[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.

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 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.

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.

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.

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.

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.

[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.

Do fibromyalgia patients use active pain management strategies? A cohort study.

OBJECTIVE: The aim of this study was to examine the types of pain management strategies used by patients with fibromyalgia. METHODS: A total of 158 patients with primary fibromyalgia attended a clinical visit to confirm the diagnosis. They completed 3 questionnaires: (i) a self-made questionnaire, (ii) Beck Depression Inventory IA (BDI IA), and (iii) Finnish version of Fibromyalgia Impact Questionnaire. The self-made questionnaire included questions about: intensity of current pain; general well-being; pain management strategies, including pain medications; efficacy of the pain management methods; current health problems other than fibromyalgia. The pain management strategies were subcategorized (e.g., physical exercise, massage and heat treatment). The strategies were also divided into active and passive types. RESULTS: The most frequently reported pain management strategies were physical exercise (54%), physical therapy (32%) and cold treatment (27%). The use of active pain management strategies, BDI IA < 10 points and age were independent predictors of the reported pain management efficacy. Patients who used active pain management strategies reported better efficacy with the BDI IA score ≥ 10 points. CONCLUSION: Active pain management strategies are most efficacious for fibromyalgia patients, regardless of the severity of fibromyalgia or optional comorbid depression.

Health-related quality of life and socioeconomic situation among diastrophic dysplasia patients in Finland.

OBJECTIVE: The purpose of the present study was to gain a comprehensive view of the quality of life and socio-economic conditions in a more representative sample of patients with diastrophic dysplasia than previously presented. METHODS: The study sample comprised 115 patients with diastrophic dysplasia, aged over 18 years. The patients were contacted, and 68 patients (59%) agreed to participate in the study. They answered a structured questionnaire, which included the items of RAND-36 and Finn-Health Assessment Questionnaire (Finn-HAQ) questionnaires. The Finn-HAQ items were linked to the categories of the International Classification of Functioning, Disability and Health (ICF). Population controls for matching the participating patients for age and sex were identified in the Finnish population registry. Demographic and social factors (educational status, employment status and household income) were collected in separated questions. RESULTS: RAND-36 showed significantly lower physical functioning in the group of diastrophic dysplasia patients than in the control group. Also, the differences in scores for energy and social functioning were significant. In the mental component scales, no significant difference was found between the groups. When compared with the controls, we found significantly lower levels in all 3 ICF components of functioning in the group of patients when Finn-MDHAQ items linked to ICF were used. Almost 75% of patients with diastrophic dysplasia belonged to the group of people with minor/low income. Some or clear worsening of economic situation due to diastrophic dysplasia was reported by 25 (58%) female and 17 (68%) male patients. CONCLUSION: In their daily living, patients with diastrophic dysplasia have marked physical difficulties, which affect their quality of life, participation in society and their financial situation. It seems that the mental situation is not greatly affected, but a more detailed study is needed to evaluate and illuminate the psychological consequences of this severe skeletal dysplasia. Overall, the pieces of information in the present study are of high importance when designing and reorganizing rehabilitation and in supportive therapy and treatment of patients with diastrophic dysplasia.

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.

Anxiety and depression are independent predictors of quality of life of patients with chronic musculoskeletal pain.

We examined the relative impact of baseline anxiety, depression and fear of movement on health related quality of life at 12-month follow-up after a multidisciplinary pain management programme. One hundred and eleven patients who had chronic musculoskeletal pain (mean age 45 years, 65% women) attended during 2003-2005 a multidisciplinary three-phase pain management programme with a total time frame of six to seven months, totalling 19 days. The Beck Anxiety Inventory was used to rate anxiety, the Beck Depression Inventory depression, the Tampa Scale of Kinesiophobia fear of movement. The generic 15D questionnaire was used to assess health related quality of life. Baseline data were collected at admission, follow-up data at 12 months. Mean health related quality of life increased significantly from baseline to 12-month follow-up. Anxiety at baseline predicted significant negative change in the health related quality of life, depression predicted significant positive change in the health related quality of life. Fear of movement did not predict any significant change in the health related quality of life. We concluded that patients with chronic musculoskeletal pain and mild to moderate depression benefit from a multidisciplinary pain management programme in contrast to anxious patients. The findings imply further research with bigger sample sizes, other than HRQoL outcome measures as well as with other groups of patients.

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.

Association of fear of movement and leisure-time physical activity among patients with chronic pain.

OBJECTIVE: The aim of this study was to clarify the association of fear of movement and physical activity among patients with chronic musculoskeletal pain. METHODS: The sample comprised 93 patients participating in a multidisciplinary pain management programme. The purpose of the programme was to regain overall functioning by means of physical and functional exercises, education and personal pain management training. Tampa Scale of Kinesio-phobia and Leisure Time Physical Activity questionnaires were completed at baseline, and at 6-month and 12-month follow-ups. RESULTS: At baseline, low and medium kinesiophobia groups showed more leisure-time physical activity than did the high kinesiophobia group (p = 0.024). At a 6-month follow-up the high kinesiophobia group had increased their physical activity index to the level of the low and medium kinesiophobia groups and maintained that change to 12-month follow-up. The effect sizes of the change in the physical activity index and pain intensity at the 12-month follow-up were both moderate (0.56) in the high kinesiophobia group. CONCLUSION: The change in physical activity and kinesiophobia was associated with the level of baseline kinesiophobia. Multidisciplinary rehabilitation seems to produce favourable effects in terms of physical activity and pain among the high kinesiophobia patients.

Survival after spinal cord injury in Finland.

OBJECTIVE: Mortality, cause of death and risk indicators for death among patients with traumatic spinal cord injury were investigated over a 30-year period. DESIGN: A cross-sectional study with retrospective data. SUBJECTS: All patients (n = 1647) aged 16 years and over who had sustained traumatic spinal cord injury during the period 1976-2005, who were admitted to Käpylä Rehabilitation Centre, Helsinki, Finland, participated in the study. METHODS: Demographic and clinical data were collected from the registers of Käpylä Rehabilitation Centre. Cause-specific mortality was assessed using Statistics Finland's official cause-of-death register. RESULTS: During the observation period (1976-2007) 419 patients died. The main causes of death were respiratory disease (28%), cardiovascular disease (21%), suicide (10%) and external causes (9.5%). The mean age at death was 55.5 years for men and 58.2 years for women. Ten-year survival was 97.9%. Mortality was significantly affected by age at onset of injury, neurological level and extent of lesion. Survival of traumatic spinal cord injury patients was approximately 50% that of the general population, and survival of the general population was 80% during the follow-up period. CONCLUSION: These results support the need for improvements in long-term rehabilitative care and regular follow-up of patients with traumatic spinal cord injury. The importance of psychosocial follow-up services must be emphasized.