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Background After COVID-19 infection, long-term impacts on functioning may occur. We studied the functioning of patients with post-COVID-19 condition (PCC) and compared them to controls without PCC.Methods This cross-sectional study consisted of 442 patients with PCC referred to rehabilitation at the Helsinki University Hospital (HUS) Outpatient Clinic for the Long-Term Effects of COVID-19, and 198 controls without PCC. Functioning was assessed with a questionnaire including WHODAS 2.0. Patients underwent physical testing including a hand grip strength test (HGST) and a 6-minute walking test (6MWT). Lifestyle was assessed by questionnaire and comorbidities were collected as ICD-10 codes from the HUS Data Lake on the HUS Acamedic platform.Results The WHODAS 2.0 average total score was 34 (SD 18) (moderate functional limitation) for patients with PCC and 6 (SD 8) (normal or mild limitation) for the controls. The disability was higher in all aspects of WHODAS 2.0 in patients with PCC. Bivariate binomial and multivariable regression analyses showed that the presence of comorbidities, anxiety, depression, and smoking predicted a WHODAS 2.0 score of 24 (moderate functional limitation) or above in the PCC group. The average 6MWT distance was 435 m (SD 98 m) in patients with PCC and 627 m (SD 70 m) in controls. HGST measurements showed no significant differences from controls.Conclusions In conclusion, patients with PCC had significantly reduced functioning based on WHODAS 2.0 scores and the 6MWT results. Comorbidities, anxiety, depression, and smoking were associated with moderate or severe limitations in functioning. Findings support that PCC is multifactorial and requires a holistic approach to rehabilitation.

Introduction: Comprehensive national spine registers are used in the Nordic countries. Register data is inherently incomplete, raising concerns about the derived results due to non-respondent bias. Few studies have addressed the effect of non-respondents on the integrity of patient-reported outcome data in national spine registers, suggesting that outcome measures after spine surgery may not differ between respondents and non-respondents. Research question: Using the Finnish national spine register (FinSpine), we aimed to assess whether non-respondents would bias patient-reported outcomes at 12 months following anterior cervical decompression and fusion (ACDF) surgery. Material and methods: FinSpine data from 5563 ACDF surgeries since 2016 were analyzed, supplemented with prescription records from the Finnish Social Insurance Institution and subcohort data from Kuopio University Hospital. Patients were grouped based on whether they completed post-operative outcome surveys. Outcomes were compared on neck and upper extremity pain, functional capacity, quality of life, sleep quality, return to work, regular use of pain medication, and opioid purchases 12 months after surgery. Results: Out of 5563 ACDF patients, 1362 (24.5%) purchased opioids during the first post-operative year. There were no significant differences in the mean cumulative opioid purchases between respondents and non-respondents. In the subcohort (n = 60), all non-respondents (n = 29) were reached and interviewed. There were no differences between respondents and non-respondents in any outcome measures at 12 months. Discussion and conclusion: Non-respondents do not bias the assessment of outcome measures following ACDF at 12 months, supporting the validity and reliability of national quality registers like FinSpine for clinical research.

Background:. The Finnish Shaft of the Humerus (FISH) trial compared open reduction and internal plate fixation (ORIF) with functional bracing in adult patients with displaced, closed humeral shaft fractures. Here, we compare the results of the patients in the randomized clinical trial (RCT [the randomized cohort]) with those of the cohort of patients who were also eligible but declined randomization (the nonrandomized cohort) to investigate if patients’ treatment preference was associated with the outcomes during a 2-year follow-up. Methods:. A total of 321 patients were treated at 2 university hospitals in Finland between November 2012 and January 2018. Of the 140 eligible patients, 82 were randomized to ORIF or functional bracing. Of the 58 patients declining randomization, 42 consented to participate in a nonrandomized cohort in which the patients were able to choose the treatment method. The primary outcome of this study was the Disabilities of the Arm, Shoulder and Hand (DASH) score. Patients in the randomized cohort and the nonrandomized cohort were analyzed separately in 3 groups: those who had (1) initial surgery, (2) successful functional bracing, and (3) late surgery due to failed functional bracing. We used mixed-model, repeated-measures analysis of variance to compare the treatment effect among the 3 groups. Results:. In the randomized cohort, 38 patients had an initial surgical procedure. Of the 44 patients randomized to functional bracing, 30 (68%) healed successfully and 14 (32%) underwent a late surgical procedure. In the nonrandomized cohort, 9 patients preferred an initial surgical procedure. Of the 33 patients preferring functional bracing, 26 (79%) healed successfully and 7 (21%) underwent late surgery. The DASH scores in the randomized cohort and the nonrandomized cohort were 6.8 (95% confidence interval [CI], 2.3 to 11.4) and 12.3 (95% CI, 0.3 to 24.3) for the initial surgery groups, 6.0 (95% CI, 1.0 to 11.0) and 3.4 (95% CI, 0 to 9.3) for the bracing groups, and 17.5 (95% CI, 10.5 to 24.5) and 20.5 (95% CI, 9.4 to 31.6) for the late surgery groups at 2 years. Conclusions:. The results of the randomized cohort and the nonrandomized cohort were comparable and suggest that patients’ treatment preferences are not associated with the treatment outcomes of these injuries. Level of Evidence:. Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Objective: To assess the effectiveness and costs of intensive stroke rehabilitation and improvements in patient pathway in the city of Lahti and in Päijät-Häme region compared with other parts in Finland. Design: Retrospective benchmarking controlled trial. Patients: Three cohorts of Finnish community-dwelling patients (n = 94,749, n = 4,184, and n = 105,458) with ischaemic stroke between 2001 and 2019. Methods: This study is based on the PERFECT 2001–2019 database of ischaemic stroke patients. PERFECT indicators describe how the stroke patients recover. The difference-in-difference method was used in the main analysis. Results: Improved stroke rehabilitation in Lahti increased the share of patients discharged home (p = 0.005) and decreased the length of first institutional episode (–4 days, p = 0.006), the share of patients institutionalized (–5.1%, p = 0.001), and the costs of first institutional episode (€–2,085, p

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Background: Knowledge of prevalence and epidemiology of cystic fibrosis (CF) and healthcare resource use among Finnish people with CF is incomplete. Methods: We conducted a population-based matched cohort study using retrospective real-world data from linked Finnish national registries. Electronic healthcare data and drug purchases of 102 people with CF were analyzed between January 2015 and December 2019 (follow-up). A 5-fold control population was matched by sex, age, and place of residence. Comorbidities and medication use that occurred at any time during follow-up were assessed; annual rates of hospital service use were adjusted for follow-up. Results: The prevalence of CF in Finland was 1.85 per 100,000. Median age at diagnosis was 1 year, with 60 % diagnosed at age 30 times higher in people with CF than matched controls.

Objective: The aim of this study was to assess the effectiveness of classification-based approach for low back pain care in Finnish primary care. Design: A benchmarking controlled trial design was used. Subjects/patients: Three primary healthcare areas and 654 low back pain patients with or without sciatica. Methods: Classification-based care (using the STarT Back Tool) was implemented using organizational-, healthcare professional-, and patient-level interventions. The primary outcome was change in Patient-Reported Outcomes Measurement Information System, Physical Function (PROMIS PF-20) from baseline to 12 months. Results: No difference was found between the intervention and control in change in PROMIS PF-20 over the 12-month follow-up (mean difference 0.33 confidence interval –2.27 to 2.9, p = 0.473). Low back pain-related healthcare use, imaging, and sick leave days were significantly lower in the intervention group. Reduction in intensity of low back pain appeared to be already achieved at the 3-month follow-up (mean difference –1.3, confidence interval –2.1 to –0.5) in the intervention group, while in the control group the same level of reduction was observed at 12 months (mean difference 0.7, confidence interval –0.2 to 1.5, treatment*time p = 0.003). Conclusion: Although classification-based care did not appear to influence physical functioning, more rapid reductions in pain intensity and reductions in healthcare use and sick leave days were observed in the intervention group.

There is ample evidence to show that people with intellectual disabilities (ID) face an increased risk of being socially excluded. The longer life expectancy of persons with ID carries new challenges. In this paper, we report on a follow-up case study of three Finnish women with ID. The women were interviewed twice (in 1995 and in 2013) and relationship maps were drawn pursuant to the interviews. In all three cases, the density of the relationship maps had decreased. In two cases, intimate relationships had remained or become even closer. In one case, intimate relationships were fewer. External services were inadequate in supporting the women to maintain their social relationships. Resources in the immediate families were decisive in determining their life course which was burdened by several extra obstacles. Some of these obstacles could possibly have been prevented if there had been a more permanent support system. The advantages and disadvantages of service and support paradigms are discussed.

Introduction After COVID-19, many continue to experience persistent debilitating symptoms, that is, long COVID. Its most prevalent symptoms are chest pain, difficulties with breathing, painful muscles, ageusia or anosmia, tingling extremities and general tiredness. This paper describes the protocol of the Long COVID Cohort Study to assess the prognosis and prognostic determinants of patients with long COVID by implementing patient-reported outcome measures (PROMs), patient-reported experience measures (PREMs) and clinical examinations during a 1-year follow-up.Methods and analysis This is a prospective, single-site cohort study consisting of administering questionnaires and clinical examinations to adult patients referred to the Clinic for Long-Term Effects of COVID-19 at Helsinki University Hospital (Hospital district of Helsinki and Uusimaa). The referrals are from all healthcare units within HUS and other hospital districts during years 2021–2023. All admitted patients have had laboratory-confirmed COVID-19. The targeted study sample size is 500 participants. The questionnaires are administered at 0, 3, 6 and 12 months. The main outcome variables are the changes in self-reported functional abilities and quality of life. In addition, we will evaluate functional abilities at baseline using neurocognitive evaluation, a 6MWT and a measurement of hand grip strength. The Long COVID Cohort Study will form a quality register for the clinic and characterise the first systematic collection of PROMs, PREMs, questionnaire and clinical examinations related to long COVID in Finland. The Study belongs to a study consortium Long COVID—HORIZON-HLTH-2021-DISEASE-04 that aims to reveal the biomechanisms of long COVID.Ethics and dissemination This study has been approved by the Helsinki University Hospital research ethics committee board, ID HUS/1493/2021 on 6 March 2021. All study participants sign written informed consent for participation. The study findings will be reported for publication in peer-reviewed journals.Trial registration number NCT05699512; Pre-results.

A feasible system for measuring patient outcomes of rehabilitation is required for assessing the real-world cost-effectiveness of rehabilitation. This study aims to assess the feasibility of measuring outcomes of rehabilitation among elderly individuals with early-stage Alzheimer's. We used the principles of Design Science to construct a set of metrics consisting of standardized PROM (Patient-Reported Outcome Measure) questionnaires, clinician-reported measures, and observational measures of functioning. We used standardized questionnaires whenever possible to ensure the validity and reliability of the questionnaires. The set of metrics was piloted on 16 individuals living at home with regular home care services. After the pilot, we further refined the set of metrics based on relevance, sensitivity to change, and applicability. We found that measurement was feasible and we propose the final set of metrics as a minimum set, which could be further improved upon by addition of metrics relevant to each subgroup of elderly individuals. We also found that using self-reported questionnaires in this population is not without difficulties. We therefore suggest that the role of informal caregivers be considered, and that accessibility of outcome questionnaires be improved.

Background: After COVID-19 infection, long-term impacts on functioning may occur. We studied the functioning of patients with post-COVID-19 condition (PCC) and compared them to controls without PCC. Methods: This cross-sectional study consisted of 442 patients with PCC referred to rehabilitation at the Helsinki University Hospital (HUS) Outpatient Clinic for the Long-Term Effects of COVID-19, and 198 controls without PCC. Functioning was assessed with a questionnaire including WHODAS 2.0. Patients underwent physical testing including a hand grip strength test (HGST) and a 6-minute walking test (6MWT). Lifestyle was assessed by questionnaire and comorbidities were collected as ICD-10 codes from the HUS Data Lake on the HUS Acamedic platform. Results: The WHODAS 2.0 average total score was 34 (SD 18) (moderate functional limitation) for patients with PCC and 6 (SD 8) (normal or mild limitation) for the controls. The disability was higher in all aspects of WHODAS 2.0 in patients with PCC. Bivariate binomial and multivariable regression analyses showed that the presence of comorbidities, anxiety, depression, and smoking predicted a WHODAS 2.0 score of 24 (moderate functional limitation) or above in the PCC group. The average 6MWT distance was 435 m (SD 98 m) in patients with PCC and 627 m (SD 70 m) in controls. HGST measurements showed no significant differences from controls. Conclusions: In conclusion, patients with PCC had significantly reduced functioning based on WHODAS 2.0 scores and the 6MWT results. Comorbidities, anxiety, depression, and smoking were associated with moderate or severe limitations in functioning. Findings support that PCC is multifactorial and requires a holistic approach to rehabilitation. KEY POINTS: The post-COVID-19 condition (PCC) has been shown to negatively impact functioning, quality of life, and mental health, with cognitive and physical impairments being prevalent. This study found that patients with PCC had significantly reduced functioning compared to controls. Key factors predicting severe disability included comorbidities, smoking, and mental health issues like anxiety and depression. The reduced functioning in patients with PCC appears to be multifactorial and not only related to COVID-19 infection. [ABSTRACT FROM AUTHOR]

Background: Persistent somatic symptoms unexplained by a defined medical or psychiatric condition often include a component of central sensitization. Many treatment options are based on cognitive behavioral therapy. Effective widely available therapies are scarce. There are self-management programs and e-therapies that aim at overcoming the central sensitization by modifying interoceptive neural networks in the brain. Objectives: This study aims to investigate the effect of a mindfulness-based amygdala and insula retraining (AIR) online program and an internet delivered therapist assisted therapy offered by Helsinki University Hospital (HUS iCBTpss) compared to treatment as usual (TAU) in the treatment of conditions causing persistent somatic symptoms. Methods: We will perform a randomized controlled trial aiming at 360 patients. Consenting patients will be randomized to three study arms: online AIR program, HUS iCBTpss (both interventions as add-ons to TAU); and TAU. Functional ability and quality of life surveys will be collected from participants at baseline and at 3, 6, and 12 months after entering the study. Conclusions: This study is one of the first to explore non-drug based online interventions developed to overcome the brain's central sensitization and are available and accessible to patients both in primary and secondary care. The results will develop the management of the common, often debilitating persistent somatic symptoms related to many conditions unexplained by a defined somatic or psychiatric illness. Trial registration number: NCT05212467. [ABSTRACT FROM AUTHOR]

The European Academy of Rehabilitation Medicine (EARM) held a debate in Hannover, Germany, on 1st of September 2016 on the pros and cons of randomized controlled trials (RCTs) and observational effectiveness studies (benchmarking controlled trials; BCTs). The debate involved a chairperson, a person presenting the substance of the debate, an opponent, and a rapporteur. The academicians participated in the discussion. Eight propositions and proposed statements formed the substance of the debate. There was agreement that a study question should be the starting point of an effectiveness study, and not the study method, i.e. RCT or BCT. The term “benchmarking” was questioned: does it mean market-oriented medicine? It was clarified that benchmarking refers to the methodological features of this study design: there must always be a comparison between peers. It was agreed that BCTs might be better than RCTs for use in rehabilitation studies, in which one often needs multi-centred studies, such as in the assessment of the effectiveness of pathways when there is complexity of processes, health systems, organizational issues, structures and facilities; or where interactions between therapists, doctors and patients differ between centres; and when assessing the implementation of rehabilitation. In addition, BCTs may deal with ethical issues, e.g. the acceptability of interventions, more easily than RCTs. Recommendations regarding the different approaches (RCTs or BCTs) should be provided by the scientific rehabilitation societies. Concern over the validity of BCTs was considered justified, as the validity criteria of BCTs cover all those related to RCTs and include the risk of selection bias between treatment arms. Appropriate description of the essentials of the study object, including adequate description of how the interventions were actualized in comparison to the study plan, are essential features for a valid and generalizable study for both RCTs and BCTs. BCTs are necessary to widen the evidence-base of effectiveness in rehabilitation. It was suggested that the rehabilitation field should support the concept of BCTs. It was proposed that education regarding BCTs is indicated, and stakeholders need to be convinced that BCTs are a valid alternative to RCTs. EARM and other physical and rehabilitation medicine (PRM) bodies could advance the use of BCTs for clinical and health policy decision-making. LAY ABSTRACT The European Academy of Rehabilitation Medicine (EARM) held a debate on the strengths and limitations of randomized controlled trials (RCTs) and observational effectiveness studies, also known as benchmarking controlled trials (BCTs), in rehabilitation. The main substance of the debate involved eight propositions and four proposed statements. The term “benchmarking” was questioned: does it mean market-oriented medicine? It was clarified that, as benchmarking refers to the features of the study design; there must be comparison between peers. It was agreed that BCTs might be better than RCTs for use in rehabilitation studies: one often needs multi-centred studies and assessment of the effectiveness of pathways; the rehabilitation processes are complex, and health systems and organizational issues are essential; and the essential interactions between therapists, doctors and patients differ between centres. Also, BCTs may deal with ethical issues more efficiently than RCTs. It was recommended that both RCTs and BCTs should be used in rehabilitation research. An essential feature of a valid and generalizable study (for both RCTs and BCTs) is appropriate description of the essentials of the study object. BCTs were considered necessary for widening the evidence-base of effectiveness in rehabilitation, and the rehabilitation field should support the concept of BCTs. It was proposed that education regarding BCTs is indicated, and stakeholders need to be convinced that BCTs are a valid alternative to RCTs. The EARM and other physical and rehabilitation medicine (PRM) bodies should advance the use of BCTs for clinical and health policy decision-making.

Abstract Background Inappropriate imaging and low-value care for low back pain (LBP) are common. A new patient-education booklet was created to overcome identified barriers to the delivery of recommended care, including the use of inappropriate imaging. Our aim was to assess the effectiveness of this booklet as part of primary care for LBP patients in comparison to usual care. Methods A cluster-randomized trial was performed. The intervention involved providing practitioners with the new patient-education booklet and a 30-min training session on its use. The booklet was provided during the clinical consult to all consenting LBP patients in the intervention group. Primary outcomes were the proportion of patients presenting with LBP who underwent imaging examinations during the first three months of follow-up and PROMIS PF-20 (Patient-Reported Outcomes Measurement Information System, 20-item physical functioning short form) change between baseline and three-month follow-up. Secondary outcomes, including sick leave and imaging examinations at 12 months, were investigated. Logistic regression using GEE-estimation was used for dichotomous outcomes, Poisson regression using GEE-estimation for count outcomes, and linear mixed models for continuous outcomes. Results Using the patient education booklet appeared to substantially reduce the proportion of LBP patients who underwent an imaging examination at three months, but the result was not statistically significant (OR 0.57, 95% confidence interval (Cl) 0.27 to 1.22). At 12 months, the effect was slightly larger and statistically significant (OR 0.50, 95%Cl 0.30 to 0.83, p = 0.008). No difference was observed in the PROMIS PF-20 T-score change between baseline and 3 months or 12 months (p = 0.365 and p = 0.923, respectively). The number of sick leave days in the intervention group was less than that in the control group at 3 months (RR 0.47, 95%Cl 0.26 to 0.83, p = 0.010) and at 12 months (RR 0.36, 95%Cl 0.18 to 0.72, p = 0.004). Conclusions The booklet appeared to be effective in reducing the proportion of LBP patients who underwent imaging examinations over 12 months. The intervention had no discernible effect on the PROMIS PF20 T-score change. The number of sick leave days was substantially lower in the intervention group. Trial registration ISRCTN, ISRCTN14389368 , Registered 4 April 2019—Retrospectively registered.

OBJECTIVE: This study aimed to investigate the effectiveness of brief training in the guideline-oriented biopsychosocial management of low-back pain (LBP) in occupational health services using a cluster-randomized design. A small sample of physiotherapists and physicians from the intervention units (N=12) were given three- to seven-day training focusing on the biopsychosocial management of LBP, while professionals in the control units (N=15) received no such training. METHODS: Eligible patients with LBP, with or without radicular pain, aged 18–65, were invited to participate. A web-based questionnaire was sent to all recruited patients at baseline, three months and one year. The primary outcome measure was disability (Oswestry Disability Index, ODI) over one year. Between-group differences were analyzed using linear and generalized linear mixed models adjusted for baseline-response delay as well as variables showing between-group imbalance at baseline. RESULTS: The final study sample comprised 234 and 81 patients in the intervention and control groups, respectively at baseline, and 137 and 47 patients, respectively, at one year. At baseline, the mean duration of pain was longer in the intervention group (P=0.017), and pain-related fear concerning physical activity was lower (P=0.012). We observed no significant difference between the groups’ primary outcome measure (adjusted one-year mean difference in the ODI: 2.3; 95% confidence interval -1.0–5.7; P=0.175) or most secondary outcomes. CONCLUSIONS: Brief training in guideline-oriented biopsychosocial management of LBP for occupational health professionals did not appear to be effective in reducing patients’ symptom over one-year follow-up compared to treatment as usual.

Objectives Basic tools that measure a hospital’s performance are required in order to benchmark or compare hospitals, but multispecialty institutional registries are rarely reported, and there is no consensus on their standard definitions and methodology. This study aimed to describe the setting up and first results of a hospital-wide surgical complication register that uses a minimal set of patient-related risk factors based on bedside data and produces outcomes data based on severity of complications.Design Cohort study.Setting Perioperative data related to all adult surgical procedures in a tertiary referral centre in Finland for 3 years (2016–2018) were included in the study. Complications were recorded according to a modified Clavien-Dindo classification, and the preoperative risk factors were compiled based on the literature and coded as numerical measures. The associations of preoperative risk factors with postoperative complications were analysed using the χ2 test or Fisher’s exact test.Results In total, 19 158 operations were performed between 2016 and 2018. Data on complications (Clavien 0–9) were recorded for 4529 surgical patients (23.6%), and 779 complications were reported (Clavien 1–9), leading to an overall complication rate of 17.2%. Of these, 4.6% were graded as major (Clavien 4–7). Patient-related risk factors with the strongest association with complications were growing American Society of Anesthesiologists Physical Status Classification System score (p

Abstract Background Guidelines recommend a biopsychosocial framework for low back pain (LBP) management and the avoidance of inappropriate imaging. In clinical practice, care strategies are often inconsistent with evidence and guidelines, even though LBP is the most common disabling health condition worldwide. Unhelpful beliefs, attitudes and inappropriate imaging are common. LBP is understood to be a complex biopsychosocial phenomenon with many known multidimensional risk factors (symptom- and lifestyle-related, psychological and social) for persistent or prolonged disability, which should be identified and addressed by treatment. The STarT Back Tool (SBT) was developed for early identification of individual risk factors of LBP to enable targeted care. Stratified care according SBT has been shown to improve the effectiveness of care in a primary care setting. A biopsychosocially-oriented patient education booklet, which includes imaging guidelines and information, is one possible way to increase patients’ understanding of LBP and to reduce inappropriate imaging. Premeditated pathways, education of professionals, written material, and electronic patient registry support in health care organizations could help implement evidence-based care. Methods We will use a Benchmarking Controlled Trial (BCT) design in our study. We will prospectively collect data from three health care regions before and after the implementation of a classification-based approach to LBP in primary care. The primary outcome will be change in PROMIS (Patient-Reported Outcomes Measurement Information System) (short form 20a) over 12-month follow-up. Discussion The implementation of a classification-based biopsychosocial approach can potentially improve the care of LBP patients, reduce inappropriate imaging without increasing health-care costs, and decrease indirect costs by reducing work disability. Using the BCT we will be able to evaluate the effectiveness of the improvement strategy for the entire care pathway. Trial registration ISRCTN, ISRCTN13273552 , retrospectively registered 13/05/2019.

Positive education aims at making strengths visible in every learner. This paper presents one of the few structured positive education interventions in Finnish inclusive classrooms. Our controlled 16-week intervention in 11 inclusive classes (from 4th to 6th graders, age 10-13 years, N[subscript interv] = 175 including 17 students with SEN having a variety of learning challenges, N[subscript contr] = 78) focused on explicit teaching of strengths in character and their usage in order to promote social skills, well-being and learning skills. Seven quantitative self-report measures, "Social competence" ("Empathy" and "Anti-Aggression" subscales), "Strength usage," "Grit" ("Consistency of Interest" and "Perseverance of Effort" subscales), "Global happiness," "School-related happiness," "Schoolwork Engagement Inventory" ("EDA," "energy," "dedication," "absorption") and "Mindset" comprised the students' pre-test--post-test battery. In addition, seven teachers were interviewed. The intervention group of students with SEN advanced over the other groups in Grit Consistency of interest subscale and in EDA. In teacher interviews, increased group cohesion and classroom spirit were documented. Interviews revealed six dominant discourses, " "praise," "well-being," "good interaction," "the significance of encounters," "the need for additional education" and "the discourse of doubt and challenges." In particular, being able to name strengths in others and support one another had grown during the intervention.

Background: The value of randomized controlled trials is dependent on the applicability of their findings to clinical decision-making. The aim of this study is to determine a definition and principles for the applicability of evidence from randomized controlled trials and systematic reviews. Methods: This narrative review searched studies from PubMed and Web of Science databases using Cochrane Collaboration’s Qualitative Evidence Syntheses guidance. Empirical studies were excluded. Based on the included studies, a definition for the concept and propositions for principles of applicability were formulated. Results: A definition and 11 propositions are presented, 6 propositions having additional sub-propositions. Low risk of bias, ability to answer to specific questions, documentation of the details of how randomized controlled trials turned out, reporting of favourable and adverse outcomes, and systematic comparison of randomized controlled trials and clinical data were considered important. Biomedical randomized controlled trials have the widest applicability, while heterogeneity in study characteristics, human perception, behaviour, environmental, equity factors, and health economic issues lessen applicability. Obtaining applicable evidence is a gradual process. Methodological and substance expertise is necessary for assessing applicability. Discussion: A definition of applicability and requirements for applicable evidence from randomized controlled trials to real-world contexts are presented. Propositions are suggested for any assessment of applicability of findings from randomized controlled trials, systematic reviews and meta-analyses.

The purpose of the current study was to examine, within an integrative predictive model, the relative contributions of sociodemographic variables, personal resources, and work wellbeing to teacher burnout. The research was conducted with special education teachers at Italian preschools--a context in which few previous studies have been carried out--and primary schools. A cross-sectional survey-based study with a sample of 194 kindergarten and primary school teachers was conducted. The results indicated that teachers' happiness at school and job satisfaction incrementally predicted variance in personal, work-related, and student-related burnout, even after controlling for the effects of sociodemographic factors and personal resources. Furthermore, the final integrative predictive model was similar for both kindergarten and primary teachers.

Abstract Background To prevent low back pain (LBP) from developing into a prolonged disabling condition, clinical guidelines advocate early stage assessment, risk‐screening, and tailored interventions. Occupational health services recommend guideline‐oriented biopsychosocial screening and individualized assessment and management. However, it is not known whether training a limited number of health care professionals improves the management process. The primary objective of this study is to investigate whether training in the biopsychosocial practice model is effective in reducing disability. Furthermore, we aim to evaluate health‐economic impacts of the training intervention in comparison to usual medical care. Methods The occupational health service units will be allocated into a training or control arm in a two‐arm cluster randomized controlled design. The training of occupational physiotherapists and physicians will include the assessment of pain‐related psychosocial factors using the STarT Back Tool and the short version of the Örebro Musculoskeletal Pain Screening Questionnaire, the use of an evidence‐based patient education booklet as part of the management of LBP, and tailored individualized management of LBP according to risk stratification. The control units will receive no training. The study population will include patients aged 18–65 with nonspecific LBP. The primary outcome is a patient‐reported Oswestry Disability Index from baseline to 12 months. By estimating group differences over time, we aim to evaluate the effectiveness of the training intervention in comparison to usual medical care, and to undertake an economic evaluation using individual patients' health care records (participant‐level data) and the participating units' registries (cluster‐level data). In addition, through interviews and questionnaires, we will explore the health care professionals' conceptions of the adoption of, the barriers to, and the facilitators of the implementation of the practice model. Discussion The evaluation of training in the guideline‐oriented biopsychosocial management of LBP in occupational health services is justified because LBP represents an enormous burden in terms of work disability.

Objective: To compare the costs and monetary benefits of non-pharmacological interventions for patients with Alzheimer’s disease in real-world settings. Methods: A systematic review was performed to determine the most effective treatment strategies for being able to stay at home for patients with Alzheimer’s disease. Care-management, family support, and multidisciplinary rehabilitation were identified as effective interventions applicable in the Finnish healthcare setting. Data on medical and social service costs, and the costs of residential care for all patients newly diagnosed with Alzheimer’s disease in 2 major cities in Finland were analysed in a 4-year follow-up study. The potential cost savings of the different treatment strategies were assessed. Results: The annual cost increased from €9,481 to €28,400 (mean per patient) during the 4-year follow-up. Cost savings were achieved in care-management, family support programmes, and rehabil-itative cognitive and social activation if the patients’ transition to long-term care was delayed by 2.8, 1.8 and 43.0 days, respectively. Conclusion: Care-management and informal caregiver support for patients with Alzheimer’s disease may benefit patients and result in concurrent cost savings. Delaying the decline in cognitive and social functioning through rehabilitation is indicated for more severe phases of Alzheimer’s disease, and the costs appear to be compensated by savings in the cost of long-term care.

The first Academic Debate was held within the European Academy of Rehabilitation Medicine (EARM) in Budapest in 2016. The question debated was: is it possible to provide a theory neutral framework to describe the lived experience of health or is there an appropriate theory to understand what constitute the most relevant factors in health (and well-being). First the link between the International Classification of Functioning, Disability and Health (ICF) and rehabilitation as a key health strategy was explained. It was then argued that supplementing the ICF by theory-based approaches (e.g. a theory of social productivity) may advance explanations with regard to participation and links with health and well-being. Thirdly, it was recalled that one of the strengths of the ICF is exactly being “theory neutral”. There was no doubt that there is a need for scientific theories to describe functioning and health. The theory of social productivity seems to be an important contribution towards this goal. However, the definition of well-being in relation to the operationalization of functioning and health needs to be further developed. The conclusion cannot be an “either-or” (classification vs theory). Projects should be set up both to further develop the ICF and to refine (or develop new) theories.

Abstract Background The etiology of non-specific low back pain (LBP) is complex and not well understood. LBP is common and causes a remarkable health burden worldwide. Leg-length discrepancy (LLD) is potentially a risk factor for development of LBP, although this relationship has been questioned. Yet only one randomized controlled study (RCT) has been performed. The objective of our study was to evaluate the effect of insoles with leg-length discrepancy (LLD) correction compared to insoles without LLD correction among meat cutters in a RCT-design. Methods The study population consisted 387 meat cutters who were over 35 years old and had been working 10 years or more. The LLD measurement was done by a laser ultrasound technique. All workers with an LLD of at least 5 mm and an LBP intensity of at least 2 on a 10-cm Visual Analog Scale were eligible. The LLD of all the participants in the intervention group was corrected 70%, which means that if the LLD was for example 10 mm the correction was 7 mm. The insoles were used at work for eight hours per day. The control group had insoles without LLD correction. The primary outcome was between-group difference in LBP intensity. Secondary outcomes included sciatic pain intensity, disability (Roland Morris), RAND-36, the Oswestry Disability Index, physician visits and days on sick leave over the first year. We used a repeated measures regression analysis with adjustments for age, gender and BMI. The hurdle model was used for days on sick leave. Results In all, 169 workers were invited and 114 (67%) responded. Of them, 42 were eligible and were randomized to the intervention (n = 20) or control group (n = 22). The workers in the intervention group had a higher improvement in LBP intensity (− 2.6; 95% confidence intervals − 3.7 – − 1.4), intensity of sciatic pain (− 2.3; − 3.4 – − 1.07) and RAND-36 physical functioning (9.6; 1.6–17.6) and a lesser likelihood of sick leaves (OR -3.7; − 7.2 - -0.2). Conclusions Correction of LLD with insoles was an effective intervention among workers with LBP and a standing job. Trial registration ISRCTN11898558. Registration date 11. Feb 2011. BioMed Central Ltd.

Well-designed, evidence-based vision and strategy are fundamental requirements for successful healthcare. This paper reviews previous comprehensive healthcare strategies (Institute of Medicine statement, Value-based healthcare, and Triple aim strategy) published in peer-reviewed scientific journals, and presents an alternative proposal for healthcare vision and Well-designed, evidence-based vision and strategy are fundamental requirements for successful healthcare. This paper reviews previous comprehensive healthcare strategies (Institute of Medicine statement, Value-based healthcare, and Triple aim strategy) published in peer-reviewed scientific journals, and presents an alternative proposal for healthcare vision and strategy. The proposed strategy includes, as prerequisites, competence of staff, healthcare leaders and leaders of health policy, and a well-functioning healthcare system. It is necessary to optimize the financing, reimbursement and incentives, organization, and regulation of the healthcare system. Strategic means to successful healthcare are to improve staff competence, implement current scientific evidence, document clinical and system-related issues, improve quality, and carry out benchmarking with peers. The vision for healthcare is to provide continuous improvement in services, in terms of accessibility, quality, fairness, effectiveness, safety and efficiency, to the patients (customers) and to the population. The new proposal shares many issues with strategies published previously. This paper sets out the prerequisites for the proposed strategy. A common vision, high levels of integrity, and a commitment to providing the best for patients and the population, are of fundamental importance. Competence at all levels of healthcare is a necessity.strategy. The proposed strategy includes, as prerequisites, competence of staff, healthcare leaders and leaders of health policy, and a well-functioning healthcare system. It is necessary to optimize the financing, reimbursement and incentives, organization, and regulation of the healthcare system. Strategic means to successful healthcare are to improve staff competence, implement current scientific evidence, document clinical and system-related issues, improve quality, and carry out benchmarking with peers. The vision for healthcare is to provide continuous improvement in services, in terms of accessibility, quality, fairness, effectiveness, safety and efficiency, to the patients (customers) and to the population. The new proposal shares many issues with strategies published previously. This paper sets out the prerequisites for the proposed strategy. A common vision, high levels of integrity, and a commitment to providing the best for patients and the population, are of fundamental importance. Competence at all levels of healthcare is a necessity.

Abstract Background Randomized trials provide the most valid evidence of effectiveness of interventions. The study aims to determine the primary study question for randomized controlled trials; to evaluate the study questions in trials on effectiveness of arthroscopic meniscectomy for meniscal rupture of the knee; and to explore the clinical and research implications. Methods Previous studies on benchmarking controlled trials were utilized. A literature search was undertaken to find the trials on arthroscopic surgery for meniscal rupture of the knee, data was extracted, and checked for accuracy twice. Results The first question in RCTs is whether to assess the pure intervention effect, or intervention effect in routine health care circumstances. The former necessitates a double blinded design and the latter a non-blind design. The trials on arthroscopic meniscectomy of the knee showed considerable differences in study characteristics. Conclusions The study question in RCTs on pure intervention effect dictates use of blinded design, while question of intervention effect in routine health care dictates use of non-blinded design. Blinding should not be considered a validity criterion when study question is on effectiveness in routine health care. When informing patients, the potential for other effects besides the pure intervention effect should be considered.

Abstract Background We assessed the effectiveness of three interventions that were aimed to reduce non-acute low back pain (LBP) related symptoms in the occupational health setting. Methods Based on a survey (n = 2480; response rate 71%) on LBP, we selected a cohort of 193 employees who reported moderate LBP (Visual Analogue Scale VAS > 34 mm) and fulfilled at least one of the following criteria during the past 12 months: sciatica, recurrence of LBP ≥ 2 times, LBP ≥ 2 weeks, or previous sickness absence. A random sample was extracted from the cohort as a control group (Control, n = 50), representing the natural course of LBP. The remaining 143 employees were invited to participate in a randomised controlled trial (RCT) of three 1:1:1 allocated parallel intervention arms: multidisciplinary rehabilitation (Rehab, n = 43); progressive exercises (Physio, n = 43) and self-care advice (Advice, n = 40). Seventeen employees declined participation in the intervention. The primary outcome measures were physical impairment (PHI), LBP intensity (Visual Analogue Scale), health related quality of life (QoL), and accumulated sickness absence days. We imputed missing values with multiple imputation procedure. We assessed all comparisons between the intervention groups and the Control group by analysing questionnaire outcomes at 2 years with ANOVA and sickness absence at 4 years by using negative binomial model with a logarithmic link function. Results Mean differences between the Rehab and Control groups were − 3 [95% CI -5 to − 1] for PHI, − 13 [− 24 to − 1] for pain intensity, and 0.06 [0.00 to 0.12] for QoL. Mean differences between the Physio and Control groups were − 3 [95% CI -5 to − 1] for PHI, − 13 [− 29 to 2] for pain intensity, and 0.07 [0.01 to 0.13] for QoL. The main effects sizes were from 0.4 to 0.6. The interventions were not effective in reducing sickness absence. Conclusions Rehab and Physio interventions improved health related quality of life, decreased low back pain and physical impairment in non-acute, moderate LBP, but we found no differences between the Advice and Control group results. No effectiveness on sickness absence was observed. Trial registration Number NCT00908102 Clinicaltrials.gov

This article presents a comparative case study on the ways in which children's school ecologies facilitate their adjusting positively to first grade in risk-filled contexts in South Africa and Finland. The insights of two children (one South African, one Finnish) from socio-economically disadvantaged communities, their teachers, parents and significant others constitute the data corpus of this study. The data were collected via semi-structured interviews, "Day-in-the-Life" video-recorded observations, and Draw-and-talk and photo elicitation methods. The data were analysed deductively using the seven, commonly recurring mechanisms of resilience as documented by Ungar (2015). The results demonstrate how resilience processes are co-constructed and gain their meaning within the given social ecology of a child. They underscore the importance of school ecologies being functional enough, in the face of socio-economic adversity, to continue to facilitate everyday resilience-supporting processes for children. The article ends by considering the lessons of this study for school psychologists.