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1.  Cruciate Ligament Reconstruction and Risk of Knee Osteoarthritis: The Association between Cruciate Ligament Injury and Post-Traumatic Osteoarthritis. A Population Based Nationwide Study in Sweden, 1987–2009 
PLoS ONE  2014;9(8):e104681.
Objective
To study the association between Cruciate Ligament (CL) injury and development of post-traumatic osteoarthritis in the knee in patients treated operatively with CL reconstruction compared with patients treated non-operatively.
Design
Population based cohort study; level of evidence II-2.
Setting
Sweden, 1987–2009.
Participants
All patients aged between 15–60 years being diagnosed and registered with a CL injury in The National Swedish Patient Register between 1987 and 2009.
Main Outcome Measures
Knee osteoarthritis.
Results
A total of 64,614 patients diagnosed with CL injury during 1987 to 2009 in Sweden were included in the study. Seven percent of the patients were diagnosed with knee OA in specialized healthcare during the follow-up (mean 9 years). Stratified analysis by follow-up showed that while those with shorter follow-up had a non-significant difference in risk (0.99, 95%CI 0.90–1.09 for follow-up less than five years compared with the non-operated cohort), those with longer follow-up had an increased risk of knee OA after CL reconstruction (HR = 1.42, 95%CI 1.27–1.58 for follow-up more than ten years compared with non-operated cohort). The risk to develop OA was not affected by sex.
Conclusion
CL reconstructive surgery does not seem to have a protective effect on long term OA in either men or women.
doi:10.1371/journal.pone.0104681
PMCID: PMC4141753  PMID: 25148530
2.  Pertrochanteric fracture of the femur in the Finnish National Hospital Discharge Register: validity of procedural coding, external cause for injury and diagnosis 
Background
Hospital discharge data is routinely collected in Finland and it is an invaluable source of information when assessing injury epidemiology as well as treatment. The database can be used when planning injury prevention and redirecting resources of the health care system. Most recently our hospital discharge register has been used to assess the incidence of surgical treatment of common fractures. This study was aimed to evaluate the coverage and accuracy of the Finnish National Hospital Discharge Register (NHDR) focusing on hip fractures. In other words, patients hospitalized for a pertrochanteric hip fracture were used to assess the validity of the NHDR.
Methods
The validity of the NHDR was assessed by comparing the data in hospital discharge register with the original patient records and radiographs in three separate hospitals; Tampere University Hospital, Hatanpää City Hospital of Tampere, and the Central Hospital of Kanta-Häme. The study analysis included 741 patients hospitalized due to pertrochanteric hip fracture between 1st January 2008 and 31st December 2010.
Results
The diagnosis was correctly placed on 96% (95% CI: 94 to 97%) of the 741 patients when radiographs were used as golden standard. The procedural coding had coverage of 98% (95% CI: 96 to 98%) and an accuracy of 88% (95% CI: 85 to 90%). The coverage of the external cause for injury was found to be 95% (95% CI: 94 to 97%) with an accuracy of 90% (95% CI: 87 to 92%).
Conclusions
Our results show that the validity of the Finnish NHDR is excellent as determined by accuracy of diagnosis and both accuracy and coverage of procedural coding and external cause for injury. The database can be used to assess injury epidemiology and changes in surgical treatment protocols.
doi:10.1186/1471-2474-15-98
PMCID: PMC4026595  PMID: 24655318
3.  Trends in the surgical treatment of proximal humeral fractures – a nationwide 23-year study in Finland 
Background
Proximal humeral fractures are common osteoporotic fractures. Most proximal humeral fractures are treated non-surgically, although surgical treatment has gained popularity. The purpose of this study was to determine changes in the surgical treatment of proximal humeral fractures in Finland between 1987 and 2009.
Methods
The study covered the entire adult (>19 y) population in Finland over the 23-year period from 1st of January 1987 to 31st of December 2009. We assessed the number and incidence of surgically treated proximal humeral fractures in each year of observation and recorded the type of surgery used. The cohort study was based on data from Finnish National Hospital Discharge Register.
Results
During the 23-year study period, a total of 10,560 surgical operations for proximal humeral fractures were performed in Finland. The overall incidence of these operations nearly quadrupled between 1987 and 2009. After the year 2002, the number of patients treated with plating increased.
Conclusion
An increase in the incidence of the surgical treatment of proximal humeral fractures was seen in Finland in 1987–2009. Fracture plating became increasingly popular since 2002. As optimal indications for each surgical treatment modality in the treatment of proximal humeral fractures are not known, critical evaluation of each individual treatment method is needed.
doi:10.1186/1471-2474-13-261
PMCID: PMC3537526  PMID: 23273247
4.  Conservative treatment, plate fixation, or prosthesis for proximal humeral fracture. A prospective randomized study 
Background
Proximal humerus fracture is the third most common fracture type after hip and distal radius fracture in elderly patients. A comprehensive study by Palvanen et al. demonstrated an increase in the annual fracture rate of 13.7% per year over the past 33 years. Should this trend continue, the fracture rate would triple over the next three decades. The increasing incidence of low-energy fractures raises questions about the optimal treatment in terms of functional outcome, pain, and rehabilitation time, as well as the economical impact. Despite the high incidence and costs of proximal humerus fractures, there is currently no valid scientific evidence for the best treatment method. Several publications, including a Cochrane review outline the need for high-quality, well-designed randomized controlled trials.
Methods/Design
The study is a prospective, randomized, national multi-center trial. The hypothesis of the trial is that surgical treatment of displaced proximal humerus fractures achieves better functional outcome, pain relief, and patient satisfaction compared to conservative treatment. The trial is designed to compare conservative and surgical treatment of proximal humerus fractures in patients 60 years and older. The trial includes two strata. Stratum I compares surgical treatment with locking plates to conservative treatment for two-part fractures. Stratum II compares multi-fragmented fractures, including three- and four-part fractures. The aim of Stratum II is to compare conservative treatment, surgical treatment with the Philos locking plate, and hemiarthroplasty with an Epoca prosthesis. The primary outcome measure will be the Disabilities of the Arm, Shoulder and Hand (DASH) score and the secondary outcome measures will be the EuroQol-5D (EQ-5D) value, OSS, Constant-Murley Score, VAS, and 15D.
Recruiting time will be 3 years. The results will be analyzed after the 2-year follow-up period.
Discussion
This publication presents a prospective, randomized, national multi-center trial. It gives details of patient flow, randomization, aftercare and also ways of analysis of the material and ways to present and publish the results.
Trial registration
ClinicalTrials.gov identifier: NCT01246167
doi:10.1186/1471-2474-13-167
PMCID: PMC3520878  PMID: 22954329
Proximal; Humerus; Fracture; Conservative; Operative; Locking plate; Prosthesis; Philos; Epoca; RCT
5.  Sports activity and the use of cigarettes and snus among young males in Finland in 1999-2010 
BMC Public Health  2012;12:230.
Background
Studies of the relationship between sports activity and smoking among adolescents and young adults report contradictory results. We examined the association between sports activity (intensity and type of sport) and the current use of snus (Swedish snuff), cigarette smoking, and the combined use of cigarettes and snus (dual use) among young males in Finland.
Methods
Data were collected from 16,746 male conscripts who completed a survey during the first days of their conscription during the years 1999-2010 (median age 19 years, response rate 95%). Main outcome measures were self-reported daily/occasional use of snus, cigarette smoking, and dual use. The association between sports activity, type of sport, and several sociodemographic background variables was assessed using logistic regression analysis.
Results
Over the study period (1999-2010), the prevalence of cigarette smoking decreased from 42% to 34%, while snus use increased from 5% to 12%, and dual use increased from 7% to 13% (p < 0.001). Compared with no physical activity, regular competitive sports activity (defined as high-intensity sports activity) was positively associated with use of snus (odds ratio [OR] 10.2; 95% confidence interval [CI]: 7.8-13.5) and negatively with cigarette smoking (OR 0.2; 95% CI: 0.1-0.3). When stratified by type of sport in multivariate models, ice hockey was most strongly associated with snus use (OR 1.6; 95% CI: 1.4-1.9) and dual use (OR 2.0; 95% CI 1.8-2.3) compared with those not playing ice-hockey, followed by other team sports for snus use (OR 1.5; 95% CI: 1.3-1.8) and dual use (OR 1.8; 95% CI: 1.6-2.0) compared with those not participating in other team-sports.
Conclusions
Our results show a clear association between snus use and intensity and type of training. Team sports were associated with increased use of snus and dual use compared with no participation in team sports. These findings should be acknowledged when planning and implementing preventive strategies.
doi:10.1186/1471-2458-12-230
PMCID: PMC3325877  PMID: 22439614
Young people/youth; Tobacco use; Snus; Smoking; Sports; Physical activity
6.  Orthotic insoles do not prevent physical stress-induced low back pain 
European Spine Journal  2010;20(1):100-104.
Orthotic insoles are suggested to prevent low back pain. This randomized controlled study assessed if customised orthotic insoles prevent low back pain. Healthy military conscripts (n = 228; mean age 19 years, range 18–29) were randomly assigned to use either customised orthotic insoles (treatment group, n = 73) or nothing (control group, n = 147). The main outcome measure was low back pain requiring a physician visit and resulting in minimum 1 day suspension from military duty. Twenty-four (33%) treated subjects and 42 (27%) control subjects were suspended from duty due to low back pain (p = 0.37; risk difference 4.3%; 95% CI: −8.7 to 17.3%). Mean suspension duration was 2 days (range 1–7) in both groups. Four (5%) treated subjects and eight (5%) control subjects were released from duty due to persistent low back pain (p = 0.92; risk difference 0%; 95% CI: −6 to 6%). Use of orthotic insoles is therefore not recommended to prevent physical stress-related low back pain.
doi:10.1007/s00586-010-1496-5
PMCID: PMC3036013  PMID: 20602123
Prevention; Lower back pain; rct
7.  Comparison of 1.5T and 3T MRI scanners in evaluation of acute bone stress in the foot 
Background
Bone stress injuries are common in athletes and military recruits. Only a minority of bone stress changes are available on plain radiographs. Acute bone stress is often visible on MRI as bone marrow edema, which is also seen in many other disease processes such as malignancies, inflammatory conditions and infections. The purpose of this study was to investigate the ability of radiographs, 1.5T and 3T MRI to identify acute bone marrow changes in the foot.
Methods
Ten patients with 12 stress fractures seen on plain radiographs underwent MRI using 1.5T and 3T scanners. T1 FSE and STIR axial, sagittal, and coronal view sequences were obtained. Two musculoskeletal radiologists interpreted the images independently and by consensus in case of disagreement.
Results
Of the 63 acute bone stress changes seen on 3T images, 61 were also seen on 1.5T images. The sensitivity of 1.5T MRI was 97% (95% CI: 89%-99%) compared with 3T. The 3T MRI images where, therefore, at least equally sensitive to 1.5T scanners in detection of bone marrow edema. On T1-weighted sequences, 3T images were slightly superior to 1.5T images in visualizing the demarcation of the edema and bone trabeculae. The kappa-value for inter-observer variability was 0.86 in the MRI indicating substantial interobserver agreement.
Conclusions
Owing to slightly better resolution of 3T images, edema characterization is easier, which might aid in the differential diagnosis of the bone marrow edema. There was, however, no noteworthy difference in the sensitivity of the 1.5T and 3T images to bone marrow edema. Routine identification of acute bone stress changes and suspected stress injuries can, therefore, be made with 1.5T field strength.
doi:10.1186/1471-2474-12-128
PMCID: PMC3121660  PMID: 21645348
8.  Mortality and cause of death in hip fracture patients aged 65 or older - a population-based study 
Background
The high mortality of hip fracture patients is well documented, but sex- and cause-specific mortality after hip fracture has not been extensively studied. The purpose of the present study was to evaluate mortality and cause of death in patients after hip fracture surgery and to compare their mortality and cause of death to those in the general population.
Methods
Records of 428 consecutive hip fracture patients were collected on a population-basis and data on the general population comprising all Finns 65 years of age or older were collected on a cohort-basis. Cause of death was classified as follows: malignant neoplasms, dementia, circulatory disease, respiratory disease, digestive system disease, and other.
Results
Mean follow-up was 3.7 years (range 0-9 years). Overall 1-year postoperative mortality was 27.3% and mortality after hip fracture at the end of the follow-up was 79.0%. During the follow-up, age-adjusted mortality after hip fracture surgery was higher in men than in women with hazard ratio (HR) 1.55 and 95% confidence interval (95% CI) 1.21-2.00. Among hip surgery patients, the most common causes of death were circulatory diseases, followed by dementia and Alzheimer's disease. After hip fracture, men were more likely than women to die from respiratory disease, malignant neoplasm, and circulatory disease. During the follow-up, all-cause age- and sex-standardized mortality after hip fracture was 3-fold higher than that of the general population and included every cause-of-death category.
Conclusion
During the study period, the risk of mortality in hip fracture patients was 3-fold higher than that in the general population and included every major cause of death.
doi:10.1186/1471-2474-12-105
PMCID: PMC3118151  PMID: 21599967
9.  Neuromuscular training with injury prevention counselling to decrease the risk of acute musculoskeletal injury in young men during military service: a population-based, randomised study 
BMC Medicine  2011;9:35.
Background
The rapidly increasing number of activity-induced musculoskeletal injuries among adolescents and young adults is currently a true public health burden. The objective of this study was to investigate whether a neuromuscular training programme with injury prevention counselling is effective in preventing acute musculoskeletal injuries in young men during military service.
Methods
The trial design was a population-based, randomised study. Two successive cohorts of male conscripts in four companies of one brigade in the Finnish Defence Forces were first followed prospectively for one 6-month term to determine the baseline incidence of injury. After this period, two new successive cohorts in the same four companies were randomised into two groups and followed prospectively for 6 months. Military service is compulsory for about 90% of 19-year-old Finnish men annually, who comprised the cohort in this study. This randomised, controlled trial included 968 conscripts comprising 501 conscripts in the intervention group and 467 conscripts in the control group. A neuromuscular training programme was used to enhance conscripts' motor skills and body control, and an educational injury prevention programme was used to increase knowledge and awareness of acute musculoskeletal injuries. The main outcome measures were acute injuries of the lower and upper limbs.
Results
In the intervention groups, the risk for acute ankle injury decreased significantly compared to control groups (adjusted hazards ratio (HR) = 0.34, 95% confidence interval (95% CI) = 0.15 to 0.78, P = 0.011). This risk decline was observed in conscripts with low as well as moderate to high baseline fitness levels. In the latter group of conscripts, the risk of upper-extremity injuries also decreased significantly (adjusted HR = 0.37, 95% CI 0.14 to 0.99, P = 0.047). In addition, the intervention groups tended to have less time loss due to injuries (adjusted HR = 0.55, 95% CI 0.29 to 1.04).
Conclusions
A neuromuscular training and injury prevention counselling programme was effective in preventing acute ankle and upper-extremity injuries in young male army conscripts. A similar programme could be useful for all young individuals by initiating a regular exercise routine.
Trial registration
ClinicalTrials.gov identifier number NCT00595816.
doi:10.1186/1741-7015-9-35
PMCID: PMC3084158  PMID: 21481230
10.  Recovery of brachial plexus lesions resulting from heavy backpack use: A follow-up case series 
Background
Brachial plexus lesions as a consequence of carrying a heavy backpack have been reported, but the typical clinical course and long-term consequences are not clear. Here we evaluated the clinical course and pattern of recovery of backpack palsy (BPP) in a large series of patients.
Methods
Thirty-eight consecutive patients with idiopathic BPP were identified from our population of 193,450 Finnish conscripts by means of computerised register. A physiotherapist provided instructions for proper hand use and rehabilitative exercises at disease onset. The patients were followed up for 2 to 8 years from the diagnosis. We also searched for genetic markers of hereditary neuropathy with pressure palsies. Mann-Whitney U-test was used to analyze continuous data. The Fischer's exact test was used to assess two-way tables.
Results
Eighty percent of the patients recovered totally within 9 months after the onset of weakness. Prolonged symptoms occurred in 15% of the patients, but daily activities were not affected. The weight of the carried load at the symptom onset significantly affected the severity of the muscle strength loss in the physiotherapeutic testing at the follow-up. The initial electromyography did not predict recovery. Genetic testing did not reveal de novo hereditary neuropathy with pressure palsies.
Conclusions
The prognosis of BPP is favorable in the vast majority of cases. Electromyography is useful for diagnosis. To prevent brachial plexus lesions, backpack loads greater than 40 kg should be avoided.
doi:10.1186/1471-2474-12-62
PMCID: PMC3076297  PMID: 21429232
peripheral nerve trauma; peripheral neuropathy; HNPP
11.  Bone Stress Injuries Are Common in Female Military Trainees: A Preliminary Study 
Although bone stress injuries are common in male military trainees, it is not known how common they are in female trainees. It also is unclear whether asymptomatic bone stress injuries heal if intensive training is continued. We prospectively followed 10 female trainees of a military Reserve Officer Course. The subjects underwent clinical and MRI examinations of the pelvis, thighs, and lower legs at the beginning, once during, and at the end of their 3-month course. We identified two to five injuries in every female trainee, all of whom already had the injuries at the beginning of the officer course. None of these injuries increased their severity despite vigorous training. Two-thirds were asymptomatic and low grade. Femoral and tibial shafts were the most common locations. Higher-grade injuries were more likely symptomatic, but regardless of the MRI findings, female trainees expressed only mild to moderate symptoms. Asymptomatic, low-grade bone stress injuries of the femoral and tibial shaft are common in female recruits undergoing heavy physical training. Because these injuries seem to remain constant or even disappear despite continued heavy physical activity, we do not recommend routine screening of asymptomatic trainees. As some bone stress fractures may have severe consequences (eg, in the femoral neck), symptomatic bone stress injuries should be examined and treated.
doi:10.1007/s11999-009-0851-5
PMCID: PMC2758974  PMID: 19384560
12.  Aetiology and risk factors of musculoskeletal disorders in physically active conscripts: a follow-up study in the Finnish Defence Forces 
Background
Musculoskeletal disorders (MSDs) are the main reason for morbidity during military training. MSDs commonly result in functional impairment leading to premature discharge from military service and disabilities requiring long-term rehabilitation. The purpose of the study was to examine associations between various risk factors and MSDs with special attention to the physical fitness of the conscripts.
Methods
Two successive cohorts of 18 to 28-year-old male conscripts (N = 944, median age 19) were followed for six months. MSDs, including overuse and acute injuries, treated at the garrison clinic were identified and analysed. Associations between MSDs and risk factors were examined by multivariate Cox's proportional hazard models.
Results
During the six-month follow-up of two successive cohorts there were 1629 MSDs and 2879 health clinic visits due to MSDs in 944 persons. The event-based incidence rate for MSD was 10.5 (95% confidence interval (CI): 10.0-11.1) per 1000 person-days. Most MSDs were in the lower extremities (65%) followed by the back (18%). The strongest baseline factors associated with MSDs were poor result in the combined outcome of a 12-minute running test and back lift test (hazard ratio (HR) 2.9; 95% CI: 1.9-4.6), high waist circumference (HR 1.7; 95% CI: 1.3-2.2), high body mass index (HR 1.8; 95% CI: 1.3-2.4), poor result in a 12-minute running test (HR 1.6; 95% CI: 1.2-2.2), earlier musculoskeletal symptoms (HR 1.7; 95% CI: 1.3-2.1) and poor school success (educational level and grades combined; HR 2.0; 95% CI: 1.3-3.0). In addition, risk factors of long-term MSDs (≥10 service days lost due to one or several MSDs) were analysed: poor result in a 12-minute running test, earlier musculoskeletal symptoms, high waist circumference, high body mass index, not belonging to a sports club and poor result in the combined outcome of the 12-minute running test and standing long jump test were strongly associated with long-term MSDs.
Conclusions
The majority of the observed risk factors are modifiable and favourable for future interventions. An appropriate intervention based on the present study would improve both aerobic and muscular fitness prior to conscript training. Attention to appropriate waist circumference and body mass index would strengthen the intervention. Effective results from well-planned randomised controlled studies are needed before initiating large-scale prevention programmes in a military environment.
doi:10.1186/1471-2474-11-146
PMCID: PMC2911403  PMID: 20602765
13.  Early risk factors for lumbar discectomy: an 11-year follow-up of 57,408 adolescents 
European Spine Journal  2008;17(10):1317-1323.
There is a lack of longitudinal studies on the risk factors of lumbar discectomy. Using combined population survey and hospital discharge register data in a prospective longitudinal design, we investigated the association between adolescent risk factors and lumbar discectomy until early middle age. A prospective cohort of health survey respondents (n = 57,408) aged 14–18 years was followed for 651,000 person-years (average follow-up, 11.3 years). Study endpoints were lumbar discectomy, death or end of follow-up. Participants’ mean age at the end of follow-up was 27 years. In multivariate Cox’s regression analysis, the significant risk factor for lumbar discectomy among male respondents was daily smoking, HR being 1.5 (95% CI 1.1–2.2). In females, frequent participation in sports clubs (HR 2.7, 95% CI 1.1–6.3) and overweight (HR 2.1; 95% CI 1.1–4.1) were significantly associated with an increased risk of lumbar discectomy. Daily smoking in males and frequent participation in sports clubs and overweight in females measured at adolescence were statistically associated with lumbar discectomy at an 11-year follow-up, although the hazard ratios were relatively small. Further study of these common risk factors and their modifications may lead to a better understanding of the causes of lumbar disc herniation.
doi:10.1007/s00586-008-0738-2
PMCID: PMC2556481  PMID: 18682991
Lumbar disc herniation; Epidemiology; Risk factors; Cohort study
14.  Musculoskeletal disorders in physically active conscripts: a one-year follow-up study in the Finnish Defence Forces 
Background
Musculoskeletal disorders (MSDs) are an important cause for morbidity in military service. They result in disabilities needing long-term rehabilitation and functional impairment leading to premature discharge from military service. The purpose of the study was to investigate the incidence and nature of MSDs in Finnish conscripts.
Methods
Two successive arrivals of 18–28-yr-old male conscripts (N = 955, median age 19) were followed for six months. MSDs, including overuse and acute injuries, treated at the garrison clinic were identified and analysed.
Results
During the 12-month study period there were 437 outpatient clinic visits in 955 persons. The occurrence rate was 33% during 6-month service while the event-based incidence was 3.3 per 1000 person-days. Occurrence peaked in summer months. The most common types of MSDs were low back pain (LBP, 20%), lower limb overuse injuries (16%) and sprains or strains (13%). Disorders mostly occurred in combat training in combat gear (40%) and during marching on foot or bicycle (28%). Overuse-related MSDs were more prevalent (66%) than traumatic ones (34%). One-third (34%) of the MSDs were recurrent and 66% were new ones. Disorders of the back and the knee were most frequently recurrent conditions (44% for both). Fractures, knee ligament ruptures, dislocations and muscle strains accounted for the highest number of service days lost. Twenty-four (2.5%) out of 955 conscripts were prematurely discharged due to MSDs.
Conclusion
Preventive measures during military service should be targeted at decreasing low back pain and lower limb overuse injuries, because these inflict the largest burden of MSDs and tend to have a chronic nature.
doi:10.1186/1471-2474-10-89
PMCID: PMC2724399  PMID: 19624829
15.  Ligament Reconstruction versus Distal Realignment for Patellar Dislocation 
Recently, medial patellofemoral ligament reconstruction has been emphasized for the treatment of patellar dislocation. This study compared the results of medial patellofemoral ligament reconstruction by adductor magnus tenodesis with distal patellar realignment in patients with recurrent patellar dislocation. Additionally, the development of patellofemoral osteoarthrosis was compared for these two procedures at a median 10-year followup. Between 1994 and 2000, 47 consecutive patients were treated for recurrent patellar dislocation by adductor magnus tenodesis (18 knees) or Roux-Goldthwait procedure (29 knees). Redislocations, subjective symptoms, and functional outcomes were evaluated. Magnetic resonance imaging was performed at followup. The incidence of patellar redislocation after surgery was 7% in the adductor magnus group and 14% in the Roux-Goldthwait group. Median Kujala scores were 88 for the adductor magnus group and 86 for the Roux-Goldthwait group. Magnetic resonance imaging revealed patellofemoral articular cartilage lesions in 22 knees (73.3%) at followup, including 14 (46.6%) with full-thickness cartilage loss. Radiographs revealed patellofemoral osteoarthritis in five patients in the Roux-Goldthwait group and in none of the patients in the adductor magnus group. Adductor magnus tenodesis is a reliable method to treat recurrent patellar dislocation. The medial patellofemoral ligament reconstruction seems to reduce the risk of osteoarthrosis compared with distal realignment surgery.
Level of Evidence: Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
doi:10.1007/s11999-008-0207-6
PMCID: PMC2384023  PMID: 18347890
16.  Incidence and trends of low back pain hospitalisation during military service – An analysis of 387,070 Finnish young males 
Background
There is evidence that low back pain (LBP) during young adulthood and military service predicts LBP later in life. The purpose of this study was to investigate the incidence and trends of LBP hospitalisation among Finnish military conscripts.
Methods
All male conscripts performing their compulsory military service during 1990–2002 were included in the study population. Altogether 387,070 military conscripts were followed throughout their six-to-twelve-month service period. Data on LBP hospitalisations were obtained from the National Hospital Discharge Register.
Results
Altogether 7,240 LBP hospitalisations were identified among 5,061 (1.3%) male conscripts during the study period. The event-based incidence of LBP hospitalisation was 27.0 (95% confidence interval (CI): 25.7–28.2). In most cases, the diagnosis was unspecified LBP (n = 5,141, 71%) followed by lumbar disc disorders (n = 2,069, 29%). Hospitalisation incidence due to unspecified LBP was 19.1 per 1,000 person-years (95% CI: 18.3 to 20.4), and 7.8 per 1,000 person-years (95% CI: 6.7 to 8.3) due to lumbar disc disorders. The incidence of unspecified LBP remained unaltered, while hospitalisation due to lumbar disc disorders declined from 1993 onwards.
Conclusion
Although conscripts accepted into military training pass physician-performed examinations as healthy, young adults, LBP hospitalisation causes significant morbidity during military service.
doi:10.1186/1471-2474-10-10
PMCID: PMC2637829  PMID: 19152697
17.  Low back pain and its risk indicators: a survey of 7,040 Finnish male conscripts 
European Spine Journal  2007;17(1):64-69.
Studies describing risk indicators of low back pain (LBP) have focused on adults, although the roots of LBP lie in adolescence and early adulthood. The objective of the present study was to assess the lifetime occurrence and risk indicators of LBP in young adult males. The survey sample comprised 7,333 male conscripts (median age 19), of which 7,040 (96%) answered a questionnaire during the first days of their conscription. The outcome was lifetime LBP prompting at least one visit to a physician. Associations between 18 background variables and LBP were analysed by logistic regression. Altogether 894 (12.7%) respondents reported LBP. Health status was a strong determinant of LBP. The strongest individual risk indicators for LBP were having two or more other than back-related diseases diagnosed by a physician during past year (OR 2.0; 95% CI 1.6–2.5), below-average self-perceived health (OR 1.6; 95% CI 1.3–2.0) and use of smokeless tobacco (OR 1.4; 95% CI 1.2–1.7). Socioeconomic status was not associated with LBP and health behaviours only weakly. The strongest risk indicators for LBP were related to health problems. Of the socioeconomic background factors, none were associated with LBP. It is evident that LBP is associated with other health problems as well, indicating that its background may be multifactorial. This presents challenges for prevention programme planning and implementation. Longitudinal cohort studies are urgently needed to enhance understanding of adolescent risk indicators of LBP.
doi:10.1007/s00586-007-0493-9
PMCID: PMC2365533  PMID: 17874146
Low back pain; Health behaviour; Risk indicators; Epidemiology
18.  Adolescents' health and health behaviour as predictors of injury death. A prospective cohort follow-up of 652,530 person-years 
BMC Public Health  2008;8:90.
Background
Injuries represent an important cause of mortality among young adults. Longitudinal studies on risk factors are scarce. We studied associations between adolescents' perceived health and health behaviour and injury death.
Methods
A prospective cohort of 57,407 Finns aged 14 to 18 years was followed for an average of 11.4 years. The end-point of study was injury death or termination of follow-up in 2001. The relationships of eight health and health behaviour characteristics with injury death were studied with adjusted Cox's proportional hazard model.
Results
We identified 298 (0.5%) injury deaths, 232 (0.9%) in men and 66 (0.2%) in women. The mean age at death was 23.8 years. In the models adjusted for age, sex and socioeconomic background, the strongest risk factors for injury death were recurring drunkenness (HR 2.1; 95% CI: 1.4–3.1) and daily smoking (HR 1.7; 95% CI: 1.3–2.2). Poor health did not predict injury death. Unintentional and intentional injury deaths had similar health and health behavioural risk factors.
Conclusion
Health compromising behaviour adopted at adolescence has a clear impact on the risk of injury death in adulthood independent from socioeconomic background. On the other hand, poor health as such is not a significant predictor of injury death. Promotion of healthy lifestyle among adolescents as part of public health programmes would seem an appropriate way to contribute to adolescent injury prevention.
doi:10.1186/1471-2458-8-90
PMCID: PMC2292710  PMID: 18366651
19.  Adolescent survey non-response and later risk of death. A prospective cohort study of 78 609 persons with 11-year follow-up 
BMC Public Health  2007;7:87.
Background
Non-response in survey studies is a growing problem and, being usually selective, it leads to under- or overestimation of health outcomes in the follow-up. We followed both respondents and non-respondents by registry linkage to determine whether there is a risk of death, related to non-response at baseline.
Methods
Sample data of biennial surveys to 12-18-year-old Finns in 1979–1997 were linked with national death registry up to 2001. The number of respondents was 62 528 (79.6%) and non-respondents 16 081 (20.4%). The average follow-up was 11.1 years, totalling 876 400 person-years. The risk of death between non-respondents and respondents was estimated by hazard ratios (HR).
Results
The number of deaths per 100 000 person-years were 229 in non-respondents and 447 in respondents (HR 2.0, 95% CI: 1.5–2.6). The hazard ratios of death were for intoxication 3.2 (95% CI: 1.9–5.4), for disease 3.1 (95% CI: 2.2–4.1), for violence-related injury 2.0 (95% CI: 1.5–2.6) and for unintentional injury 1.8 (95% CI: 1.3–2.4) in non-respondents vs. respondents. The association between non-response and death increased with age at baseline, and the increase persisted after the age of 25.
Conclusion
Our study demonstrated significantly increased rates of death among adolescent non-respondents in a follow-up. The highest hazard ratios were seen in disease- and violence-related deaths. The death rate varied between respondents and non-respondents by death type. Increased rates of death persisted beyond the age of 25.
doi:10.1186/1471-2458-7-87
PMCID: PMC1885252  PMID: 17519009

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