Based on the national prevalence data, the incidence rate of patients with AS for traumatic SCI was found to be 11.4 times greater than expected for the population at large. The mean age of the patients with AS was clearly higher (55.3 yrs) than the mean age of the whole group of patients (36.4 yrs) with traumatic SCI. The neurologic injury was at the cervical level in 84% of the patients with AS, but only in 48% of the patients with traumatic SCI in general. Among the patients with AS, the SCI was caused by slipping in 53% of the cases, whereas slipping was the reason for SCI only in 7% of the cases in general. CONCLUSION: Patients with AS seem to run a higher risk of traumatic SCI than the people at large, and the injury levels are higher. In particular, male patients with advanced AS should be instructed to install preventive devices such as night lights and handrails, supports or head rests when driving a car, and they should avoid walking on slippery surfaces, loose carpets etc. They also should be encouraged to avoid excessive use of alcohol and activities involving the risk of physical injury such as contact sports.

Augmentative and alternative communication methods in locked-in syndrome.

Locked-in syndrome is a neurological condition due to a brain disease or an injury affecting the brain stem. The symptoms are tetraplegia, double-sided facial paresis, anarthria/dysarthrophonia, dysphagia and reactive involuntary laughing and crying. Vertical eye movements are the only commonly remaining voluntary motor function. Although the linguistic abilities as well as intellectual and emotional functions as a whole remain intact, all the motor abilities of self expression are lost. Seventeen chronic locked-in syndrome patients referred to Käpylä Rehabilitation Centre between 1979-2000 are reported. The multidisciplinary rehabilitation team developed an individual alternative communication method for all patients and trained them to use it by minor movements of e.g. thumb, chin or head. An alternative communication method enabled most of the patients to interact with other people using practical as well as theoretical thinking and decision making.

Coping strategies, pain, and disability in patients with hemophilia and related disorders.

OBJECTIVE: To analyze the use of various coping strategies in homogeneous groups of patients with hemophilia and von Willebrand's disease and to investigate the relationship between the state of the disease, the use of coping strategies, and management of the disease. METHODS: The coping strategies measured by the Coping Strategies Questionnaire were analyzed in 3 homogeneous groups of 224 patients. Psychosocial well-being (PWB) measured by the Rand 36-item Health Survey 1.0 was used as an indicator of management of the disease. The pain factor consisted of the following variables: pain intensity, use of analgesics, Functional Disability Index, and physical activity level. RESULTS: The groups of patients differed significantly only in the use of the catastrophizing strategy (CAT). In all pain groups, distraction was the most commonly used coping strategy. A significant interaction effect of pain factor and age on PWB (P = 0.04) was found. The mediating function of the CAT strategy was confirmed by the series of regression analyses. CONCLUSION: The coping strategy profile in hemophilia was found to be similar to those in other chronic pain states. The use of the strategies does not depend on the severity of the disease. We confirmed the role of age and the use of the CAT strategy as, respectively, moderator and mediator in the pattern of relationships between the clinical state of the disease and psychosocial well-being.

Nationwide epidemiology of hospitalized patients with first-time traumatic brain injury with special reference to prevention.

The national data of hospitalized TBI-patients were gathered retrospectively during the years 1991-95 from the Hospital Discharge Register. The inclusion criteria were: TBI as the primary diagnosis (ICD-9: 800, 801, 803, 850, 851-854), no history of previous TBI during the previous three years and the hospitalization of the patient. The incidence of TBI varied from 4 793-5 055 (95-100 per 100,000 people), comprising altogether 24,497 patients. The biggest subgroups of external cause were the sudden fall (61%) and vehicle accidents (26%). The biggest subgroups of the place of accident were the home (33%) and the traffic area (30%). The data reflect an assumption that many causes of TBI are preventable.

Epidemiology of lower limb amputees in Southern Finland in 1995 and trends since 1984.

The purpose of this study was to look at the current epidemiological trends of lower limb amputees in 1995 and the trends since 1984 in the area of Southern Finland with 1.3 million inhabitants. During the one-year period, the lower limb amputation was performed on 366 patients. The overall amputation rate has been unchanged since 1984 being 28.0 per 100,000 inhabitants in 1995. The mean age was 71.4 years. The overall amputation rate was 28.0 per 100,000 inhabitants. Of the 366 patients in the study 30% had arteriosclerosis without diabetes mellitus and 49% had diabetes. Diabetes mellitus has become the most common cause of amputation since 1985. Tumours were the cause in 2% and trauma in 4%. The most common unilateral amputations were trans-femoral amputations (29%) followed by trans-tibial amputations (28%) and toe amputations (24%). The unilateral trans-tibial/trans-femoral ratio was 0.54 in 1984 and 0.95 in 1995. The one-year mortality rate was 39% in 1984 and 40% in 1995. The rate of amputation has been relatively constant over the last ten years. The age related incidence in the older age groups has also been unchanged over the last ten years. Better control of diabetes and prophylactic foot care of diabetics can have a positive contribution in prevention of lower limb amputations. The current rehabilitation and prosthetic services of the lower limb amputees can be planned in the south of Finland on the basis of the incidence of 28 per 100,000 inhabitants.

Cathepsin G in degenerating and healthy discal tissue.

OBJECTIVES: To assess the eventual presence, tissue localization, molecular forms, amount and activity of cathepsin G in the annulus fibrosus. METHODS: Normal non-autolytic disc tissue was collected from cadavers within six hours after death. Degenerate disc samples were collected from low back pain patients undergoing anterior interbody fusion due to severe, discographically verified and painful disc degeneration, and from the posterior parts of intervertebral discs from 10 patients undergoing microscopic discoidectomy because of intervertebral herniation. Avidin-biotinperxidase complex staining of cathepsin G was quantitated by morphometry. Cellular localization was analyzed using double immunofluorescence staining of cathepsin G and CD68, proline 4-hydroxylase or von Willebrand factor. Neutral salt extracts were analyzed by using synthetic cathepsin G substrate in spectrophotometry, dot-immunoblotting and Western blotting. RESULTS: Histological and morphometric image analysis showed increased cellularity, increased numbers of cathepsin G positive cells and neovascularization in degenerated discs compared to control discs. Neutral salt extract of disc tissue, degenerated or normal, in contrast to control material from synovial capsular tissue, did not contain measurable cathepsin G activity, although immunoreactive enzyme was detected in dot-immunoblotting. Western blotting demonstrated that the discal cathepsin G had an apparent molecular weight of 27 kDa. CONCLUSION: Due to its properties and localization in normal and pathologically altered tissue, cathepsin G probably plays both a direct and an indirect role in extracellular matrix degradation in the annulus fibrosus. Extracted cationic cathepsin G was immunoreactive, but was functionally inhibited by serpins or, more likely, by polyanionic proteoglycans and saccharins derived from the connective tissue matrix of the annulus fibrosus.

Spinal cord injuries in ice hockey in Finland and Sweden from 1980 to 1996.

Traumatic spinal cord injury (SCI) in the cervical or thoracic region is one of the most catastrophic types of sport injuries. This study was designed to determine incidence and mechanisms of major SCI in ice hockey in Finland and Sweden from 1980 to 1996 in order to find possibilities for prevention. Retrospective analysis of injury occurrence were carried out. Medical case records were reviewed and injured players were interviewed to complete the data. From 1980 to 1996, there were 16 accidents involving spinal cord injury with permanent disability. All players were male. The mean age was 21.1 years (range = 14 to 33 yr). In 50% of the cases the mechanism was body checking from behind and a blow to the head from the boards. In 69% of the cases the vertebral injury was fracture or/and luxation between C5 and C7. The neurological endstate was tetraplegia/paresis in 10 cases and paraplegia/paresis of the lower extremities in 6 cases. Ice hockey is one of the most popular sports in Europe, and the number of participants is still increasing. The typical mechanism in SCI is body checking from behind, falling down and a head-first blow from the boards. These serious injuries may be prevented by changing the rules (banning body checking near the boards) with strict refereeing and education of trainers and players.

Mechanisms explaining the association between low back trouble and deficits in information processing. A controlled study with follow-up.

STUDY DESIGN: A controlled study with a 6-month follow-up period. OBJECTIVES: To find an explanation for the association between impairment in information processing, i.e., slow reaction times, and chronic low back trouble. SUMMARY OF BACKGROUND DATA: Low back trouble, chronic pain in general, and depression have been associated with impaired cognitive functions and slow reaction times. It is a common phenomenon that the preferred hand performs better than the nonpreferred hand in motor tasks. The authors hypothesized that chronic low back trouble hampers the functioning of short-term memory in a way that leads the preferred hand to loose its advantage over the nonpreferred hand, but that the advantage would be restored during the rehabilitation. METHODS: Sixty-one healthy control subjects and 68 patients with low back trouble participated in the study. Reaction times for the preferred and nonpreferred upper limbs were tested. A multiway analysis of covariance was used to examine the group, handedness, and rehabilitation effects on reaction times. The hypothesis was specifically tested with a third-degree interaction: group-handedness-rehabilitation. RESULTS: A significant interaction among group, handedness, and rehabilitation was found (P = 0.05). At the beginning, the reaction times for the preferred hand were faster among the control subjects (P = 0.001), but not among the patients with low back trouble (P = 0.62). After the rehabilitation, the preferred hand was faster both among the control subjects (P = 0.001) and the patients with low back trouble (P = 0.0002). During the rehabilitation, back pain, psychological distress, and general disability decreased significantly among the patients with chronic low back trouble. CONCLUSIONS: The results support the hypothesis that chronic low back trouble (i.e., pain, psychological distress, and general disability) hampers the functioning of short-term memory, which results in decreased speed of information processing among patients with chronic low back trouble.

One-footed and externally disturbed two-footed postural control in patients with chronic low back pain and healthy control subjects. A controlled study with follow-up.

STUDY DESIGN: A study of postural control during one-footed and externally disturbed two-footed stance among healthy control subjects and patients with chronic low back pain at the beginning of a functional back restoration program and 6 months later at follow-up examination. OBJECTIVES: To study postural control cross-sectionally among control subjects and patients with low back pain, and to evaluate the effects of functional restoration on the postural control parameters in a follow-up examination. SUMMARY OF BACKGROUND DATA: Deficits of motor skills and coordination have been reported in association with musculoskeletal disorders. It has been found that patients with chronic low back pain have impaired psychomotor control, but the impairment is reversible with successful low back rehabilitation. It is insufficiently known how functional activation and intensive physical training affect postural control. METHODS: Sixty-one healthy volunteers (32 men, 29 women) and altogether 99 patients with low back pain participated in the study. Sixty-eight patients (33 men, 35 women) had moderate and 31 (18 men, 13 women) had severe low back pain. Postural stability was measured with a force platform. In two-footed stance, vibration stimulation on calf and back muscles was used to disturb the balance. Center point of force-velocity (cm/sec), average position shift in anteroposterior direction (cm), and maximal position shift in lateral direction (cm) were used as the parameters. RESULTS: Reliability of all tests was acceptable. Center point of force-velocity was the most sensitive parameter and the one-footed measurement the most sensitivetest for evaluating postural stability. At the beginning, the patients with severe low back pain had poorer one-footed postural control compared with the control subjects (P = 0.0003). The subgroup of patients with moderate low back pain participated in the restoration program. The outcome of the restoration program was considered good if the disability because of low back pain (Oswestry index) decreased during the restoration program and poor if the disability increased or did not change. The one-footed postural stability remained primarily at the same level as the initial results in the control and good outcome groups, but became significantly poorer in the poor outcome group. The difference between poor outcome and control groups was statistically significant (P = 0.04). CONCLUSIONS: Impaired postural stability seems to be one factor in multidimensional symptomatology of patients with chronic low back trouble. Postural stability is easily disturbed in case of impairment in strength, coordination, or effective coupling of muscles in the lumbar and pelvic area. Patients with chronic low back pain seem to experience impairment in these functions, which should be taken into consideration when back rehabilitation programs are planned.

Bone mineral status after pediatric spinal cord injury.

The impact of spinal cord injury (SCI) on later bone mineral status was studied in 35 adults who had sustained their injury in childhood. The median age of the patients was 31 years, the median age at injury 12.9 years and the median time period from injury was 19 years. The methods used in the study were clinical interview and examination, measurement of bone mineral density (BMD) of the lumbar spine and the proximal femur with dual energy X-ray absorptiometry (DEXA) and estimation of bone turnover with biochemical markers. The densitometric examination revealed that the BMD at the lumbar spine was within the normal range but grossly decreased in the femoral region. Moreover, there was a significant difference in BMD between patients with high (C2-T6) and low (below T6) lesions in the lumbar spine as well as in the femoral region. Patients with lower lesions had higher BMD values. The markers of bone turnover which were studied were serum and urinary calcium and phosphate serum alkaline phosphatase and its isoenzymes, osteocalcin, carboxyterminal propeptide of human type I procollagen (PICP), carboxyterminal telopeptide of type I collagen (ICTP) and urinary deoxypyridinoline. These markers of bone metabolism showed no signs of ongoing accelerated bone formation or resorption. The present study suggests that caution should be observed in weight bearing training or mobilisation of patients with pediatric SCI or perhaps with long standing SCI because of increased fracture risk. The prevention of dissociated osteoporosis should be investigated further in order to avoid fractures of weakened bones. The modes of prevention might be found in the use of modern pharmacotherapy of osteoporosis and from correctly dosage physical training.

Ten-year survival of Finnish lower limb amputees.

Data on mortality for the ten years following lower limb amputation were obtained from all the 16 surgical units in Southern Finland and the National Social Insurance Institution. In Southern Finland during the period 1984-1985, amputations of the lower limb were performed on 705 patients, of whom 382 (54%) were women and 323 (46%) men. The majority of the amputations, 47% were performed for vascular diseases and 41% were performed for diabetes mellitus. The overall survival was 62% at one year after amputation, 49% at two years, 27% at five years and 15% at ten years. The median survival after amputation was 1 yr 5 mth for the women and 2 yr 8 mth for the men. Of the arteriosclerotics, 43% died within one postoperative year while 43% lived longer than two years and 23% longer than five years. The median survival of arteriosclerotics was 1 yr 6 mth. The corresponding figure for patients with diabetes was 1 yr 11 mth. Of the diabetics, 38% died within one postoperative year while 47% lived longer than two years and 20% longer than five years. Of the trauma patients, 86% lived longer than five years and 71% longer than ten years. Of the trans-femoral amputees, 54% lived longer than one year, 36% over two years, 18% over five years and 8% over ten years. The corresponding figures for trans-tibial amputees were 70%, 53%, 21% and 4%. Many elderly vascular and diabetic patients undergoing amputation have a reduced physiological reserve and high mortality. The more proximal the amputation, the greater the risk that the patient will never be able to walk or that the duration of use of the prosthesis will be short. If a prosthesis seems to be a reasonable option for the elderly amputee, any delays in prosthetic fitting should be avoided in older age groups.