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Background A spinal cord injury (SCI) has multiple effects on the persons’ life, and can lead to impairments in activities, social participation, and environmental factors. Rehabilitation is important for regaining functioning and new skills. The aim of the study wasto determine the factors that people with SCI perceived as promoting and facilitating their rehabilitation, and what they found to be challenges and possible barriers. Methods This study was part of a larger, mixed method Finnish Spinal Cord Injury study (FinSCI). The current study had a qualitative approach and used a deductive-inductive content analysis. The deductive approach was guided by a theory of six phases of a rehabilitation process by Autti-Rämö, followed by an inductive analysis to describe in-depth the perceptions of persons with SCI in each phase of the rehabilitation process. We collected the data by interviews from 45 persons representing participants from FinSCI study and used a structured interview guide. Results We found 28 facilitators and 19 barriers in the rehabilitation process. The majority of the facilitators and barriers were related to the phase of rehabilitation planning. There were more barriers than facilitators at the beginning of the rehabilitation process in applying for and accessing treatment or rehabilitation, and during the implementation of rehabilitation. As for the facilitators that progressed the rehabilitation process, some of them included: successful or realized, planned treatments, rehabilitation events, clear goals, multidisciplinary teamwork, support, and monitoring various changing situations, and rehabilitating one’s own capability and activity. The barriers were: delays, challenges and deficiencies in the planning and implementation of their treatment or rehabilitation, the lack of different rehabilitation professionals’ skills and resources, and different patients’ personal factors, which made the progress of the rehabilitation process cumbersome. Conclusions We identified that communication and interaction were common denominators for the facilitators and barriers. Good communication and interaction among rehabilitation professionals and rehabilitees promoted the occurrence and repetition of facilitating factors during different phases of the rehabilitation process. Good care and good rehabilitation practice for people with SCI were the result of multidisciplinary teamwork, in which a person with SCI was an active member.

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.

ICF-luokitus on biopsykososiaalinen viitekehys, joka mahdollistaa asiakkaan toimintakyvyn ja siihen nivoutuvien tekijöiden kokonaisvaltaisen ymmärtämisen. ICF-luokituksen Yksilötekijät -osa-alueen tarkempi kuvaus on kesken, mikä vaikeuttaa ICF-luokituksen täysipainoista hyödyntämistä. Tämän kartoittavan kirjallisuuskatsauksen tavoitteena oli kuvata, mitä teemoja tutkimuksissa oli tunnistettu ICF-luokituksen mukaisiksi yksilötekijöiksi ja miten yksilötekijöiden luokittelun ja huomioisen tarvetta käytännön työssä perusteltiin. Systemaattinen tiedonhaku tehtiin Cinahl, Pubmed, Science Direct ja Sport Discus sekä Finna, Helda, Helka, Julkari ja Medic -tietokannoista rajautuen vuosina 2010–2020 julkaistuihin artikkeleihin. Teoriaohjaavan aineiston analyysimenetelmällä artikkeleista eritellyt yksilötekijät luokiteltiin Geyh ym. (2019) mukaan seitsemään luokkaan: 1. Sosio-demografiset tekijät, 2. Asema välittömässä sosiaalisessa ja fyysisessä kontekstissa, 3. Henkilökohtaisen elämän historia, 4. Henkilökohtainen kokemus tunteista, 5. Henkilökohtainen kokemus omista ajatuksista ja uskomuksista, 6. Motiivit ja 7. Toistuvat kokemukselliset ja käyttäytymisen mallit. Mukaanottokriteerit täyttävissä 226 artikkelissa oli käsitelty runsaasti erilaisia yksilötekijöitä. Ne linkittyivät kaikkiin Geyh ym. (2019) luokkiin ja osa jäi luokituksen ulkopuolelle. Lisäksi osassa tutkimuksissa oli määritelty yksilötekijöiksi tekijöitä, jotka olivat linkitettävissä jollekin toiselle ICF-osa-alueelle tai jotka eivät kuvanneet toimintakykyä. Päätelmiä yksilötekijöiden roolista kuntoutuksessa oli tehty 50 (22 %) tutkimuksista. ICF:n yksilötekijöiden kirjo tutkimuksissa oli laaja, ja niiden huomioiminen osana toimintakykytietoa laajentaa ymmärrystä asiakkaan tilanteesta ja kuntoutumiseen vaikuttavista tekijöistä. Tämän tutkimuksen perusteella ei kuitenkaan ole mahdollista suositella, tulisiko ja miten yksilötekijöitä luokitella tarkemmin. Abstract The ICF personal factors are part of a comprehensive assessment of functioning - a scoping review of ICF personal factors in the rehabilitation studies The ICF classification is a biopsychosocial frame of reference that contributes to a holistic understanding of the client’s functioning and the factors involved. A more detailed description of the ICF personal factors is pending, which makes it difficult to apply the ICF classification in full. The aim of this scoping review was to describe which themes were identified in the studies as personal factors according to the ICF classification and what conclusions have been drawn about their further coding in the ICF classification. A systematic search was performed on the Cinahl, Pubmed, Science Direct and Sport Discus as well as Finnish databases (Finna, Helda, Helka, Julkari and Medic), based on articles published in 2010–2020. According to Geyh et al. (2019), the personal factors specified in the articles by, were classified into seven categories: socio-demographical 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. The search yielded 226 studies that met the inclusion criteria. The articles had addressed a wide variety of personal factors that linked to all seven categories defined by Geyh et al. (2019). In addition, some studies had defined as personal factors that were linkable to other components of the ICF or that did not describe functioning. About 50 (22 %) of the studies had made conclusions on the role of personal factors in rehabilitation. The range of personal factors in the ICF classification addressed in the studies is wide and taking them into account as part of functioning information expands the understanding of the client's situation and the factors influencing rehabilitation However, based on this study, it is not possible to recommend a more precise coding of personal factors. Keywords: ICF, personal factors, rehabilitation, scoping review

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

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.

Study design A cross-sectional survey of the Finnish population with spinal cord injury (FinSCI database). Objectives To describe the functional independence of the population with spinal cord injury (SCI) in Finland and to identify how generic and lesion characteristics affect their functional independence. Setting The participants were recruited from the registers of three SCI outpatient clinics responsible for lifelong follow-up and care for people with SCI in Finland. Methods The data were retrieved from FinSCI (n = 1772). The response rate was 50% (n = 884). The Spinal Cord Independence Measure-Self Report (SCIM-SR) was used. The data were analyzed with univariate testing, factor analyses, and multiple linear regression models. Results The median (percentiles 25; 75) SCIM-SR total score was 76.0 (58.8; 89.0), and the score was 18.0 (13.0; 20:0) for the self-care sub-scale, 33.0 (25.0; 39.0) for the respiration and sphincter management sub-scale and 29.0 (16.0; 36.8) for the mobility sub-scale. The higher the neurological level in groups AIS A, B, and C, the lower the functional ability. Group AIS D at any injury level had the highest level of functional ability. Age and the number of years since injury negatively influenced the SCIM-SR scores for every sub-scale. Conclusion Based on the International Spinal Cord Injury Core Data Set, the severity of SCI can differentiate persons with SCI according to their functional ability. The results suggest that SCI affects individuals’ health more than ageing alone does, thereby reducing the functional ability and independence of persons with SCI over time.

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.

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 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 p 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 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.

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.

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.

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. Electronic supplementary material The online version of this article (10.1007/s10926-019-09837-2) contains supplementary material, which is available to authorized users.

Background: Systems for health must evolve to become learning systems, facilitating the implementation of Universal Health Coverage, the integration of social and health services, and the democratization of health data to put service users at the center. Objectives: The ICanFunction mHealth Solution (mICF) is described and its application explored. mICF’s primary aim is to empower service users to achieve health equity through communication of their needs and aspirations with service providers. Furthermore, mICF has potential to become a tool to enhance interprofessional teamwork and to provide meaningful data for policy development to attain health equity. Methods: An international collaborative defined the project’s scope, as well as the content and technology towards a viable prototype. The project development is described since conception: a comprehensive needs assessment, first prototype, and future steps. Results: Responses (n=1,191) from 32 countries informed mICF’s scope, content, and prototype design. A linking platform, connecting natural language to the terms of the International Classification of Functioning, Disability and Health (ICF), was developed and a first minimum viable product was tested. Conclusion: mICF could facilitate a shift from disease-focused, institution-based, biomedical service provision to collaborative, person-centered, community-based services with a bio-psycho-social-spiritual approach. mICF should contribute information for more tailored interventions towards Universal Health Coverage through active participation of service 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.

Renewable energy has a significant role to play in helping the world achieve the greenhouse gas emission reduction necessary to achieve the pathway to a 2°C increase in global temperature. Electricity generation from wind and solar resources can contribute immensely to the decarbonization of power generation, but these resources are intermittent. High penetration of intermittent renewable power generation can cause grid stability and control issues for network operators, with fast response fossil fuel power plant necessary to provide security of supply and maintain grid stability. Increasingly natural gas-fueled distributed power generation is being installed to provide the necessary grid support. However, hybrid power plants comprised of a fossil fuel power generating system, a renewable power generation system and energy storage can provide both the low CO2 electricity required to meet environmental constraints, and the despatchability and stability required by grid operators. Integrated Solar Combined Cycle Power Plants (ISCCs), comprising a Concentrated Solar Power plant and a natural gas fired combined cycle plant, have the potential to simultaneously reduce fossil fuel consumption, provide secure, highly predictable electricity generation, and reduce the cost of integrating renewable energy into a power system. While a number of ISCCs have been built at a larger scale (above 150MW power output), the concept has rarely been adopted for smaller scale distributed power applications. In addition, the traditional ISCC concept uses a steam bottoming cycle, which consumes water, and often locations where distributed ISCC could be utilized suffer from a scarcity of fresh water. This paper evaluates whether replacing the steam bottoming cycle with an Organic Rankine Cycle (ORC) alternative can provide a simpler, lower cost distributed ISCC solution that can be utilized on smaller and island grid systems, or mini- and micro-grids, to provide an affordable, water-free, low carbon power generation system.

Objectives: The aim of this study was to analyze and describe process and outcomes of two pilot assessments based on the HTA Core Model, discuss the applicability of the model, and explore areas of development.Methods: Data were gathered from HTA Core Model and pilot Core HTA documents, their validation feedback, questionnaires to investigators, meeting minutes, emails, and discussions in the coordinating team meetings in the Finnish Office for Health Technology Assessment (FINOHTA).Results: The elementary structure of the HTA Core Model proved useful in preparing HTAs. Clear scoping and good coordination in timing and distribution of work would probably help improve applicability and avoid duplication of work.Conclusions: The HTA Core Model can be developed into a platform that enables and encourages true HTA collaboration in terms of distribution of work and maximum utilization of a common pool of structured HTA information for national HTA reports.

Objectives: The aim of this study was to develop and test a generic framework to enable international collaboration for producing and sharing results of health technology assessments (HTAs).Methods: Ten international teams constructed the HTA Core Model, dividing information contained in a comprehensive HTA into standardized pieces, the assessment elements. Each element contains a generic issue that is translated into practical research questions while performing an assessment. Elements were described in detail in element cards. Two pilot assessments, designated as Core HTAs were also produced. The Model and Core HTAs were both validated. Guidance on the use of the HTA Core Model was compiled into a Handbook.Results: The HTA Core Model considers health technologies through nine domains. Two applications of the Model were developed, one for medical and surgical interventions and another for diagnostic technologies. Two Core HTAs were produced in parallel with developing the model, providing the first real-life testing of the Model and input for further development. The results of formal validation and public feedback were primarily positive. Development needs were also identified and considered. An online Handbook is available.Conclusions: The HTA Core Model is a novel approach to HTA. It enables effective international production and sharing of HTA results in a structured format. The face validity of the Model was confirmed during the project, but further testing and refining are needed to ensure optimal usefulness and user-friendliness. Core HTAs are intended to serve as a basis for local HTA reports. Core HTAs do not contain recommendations on technology use.

Purpose A systematic review was conducted to review the effectiveness of workplace accommodation (WA) regarding employment, work ability, and cost-benefit among disabled people. It also describes the evidence gained on the barriers and facilitators of WA process to sustain employment. Methods We reviewed systematically current scientific evidence about effectiveness of WA among disabled persons. The outcomes were employment, work ability, and cost-benefit. Qualitative studies of employment facilitators and barriers were also included. The population comprised people with physical disability, visual impairment, hearing impairment, cognitive disability, or mental disability, aged 18–68 years. CINAHL, the Cochrane Library, Embase, Medic, OTseeker, PEDro, PsycInfo, PubMed, Scopus, and Web of Science were searched for peer-reviewed articles published in English from January 1990 to November 2012. Results Three quantitative (one randomized controlled, one concurrently controlled, and one cohort) and eight qualitative studies met the inclusion criteria. There was moderate evidence that specific types of WA (vocational counselling and guidance, education and self-advocacy, help of others, changes in work schedules, work organization, and special transportation) promote employment among physically disabled persons and reduce costs. There was low evidence that WA (liaison, education, work aids, and work techniques) coordinated by case managers increases return to work and is cost-effective when compared with the usual care of persons with physical and cognitive disabilities. The key facilitators and barriers of employment were self-advocacy, support of the employer and community, amount of training and counselling, and flexibility of work schedules and work organization. Conclusions More high-quality studies using validated measures of the work ability and functioning of disabled persons are needed. The identified barriers and facilitators found in the qualitative studies should be used to develop quantitative study designs.

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.

This overview summarizes the available evidence from systematic reviews of outcomes studies on various assistive technologies (AT) for persons with disabilities. Systematic reviews published betwee ...

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.

Health technology assessment (HTA) is generally defined as a multidisciplinary research field that aims to produce objective knowledge for decision makers on the benefits, costs and harms of a technology. This paper describes an attempt to develop a systematic relational model for the evaluation of the patient aspects of health technologies, and in particular employs actor-network theory (ANT), with its emphasis on a non-linear innovation process, translations, co-production of technology and context and socio-material networks. It first considers the ontological and other presumptions of mainstream HTA and suggests an alternative relational ontology and approach. It then analyses the patient aspects of health technology by defining its scope and other issues that may provide a general framework for studying and evaluating the patient aspects of health technology. It then briefly discusses the implications of the relational approach in regard to the empirical practice of the whole HTA.

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.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.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.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.

We conducted a criteria-based appraisal of systematic reviews on the effectiveness of physiotherapy and conductive education interventions in children with cerebral palsy (CP). Computerized bibliographic databases were searched without language restriction up to August 2007. Reviews on trials and descriptive studies were included. Two reviewers independently identified, selected, and assessed the quality of the reviews using the criteria from the Overview Quality Assessment Questionnaire complemented with decision rules. Twenty-one reviews were included, six of which were of high methodological quality. Altogether, the reviews included 23 randomized controlled trials and 104 observational studies on children with CP. The high-quality reviews found some evidence supporting strength training, constraint-induced movement therapy, or hippotherapy, and insufficient evidence on comprehensive physiotherapy and occupational therapy interventions. Conclusions in the other reviews should be interpreted cautiously, although, because of the poor quality of the primary studies, most reviews drew no conclusions on the effectiveness of the reviewed interventions. Reviews on complex interventions in heterogeneous populations should use rigorous methods and report them adequately, closely following the Quality of Reporting of Meta-Analyses recommendations.

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.

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.

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.

Teknologioilla pyritään vastaamaan yleisimpiin ikääntyneiden eri elämäntilanteisiin liittyviin toiveisiin ja tarpeisiin. Näitä ovat mahdollisuus elää yksilöllistä hyvää elämää, sosiaalisen vuorovaikutuksen säilyminen läheisten kanssa sekä turvallisuuden tunteen säilyttäminen. (1, 2) Iäkkäillä on lisääntyvästi valmiuksia teknologian käyttöön, mutta hoivapalveluissa tai kotona teknologioiden uudet mahdollisuudet jäävät usein vielä huomaamatta. Teoreettisten mallien ja empiiristen tutkimusten avulla on tunnistettu niitä tekijöitä, jotka vaikuttavat teknologian hyväksymiseen ja käyttöönottoon. Iäkkäiden teknologiapelot näyttäisivät hiljalleen vähenevän. Tärkeimpiä vaatimuksia uusien teknologioiden kehittämiselle iäkkäille ovat teknologian tuttuus ja sen soveltuminen luontevana osana arkiympäristöä.

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.

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.

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.

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.

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.Systematic review.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.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.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.

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.

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.

The population of Finland is ageing with greater demand for health and social care; homecare workers are over-burdened with keeping up with this change whilst ageing themselves. Technology is seen as one of the most promising solutions to tackling these challenges. In the national KATI programme, six regional projects will implement technology solutions and adopt new technology-based practices in a coordinated manner to support the ageing of older people at home as well as the homecare professionals and services. In this article, we give an overview of the variety of technology solutions being implemented and the first ethical questions that have been raised by the projects in the early phase. Thereafter, we highlight three different theoretical approaches that support the ethical and sustainable technology implementation advanced by the programme. The approaches 1) emphasize the holistic perspective on the health of the older person and the method of discourse ethics to seek for consensus about the technology solutions, 2) learn from safety research and the change theory for better ethical design of AI systems, and 3) analyse the technology implementations and the programme from a systemic perspective within the framework of socio-technological transition. Our expectation is that the approaches will provide theoretical tools and heuristics that can be used to ensure that the ultimate goal of the KATI programme, a national, continuing collaborative model of technology-supported ageing and care of older people at home, will be ethical and sustainable.

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.