Environmental barriers perceived by the Finnish population with spinal cord injury: a cross-sectional survey

STUDY DESIGN

Cross-sectional survey of the Finnish population with spinal cord injury (SCI).

OBJECTIVES

To explore the frequencies of perceived environmental barriers (EB) that made participation harder for the Finnish population with SCI and to compare the occurrence of perceived EBs by gender, age, time since injury, and injury severity.

SETTING

Participants were recruited from the registers of the three SCI outpatient clinics responsible for the lifelong care of people with SCI in Finland.

METHODS

The self-administered Nottwil Environmental Factors Inventory Short Form (NEFI-SF) collected in the Finnish Spinal Cord Injury Study (FinSCI) (n = 1772) was used. Nonparametric tests and multinomial logistic regression models were utilized.

RESULTS

880 individuals responded to the NEFI-SF items (response rate 50%). Climate was perceived as a barrier by 72% and a serious one by 44% of the respondents. The rates regarding public access were 59% and 24%, private home access 46% and 18%, and long-distance transport 45% and 20%. Four out of ten respondents reported that finances, lack of assistive devices for short-distance transport, and political decisions restricted their participation. The NEFI-SF total scores were higher (meaning more perceived restrictions by EBs) for those more severely injured.

CONCLUSIONS

Climate, access to public and private places, challenges with transport, finances, and political decisions were the EBs most frequently perceived to restrict participation by the Finnish population with SCI. Most EBs that were prominent causes of restrictions are modifiable. Greater accessibility to the built environment, equal services to all, and positive special treatment could reduce their effects.

Facilitators and barriers in the rehabilitation process described by persons with spinal cord injury: a deductive-inductive analysis from the Finnish spinal cord injury study

BACKGROUND

This study aimed to determine the factors that promote and facilitate rehabilitation as well as challenges and possible barriers perceived by people with spinal cord injury (SCI).

MATERIALS AND METHODS

This study was part of a larger, mixed-method Finnish Spinal Cord Injury (FinSCI) study. We interviewed 45 persons with SCI representing participants from the FinSCI study and used a qualitative approach and a deductive-inductive content analysis to analyse the data.

RESULTS

We identified 28 facilitators and 19 barriers in the rehabilitation process. The majority of the facilitators and barriers were related to the rehabilitation planning phase. There were more barriers than facilitators in applying for and accessing treatment or rehabilitation and during the implementation of rehabilitation. Facilitators consisted of successful, realized, or planned treatments or rehabilitation events; clear goals; multidisciplinary teamwork; support and monitoring in various changing situations; and the rehabilitees' own capabilities and activities, among other things. The barriers included delays, challenges and deficiencies in the planning and implementation of treatment or rehabilitation; the lack of different skills; and resources of rehabilitation professionals; and different personal factors, which made the rehabilitation process cumbersome.

CONCLUSIONS

Good communication and interaction between stakeholders are crucial for the progress of rehabilitation.

How to adopt technologies in home care: a mixed methods study on user experiences and change of home care in Finland

BACKGROUND

There is a need for better adoption of technology to meet the needs of home care professionals, older people, and informal caregivers.

METHODS

Mixed methods were used to describe and analyse quantitative and qualitative data in a Finnish governmental programme called KATI. The study was three-fold: it 1) listed what kinds of technologies were piloted and deployed in a national study, 2) provided information from the perspectives of home care professionals about requirements to use technology by using focus-group interviews, and 3) assessed experiences of how the adoption of technology changes work and work processes over time by using repeated surveys. Informants in interviews (n = 25) and surveys (n = 90) were home care professionals, who also described the perspectives of older people and informal caregivers. The conceptual models framing the study were adapted from the Technology Acceptance Model and DirVA PROVE-IT.

RESULTS

There were 80 technology pilots, in which variety of technologies were followed in home care. Familiarity with, commitment to and understanding of technology benefits were considered to be requirements for the technology to be used. The adoption of technology provided new skills and information about older people's wellbeing, realisation of treatment and new possibilities in home care. It developed new procedures to focus on older people's needs and motivated professionals by gained concrete aid. It enabled them to leave out some concrete procedures as unnecessary. On the other hand, there were also pessimistic and negative experiences when technology use provided nothing new or did not change anything.

CONCLUSIONS

The adoption of technology is dependent on the technology and its integration into the prevailing service practice. When they both work, it is possible to leave out unnecessary procedures in care, allocate resources and save time. It is possible to be aware of older people's safety and how they cope at home, find new ways to get involved in older people's lives, gain insight, and make changes at work. Continuous on-site training, modifications in service practices and communication throughout organisations is needed.

Factors associated with use of wearable technology to support activity, well-being, or a healthy lifestyle in the adult population and among older adults

The use of wearable technology, which is often acquired to support well-being and a healthy lifestyle, has become popular in Western countries. At the same time, healthcare is gradually taking the first steps to introduce wearable technology into patient care, even though on a large scale the evidence of its' effectiveness is still lacking. The objective of this study was to identify the factors associated with use of wearable technology to support activity, well-being, or a healthy lifestyle in the Finnish adult population (20-99) and among older adults (65-99). The study utilized a cross-sectional population survey of Finnish adults aged 20 and older (n = 6,034) to analyse non-causal relationships between wearable technology use and the users' characteristics. Logistic regression models of wearable technology use were constructed using statistically significant sociodemographic, well-being, health, benefit, and lifestyle variables. Both in the general adult population and among older adults, wearable technology use was associated with getting aerobic physical activity weekly according to national guidelines and with marital status. In the general adult population, wearable technology use was also associated with not sleeping enough and agreeing with the statement that social welfare and healthcare e-services help in taking an active role in looking after one's own health and well-being. Younger age was associated with wearable technology use in the general adult population but for older adults age was not a statistically significant factor. Among older adults, non-use of wearable technology went hand in hand with needing guidance in e-service use, using a proxy, or not using e-services at all. The results support exploration of the effects of wearable technology use on maintaining an active lifestyle among adults of all ages.

Physical health among the Finnish spinal cord injury population according to the Patient Reported Outcome Measurement Information System (PROMIS®)

OBJECTIVE

The aim of this study is to assess the physical health in the Finnish Spinal cord injury (SCI) population using the Patient Reported Outcome Measurement Information System (PROMIS®) and make a comparison to the general United States (US) population. Furthermore, the aim is to explore the associations between pain interference, pain intensity, sleep disturbance, and fatigue and physical function.

DESIGN

Cross-sectional study. This study is part of the Finnish Spinal Cord Injury (FinSCI) community survey study.

SETTING

Community, Finland.

PARTICIPANTS

884 persons with SCI.

INTERVENTIONS

Not applicable.

OUTCOME MEASURES

Physical health was measured with custom Patient Reported Outcome Measure System (PROMIS®) short forms.

RESULTS

Higher age and lesion level indicated more severe physical function impairments. Persons ≥46 years exhibited more pain interference symptoms compared to younger participants. On average, the Finnish SCI population had 1.3 SD lower physical function and 0.9 SD higher pain interference T-scores compared to the US general population (P < 0.001). The most significant association was observed between pain interference and physical function (r = -0.364, P < 0.001).

CONCLUSIONS

The present study provides a description of the state of physical health in the Finnish spinal cord injury population, as well as the associations between the physical health areas. The results highlight the substantiality of pain management in terms of improving physical function.

TRIAL REGISTRATION NUMBER

NCT04649814.

20 Years of ICF-International Classification of Functioning, Disability and Health: Uses and Applications around the World

The International Classification of Functioning Disability and Health (ICF) was approved in 2001 and, since then, several studies reported the increased interest about its use in different sectors. A recent overview that summarizes its applications is lacking. This study aims to provide an updated overview about 20 years of ICF application through an international online questionnaire, developed by the byline authors, and sent to each World Health Organization Collaborating Centers of the Family of International Classifications (WHO-FIC CCs). Data was collected during October 2020 and December 2021 and descriptive content analyses were used to report main results. Results show how, in most of the respondent countries represented by WHO-FIC CCs, ICF was mainly used in clinical practice, policy development and social policy, and in education areas. Despite its applications in different sectors, ICF use is not mandatory in most countries but, where used, it provides a biopsychosocial framework for policy development in health, functioning and disability. The study provides information about the needs related to ICF applications, that can be useful to organize targeted intervention plans. Furthermore, this survey methodology can be re-proposed periodically to monitor the use of the ICF in the future.

Health-related factors for work participation of persons with Spinal Cord Injury in Finland

OBJECTIVE

To explore work participation and the health-related factors affecting work participation among the Finnish Spinal Cord injury (FinSCI) study population (n = 884).

METHODS

A cross-sectional explorative observational study in the FinSCI community survey applying Patient-Reported Outcomes Measurement Information System (PROMIS®) forms on Social Health and Global Health. Analyses of socio-demographic and injury-related data were performed.

RESULTS

Employment among the study population (n = 452) was 26.5%. Physical, Mental, Social and General Health were better in the employed group compared with work-age persons not working. Logistic regression showed that work participation was related to all health domains, but Physical Health and Ability to Participate in Social Roles and Activities in Social Health were the strongest indicators of likelihood of being at work. Paraplegia and young age were associated with increased likelihood of work participation.  Conclusion: The first national survey among people with spinal cord injury in Finland shows low level of employment. The results suggest that pain, physical function, and ability to participate in social roles should be monitored by health and vocational professionals when assessing a person's likelihood of being in work.

Prevalence of comorbidities and secondary health conditions among the Finnish population with spinal cord injury

Study design

A cross-sectional study.

Objectives

To explore the prevalence of comorbidities, secondary health conditions (SHCs), and multimorbidity in the Finnish population with spinal cord injury (SCI).

Setting

The data were collected from the Finnish Spinal Cord Injury Study (FinSCI). Participants were identified from three SCI outpatient clinics responsible for the lifelong follow-up of persons with SCI in Finland, (n = 884 participants, response rate; 50%).

Methods

The FinSCI-questionnaire included a question from the National Study of Health, Well-being, and Service (FinSote) for screening 12 comorbidities. The reference data of the general population for that question were received from the Finnish Institute for Health and Welfare. The Spinal Cord Injury Secondary Condition Scale (SCI-SCS) was used to screen 16 SHCs. The data were analysed with univariate testing and multivariable negative binomial regression modelling.

Results

The most common comorbidities were high blood pressure/hypertension (38%), back problems (28%), and high cholesterol (22%). The most common SHCs were joint and muscle pain (81%), muscle spasms (74%), chronic pain (71%), and bowel problems (71%). The prevalence of comorbidities was highest among persons aged ≥76 years (mean; 2.0; scale range; 0–12). The prevalence of SHCs was highest in the severity of SCI group C1–4 AIS A, B, and C (mean; 8.9; scale range; 0–16).

Conclusions

Further research on geriatrics in SCI, non-traumatic SCI, and knowledge of the needs of persons with cervical lesion AIS A, B, or C is required, due to the fact that the prevalence of multimorbidity is high in these groups.

ICF Personal Factors Strengthen Commitment to Person-Centered Rehabilitation – A Scoping Review

Background: The International Classification of Functioning, Disability and Health (ICF) classification is a biopsychosocial frame of reference that contributes to a holistic understanding of the functioning of a client and the factors involved. Personal factors (PFs) are not currently classified in the ICF due to large societal and cultural diversity and lack of clarity in the scope of such factors.

Aims: To ascertain which factors in the ICF classification have been defined as PFs in different studies and what conclusions have been drawn on their role in the ICF classification.

Methods: The study was a scoping review. A systematic search for articles published in 2010–2020 was performed on the Cinahl, Pubmed, ScienceDirect, and Sport Discus databases. The PFs specified in the articles were classified according to the seven categories proposed by Geyh et al. socio-demographic factors; position in the immediate social and physical context; personal history and biography; feelings; thoughts and beliefs; motives; and general patterns of experience and behavior.

Results: The search yielded 1,988 studies, of which 226 met the inclusion criteria. The studies had addressed a wide variety of PFs that were linked to all seven categories defined by Geyh et al. Some studies had also defined PFs that were linkable to other components of the ICF or that did not describe functioning. Approximately 22% (51) of the studies discussed the role of PFs in rehabilitation.

Conclusions: The range of PFs in the ICF classification addressed in the reviewed studies is wide. PFs play an important role in rehabilitation. However, according to the reviewed studies, a more precise coding of PFs is not yet warranted.

Towards an ICF-based self-report questionnaire for people with skeletal dysplasia to study health, functioning, disability and accessibility

BACKGROUND

Little is known about the spectrum of everyday challenges that people with skeletal dysplasia face because of their health and functioning. We aimed to identify factors related to health, functioning and disability in people with skeletal dysplasia, and their challenges with accessibility in order to form a self-reported questionnaire for national data collection. The comprehensive musculoskeletal post-acute core set of the International Classification of Functioning, Disability and Health (ICF) was used as a framework.

METHODS

An iterative, participatory and qualitative process was used to formulate a questionnaire. Items were searched from Patient-Reported Outcomes Measurement Information System and from other self-report instruments, additional items were formulated using ICF linking rules. Expert panels from the target population assessed the face and content validity in thematic interviews.

RESULTS

The questionnaire demonstrated its relevance, comprehensiveness and feasibility for people with skeletal dysplasia. The ICF linkages showed the contents' correspondence to the construct. Expert panels added 15 categories and one on chapter level to the core set and confirmed content validity. The final survey covers 86 ICF categories and 173 ICF-linked items that were grouped to 33 questions.

CONCLUSIONS

The content of the questionnaire proved to be sufficiently valid for people with skeletal dysplasia. It can be used to explore their health, functioning, disability and accessibility to develop care and rehabilitation policies, to plan services and to provide information to various parties involved.

Functioning and equality according to International Classification of Functioning, Disability and Health (ICF) in people with skeletal dysplasia compared to matched control subjects - a cross-sectional survey study

Background

Skeletal dysplasias are rare disorders often leading to severe short stature. This study aimed to gain new comprehensive information about functioning and equality in people affected by skeletal dysplasia compared to matched controls without skeletal dysplasia.

Methods

Functioning was assessed by questionnaire, which was formed by operationalizing International Classification of Functioning, Disability and Health (ICF) core set’s categories into the items according to the ICF linking rules, using primarily Patient Reported Outcomes Measurement Information System PROMIS® - items.

Results

Altogether 80 subjects with skeletal dysplasia and 55 age-, gender- and place of residence -matched controls participated. People with skeletal dysplasia experienced more pain (p < 0.001) and the pain interfered more their daily lives (p = 0.037) compared to the controls. They had more problems related to musculoskeletal functions and exercise tolerance, difficulties in mobility, used more assistive products and technology and were more affected by climate and seasonal changes (p < 0.001). They met challenges in self-care, acquisition of goods and services and household tasks (p < 0.001) and in participating in close social relationships, leisure time activities (p < 0.001) and associations and organizational services (p = 0.007). They felt less satisfied with remunerative work (p = 0.003), felt more inequality (p = 0.008), met more negative attitudes of others (p < 0.001) and felt having less support given by family and friends (p = 0.022). They used more social and health services and experienced more dissatisfaction with those.

Conclusions

Our study indicates that skeletal dysplasias restrict functioning extensively and significantly affect daily living. By building accessible environment and improving equal services, functioning could be improved.

Avoiding the Banality of Evil in Times of COVID-19: Thinking Differently with a Biopsychosocial Perspective for Future Health and Social Policies Development

The COVID-19 pandemic provides the opportunity to re-think health policies and health systems approaches by the adoption of a biopsychosocial perspective, thus acting on environmental factors so as to increase facilitators and diminish barriers. Specifically, vulnerable people should not face discrimination because of their vulnerability in the allocation of care or life-sustaining treatments. Adoption of biopsychosocial model helps to identify key elements where to act to diminish effects of the pandemics. The pandemic showed us that barriers in health care organization affect mostly those that are vulnerable and can suffer discrimination not because of severity of diseases but just because of their vulnerability, be this age or disability and this can be avoided by biopsychosocial planning in health and social policies. It is possible to avoid the banality of evil, intended as lack of thinking on what we do when we do, by using the emergence of the emergency of COVID-19 as a Trojan horse to achieve some of the sustainable development goals such as universal health coverage and equity in access, thus acting on environmental factors is the key for global health improvement.

Development and content validity of the Abilitator: a self-report questionnaire on work ability and functioning aimed at the population in a weak labour market position

BACKGROUND

The unemployed have lower work ability and poorer health than the employed. This situation deteriorates when unemployment continues. The long-term unemployed often have co-morbidities and face many other challenges. This increases the need for a multidimensional assessment of work ability and functioning in different service settings. In this study, we describe the development and analyse the content validity of the Abilitator, a self-report questionnaire on work ability and functioning for those in a weak labour market position.

METHODS

The Abilitator was developed in 2014-2017. Its construct was assessed by members of academic expert panels (n = 30), practical expert panels of professionals (n = 700) and target group clients (n = 28). The structure and the content of the questionnaire was co-developed in 29 workshops and adjusted twice based on the expert panels' feedback. The Abilitator was also implemented among target group clients (n = 3360) in different services and projects. During its development the Abilitator was linked to the International Classification of Functioning, Disability and Health (ICF). The content validation process followed the guidelines recommended by the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) panel.

RESULTS

The construct of the Abilitator combines the multidimensional and biopsychosocial models of work ability and functioning. It also includes aspects of social inclusion and employability. It evaluates social, psychological, cognitive and physical functioning, and the ability to cope with everyday life. The content of these concepts was validated by the academic and practical expert panels. The Abilitator's 79 ICF codes covered 57% of the Generic, 77% of the Brief Vocational Rehabilitation, and 8% of the Minimal Environmental ICF Core Sets. When compared with the Work Ability Index (WAI) and the World Health Organization Disability Assessment Schedule (WHODAS 2.0), the direct equivalences of the ICF codes were 36 and 44%, respectively.

CONCLUSION

The Abilitator sufficiently comprehensively covers the relevant aspects to enable the assessment of the overall work ability and functioning of the population in a weak labour market position.

The Effectiveness of Rehabilitation Interventions on the Employment and Functioning of People with Intellectual Disabilities: A Systematic Review

Purpose This systematic review analyzed the effectiveness of rehabilitation interventions on the employment and functioning of people with intellectual disabilities (ID), as well as barriers and facilitators of employment. Methods This was a systematic review of quantitative, qualitative, and mixed methods studies. The outcomes were employment, transition to the open labor market and functioning. The review included qualitative studies of employment barriers and facilitators. The population comprised people with ID aged 16-68 years. Peer-reviewed articles published in English between January 1990 and February 2019 were obtained from the databases Cinahl, the Cochrane Library, Embase, Eric, Medic, Medline, OTseeker, Pedro, PsycInfo, PubMed, Socindex, and the Web of Science. We also searched Google Scholar and Base. The modified selection instrument (PIOS: participants, intervention, outcome, and study design) used in the selection of the articles depended on the selection criteria. Results Ten quantitative (one randomized controlled, one concurrently controlled, and eight cohort studies), six qualitative studies, one multimethod study, and 21 case studies met the inclusion criteria. The quantitative studies showed that secondary education increases employment among people with ID when it includes work experience and personal support services. Supported employment also increased employment in the open labor market, which sheltered work did not. The barriers to employment were the use of sheltered work, discrimination in vocational experience, the use of class teaching, and deficient work experience while still at school. The facilitators of employment were one's own activity, the support of one's family, job coaching, a well-designed work environment, appreciation of one's work, support form one's employer and work organization, knowledge and experience of employment during secondary education, and for entrepreneurs, the use of a support person. Conclusions The employment of people with ID can be improved through secondary education including proper teaching methods and personal support services, the use of supported work, workplace accommodations and support from one's family and employer. These results can be utilized in the development of rehabilitation, education, and the employment of people with ID, to allow them the opportunity to work in the open labor market and participate in society.

Creating national guidelines for assessing functional and work capacity of recently settled persons

Problem

The measurement of functioning in clinical practice should be systematic and comprehensive. However, different versions of the same functioning measure are used e.g. by physicians, psychologists, physiotherapists and occupational therapists. The TOIMIA network of experts aims to harmonize and develop the measuring of functioning in Finland.

Description of the problem

With increasing immigration to Finland, a specific need for guidelines on how to assess functional and work capacity of recently settled persons was identified. Led by the National Institute for Health and Welfare (mobiTARMO-project, 2017-2020), guidelines for assessing functional and work capacity in the integration phase are in preparation.

Results

The guidelines on assessing functional and work capacity in the integration phase include four principles: Functional and work capacity assessment should be done with culturally and linguistically appropriate methods.Assessment should be based on shared expertise of the professional and the client.Assessment should be comprehensive, and take into consideration physical, psychological, social and cognitive functional capacity, activities of daily living, and environmental factors.Assessment should be systematic and lead to further actions and necessary services.The national guidelines will be disseminated as free online access material in the Terveysportti health portal to professionals in clinical practice and research.

Lessons

There are specificities to the cross-cultural assessment of functional and work capacity of recently settled persons. National guidelines can be created through broad collaboration of different organizations, as in the TOIMIA network of experts in Finland.

Key messages

Jointly agreed principles on how to assess functional and work capacity in the integration phase benefit professionals and clients. National guidelines can be created, disseminated and taken into practice through broad collaboration.

Health, functioning and accessibility among spinal cord injury population in Finland: Protocol for the FinSCI study

BACKGROUND AND PURPOSE

The purpose of the Finnish Spinal Cord Injury Study (FinSCI) is to identify factors related to the health and functioning of people with spinal cord injury, their challenges with accessibility, and how such factors are interconnected. The International Classification of Functioning, Disability and Health (ICF) is used as a structured framework in the study.

DESIGN

Protocol of mixed methods study.

RESULTS

Study participants were recruited from all 3 SCI outpatient clinics in Finland. The final target group consists of 1,789 subjects with spinal cord injury. The final questionnaire was formed from 5 different patient-reported instruments. The spinal cord injury-specified instruments are the Spinal Cord Injury Secondary Condition Scale, the Spinal Cord Independence Measure, and the Nottwil Environmental Factors Inventory Short Form. In addition, questions from the following generic instruments were chosen after a selection process: the Patient-Reported Outcomes Measurement Information System, PROMIS®, and the National Study of Health, Well-being and Service, FinSote. Altogether, the final questionnaire covers 64 ICF categories and consists of 151 ICF-linked questions.

CONCLUSION

The formulated questionnaire covers widely different aspects of health, functioning and accessibility. The questionnaire results and subsequent interviews will help in developing care and rehabilitation policies and services for people with spinal cord injury.

Psychometric properties of the NOMO 1.0 tested among adult powered-mobility users

Background.

The Nordic Mobility Related Outcome Evaluation of Assistive Device Intervention (NOMO 1.0) instrument evaluates the effectiveness of mobility devices in assessing mobility-related participation, captured by three scales (Need for Assistance, Frequency, and Ease/Difficulty) and one index (Participation Repertoire).

Purpose.

This study aimed to investigate a range of psychometric properties of the NOMO 1.0 in a sample of adult powered mobility device (PMD) users.

Method.

Data collected from PMD users ( N = 248) in Denmark, Finland, and Norway as part of a larger study were analyzed using state-of-the-art statistical methods.

Findings.

The acceptability and applicability of the NOMO 1.0 items were generally within recommended values. Some floor/ceiling effects were found and the reliability was acceptable for only the Frequency scale. The factor analysis identified one component for the Need for Assistance scale and six components of the Frequency scale.

Implications.

The NOMO 1.0 should be used for research purposes and not for clinical practice. Better reliability should be established for the Need for Assistance and Ease/Difficulty scales prior to further psychometric testing to establish the validity of the NOMO 1.0.

Functioning and Challenges in Equality and Accessibility Among People with Short Stature

Accessibility is not the same for all of us. This study concerns people with short stature, their functioning and challenges in equality and accessibility in our environment based on average measures.

Effectiveness of Powered Mobility Devices in Enabling Community Mobility-Related Participation: A Prospective Study Among People With Mobility Restrictions

OBJECTIVE

To investigate the effectiveness of powered mobility device (ie, powered wheelchair and scooter) interventions over a 1-year period in Nordic countries.

DESIGN

Prospective design.

SETTING

The study involved community-dwelling participants from Denmark, Finland, and Norway.

PARTICIPANTS

In all, 180 participants with different self-reported impairments participated in the study. The mean age was 68.7 years (95% confidence interval [CI] = 39.9-97.5 years), and 47.8% of the participants were men.

METHODS

Two face-to-face interviews about mobility and mobility-related participation were conducted with participants in their homes. The first interview took place shortly before the participants received their powered mobility device, and the second took place about 1 year later (mean, 386.9 days; standard deviation = 52.78).

MAIN OUTCOME MEASURES

Changes in frequency, ease/difficulty, and number of mobility-related aspects of participation in daily life were investigated in the total sample and in subgroups by means of the NOMO 1.0 instrument, applying a structured interview format.

RESULTS

In the total sample, the frequency of shopping for groceries (P < .001, effect size = 0.29, 95% CI = 0.08-0.50) and going for a walk/ride (P < .001, effect size = 0.62, 95% CI = 0.41-83) increased, whereas the number of aspects of participation performed (P < .001) increased only slightly. Going to a restaurant/café/pub, shopping for groceries, doing other shopping, posting letters, going to the bank or the chemist's, going for a walk/ride, and visiting family/friends became easier (P < .001 to P = .001); effect sizes varied between 0.50 (95% CI = 0.29-0.71) and 0.85 (95% CI = 0.63-1.07). Men, persons who used scooters, and persons with poor self-reported health seem to benefit the most from the intervention.

CONCLUSIONS

Powered mobility device interventions mainly contribute to mobility-related participation by making participation easier for people with mobility restrictions and by increasing the frequency of aspects of participation such as shopping for groceries and going for a walk/ride. The effects varied with regard to the subgroups. The present study further strengthens the current evidence that powered mobility devices increase mobility-related participation in daily life among certain subgroups of adults with mobility restrictions.

Test-retest reliability and agreement of the Satisfaction with the Assistive Technology Services (SATS) instrument in two Nordic countries

PURPOSE

The purpose of this study was to investigate test-retest reliability, agreement, internal consistency, and floor- and ceiling effects of the Danish and Finnish versions of the Satisfaction with the Assistive Technology Services (SATS) instrument among adult users of powered wheelchairs (PWCs) or powered scooters (scooters).

METHOD

Test-retest design, two telephone interviews 7-18 days apart of 40 informants, with mean age of 67.5 (SD 13.09) years in the Danish; and 54 informants with mean age of 55.6 (SD 12.09) years in the Finnish sample.

RESULTS

The intra-class correlation coefficient varied between 0.57 and 0.93 for items in the Danish and between 0.41 and 0.93 in the Finnish sample. The percentage agreement varied between 54.2 and 79.5 for items in the Danish and between 69.2 and 81.1 in the Finnish sample, while the Cronbach's alpha values varied between 0.87 and 0.96 in the two samples. A ceiling effect was found in all items of both samples.

CONCLUSIONS

This study indicates that the SATS may be reliably administered for telephone interviews among adult PWC and scooter users, and give information about aspects of the service delivery process for quality development improvement purposes. Further psychometric testing of the SATS is required.

Ethical issues of obesity surgery--a health technology assessment

New surgical technologies may challenge societal values, and their adoption may lead to ethical challenges. Despite proven cost-effectiveness, obesity (bariatric) surgery and its public funding have been questioned on ethical arguments relating to, for example, the self-inflicted or non-disease nature of obesity. Our aim was to analyze the ethical issues relevant to bariatric surgery. A comprehensive health technology assessment was conducted on bariatric surgery for morbid obesity using the EUnetHTA method, including a fully integrated ethical analysis. The ethical arguments suggesting that obesity should not be surgically treated because it is self-inflicted were rejected. Medicalization of obesity may have both positive and negative effects that impact the various stakeholders differently, thus being difficult to balance. Informing bariatric surgery patients and actively supporting their autonomy is exceptionally important, as the benefits and harms of both obesity and bariatric surgery are complex, and the outcome depends on how well the patient understands and adheres to the life-long changes in eating habits required. Justice considerations are important in organizing surgical treatment of obesity, as the obese are discriminated against in many ways and obesity is more common in socioeconomically disadvantaged populations who might have problems of access to treatments. Obesity should be treated like other diseases in health care, and obesity surgery rationed like other cost-effective treatments. Positive actions to ensure patient autonomy and just access to surgical treatments may be warranted.

Lymphoedema therapy in breast cancer patients: a systematic review on effectiveness and a survey of current practices and costs in Finland

BACKGROUND

This study systematically evaluates the effects and harms of physiotherapy methods and explores current treatment practices and costs in relation to lymphoedema in breast cancer patients in Finland.

MATERIAL AND METHODS

A systematic review of randomized controlled trials (RCTs) on physiotherapy interventions for breast cancer patients with lymphoedema. A postal survey to lymph therapists, a telephone and register survey for therapy costs.

RESULTS

We identified 14 RCTs, of which two had moderate and the others high risk of bias. There was moderate evidence that compression bandages decreased lymphoedema, and that pneumatic pumps had no effect on lymphoedema. In Finland lymph therapy practice is a combination of manual lymph drainage (MLD), compression bandages, therapeutic exercises and guidance for self-treatment, with an annual average cost of EUR 799 per patient.

CONCLUSIONS

Compression bandages are likely to reduce upper limb lymphoedema in breast cancer patients. Evidence on other physiotherapy methods and their combinations is limited due to the poor quality of the trials. No evidence was found on any outcomes other than upper limb volume. We call for well-designed trials with patient-related outcomes on the effectiveness of MLD, guidance and therapeutic exercises.

[Effects of bariatric surgery on mental and social well-being]

Morbid obesity is associated with severely invalidizing symptoms and a strong stigma, which restrict the management of daily life. The handicaps of morbid obesity are so severe that patients are ready to accept even inconvenient adverse effects or high risks from the treatment. Seeking antiobesity surgery is mainly done for health reasons, but is perceived to have a broad effect on functional capacity, self-image as well as on mental and social well-being. By the help of anti-obesity surgery, many patients not only gain control over eating, but also over other fields of life.

[Provision of surgical treatment for the morbidly obese in Finland]

The number of and demand for surgical treatments of morbid obesity are quickly increasing in Finland. The resources and action models differ regionally. The position of antiobesity surgery among antiobesity treatments should be defined more clearly than is now the case in Finland. Also a decision should be made how these operations are included in the patient's treatment guarantee. There should be a public discussion on how to centralise the operations into sufficiently large units of expertise and availability of the treatment in various parts of Finland must be guaranteed. Treatment chains should be standardized, at the same time ascertaining adequate expertise of various health care providers.

[Effectiveness and safety of bariatric surgery]

Evidence for the effectiveness of surgical treatment of morbid obesity on life span, quality of life and associated diseases proves it an applicable alternative for the morbidly obese in cases where other means of controlling obesity have remained ineffective. The operation causes significant weight reduction even within a 15-year follow-up. Surgical mortality after an endoscopic operation is usually less than 0.5%. After the operation, patients fairly often experience various symptoms of the digestive tract. Common complications include various infections and functional disturbances associated with the band.

[Ethical aspects of bariatric surgery]

Attitude to obesity determines the attitude to antiobesity surgery: is obesity a disease among other diseases belonging to the public health care, or a characteristic resulting from living habits, remaining under the person's own responsibility? Antiobesity surgery requires supporting the patients' right to self-determination. Other treatments for obesity should be available, and this procedure necessitating permanent adjustments of living habits requires sufficient advance preparation. The patient's guarantee governing the treatment of obesity as a whole seems relevant. Assessment of the need for surgery is, however, difficult and the benefits and disadvantages differ among the various stakeholders.

Effects and side-effects of surgery for snoring and obstructive sleep apnea--a systematic review

STUDY OBJECTIVES

Many patients undergo surgery for snoring and sleep apnea, although the efficacy and safety of such procedures have not been clearly established. Our aim was systematically to review studies of the efficacy and adverse effects of surgery for snoring and obstructive sleep apnea.

DESIGN

Systematic review.

MEASUREMENTS

PubMed and Cochrane databases were searched in September 2007. Randomized controlled trials of surgery vs. sham surgery or conservative treatment in adults, with daytime sleepiness, quality of life, apnea-hypopnea index, and snoring as outcomes were included. Observational studies were also reviewed to assess adverse effects. Evidence of effect required at least two studies of medium and high quality reporting the same result.

RESULTS

Four studies of benefits and 45 studies of adverse effects were included. There was no significant effect on daytime sleepiness and quality of life after laser-assisted uvulopalatoplasty and radiofrequency ablation. The apnea-hypopnea index and snoring was reduced in one trial after laser-assisted uvulopalatoplasty but not in another trial. Subjective snoring was reduced in one trial after radiofrequency ablation. No trial investigating the effect of any other surgical modality met the inclusion criteria. Persistent side-effects occurred after uvulopalatopharyngoplasty and uvulopalatoplasty in about half the patients and difficulty in swallowing, globus sensation and voice changes were especially common.

CONCLUSIONS

Only a small number of randomized controlled trials with a limited number of patients assessing some surgical modalities for snoring or sleep apnea are available. These studies do not provide any evidence of effect from laser-assisted uvulopalatoplasty or radiofrequency ablation on daytime sleepiness, apnea reduction, quality of life or snoring. We call for research of randomized, controlled trials of surgery other than uvulopalatopharyngoplasty and uvulopalatoplasty, as they are related to a high risk of long-term side-effects, especially difficulty swallowing.

Effectiveness of physical therapy interventions for children with cerebral palsy: a systematic review

BACKGROUND

To assess the effectiveness of physical therapy (PT) interventions on functioning in children with cerebral palsy (CP).

METHODS

A search was made in Medline, Cinahl, PEDro and the Cochrane library for the period 1990 to February 2007. Only randomized controlled trials (RCTs) on PT interventions in children with diagnosed CP were included. Two reviewers independently assessed the methodological quality and extracted the data. The outcomes measured in the trials were classified using the International Classification of Functioning, Disability and Health (ICF).

RESULTS

Twenty-two trials were identified. Eight intervention categories were distinguished. Four trials were of high methodological quality. Moderate evidence of effectiveness was established for two intervention categories: effectiveness of upper extremity treatments on attained goals and active supination, and of prehensile hand treatment and neurodevelopmental therapy (NDT) or NDT twice a week on developmental status, and of constraint-induced therapy on amount and quality of hand use. Moderate evidence of ineffectiveness was found of strength training on walking speed and stride length. Conflicting evidence was found for strength training on gross motor function. For the other intervention categories the evidence was limited due to low methodological quality and the statistically insignificant results of the studies.

CONCLUSION

Due to limitations in methodological quality and variations in population, interventions and outcomes, mostly limited evidence on the effectiveness of most PT interventions is available through RCTs. Moderate evidence was found for some effectiveness of upper extremity training. Well-designed trials are needed especially for focused PT interventions.

The effect of beta-glucan on the glycemic and insulin index

OBJECTIVE

To determine the effects of oat products with increasing beta-glucan content on the glycemic (GI) and insulin indexes (II) of oat products, and to establish the effect of physical properties of beta-glucan on these physiological responses.

DESIGN

Test group (n=10) randomly attended to three glucose tolerance tests and glycemic response tests for four oat bran products.

SETTINGS

Functional Foods Forum and the Department of Food Chemistry, University of Turku, and the Department of Food Technology, University of Helsinki.

SUBJECTS

One male and nine female volunteers were recruited from university students and staff, and all completed the study.

INTERVENTIONS

GI and II of different products were calculated for each subject using the average of parallel glucose tolerance tests and the subsequent glycemic/insulinemic responses for each product. Average indexes for products were calculated according to the individual data.

RESULTS

The glycemic responses to oat products with increasing amounts of beta-glucan had lower peak values than the reference glucose load. The amount of extractable beta-glucan had a high correlation between the glycemic and insulinemic response.

CONCLUSION

In addition to the total amount of beta-glucan in oat products, the amount of extractable beta-glucan in oat products explains the magnitude of the decrease in glycemic responses to carbohydrate products.

A systematic review finds that methodological quality is better than its reputation but can be improved in physiotherapy trials in childhood cerebral palsy

OBJECTIVES

To identify critical issues in performing randomized controlled trials (RCTs) on complex interventions such as physiotherapy in multifaceted disabilities like cerebral palsy (CP); to systematically assess how well trials handled patient characteristics, key components of complex interventions, and outcome assessments; to make suggestions for improving the effectiveness of physiotherapy research.

DESIGN AND METHODS

A methodological review. An ongoing metareview served as sampling frame. RCTs on physiotherapy in children with CP published after 1990 were eligible. The main outcome measures were sampling, recruitment, and comparability of groups; defined components of a complex intervention; outcome measures according to the World Health Organization International Classification of Functioning and clinical interpretation of score change.

RESULTS

Fifty-seven clinical trials were identified, of which 14 RCTs were included. Most studies used simple randomization, complemented by balancing techniques such as matching or stratification. Only three of 14 studies specified concealed allocation. Numerous studies provided sufficient details on components of a complex intervention (e.g., 'standardized intervention' (12/14); 'the active therapeutic ingredient' (8/15). Overlap of instruments across studies was poor, only instruments on activity endpoints were more homogeneous. The clinical interpretation of observed score changes was mostly missing.

CONCLUSION

We found good to fair methodological quality in a considerable number of RCTs on physiotherapy in CP children. Nevertheless, improvement is indicated for certain areas in design and performance of future studies. This review shows that informative RCTs on complex interventions for multifaceted disabilities are feasible.

Quality of reporting of randomized, controlled trials in cerebral palsy

OBJECTIVES

In conducting reviews on the effectiveness of physiotherapy interventions on children with cerebral palsy, the assessment of trials can be hampered by problems in reporting. Therefore, we set out to evaluate trial reporting by using the Consolidated Standards of Reporting Trials (CONSORT) statement recommendations.

METHODS

Randomized, controlled trials published in 1990 or later were identified in literature searches for reviews on the effectiveness of physiotherapy interventions on children with cerebral palsy. Two independent reviewers evaluated the trial reporting by using a modified 33-item Consolidated Standards of Reporting Trials checklist.

RESULTS

We identified 15 randomized, controlled trials. Almost half (48%) of the applicable items were reported adequately. Inadequate reporting was found in the following items: outcome measures, sample-size determination, details of the sequence generation, allocation concealment and implementation of the randomization, success of assessor blinding, recruitment and follow-up dates, intention-to-treat analysis, precision of the effect size, co-interventions, and adverse events.

CONCLUSIONS

Only a small number of sufficiently reported trials were found. Because nearly all items had been described in at least 1 article, high-quality reporting seems feasible. Assessment of trials depends on appropriate reporting, and poor reporting jeopardizes judgments on the clinical implications. Authors of randomized, controlled trials are encouraged to follow the Consolidated Standards of Reporting Trials criteria. There is a clear need to improve the quality of reporting of trials in this field.

Effectiveness of Upper and Lower Limb Casting and Orthoses in Children with Cerebral Palsy

The objective of this overview is to summarize from systematic reviews the evidence on the effectiveness of using upper and lower limb casting or orthoses in children with cerebral palsy. We used computerized bibliographic databases to search for systematic reviews without any language restrictions. Identification, selection, quality assessment, and data extraction were performed independently by two investigators. Of the 40 identified reviews, 23 were selected for closer consideration, and five reviews met the inclusion criteria. The quality of existing systematic reviews and original studies included in our reviews varied widely. The following evidence was found: (1) casting of lower limbs has a short-term effect on passive range of movement; (2) orthoses that restrict ankle plantar flexion have a favorable effect on an equinus walk, but the long-term clinical significance is unclear; (3) evidence on managing upper limb problems with casting or splinting in children with cerebral palsy is inconclusive. Our conclusion is that there is a paucity of evidence from primary studies on the use of orthoses in children with cerebral palsy. More original, well-designed research is needed.

Salmeterol/fluticasone propionate (50/100 microg) in combination in a Diskus inhaler (Seretide) is effective and safe in children with asthma

The aim of this study was to compare the efficacy and safety in children of salmeterol (50 microg twice daily) plus fluticasone propionate (100 microg twice daily) when delivered together via a single Diskus inhaler (Seretide; combination therapy) or concurrently using two separate Diskus inhalers (concurrent therapy). In a multicenter, randomized, double-blind, double-dummy, parallel-group study, 257 children with reversible airways obstruction who remained symptomatic on inhaled corticosteroids (200-500 microg daily) alone were randomized to combination or concurrent therapy for 12 weeks. Efficacy was assessed by measuring daily peak expiratory flow (PEF), symptom scores, and rescue salbutamol use. In addition, lung function tests were performed at each clinic visit. Safety assessments included monitoring of adverse events and morning serum cortisol concentrations. The primary efficacy parameter (mean morning PEF) increased during treatment in both groups; adjusted mean changes were 33 and 28 L/min for the combination and concurrent therapies, respectively. The 90% confidence interval for the difference in mean morning PEF between treatment groups was within the +15 L/min criterion for clinical equivalence. Similarly, there were improvements in pulmonary function, symptom score, and rescue salbutamol use during treatment in both groups, with no significant differences between the combination and concurrent therapy groups for any of these secondary efficacy parameters. Both treatment regimens were well-tolerated and had comparable adverse event profiles. Mean morning serum cortisol levels increased similarly in both groups during the study. In conclusion, salmeterol and fluticasone propionate therapy given as a new combination product is as safe and effective in children with asthma as the same drugs given concurrently via separate inhalers.

Regulation of interleukin-1 beta production by glucocorticoids in human monocytes: the mechanism of action depends on the activation signal

Glucocorticoids are known to downregulate interleukin-1 beta production in monocytic cells by two different mechanims: direct inhibition of the gene transcription and destabilization of the preformed interleukin-1 beta mRNA. Now we have examined the effect of the nature of the monocyte activating signal on these two inhibitory mechanims. When human monocytes were preincubated with dexamethasone for 1 hour and then stimulated either with bacterial lipopolysaccharide or phorbol myristate, it was found that dexamethasone inhibited the lipopolysaccharide-induced interleukin-1 beta protein production, but the phorbol myristate-induced production was increased 3-10 fold. This difference was also seen at the mRNA level. When dexamethasone was added to the cultures 3 hours after the stimulators, it clearly decreased the interleukin-1 beta mRNA levels regardless of the stimulator used (although the effect was clearly weaker on the PMA-induced mRNA). Thus these data suggest that the phorbol myristate-induced signal (prolonged protein kinase C activation?) cannot be inhibited by prior incubation with dexamethasone and it also protects the induced mRNA for the degradative action of dexamethasone.