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Introduction: Chronic subdural haematomas (CSDHs) are one of the most common neurosurgical conditions. The goal of surgery is to alleviate symptoms and minimise the risk of symptomatic recurrences. In the past, reoperation rates as high as 20%-30% were described for CSDH recurrences. However, following the introduction of subdural drainage, reoperation rates dropped to approximately 10%. The standard surgical technique includes burr-hole craniostomy, followed by intraoperative irrigation and placement of subdural drainage. Yet, the role of intraoperative irrigation has not been established. If there is no difference in recurrence rates between intraoperative irrigation and no irrigation, CSDH surgery could be carried out faster and more safely by omitting the step of irrigation. The aim of this multicentre randomised controlled trial is to study whether no intraoperative irrigation and subdural drainage results in non-inferior outcome compared with intraoperative irrigation and subdural drainage following burr-hole craniostomy of CSDH., Methods and Analysis: This is a prospective, randomised, controlled, parallel group, non-inferiority multicentre trial comparing single burr-hole evacuation of CSDH with intraoperative irrigation and evacuation of CSDH without irrigation. In both groups, a passive subdural drain is used for 48 hours as a standard of treatment. The primary outcome is symptomatic CSDH recurrence requiring reoperation within 6 months. The predefined non-inferiority margin for the primary outcome is 7.5%. To achieve a 2.5% level of significance and 80% power, we will randomise 270 patients per group. Secondary outcomes include modified Rankin Scale, rate of mortality, duration of operation, length of hospital stay, adverse events and change in volume of CSDH., Ethics and Dissemination: The study was approved by the institutional review board of the Helsinki and Uusimaa Hospital District (HUS/3035/2019 §238) and duly registered at ClinicalTrials.gov. We will disseminate the findings of this study through peer-reviewed publications and conference presentations., Trial Registration Number: NCT04203550., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The relevance of health-related behaviors to exclusion from the labor market in early adulthood remains poorly studied in relation to the magnitude of the problem. We explored whether adolescents' accumulated unhealthy behaviors and psychosocial problems are associated with later labor market exclusion, and whether multisite musculoskeletal pain (MMSP) impacts these relations., Methods: We gathered questionnaire data on unhealthy behaviors and psychosocial problems and MMSP among adolescents aged 15 to 16 belonging to the Northern Finland Birth Cohort 1986. The findings were combined with registry data on unemployment, employment and permanent work disability during a five-year follow-up between the ages of 25 and 29 (n = 6692). In the statistical modeling we used education, family leave and socioeconomic status of childhood family as potential confounders, as well as latent class and logistic regression analyses., Results: The Externalizing behavior cluster associated with over one year of unemployment (RR 1.64, CI 1.25-2.14) and permanent work disability (OR 2.49, CI 1.07-5.78) in the follow-up among the men. The Sedentary cluster also associated with over one year (RR 1.41, CI 1.13-1.75) and under one year of unemployment (RR 1.25, CI 1.02-1.52) and no employment days (RR 1.93, CI 1.26-2.95) among the men. Obese male participants were at risk of over one year of unemployment (RR 1.50, CI 1.08-2.09) and no employment days (RR 1.93, CI 1.07-3.50). Among the women, the Multiple risk behavior cluster related significantly to over one year of unemployment (RR 1.77, CI 1.37-2.28). MMSP had no influence on the associations., Conclusions: Unhealthy behavior patterns and psychosocial problems in adolescence have long-term consequences for exclusion from the labor market in early adulthood, especially among men. Simultaneously supporting psychological well-being and healthy behaviors in adolescence may reduce labor market inclusion difficulties in the early phase of working life.

Importance: Humeral shaft fractures traditionally have been treated nonsurgically, but there has been a steady increase in the rate of surgery over the past 2 decades without high-quality evidence to justify the trend., Objective: To compare the effectiveness of surgical treatment with open reduction and internal plate fixation to nonsurgical treatment with functional bracing in the treatment of closed humeral shaft fractures., Design, Setting, and Participants: Randomized clinical trial conducted at 2 university hospital trauma centers in Finland, enrollment between November 2012 and January 2018 with a final follow-up of January 2019. A total of 82 adult patients with closed, unilateral, displaced humeral shaft fracture met criteria for inclusion. Patients were excluded if they had cognitive disabilities preventing them from following the protocol or had multimorbidity or multiple trauma., Interventions: Patients were randomly assigned to surgical treatment with open reduction and internal plate fixation (n = 38) or to nonsurgical treatment with functional bracing (n = 44)., Main Outcome and Measure: The primary outcome was Disabilities of Arm, Shoulder and Hand (DASH) score at 12 months (range, 0 to 100 points, 0 denotes no disability and 100 extreme disability; minimal clinically important difference, 10 points)., Results: Among 82 patients who were randomized (mean age, 48.9 years; 38 women [46%]; 44 men [54%]), 78 (95%) completed the trial. Thirteen (30%) of the patients assigned to functional bracing underwent surgery during the 12-month follow-up period to promote healing of the fracture. At 12 months, the mean DASH score was 8.9 (95% CI, 4.2 to 13.6) in the surgery group and 12.0 (95% CI, 7.7 to 16.4) in the bracing group (between-group difference, -3.1 points; 95% CI, -9.6 to 3.3; P = .34). Eleven patients (25%) allocated to functional bracing developed fracture nonunion. Three patients (8%) allocated to surgery developed a temporary radial nerve palsy., Conclusions and Relevance: Among patients with closed humeral shaft fracture, internal fixation surgery, compared with nonoperative functional bracing, did not significantly improve functional outcomes at 12 months. However, the substantial amount of treatment crossover from nonoperative to surgical treatment should be considered when interpreting the trial results., Trial Registration: ClinicalTrials.gov Identifier: NCT01719887.

Purpose: Work disability (WD) as a medico-legal concept refers to disability benefits (DB) that are granted due to diseases that permanently reduce work ability. We studied whether an occupational healthcare instrument for the prediction of sickness absence (SA) risk-a health risk appraisal (HRA)-also predicts permanent WD., Methods: HRA results were combined with registry data on DB of 22,023 employees from different industry sectors. We analysed how the HRA risk categories predict DB and considered occupational group, gender, age, and prior SA as confounding variables. Cumulative incidence function illustrates the difference between the HRA risk categories, and the Fine-Gray model estimates the predictors of WD during 6-year follow-up., Results: The most common primary reasons for permanent WD were musculoskeletal (39%) and mental disorders (21%). Self-reported health problems in the HRA, labelled as "WD risk factors", predicted DB when controlling for age and prior SA. Hazard ratios were 10.9 or over with the lower limit of the 95% confidence interval 3.3 or over among those with two simultaneous WD risk factors. 14% of the females and 17% of the males with three or more simultaneous WD risk factors had received a DB, whereas the respective figures among those without findings were 1.9% and 0.3%., Conclusions: Self-reported health problems in the HRA, especially multiple simultaneous WD risk factors, predict permanent WD among both genders across occupational groups. Screening WD risk with a self-administered questionnaire is a potential means for identifying high-risk employees for targeting occupational healthcare actions.

Knowledge-intensive work requires capabilities like monitoring multiple sources of information, prioritizing between competing tasks, switching between tasks, and resisting distraction from the primary task(s). We assessed whether subjective cognitive complaints (SCC), presenting as self-rated problems with difficulties of concentration, memory, clear thinking and decision making predict sickness absence (SA) in knowledge-intensive occupations. We combined SCC questionnaire results with reliable registry data on SA of 7743 professional/managerial employees (47% female). We excluded employees who were not active in working life, on long-term SA, and those on a work disability benefit at baseline. The exposure variable was the presence of SCC. Age and SA before the questionnaire as a proxy measure of general health were treated as confounders and the analyses were conducted by gender. The outcome measure was the accumulated SA days during a 12-month follow-up. We used a hurdle model to analyse the SA data. SCC predicted the number of SA days during the 12-month follow-up. The ratio of the means of SA days was higher than 2.8 as compared to the reference group, irrespective of gender, with the lowest limit of 95% confidence interval 2.2. In the Hurdle model, SCC, SA days prior to the questionnaire, and age were additive predictors of the likelihood of SA and accumulated SA days, if any. Subjective cognitive complaints predict sickness absence in knowledge-intensive occupations, irrespective of gender, age, or general health. This finding has implications for supporting work ability (productivity) among employees with cognitively demanding tasks., (© 2020 The Authors.)

Background: The research objectives of the 5-year and 10-year assessments in the Finnish degenerative meniscal lesion study (FIDELITY) are twofold: (1) to assess the long-term efficacy of arthroscopic partial meniscectomy (APM) in adults (age 35 to 65 years) with a degenerative meniscus tear and (2) to determine the respective effects of APM and degenerative meniscus tear on the development of radiographic and clinical knee osteoarthritis (OA)., Methods and Design: FIDELITY is an ongoing multi-center, randomized, participant and outcome assessor blinded, placebo-surgery-controlled trial in 146 patients. This statistical analysis plan (SAP) article describes the overall principles for analysis of long-term outcomes (5-year and 10-year follow up), including how participants will be included in each analysis, the primary and secondary outcomes and their respective analyses, adjustments for covariates, and the presentation of the results. In addition, we will present the planned sensitivity and subgroup analyses., Discussion: To assess the long-term efficacy of APM on knee symptoms and function we are carrying out a long-term (5-year and 10-year) follow up of our placebo-surgery-controlled FIDELITY trial according to statistical principles outlined in detail in this document. As our second primary objective, whether APM (resection of torn meniscus tear) accelerates or delays the development of knee osteoarthritis in patients with an arthroscopically verified degenerative tear of the medial meniscus, a pre-registered follow-up is also carried out., Trial Registration: ClinicalTrials.gov, NCT00549172 (Arthroscopy in the Treatment of Degenerative Medial Meniscus Tear). Registered on 25 October 2007 (NCT00549172). ClinicalTrials.gov, NCT01052233 (Development of Knee Osteoarthritis After Arthroscopic Partial Resection of Degenerative Meniscus Tear). Registered on 20 January 2010.

Introduction: Although a great majority of patients with cervical radiculopathy syndrome can successfully be treated non-operatively, a considerable proportion experience persistent symptoms, severe enough to require neurosurgical intervention. During the past decade, cervical spine procedures have increasingly been performed on an outpatient basis and retrospective database analyses have shown this to be feasible and safe. However, there are no randomised controlled studies comparing outpatient care with inpatient care, particularly with emphasis on the patients' perception of symptom relief and their ability to return to normal daily activities and work., Methods and Analysis: This is a prospective, randomised, controlled, parallel group non-inferiority trial comparing the traditional hospital surveillance (inpatient, patients staying in the hospital for 1-3 nights after surgery) with outpatient care (discharge on the day of the surgery, usually within 6-8 hours after procedure) in patients who have undergone anterior cervical decompression and fusion procedure. To determine whether early discharge (outpatient care) is non-inferior to inpatient care, we will randomise 104 patients to these two groups and follow them for 6 months using the Neck Disability Index (NDI) as the primary outcome. We expect that early discharge is not significantly worse than the current care in terms of change in NDI. Non-inferiority will be declared if the mean improvement for outpatient care is no worse than the mean improvement for inpatient care, by a margin of 17.3%. We hypothesise that a shorter hospital stay results in more rapid return to normal daily activities, shorter duration of sick leave and decreased secondary costs to healthcare system. Secondary outcomes in our study are arm pain and neck pain using the Numeric Rating Scale, operative success (Odom's criteria), patient's satisfaction to treatment, general quality of life (EQ-5D-5L), Work Ability Score, sickness absence days, return to previous leisure activities and complications., Ethics and Dissemination: The study was approved by the institutional review board of the Helsinki and Uusimaa Hospital District on 6 June 2019 (1540/2019) and duly registered at ClinicalTrials.gov. We will disseminate the findings of this study through peer-reviewed publications and conference presentations., Trial Registration Number: NCT03979443., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: To study whether self-reported health problems predict sickness absence (SA) from work in employees from different industries., Methods: The results of a health risk appraisal (HRA) were combined with archival data of SA of 21 608 employees (59% female, 56% clerical). Exposure variables were self-reported health problems, labelled as 'work disability (WD) risk factors' in the HRA, presence of problems with occupational well-being and obesity. Age, socioeconomic grading and the number of SA days 12 months before the survey were treated as confounders. The outcome measure was accumulated SA days during 12-month follow-up. Data were analysed separately for males and females. A Hurdle model with negative binomial response was used to analyse zero-inflated count data of SA., Results: The HRA results predicted the number of accumulated SA days during the 12-month follow-up, regardless of occupational group and gender. The ratio of means of SA days varied between 2.7 and 4.0 among those with 'WD risk factors' and the reference category with no findings, depending on gender and occupational group. The lower limit of the 95% CI was at the lowest 2.0. In the Hurdle model, 'WD risk factors', SA days prior to the HRA and obesity were additive predictors for SA and/or the accumulated SA days in all occupational groups., Conclusion: Self-reported health problems and obesity predict a higher total count of SA days in an additive fashion. These findings have implications for both management and the healthcare system in the prevention of WD., Competing Interests: Competing interests: MP and HA are employed by Terveystalo, ST is employed by Evalua International and JU, JO, MK and TN are employed by the University of Tampere., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Musculoskeletal (MS) pain is common. It often exists in several sites and is recurrent. Psychosocial difficulties and unhealthy behaviours have been related to multisite MS pain, but no literature has assessed the impact of accumulated psychosocial and lifestyle factors on recurrent multiple MS pain., Methods: Our data were gathered from two questionnaires of the well-known Northern Finland Birth Cohort 1986 (NFBC1986), sent to members when they were aged 16 and 18. A total of 1,625 adolescents (712 boys and 913 girls) answered questions on smoking, physical activity, sedentary behaviour, sleeping and emotional and behavioural problems at 16 years and on musculoskeletal pain at 16 and 18 years. Weight and height measurements were taken at a health examination at baseline. A latent class analysis and multinomial regression analysis were conducted., Results: We identified four clusters among both sexes. "Externalizing behavior" among both genders (OR 2.98, CI 1.73-5.13 among boys; OR 2.38, CI 1.38-4.11 among girls), "Multiple risk behaviors" among girls (OR 2.73, CI 1.30-5.71) and a "Sedentary" cluster among boys (OR 1.85, CI 1.21-2.82) were associated to recurrent multisite MS pain. "Obese" clusters had no significant associations with recurrent multiple MS pain., Conclusions: Adolescents with psychosocial difficulties and/or several adverse health behaviours were at an increased risk of recurrent multisite MS pain, which emphasizes the importance of simultaneously studying multiple rather than single factors. The identification of risk groups may help more accurately target preventive interventions., Significance: This study found subgroups of adolescents at risk of recurrent multisite musculoskeletal pain during late adolescence. The accumulation of multiple adverse behaviours is likely to provide new perspectives for understanding the multidimensional nature of multiple MS pains., (© 2019 European Pain Federation - EFIC®.)

Introduction: Humeral shaft fractures represent 1%-3% of all fractures and 20% of humeral fractures in adults. The treatment of these fractures is mainly conservative and operative treatment is usually reserved for specific circumstances. To date, no randomised controlled trial (RCT) has compared operative treatment of humeral shaft fractures with conservative treatment., Methods and Analysis: We will conduct an RCT to compare the effectiveness and cost-effectiveness of surgical and conservative treatment of humeral shaft fractures. After providing informed consent, 80 patients from 18 years of age with humeral shaft fracture will be randomly assigned to open reduction and internal fixation with locking plate or conservative treatment with functional bracing. We will follow the patients for 10 years and compare the results at different time points. The primary outcome will be Disabilities of Arm, Shoulder and Hand (DASH) at 12 months. The secondary outcomes will include Numerical Rating Scale for pain at rest and in activities, Constant Score and quality of life instrument 15D. Patients not willing to participate in the RCT will be asked to participate in a prospective cohort follow-up study, 'the declined cohort'. This cohort will be followed up at the same time points as the randomised patients to assess the potential effect of participation bias on RCT results and to enhance the external validity of the RCT. In one of the recruiting centres, all cooperative patients with humeral shaft fractures not eligible for randomisation will be asked to participate in a 'non-eligible cohort' study. We will use blinded data interpretation of the randomised cohort to avoid biased interpretation of outcomes. Our null hypothesis is that there is no clinically relevant difference in the primary outcome measure between the two treatment groups. We will consider a difference of a minimum of 10 points in DASH clinically relevant., Ethics and Dissemination: The institutional review board of the Helsinki and Uusimaa Hospital District has approved the protocol. We will disseminate the findings of this study through peer-reviewed publications and conference presentations., Trial Registration Number: NCT01719887; pre-results., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Introduction: Arthroscopic subacromial decompression (ASD) is the most commonly performed surgical intervention for shoulder pain, yet evidence on its efficacy is limited. The rationale for the surgery rests on the tenet that symptom relief is achieved through decompression of the rotator cuff tendon passage. The primary objective of this superiority trial is to compare the efficacy of ASD versus diagnostic arthroscopy (DA) in patients with shoulder impingement syndrome (SIS), where DA differs only by the lack of subacromial decompression. A third group of supervised progressive exercise therapy (ET) will allow for pragmatic assessment of the relative benefits of surgical versus non-operative treatment strategies., Methods and Analysis: Finnish Subacromial Impingement Arthroscopy Controlled Trial is an ongoing multicentre, three-group randomised controlled study. We performed two-fold concealed allocation, first by randomising patients to surgical (ASD or DA) or conservative (ET) treatment in 2:1 ratio and then those allocated to surgery further to ASD or DA in 1:1 ratio. Our two primary outcomes are pain at rest and at arm activity, assessed using visual analogue scale (VAS). We will quantify the treatment effect as the difference between the groups in the change in the VAS scales with the associated 95% CI at 24 months. Our secondary outcomes are functional assessment (Constant score and Simple shoulder test), quality of life (15D and SF-36), patient satisfaction, proportions of responders and non-responders, reoperations/treatment conversions, all at 2 years post-randomisation, as well as adverse effects and complications. We recruited a total of 210 patients from three tertiary referral centres. We will conduct the primary analysis on the intention-to-treat basis., Ethics and Dissemination: The study was approved by the Institutional Review Board of the Pirkanmaa Hospital District and duly registered at ClinicalTrials.gov. The findings of this study will be disseminated widely through peer-reviewed publications and conference presentations., Trial Registration Number: NCT00428870; Pre-results., Competing Interests: Competing interests: ST reports personal fees from Evalua group of companies, personal fees from DBC group of companies, and personal fees from insurance companies, outside the submitted work.KK reports an honorarium for a lecture from Linvatec, outside the submitted work. TLNJ reports an honorarium for a lecture on osteoporosis from AMGEN (donated to AllTrials campaign). Authors not named here have disclosed no conflicts of interest., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Purpose: Chronic low back pain and lumbar spinal stenosis (LSS) seem to deteriorate lumbar muscle function and proprioception but the effect of surgery on them remains unclear. This study evaluates the effect of decompressive surgery on lumbar movement perception and paraspinal and biceps brachii (BB) muscle responses during sudden upper limb loading in LSS., Methods: Low back and radicular pain intensity (VAS) and Oswestry Disability Index (ODI) were measured together with lumbar proprioception and paraspinal and BB muscle responses prior to and 3 and 24 months after surgery in 30 LSS patients. Lumbar proprioception was assessed by a previously validated motorized trunk rotation unit and muscle responses for sudden upper limb loading by surface EMG., Results: Lumbar perception threshold improved after surgery during 3-month follow-up (from 4.6° to 3.1°, P = 0.015) but tend to deteriorate again during 24 months (4.0°, P = 0.227). Preparatory paraspinal and BB muscle responses prior to sudden load as well as paraspinal muscle activation latencies after the load remained unchanged., Conclusion: Impaired lumbar proprioception seems to improve shortly after decompressive surgery but tends to deteriorate again with longer follow-up despite the sustaining favorable clinical outcome. The surgery did not affect either the feed-forward or the feed-back muscle function, which indicates that the abnormal muscle activity in LSS is at least partly irreversible.

Purpose: Low back pain (LBP) is common already in adolescence, and many risk indicators including both psychosocial and lifestyle factors have been recognized. Our purpose was to assess whether the co-occurrence of psychosocial (externalizing and internalizing) problems and lifestyle factors (leisure time physical activity, sedentary behaviour, sleep, smoking, and overweight/obesity) associate with LBP at 16 years cross-sectionally or with new LBP at 18-year follow-up., Methods: The study population, drawn from the Northern Finland Birth Cohort 1986, consisted of 1625 participants (712 boys and 913 girls) who completed a questionnaire on potential explanatory factors at 16 years and on LBP at 16 and 18 years. The outcome measure was 'reporting LBP' or 'consultation for LBP' during the past 6 months. Latent Class Analysis (LCA) was utilized to study the co-occurrence of the explanatory factors., Results: Among both genders, four clusters were found. Externalizing behaviour problems were associated with 'reporting LBP' (RR 1.5, boys 1.4, girls) and 'consultation for LBP' (RR 1.6 for both genders) at baseline among both genders. In addition, the cluster of multiple risk behaviours was associated with both 'reporting LBP' (RR 1.3) and 'consultation for LBP' (RR 2.5) and the obese cluster with 'consultation for LBP' (RR 1.7) among girls. Externalizing behaviour problems at 16 years predicted 'consultation for LBP' at 18 years among girls (RR 3.6)., Conclusions: Our results stress the role of psychosocial factors in reporting and seeking care for adolescent LBP.

Objective: Musculoskeletal (MS) pain, especially in multiple body sites, may develop into a disabling problem. Still, the long-term risk factors of MS pain are insufficiently known. We examined whether adverse health behaviors in adolescence are associated with the number of pain sites in adulthood., Setting: The study population was a subgroup (n = 5,737) of the 1966 Northern Finland Birth Cohort, which had answered a postal questionnaire on health behaviors at the age of 14 and a pain questionnaire at approximately 31 years., Results: Adverse health behaviors in adolescence, such as occasional smoking (odds ratio (OR) 1.6; 95% confidence interval (CI) 1.0-2.6) and overweight/obesity (1.7; 1.0-2.8) among males, and daily smoking (1.9; 1.0-3.5) and regular use of alcohol (2.2; 1.0-4.8) among females predicted pain in three or more body regions at the age of 31. Physical inactivity (1.6; 1.1-2.5) and moderate physical activity (1.7; 1.1-2.6) were risk factors for two pain sites among females. In addition, the ORs for pain in three or more body regions were high, but the CIs were broad for daily smoking among males and overweight/obesity among females (1.7; 0.8-3.5 and 1.4; 0.8-2.2, respectively)., Conclusions: As adverse health behaviors in adolescence were moderately associated with multisite MS pains in adulthood, the effectiveness of intervening in adverse health behaviors in adolescence as regards later MS pain should be analyzed., (Wiley Periodicals, Inc.)

Background: Adolescent'psychosocial problems associate with unhealthy behaviors, but data on co-occurring patterns is sparse. We investigated 1) whether adolescents could be categorized into meaningful subgroups with respect to psychosocial and lifestyle factors, 2) whether the prevalence of physical inactivity, overweight and smoking vary within the subgroups and 3) whether these unhealthy behaviors persist in a two-year follow-up., Methods: The study was based on a subgroup of the 1986 Northern Finland Birth Cohort, which consisted of adolescents who replied to a postal questionnaire at 16 years (n = 6792) and a subgroup of this sample at 18 years (n = 1552). Latent class analysis (LCA) was performed to establish clusters at 16 years., Results: Smoking co-existed with emotional and behavioral problems in both genders. Boys with the most inactive lifestyle slept poorly, whereas multiple problems co-occurred among girls. Those with a high body mass index (BMI) separated as groups of their own. Different combinations of adverse lifestyle and emotional and behavioral problems were relatively common in both sexes as only 51% of boys and 67% of girls belonged to the reference cluster with low probability for these findings. Physical inactivity, high BMI and smoking tended to persist over the two-year follow-up., Conclusions: It seems that lifestyle and psychosocial factors divide adolescents into distinct subgroups in which unhealthy lifestyle patterns remain between the ages of 16 and 18. This may indicate problems in other life areas and expose them to an increased risk of future health problems.

Objective: The aim of this study was to determine the effectiveness of face-to-face information for the treatment of mild low-back pain (LBP) in an occupational health (OH) setting., Methods: We conducted a 48-month randomized controlled trial (RCT) with two 1:1 allocated parallel groups of forestry company employees. Eligibility criteria included permanent employment, age <57 years, and mild LBP [visual analogue scale (VAS) 10-34 mm] in a survey. The intervention group received the Back Book, an information booklet on how to manage LBP, with an additional face-to-face review of the booklet by an OH nurse. The control group received the booklet only. Primary outcomes were physical impairment (Roland-Morris 18-item (RM-18) Disability Questionnaire), LBP (VAS 100 mm), health-related quality of life [15-dimensional quality of life (15-D)] during two years and sickness absence (SA) up to four years. Participants were assigned using block randomization with a computer-generated scheme., Results: The RCT comprised 181 participants (72% male, mean age 44 years). There were no differences between the treatment arms in any of the primary outcomes at any time point. At 24 months, the mean group differences (intervention versus control) were: RM-18: 0 [95% confidence interval (95% CI) -1-1], VAS: 3 mm (95% CI -3-8), and 15-D 0.00 (95% CI -0.02-0.02). The difference in cumulative sickness absence days at 48 months were -3 (95% CI -28-21) for total and 1 (95% CI -3-5) for LBP specific sick leaves. Exploratory analysis revealed no differences at subgroup-levels either., Conclusions: Face-to-face patient information by an OH nurse in addition to a booklet was not more effective than the booklet alone in treating employees with mild LBP in an OH setting.

Objective: To evaluate factors that characterize employees who did not participate in a physical activity intervention in an occupational setting and assess how selective participation affects inferences from the data., Methods: Employees were asked to complete a health risk appraisal. The respondents were invited to participate in a physical activity intervention. We compared predictors of sickness absence (register data) among all respondents and those who participated in the intervention, using Bayesian regression analysis., Results: Of 1116 employees, 817 (73%) responded, of whom 544 (67%) participated in the intervention. Participants had better health behaviors and fewer health problems than those who did not participate. The predictors of sickness absence in all respondents differed from those who participated in the intervention., Conclusions: Selective participation may reduce the potential benefit of interventions and limit generalizability of findings.

Study Design: Cross-sectional study in a subcohort of the 1986 Northern Finland Birth Cohort (n = 1987)., Objective: To investigate the role of environmental factors and LBP history in sciatica symptoms among Finnish young adults., Summary of Background Data: History of low back pain (LBP), smoking, and male sex are associated with sciatica in adult populations. The role of the environmental determinants of sciatica has not been evaluated in populations consisting of only adolescents., Methods: Sciatic symptoms and environmental exposures were elicited by a mailed questionnaire and the associations were analyzed using multinomial logistic regression., Results: Female sex was associated with severe sciatica at 18 years (OR, 3.9; 95% confidence interval (CI), 1.6-9.3). Both reported LBP at 16 years and LBP requiring consultation of a health care professional were associated with mild sciatica at 18 years (OR, 2.5; 95% CI, 1.3-4.9; and OR, 3.8; 95% CI, 1.2-11.9). In addition, LBP at 16 years requiring consultation of a health care professional was associated with severe sciatica at 18 years (OR, 5.0; 95% CI, 1.7-15.3). Smoking, obesity, physical workload, and level of physical activity were not associated with sciatica., Conclusion: Females reported sciatic pain more often than males. LBP at 16 years predicted sciatica at 18 years., Level of Evidence: 2.

Study Design: A prospective cohort study in adolescents aged 7 to 19 years., Objective: To evaluate whether persistent overweight increases the risk of low back pain (LBP) among adolescents., Summary of Background Data: Overweight and LBP are common health problems in adolescents. Their relationship is still controversial among adolescents, as well as among adults., Methods: The study population, the Oulu Back Study, was drawn from the Northern Finland Birth Cohort 1986. The final study sample included 1660 adolescents (56% females). The subcohort of 786 subjects (57% females) was used in the analysis of waist circumference. The association between the area under the curve of body mass index from 7 to 16 years, and from 16 to 18 years, and area under the curve of waist circumference from 16 to 19 years, and LBP during the past 6 months was evaluated separately for incident (reporting LBP at 18 or 19 yr but not at 16 yr) and persistent LBP (reporting LBP at 16 and 18 yr or 19 yr). Relative risks (RR) and their 95% confidence intervals (95% CI) were adjusted for smoking, leisure time physical activity, and family socioeconomic status at 16 years and stratified by sex., Results: Body mass index from 16 to 18 years among girls and body mass index from 7 to 16 years among boys predicted incident LBP at 18 years (girls: RR, 1.09; 95% CI, 1.01-1.18; boys: RR, 1.15; 95% CI, 1.00-1.32). Among boys, waist circumference from 16 to 19 years was also associated with incident LBP (RR, 1.16; 95% CI, 1.02-1.32). Overweight was not associated with persistent LBP., Conclusion: In this population-based cohort study, persistent overweight slightly increased the risk of incident LBP, but the time period during which overweight was related to incident LBP differed between sexes., Level of Evidence: 2.

Introduction: Impaired muscle function and lumbar proprioception have been observed in lumbar spinal stenosis (LSS) but those have not been studied in LSS patients with age-matched controls. We assessed lumbar movement perception and paraspinal and biceps brachii (BB) muscle responses during sudden upper limb loading in age-matched healthy subjects and patients with LSS., Methods: The study included 30 patients selected for an operation due to LSS and 30 age-matched controls without chronic back pain. The paraspinal and BB muscle responses for upper limb loading during unexpected and expected conditions were measured by surface EMG. The ability to sense lumbar rotation was assessed in a previously validated motorized trunk rotation unit in a seated position. Pain, disability and depression scores were recorded., Results: Patients had poorer lumbar perception (mean difference 2.3 ± 0.6°, P < 0.001) and longer paraspinal muscle response latencies [mean difference 4.6 ± 0.6 ms (P = 0.033)] than age-matched healthy controls. Anticipation increased paraspinal and BB muscle activation prior to the load perturbation (P < 0.001) but less in LSS patients than in controls [9 vs. 30 %, P = 0.016 (paraspinals); 68 vs. 118 %, P = 0.047 (BB)]., Conclusions: The observed impairments in lumbar proprioception and activation of paraspinal and upper limb muscles indicate an extensive loss of both sensory and motor functions in LSS. The main new finding was decreased anticipatory muscle activation during expected upper limb loading reflecting involvement of central movement control mechanisms.

Background: The role of environmental factors in lumbar intervertebral disc degeneration (DD) in young adults is largely unknown. Therefore, we investigated whether body mass index (BMI), smoking, and physical activity are associated with lumbar DD among young adults., Methods: The Oulu Back Study (OBS) is a subpopulation of the 1986 Northern Finland Birth Cohort (NFBC 1986) and it originally included 2,969 children. The OBS subjects received a postal questionnaire, and those who responded (N = 1,987) were invited to the physical examination. The participants (N = 874) were invited to lumbar MRI study. A total of 558 young adults (325 females and 233 males) underwent MRI that used a 1.5-T scanner at the mean age of 21. Each lumbar intervertebral disc was graded as normal (0), mildly (1), moderately (2), or severely (3) degenerated. We calculated a sum score of the lumbar DD, and analyzed the associations between environmental risk factors (smoking, physical activity and weight-related factors assessed at 16 and 19 years) and DD using ordinal logistic regression, the results being expressed as cumulative odds ratios (COR). All analyses were stratified by gender., Results: Of the 558 subjects, 256 (46%) had no DD, 117 (21%) had sum score of one, 93 (17%) sum score of two, and 92 (17%) sum score of three or higher. In the multivariate ordinal logistic regression model, BMI at 16 years (highest vs. lowest quartile) was associated with DD sum score among males (COR 2.35; 95% CI 1.19-4.65) but not among females (COR 1.29; 95% CI 0.72-2.32). Smoking of at least four pack-years was associated with DD among males, but not among females (COR 2.41; 95% CI 0.99-5.86 and 1.59; 95% 0.67-3.76, respectively). Self-reported physical activity was not associated with DD., Conclusions: High BMI at 16 years was associated with lumbar DD at 21 years among young males but not among females. High pack-years of smoking showed a comparable association in males, while physical activity had no association with DD in either gender. These results suggest that environmental factors are associated with DD among young males.

Purpose: To evaluate whether midsagittal (abdominal) obesity in magnetic resonance imaging (MRI), waist circumference (WC) and body fat percentage are associated with lumbar disc degeneration in early adulthood., Methods: We obtained the lumbar MRI (1.5-T scanner) of 325 females and 233 males at a mean age of 21 years. Lumbar disc degeneration was evaluated using Pfirrmann classification. We analysed the associations of MRI measures of obesity (abdominal diameter (AD), sagittal diameter (SAD), ventral subcutaneous thickness (VST), and dorsal subcutaneous thickness (DST)), WC and body fat percentage with disc degeneration sum scores using ordinal logistic regression., Results: A total of 155 (48%) females and 147 (63%) males had disc degeneration. AD and SAD were associated with a disc degeneration sum score of ≥3 compared to disc degeneration sum score of 0-2 (OR 1.67; 95% confidence interval (CI) 1.20-2.33 and OR 1.40; 95% CI 1.12-1.75, respectively) among males, but we found no association among females. WC was also associated with disc degeneration among males (OR 1.03 per one cm; 95% CI 1.00-1.05), but not among females., Conclusion: Measures of abdominal obesity in MRI and waist circumference were associated with disc degeneration among 21-year-old males.

Objective: Physical activity (PA) may reduce the risk of coronary heart disease (CHD) by inducing beneficial changes in several risk factors. We studied the associations between PA and a range of risk markers of CHD in young adults., Methods and Results: We measured serum lipoproteins, oxidized LDL, adipokines, inflammatory markers, metabolic markers, and arginine metabolites in 2,268 individuals (age 24-39 y). Participants were asked frequency, duration, and intensity of PA in leisure time. In addition, commuting to work was assessed. In both sexes, PA was inversely associated with waist circumference (all P < 0.0001). After controlling for sex, age, and waist circumference, PA was directly associated with HDL-cholesterol and apolipoprotein A1, and inversely with heart rate, smoking, oxidized LDL, apolipoprotein B, insulin, glucose, C-reactive protein, leptin, L-arginine, and phospholipase A2 activity (all P < 0.05)., Conclusion: These population-based data are consistent with the idea that the beneficial effects of PA on CHD risk are mediated by favorable influences on several risk factors, as judged by independent relations to markers of lipoprotein metabolism, glucose metabolism, and inflammation. These associations reflect beneficial effects on cardiovascular health in both sexes and may offer mechanistic insights for the inverse association between PA and CHD.

Study Design: A cross-sectional magnetic resonance imaging (MRI) study., Objective: We investigated the association among Modic changes, Schmorl's nodes, spondylolytic defects, high-intensity zone lesions, radial tears, herniations, and low back symptom severity., Summary of Background Data: Disc degeneration is associated with low back pain in early adulthood, but the associations between other MRI findings and low back pain are not well known., Methods: Questionnaire data and MRI scans (1.5-T) were available for 554 subjects derived from a birth cohort at 21 years of age. Data on low back pain and back-related functional limitations at 18, 19, and 21 years of age were used for clustering of subjects, using latent class analysis. We used logistic regression with adjustment for the degree of disc degeneration to evaluate the associations between specific imaging findings and low back symptom severity., Results: The prevalence of herniations was 20%, Schmorl's nodes 17%, radial tears 9.9%, high-intensity zone lesions 3.2%, spondylolytic defects 5.8%, and Modic changes 0.7%. Latent class analysis produced 5 clusters: "Always Painful" (n = 65) meant painful at all time points and "Recent Onset Pain" (n = 56) meant increasing symptom severity, whereas subjects in the "Moderately Painful" (n = 73), "Minor Pain" (n = 193), and "No Pain" (n = 167) clusters had fewer symptoms. Compared with the "No Pain" cluster, Schmorl's nodes were more likely to occur in the "Always Painful" cluster (P = 0.017) and herniations in the 3 most painful clusters (P < 0.001). Herniations were associated with low back symptom severity (odds ratio, 2.5; 95% confidence interval, 1.4-4.4). Schmorl's nodes and radial tears were associated with symptoms in crude analyses only, whereas high-intensity zone lesions and spondylolytic defects occurred in similar frequencies in all clusters., Conclusion: Herniations were most likely in the subjects with recent onset or persistent (3-yr period) low back symptoms, although they were also detected in subjects with no symptoms. The clinical relevance of herniations on MRI remains to be evaluated in the context of symptoms.

Objective: To investigate how self-reported musculoskeletal pain and health-related quality of life (HRQoL) are associated among young adults., Design and Setting: The study population consisted of a subgroup of the Northern Finland Birth Cohort 1986 at the age of 19 (N=874), who completed the 15-dimensional (15D) HRQoL questionnaire (score 0 to 1) and answered questions about six-month period prevalence of musculoskeletal pain in neck, shoulder, low back, and peripheral location., Results: Half of the males and one third of the females reported a 15D score of at least 0.98 and were selected as the reference group in the multinomial logistic regression analysis. Young adults who reported multiple pains had significantly lower 15D scores than those reporting pain in only one location or no pain at all. After adjustments for other health problems, psychosocial distress, parental occupation, and the young adults' own employment status, the reporting of single musculoskeletal pain odds ratio (OR) 2.6 and multiple pains (ORs up to 11.9) among females, and multiple pains (ORs up to 4.6) among males were associated with a 15D score of 0.94 or less., Conclusions: The number of involved sites of self-reported musculoskeletal pain was associated with the level of reduction in HRQoL among young adults., (Wiley Periodicals, Inc.)

Objectives: There are a limited number of studies about the cost-effectiveness of occupational health and safety (OSH) interventions. Applying the results of a cost-effectiveness study from one country to another is hampered by differences in the organization of healthcare and social security. In order to find out how these problems can be overcome, we transferred the results of a Dutch occupational cost-effectiveness study to the Finnish situation and vice-versa., Methods: We recalculated incremental cost-effectiveness ratios (ICER) for the target country based on resource use in the original study and the associated costs in the target country. We also allocated the costs to the employer, the employee, and tax-payers., Results: We found that the ICER did not differ very much from those in the original studies. However, the different healthcare funding structure led to a more unfavorable ICER for employers in the Netherlands. Both interventions represented a cost saving for tax-payers and employees. Employers had to invest euro10-54 to avert one day of sick leave., Conclusions: We conclude that results of cost-effectiveness studies can be transferred from one country to another, but many adjustments are needed. An extensive description of the intervention, a detailed list of resource use, allocation of costs to various parties, and detailed knowledge of the healthcare systems in the original studies are necessary to enable calculations.

Introduction: In a recently published randomized controlled trial (RCT), a targeted occupational health (OH) intervention was found effective in an intention-to-treat analysis in controlling sickness absence among workers with high risk of sickness absence, compared to usual care. We performed an exploratory subgroup analysis in order to detect possible effect modifiers and mediators., Methods: Age, gender, working status, severity of physical impairment, depression score, self-rated working ability, co-morbidity, and sickness absence characteristics in the previous 12 months were identified as potential effect modifiers (n = 382). We conducted regression analyses with the potential effect modifiers and a mediator (treatment attendance as intended) as explanatory variables. The difference of sickness absence days during the previous year and the follow-up year was the dependent variable., Results: The intervention was especially effective in the subgroups of workers who were certain that they will not be able to continue working in their current job due to health-related reasons (-74 days; 95% CI -105 to -43), had co-morbidities (-22.5 days; 95% CI -35.5 to -9.5), or severe physical impairment at work (-17.5 days; 95% CI -28.5 to -6.5). A modifying effect of age, gender, working status, depressive symptoms, or prior sickness absence on the effectiveness of this OH intervention was not found., Conclusions: This targeted OH intervention seems especially suitable for workers who consider that they are no longer able to continue working due to health reasons and have high level of physical impairment or co-morbidities. The findings from these exploratory analyses should be tested in future RCTs.

Study Design: A cross-sectional imaging study of young adults., Objective: To investigate the prevalence of disc degeneration (DD) and displacement, anular tears, and Modic changes in lumbar magnetic resonance imaging (MRI) among young adults., Summary of Background Data: Although low back pain in young adulthood is common, the prevalence of spinal MRI findings at this age remains virtually unknown., Methods: The study population was a subcohort of the Northern Finland Birth Cohort 1986. Subjects living within 100 km of Oulu (n = 874) were invited to participate in lumbar MRI at 20 to 22 years of age (mean: 21.2 years). Degree of DD, type of Modic changes, and presence of disc bulges, herniations, high intensity zone (HIZ) lesions, and radial tears at all lumbar levels were assessed., Results: Three hundred twenty-five women and 233 men (n = 558) attended the MR imaging. DD was significantly more frequent in men (54% vs. 42%, P = 0.005), as was multiple DD (21% vs. 14%, P = 0.036). The prevalences of disc bulges and radial tears were 25% and 9.1%, respectively, without gender differences. HIZ lesions were more common among women than men (8.6% vs. 4.3%, P = 0.046), whereas herniations were significantly more common among men (5.6% vs. 2.5%, P = 0.047). Only 2 disc extrusions were observed, one in each gender. All degenerative disc findings were more common at the L5-S1 level except HIZ lesions, which were most likely at L4-L5. The prevalence of the Modic changes was 1.4%, without gender difference, type I being more common than type II. Typically, Modic changes were located adjacent to a DD Grade 4 disc and at the 2 lowest levels., Conclusion: Almost half of young Finnish adult aged 21 years had at least one degenerated disc, and a quarter had a bulging disc. Modic changes and disc herniations were, however, relatively rare.

Aims: We have shown in a cross-sectional setting that an IL6 haplotype (GGGA) is associated with intervertebral disc disease (IDD) characterized by sciatica. The aim of this study was to evaluate the prognostic role of the GGGA haplotype in IDD., Methods: DNA from 153 sciatica patients who participated in a randomized controlled trial of periradicular infiltration was analysed for IL6 variations rs1800797 (-596A>G), rs1800796 (-572G>C), rs1800795 (-174G>C), and rs13306435 (+15T>A). The patients recorded back and leg pain intensity and duration, disability by Oswestry Index and back-related sickness absence over a three-year follow-up. Repeated measures and univariate analysis of variance with adjustment for age, gender and physical work load were used in statistical analyses for the last two-years of the follow-up., Results: The prevalence of the GGGA haplotype was 9% (14/153). Subjects with the GGGA haplotype did not differ from those without the haplotype with respect to pain intensity, or disability score, but days with back and leg pain and days on sick leave were significantly higher among subjects with the IL6 haplotype after adjustment for occupation (p=0.006, 0.001 and 0.002, respectively). An interaction between the IL6 haplotype and physical work load was significant for the duration of back and leg pain and sick leave (p=0.038, 0.011 and 0.006, respectively)., Conclusions: This is the first observation of any prognostic genotype among sciatica patients. The IL6 haplotype GGGA predicted the number of days with back or leg pain and also sickness absence. Subjects with the IL6 haplotype may be more vulnerable when doing physically demanding jobs.

Both low back pain (LBP) and obesity are common public health problems, yet their relation remains controversial. The aim of this study was to investigate the associations between weight-related factors and the prevalence of LBP in young adults in Finland. Participants in the ongoing Cardiovascular Risk in Young Finns Study aged 24-39 years were included (N = 2,575). In 2001, 31.2% of men and 39.5% of women reported LBP with recovery within a month or recurrent or continuous pain during the preceding 12 months. For women only, those with higher body mass index, waist circumference, hip circumference, waist-to-hip ratio, serum leptin level, and C-reactive protein level showed an increased prevalence of LBP. With all weight-related factors in the model, only waist circumference was related to LBP in women. For women, the odds ratios of LBP were 1.2 (95% confidence interval: 0.8, 1.8) for a waist circumference of 80-87.9 cm and 1.8 (95% confidence interval: 1.0, 3.2) for a waist circumference of > or =88 cm compared with a waist circumference of <80 cm. This association was independent of C-reactive protein, leptin, and adiponectin levels. The authors' findings in a relatively young population suggest that abdominal obesity may increase the risk of LBP in women.

Low back pain (LBP) is a common health problem already in adolescence. Physical activity has been suggested as a risk factor for LBP in adolescents, but the current evidence is conflicting. This study examined the association of physical activity and amount of sitting with LBP. The study population consisted of 5999 boy and girl members of the Northern Finland 1986 birth cohort who responded to mailed questions at the age of 15-16 years. LBP during the past 6 months was classified as "no LBP,""reporting LBP" (not seeking medical help), or "consultation for LBP." Odds ratios and 95% confidence intervals obtained by multinomial logistic regression were adjusted for smoking and body mass index. Being physically very active (more than 6 h of brisk physical activity per week) was associated with increased prevalence of "consultation for LBP" in both sexes, and with "reporting LBP" in girls, compared with being moderately active (2-3 h of brisk physical activity per week). High amount of sitting associated with "consultation for LBP" and "reporting LBP" in girls, but not in boys. We conclude that very active participation in physical activities in both sexes and a high amount of sitting in girls are related to self-reported LBP.

Objectives: To evaluate the effectiveness of two occupational health intervention programmes, both compared with usual care., Methods: Based on a health survey, 1341 employees (88% males) in construction, service and maintenance work were classified into three groups: "low risk" (n = 386), "intermediate risk" (n = 537) and "high risk" (n = 418) of sickness absence. Two separate randomised trials were performed in the groups "high risk" and "intermediate risk", respectively. Those high risk subjects that were allocated to the intervention group (n = 209) were invited to occupational health service for a consultation. The intervention included, if appropriate, a referral to specialist treatment. Among the intermediate risk employees those in the intervention group (n = 268) were invited to call a phone advice centre. In both trials the control group received usual occupational health care. The primary outcome was sickness absence during a 12-month follow-up (register data)., Results: The high risk group, representing 31% of the cohort, accounted for 62% of sickness absence days. In the trial for the high risk group the mean sickness absence was 30 days in the usual care group and 19 days in the intervention group; the mean difference was 11 days (95% CI 1 to 20 days). In the trial for the intermediate risk group the mean sickness absence was 7 days in both arms (95% CI of the mean difference -2.3 to 2.4 days)., Conclusions: The identification of high risk of work disability was successful. The occupational health intervention was effective in controlling work loss to a degree that is likely to be economically advantageous within the high risk group. The phone advice intervention for the intermediate risk group was not effective in controlling work loss primarily due to poor adherence.

Objectives: To determine whether, from a healthcare perspective, a specific occupational health intervention is cost effective in reducing sickness absence when compared with usual care in occupational health in workers with high risk of sickness absence., Methods: Economic evaluation alongside a randomised controlled trial. 418 workers with high risk of sickness absence from one corporation were randomised to intervention (n = 209) or to usual care (n = 209). The subjects in the intervention group were invited to occupational health service for a consultation. The intervention included, if appropriate, a referral to specialist treatment. Register data of sickness absence were available for 384 subjects and questionnaire data on healthcare costs from 272 subjects. Missing direct total cost data were imputed using a two-part regression model. Primary outcome measures were sickness absence days and direct healthcare costs up to 12 months after randomisation. Cost effectiveness (CE) was expressed as an incremental CE ratio, CE plane and CE acceptability curve with both available direct total cost data and missing total cost data imputed., Results: After one year, the mean of sickness absence was 30 days in the usual care group (n = 192) and 11 days less (95% CI 1 to 20 days) in the intervention group (n = 192). Among the employees with available cost data, the mean days of sickness absence were 22 and 24, and the mean total cost euro974 and euro1049 in the intervention group (n = 134) and in the usual care group (n = 138), respectively. The intervention turned out to be dominant-both cost saving and more effective than usual occupational health care. The saving was euro43 per sickness absence day avoided with available direct total cost data, and euro17 with missing total cost data imputed., Conclusions: One year follow-up data show that occupational health intervention for workers with high risk of sickness absence is a cost effective use of healthcare resources.

Objectives: To study the associations between self-reported health problems and sickness absence from work., Methods: The results of a questionnaire survey were combined with archival data of sickness absence of 1341 employees (88% males; 62% blue-collar) in the construction, service and maintenance work within one corporation in Finland. Sex, age and occupational grading were controlled as confounders. A zero-inflated negative binomial (ZINB) regression model was used in the statistical analysis of sickness absence data., Results: The prevalence of self-reported health problems increased with age, from 23% in 18-30-year-olds to 54% in 55-61-year-olds. However, in those aged 18-30 years, 71% had been absent from work and in those aged 55-61 years this proportion was 53%. When health problems and occupational grading were accounted for in the ZINB model, age as such was not associated with the number of days on sick leave, but the young workers still had higher propensity for (any) sickness absence than the old. Self-rated future working ability and musculoskeletal impairment were strong determinants of sickness absence. Among those susceptible to taking sick leave, the estimated mean number of absence days increased by 14% for each rise of 1 unit of the impairment score (scale 0-10)., Conclusions: Young subjects had surprisingly high probability for sickness absence although they reported better health than their older colleagues. A higher total count of absence days was found among subjects reporting health problems and poorer working ability, regardless of age, sex and occupational grade. These findings have implications for both management and the healthcare system in the prevention of work disability.

Study Design: Cross-sectional epidemiologic study., Objective: To evaluate the interaction between known genetic risk factors and whole-body vibration for symptomatic intervertebral disc disease (IDD) in an occupational sample., Summary of Background Data: Risk factors of IDD include, among others, whole-body vibration and heredity. In this study, the importance of a set of known genetic risk factors and whole-body vibration was evaluated in an occupational sample of train engineers and sedentary controls., Methods: Eleven variations in 8 genes (COL9A2, COL9A3, COL11A2, IL1A, IL1B, IL6, MMP-3, and VDR) were genotyped in 150 male train engineers with an average of 21-year exposure to whole-body vibration and 61 male paper mill workers with no exposure to vibration. Subjects were classified into IDD-phenotype and asymptomatic groups, based on the latent class analysis., Results: The number of individuals belonging to the IDD-phenotype was significantly higher among train engineers (42% of train engineers vs. 17.5% of sedentary workers; P = 0.005). IL1A -889T allele represented a significant risk factor for the IDD-phenotype both in the single marker allelic association test (P = 0.043) and in the logistic regression analysis (P = 0.01). None of the other allele markers was significantly associated with symptoms when analyzed independently. However, for all the SNP markers considered, whole-body vibration represents a nominally significant risk factor., Conclusion: The results suggest that whole-body vibration is a risk factor for symptomatic IDD. Moreover, whole-body vibration had an additive effect with genetic risk factors increasing the likelihood of belonging to the IDD-phenotype group. Of the independent genetic markers, IL1A -889T allele had strongest association with IDD-phenotype.

Study Design: A cross-sectional survey among adolescents aged 15-16 years., Objective: To evaluate whether physical activity or sedentary activities associate with neck and shoulder symptoms among adolescents., Summary of Background Data: Findings of associations between physical exercise and neck or shoulder pain in adolescents are controversial., Methods: The study population consisted of adolescents belonging to the Northern Finland Birth Cohort 1986. The present analyses included 3185 girls and 2808 boys. Associations of physical activity level, total sitting time, and different kinds of sedentary activities with neck or occipital pain and shoulder pain were analyzed at 15-16 years of age using logistic regression. Reporting pain (not seeking medical help) and consultation for pain (seeking medical help) were assessed separately in girls but were combined in boys because of a low prevalence of severe pain., Results: Almost half of the girls and one third of the boys reported mild neck or occipital pain, or shoulder pain, and 5% of girls and 2% of boys reported severe neck or occipital pain, or shoulder pain during the past 6 months. High-level physical activity associated with an increased prevalence of both severe neck or occipital pain and severe shoulder pain in girls, but not in boys. Prolonged sitting was associated with a high prevalence of neck or occipital pain and shoulder pain in girls, and neck or occipital pain in boys. Of various sedentary activities, television watching and reading books associated with neck or occipital pain in girls, whereas playing or working with a computer associated with neck or occipital pain in boys. In girls, television watching also associated with mild shoulder pain., Conclusions: Neck or occipital pain and shoulder pain are very common symptoms among adolescents, and both prolonged sitting and a high level of physical activity seem to be related to them.

Study Design: A cross-sectional comparative study between healthy controls and patients with chronic low back pain (LBP)., Objective: To assess the effect of chronic LBP on biceps brachii muscle activation during sudden upper-limb loading., Summary of Background Data: Chronic LBP is related to altered trunk muscle function. However, it is not known if these changes are also found in upper-limb function, indicating a general effect., Methods: Surface electromyographic recordings were made from the biceps brachii bilaterally from 22 control subjects without chronic LBP and 29 patients with chronic LBP. Electromyography was recorded during expected and unexpected limb loading, with the activation pattern recorded for analysis at 150 milliseconds before loading, and 3 consecutive 50 milliseconds periods following loading. RESULTS.: Chronic LBP patients had decreased biceps brachii activation before expected perturbation (P = 0.035) and during the third 50-millisecond period (from 100 to 150 milliseconds) after unexpected perturbation (P = 0.010). During the first 2, 50-millisecond periods (from 0 to 100 milliseconds) after the perturbation, the activation was similar., Conclusions: Chronic LBP did not affect reflex activation of biceps brachii muscles but decreased preparatory and triggered reactions. The finding indicates that back pain may disturb higher level information processing in motor control.

The purpose of this study was to assess if chronic low back pain patients have impaired paraspinal muscle O2 turnover and endurance capacity as compared to healthy control subjects during dynamic exercise. Middle-aged healthy male subjects (n = 12, control) and male patients with chronic low back pain (n = 17, CLBP) participated in the study. L4–L5 level paraspinal muscle fatigue was objectively assessed during earlier validated 90 s dynamic back endurance test (spectral EMG, MPFslope). Also EMG amplitude (EMGamplitude) and initial MPF (MPFinitial) were assessed from the initial 5 s of the endurance contraction. Simultaneously near infrared spectroscopy (NIRS) was used for quantitative measurement of local L4–L5 paraspinal muscle O2 consumption. Subcutaneous tissue thickness (ATT) was measured from the EMG and NIRS recording sites. The results indicated that control and CLBP groups were compatible as regarding anthropometric variables, paraspinal muscle activation levels (EMGamplitude), initial MPF (MPFinitial) and ATT. When the ATT was used as a covariate in the ANOVA analysis, CLBP group did not show significantly greater paraspinal muscle fatigability (right MPFslope – 12.2 ± 10.7%/min, left right MPFslope – 12.6 ± 13.3%/min) or O2 consumption (right NIRSslope – 52.8 ± 79.6 μM/l/s) as compared to healthy controls (right MPFslope – 11.9 ± 7.6%/min, left MPFslope – 12.7 ± 8.6%/min, right NIRSslope – 53.7 ± 95.2 μM/l/s). As a conclusion, these CLBP male patients did not show any impaired rate of paraspinal muscle oxygen consumption or excessive paraspinal muscle fatigability during dynamic exercise as compared with healthy controls. Subcutaneous tissue thickness has a strong influence on the NIRS and EMG amplitude measurements and, if unchecked, it could result in the false interpretation of the results.

We showed previously that chronic Chlamydia pneumoniae infection increases the risk of lumbar artery occlusion. We did not evaluate, however, the effect of other risk factors for cardiovascular diseases in combination with this chronic infection. The purpose of this study was to investigate the combined effect of chronic C. pneumoniae infection and other known determinants of artery occlusion in a population of sciatica patients. Two-dimensional time-of-flight magnetic resonance angiography (MRA) was used to evaluate lumbar arteries at baseline and three years. The arteries on both sides (L1-L4) were evaluated visually and scored as normal, narrowed or occluded. Logistic regression analysis was performed separately for baseline total arterial stenosis and each L1-L4 segmental artery pair, and for incident new stenosis during the follow-up period. The determinants analyzed included age, body mass index (BMI, kg/m(2)), education, gender, and smoking, in addition to presence of chronic C. pneumoniae infection. MRA was obtained at baseline for 147 patients and at 3 years for 134 patients. Sixty-four (47.8%) of 134 patients had new arterial stenosis. Total incidence of new arterial stenosis was distributed quite evenly between the individual segmental levels, varying from 12.7 to 18.6%. BMI was the only predictor of new arterial stenosis (odds ratio (OR) 1.13). A reasonable logistic model could be established only for baseline L4 and total arterial scores. At L4, education was a protective factor (OR 0.07), whereas age (OR for the oldest age group 6.7) and BMI (OR 1.17) were associated with increased risk of occlusion. For total arterial score, chronic C. pneumoniae infection was an independent determinant of arterial occlusion, increasing the risk to almost eightfold. Additionally, BMI (OR 1.16), and age (for the oldest age group OR 11.4) were significant determinants for stenosis. Smoking was not statistically significant. As chronic C. pneumoniae infection was an independent determinant of lumbar artery occlusion, treatments of this chronic infection may have an impact on lumbar diseases. The importance of BMI for new arterial stenosis suggests that weight reduction may also have a beneficial effect in lumbar artery disease.

Musculoskeletal disorders of which low back pain (LBP) accounts for more than 50% are now the most common cause of chronic incapacity in industrialized countries. The traditional approach in looking for the reason (etiology) for musculoskeletal disorders is to search structural failures but, in most cases, it is difficult to find an explicit reason for back pain. Many scientists now consider spine disorders as multifactorial, bio-psycho-social problems. Pain has clear effects on motor control. Therefore, LBP can also induce changes in neuromuscular control and motor performance, i.e., causing various functional deficits. Another feature, which deserves special consideration with reference to back problems, concerns the numerous psychological factors, which are involved in mediating the relationships between physical impairment, pain and disability. The new scientific knowledge on functional deficits is increasingly being transferred to clinical applications, where the aim is to reverse them with physical rehabilitation. As a result of the recognition of the behavioral (psychological) problems with LBP, psychological, behavioral and educational interventions are commonly combined with the physical rehabilitation for LBP also. Basically, functional rehabilitation includes systematic quantification of both the physical function and psychological factors, which drive the therapeutic process. The exercises used in the functional rehabilitation usually revolve around the treatment of the spine as a functional unit. Thus many programs for functional rehabilitation use rehabilitation equipment (iso-inertial/isokinetic) by properly trained physiotherapists. However, some centers use regular fitness equipment or aerobics-type exercises. Furthermore, some relaxation and ergonomic exercises are typically proposed, and psychological support provided along the treatment. There exists both an outpatient and an inpatient functional rehabilitation approach. They are described in the paper together with the first results obtained in Italy with the outpatient approach.

The paraspinal muscle responses for unexpected and expected upper limb loading were investigated by surface EMG of 20 healthy volunteers. The simultaneous trunk and hand accelerations with paraspinal, biceps brachii and soleus muscles EMG were measured in four subjects. A short-latency response of approximately 50 ms was observed in paraspinal muscles. The latency was approximately 3 ms shorter (P = 0.017) during "expected" trials on average and the latency shortened during the first three expected trials (P = 0.02). Anticipation also decreased the magnitude of the response (P < 0.05). Trunk movement initiated approximately 35 ms and approximately 50 ms after the impact of the load at T6 and T12 levels, respectively. In conclusion, visual expectation shortens the latency and decreases the magnitude of the paraspinal muscle response to sudden upper limb loading. Also, the trial repetition has an effect on reflex latency if visual information is available. These results indicate that anticipation modulates the reflex control of paraspinal muscles, which may be significant in understanding spinal function.

When frail older people become acutely ill, they are at increased risk of further functional deterioration and rehabilitation is needed to restore functioning. The effects of an out-patient multicomponent training program including strength training after hospitalization were studied in a randomized controlled trial. Sixty-eight women (mean age 83.0 +/- 3.9 years) who were hospitalized due to an acute illness and were mobility impaired at admission were randomized into training (N = 34) and home exercise (N = 34) groups. Maximal voluntary isometric strength of knee extension and hip abduction, dynamic balance, and maximal walking speed were measured before and after the 10-week training period, and 3 and 9 months after the end of the intervention. After the intervention, significant improvements were observed in the training group compared to the home exercise group in the maximal voluntary isometric knee extension strength (20.8% vs. 5.1%, P= 0.009), balance scale (+ 4.4 points vs. -1.3 points, P= 0.001) and walking speed (+ 0.12 m s-1 vs. -0.05 m s-1, P= 0.022). Effects on knee extension and hip abduction strength, balance and walking speed were observed 3 months later, and some effects on hip abduction strength (9.0% vs. -11.8%, P= 0.004) and mobility were still apparent even 9 months after the intervention.

Study Design: A descriptive study of the associations between different neurophysiologic findings in patients with lumbar spinal stenosis., Objectives: To evaluate the ability to sense a change in lumbar position and the associations between lumbar movement perception, postural stability, and motor-evoked potentials and somatosensory-evoked potentials., Summary of Background Data: Patients with low back pain have impaired postural control and impaired lumbar proprioception. Altered motor-evoked potentials and somatosensory-evoked potentials have been often observed in lumbar spinal stenosis., Methods: The study included 26 patients with clinically and radiologically diagnosed lumbar spinal stenosis. Their ability to sense lumbar rotation was assessed in a previously validated motorized trunk rotation unit in the seated position. The abilities to indicate the movement direction and the movement magnitude were used as indexes of the ability to sense the lumbar rotatory movement. The postural stability was measured with a vertical force platform. The motor-evoked potentials were elicited by transcranial and lumbar stimulation and recorded from anterior tibialis muscles. The somatosensory-evoked potentials were elicited by transcutaneous electrical stimulation of the tibial nerve at the ankle., Results: Twenty patients (76.9%; P = 0.006) reported the wrong movement direction. Furthermore, the patients consistently localized the movement sensation in their shoulders instead of the lumbar region. The altered motor-evoked potentials and somatosensory-evoked potentials were observed in 11 and 16 patients, respectively. Abnormal motor-evoked potentials had inconsistent associations with impaired movement perception and postural stability and abnormal somatosensory-evoked potentials had no associations with other findings., Conclusions: Many patients with lumbar spinal stenosis have difficulties in sensing the lumbar rotational movement, which may indicate impaired proprioceptive abilities. Abnormal motor-evoked potentials and somatosensory-evoked potentials are also frequent in lumbar spinal stenosis but do not necessarily occur in the same patients as the abnormal ability to sense trunk movement. These new findings add to our understanding of the pathophysiology of lumbar spinal stenosis.

Introduction: Active treatments are advocated for the management of non-specific chronic low back pain (CLBP), although few studies have documented the relative efficacy of differing types of programme. A number of the available treatments comprise exercise routines on specially designed training machines, which are ostensibly better disposed to reverse the compromised trunk muscle function displayed by these patients than are 'free exercise' programmes. However, in using these muscle-training programmes, the physiological or anatomical adaptations that might account for the improved performance are rarely investigated, let alone identified. This is an important issue, because if the 'newly-acquired strength' is mostly specific to performance on the devices on which the patient has trained and been tested, and reflects the skill in executing these particular tasks, this will not necessarily assist the patient during performance of his/her everyday activities. The aims of the present study were (1) to quantify the changes in back muscle performance in chronic LBP patients following 3 months active therapy, and (2) to analyse the corresponding changes in activation and cross-sectional area of the paraspinal muscles., Methods: 148 individuals (57% women) with CLBP (age 45.0+/-10.0 years; duration of LBP 10.9+/-9.5 years) were randomised to a treatment which they attended 2/week for 3 months: active physiotherapy, muscle reconditioning on training devices, or low-impact aerobics. Pre- and post-therapy, assessments were made of isometric trunk muscle strength in each plane of movement and of erector spinae activation (using surface electromyography) during back extension. In a sub-group of 56 patients, the cross-sectional area of the paravertebral muscles was determined using magnetic resonance imaging (MRI). In all patients, self-rated pain intensity, pain frequency and disability were assessed before and after therapy., Results: 132/148 patients completed the therapy. Isometric strength in each movement plane increased significantly in all groups post-therapy. Apart from trunk extension, the changes were significantly greater in the devices group than in the other two groups (Fig 1). Activation of the paraspinal muscles during back extension also increased significantly in all groups (Fig 2) and was weakly, but significantly (r = 0.37; p = 0.0001) correlated with increased strength in back extension. Although, at baseline, highly significant correlations were observed between the size of the paraspinal muscles (at L3/4 and at L4/5) and isometric back extension strength (r=0.75; p< 0.0001), post-training increases in strength were not accompanied by corresponding changes in muscle size. None of the improvements in strength showed any relationship with the clinical changes in pain and disability, regardless of whether the latter were examined on an individual basis or in relation to 'outcome groups'., Conclusion: The superior trunk strength shown by the devices group post-therapy was considered to be attributable, in part, to a 'learning effect', of the type often seen when training and testing are carried out on the same machines. These gains are considered to be mostly 'task-specific'. However, part of the improvement in strength after active therapy (in all groups) also appeared to be due to an increased neural activation of the trunk muscles. These positive effects should be transferable to the performance of everyday activities for which the same muscles are employed, although the percentage improvement is probably not as high as the measured increase in strength might suggest. Possible roles for improved co-ordination and changes in motivation and/or pain tolerance after therapy cannot be excluded. No differences in the clinical outcome were observed between the three therapy groups, and the changes in physical performance after therapy did not correlate with the clinical outcome. It is therefore questionable whether strength measurements have any clinical significance in documenting the success of rehabilitation programmes, other than on a motivational basis. The results of the present study suggest that the value of supervised active therapy programmes does not reside in the reversal of specific muscular deficiencies, but rather in the provision of a source of confirmation/encouragement for the patient, that movement is not harmful, and a foundation upon which to further build. Whether the utilisation of specific training devices, or individual instruction, is necessary to elicit these particular effects is questionable.

Objectives: To examine the relative efficacy of three active therapies for patients with chronic low back pain., Methods: One hundred and forty-eight subjects with chronic low back pain were randomized to receive, twice weekly for 3 months, (i) active physiotherapy, (ii) muscle reconditioning on training devices, or (ii) low-impact aerobics. Questionnaires were administered to assess pain intensity, pain frequency and disability before and after therapy and at 6 and 12 months of follow-up., Results: One hundred and thirty-two of the 148 patients (89%) completed the therapy programmes and 127 of the 148 (86%) returned a questionnaire at all four time-points. The three treatments were equally efficacious in significantly reducing pain intensity and frequency for up to 1 yr after therapy. However, the groups differed with respect to the temporal changes in self-rated disability over the study period (P=0.03): all groups showed a similar reduction after therapy, but for the physiotherapy group disability increased again during the first 6 months of follow-up whilst the other two groups showed a further decline. In all groups the values then remained stable up to the 12-month follow-up. The larger group size and minimal infrastructure required for low-impact aerobics rendered it considerably less expensive to administer than the other two programmes., Conclusions: The introduction of low-impact aerobic exercise programmes for patients with chronic low back pain may reduce the enormous costs associated with its treatment.

Study Design: An observational follow-up., Objectives: To analyze the role of physical exercise and inactivity on the long-term outcome after active outpatient low back rehabilitation., Summary of Background Data: There is considerable evidence documenting the efficacy of exercise in the conservative treatment of chronic low back pain, but the role of exercises after the guided treatment period on the long-term success and maintenance of the results is not known., Methods: One hundred twenty-five patients with low back pain, who had participated in a 12-week active low back rehabilitation program, were asked about subjective pain and disability on the average of 14 months after the treatment. The outcomes were defined as a recurrence of persistent pain and work absenteeism, and a survival or failure analysis was performed between those who had continued exercising and who had been physically inactive., Results: Recurrences of persistent pain during the follow-up period were fewer (P = 0.03) among those who had maintained regular exercise habits after the treatment than among those who had been physically inactive. Similarly, work absenteeism was less (P < 0.01) among physically active than among physically inactive persons. However, patients with good outcome in pain reduction after low back pain rehabilitation were more likely to participate in physical exercise., Conclusions: Exercises are beneficial after guided treatment in the maintenance of the results of active treatment for recurrent chronic low back pain in the long term, but those with less favorable outcome in rehabilitation are less likely to participate in exercises afterward. In active treatment programs, it is recommended that exercises be incorporated after the guided treatment.

Study Design: A randomized comparative study with single-blind outcome assessments., Objectives: To compare the efficacy of a multimodal treatment emphasizing proprioceptive training (ACTIVE) with activated home exercises (HOME) and recommendation of exercise (CONTROL) in patients with nonspecific chronic neck pain., Summary of Background Data: The efficacy of active exercises and passive physiotherapy for neck trouble has been somewhat disappointing in the previous few studies., Methods: Seventy-six patients (22 men, 54 women) with chronic, nonspecific neck pain participated. Sixty-two participated the 1-year follow-up. Subjective pain and disability, cervical ranges of motion, and pressure pain threshold in the shoulder region were measured at baseline, at 3 months, and at 12 months. The ACTIVE treatment consisted of 24 sessions of proprioceptive exercises, relaxation, and behavioral support. The HOME regimen included a neck lecture and two sessions of practical training for home exercises and instructions for maintaining a diary of progress. The CONTROL treatment included a lecture regarding care of the neck with a recommendation to exercise., Results: The average self-experienced total benefit was highest in the ACTIVE group, and the HOME group rated over the CONTROL group (P < 0.001). Differences between the groups in favor of the ACTIVE treatment were recorded in reduction of neck symptoms and improvements in general health and self-experienced working ability (P < 0.01-0.03). Changes in measures of mobility and pressure pain threshold were minor., Conclusions: Regarding self-experienced benefit, the multimodal treatment was more efficacious than activated home exercises that were clearly more efficacious than just advising. No major differences were noted in objective measurements of cervical function between the groups, but the content validity of these assessments in chronic neck trouble can be questioned.

Objectives: To investigate the association between leisure physical activity and various pain symptoms in adolescents., Methods: In this nationwide cohort based cross sectional study in Finland, 698 schoolchildren, 344 girls and 354 boys, aged 10 to 17 years responded to a questionnaire on pain symptoms (neck and shoulder pain, upper back pain, low back pain, upper limb pain, lower limb pain, headache, and abdominal pain) and physical activity habits and also participated in a fitness test., Results: Reported physical activity correlated with measured fitness. Musculoskeletal pains (p = 0.013) (in particular low back pain (p = 0.022), upper limb pain (p<0.001), and lower imb pain (p<0.001)) were found more often in subjects participating in large amounts of leisure physical activity, while non-musculoskeletal pains (p = 0.065) (in particular headache among boys (p = 0.004)) tended to be less common. Co-occurrence of different musculoskeletal pains was common in subjects participating in sports., Conclusions: In addition to its likely long term health benefits, vigorous physical activity causes musculoskeletal pains during adolescence. This should be considered when tailoring health promotion programmes to adolescents. Also, co-occurrence of musculoskeletal pains may occur as the result of sports activity, which should be considered as a confounder in epidemiological studies on fibromyalgia and related issues.

Background: Low educational level is associated with an increased risk of coronary heart disease. The aim of the present study was to examine the relationships between education and common cardiovascular risk factors in young adults., Methods: Trends in conventional risk factors of young adults aged 21, 24, 27 and 30 years in 1992 (n = 443) were examined across the educational groups as part of a 12-year follow-up study, the Cardiovascular Risk in Young Finns Study. Education was determined as participants' own educational level and as parental years of schooling., Results: In males, subject's own education was related inversely and independently of parental school years to serum total and low density lipoprotein (LDL) cholesterol concentration, smoking and body mass index. In females, participant's own educational level associated inversely with smoking and physical inactivity. Parental school years was associated inversely and independently of one's own educational level with serum total and LDL cholesterol values and waist-hip ratio in females. In both genders, parental education was a stronger determinant of diet (butter use) than one's own educational level., Conclusions: The least educated young adults have adopted a more adverse lifestyle than the more educated. The risk factor profile in young adulthood, especially in females, is still affected by parental education. The influences of one's own and parental educational level on vascular risk profile should be taken into consideration when planning public health campaigns among young adults.