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Anttila S, Määttä J, Heikkala E, Arokoski J, Karppinen J, Oura P. Associations of socioeconomic and lifestyle characteristics, psychological symptoms, multimorbidity, and multisite pain with sciatica - a 15-year longitudinal study. Spine J 2024; 24:842-850. [PMID: 38211903 DOI: 10.1016/j.spinee.2023.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 12/03/2023] [Accepted: 12/27/2023] [Indexed: 01/13/2024]
Abstract
BACKGROUND CONTEXT Sciatica is defined as pain radiating from the low back to the leg, usually below the knee. It is a disabling condition that causes a major burden to health care and society. Previous evidence of the multifactorial etiology of sciatica comes mostly from cross-sectional studies. Larger, longitudinal studies with a multidimensional set of variables are needed. PURPOSE To examine how socioeconomic and lifestyle characteristics, psychological symptoms, multimorbidity, and multisite pain are associated with sciatica. STUDY DESIGN A longitudinal study of the Northern Finland Birth Cohort 1966. PATIENT SAMPLE In total 6,683 working-aged members of the Northern Finland Birth Cohort 1966. OUTCOME MEASURES Self-reported sciatic pain status over a 15-year study period. METHODS We conducted a 15-year longitudinal study from the age of 31 to 46. We used multivariable generalized estimation equations analysis to examine how socioeconomic characteristics (low education, unemployment, and living alone), lifestyle characteristics (overweight, obesity, current smoking, and physical inactivity), psychological symptoms (depression, anxiety), multimorbidity, and multisite pain were associated with sciatica. RESULTS At the age of 31, 21.1% of the study population reported sciatic pain and at the age of 46, 36.7%. Multisite pain was clearly the strongest factor associated with sciatica (odds ratio [OR] 2.61, 95% confidence interval [CI] 2.34‒2.92). In descending order of effect size, older age, low education, psychological symptoms, multimorbidity, overweight, obesity, physical inactivity and current smoking were positively associated with sciatica. Their ORs varied between 1.17 and 2.18. Living alone was negatively associated with sciatica (OR 0.81, 95% CI 0.72‒0.90). CONCLUSIONS Multisite pain had the strongest association with sciatica. The effect sizes of the other factors were clearly smaller. To our knowledge this is the first study to evaluate the association of multisite pain with sciatica. This finding may have considerable implications for clinical work treating patients with sciatica.
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Affiliation(s)
- Sanna Anttila
- Medical Research Center Oulu, Oulu University Hospital, University of Oulu, P.O. Box 8000, FI-90014, Oulu, Finland; Research Unit of Health Sciences and Technology, University of Oulu, P.O. Box 8000, FI-90014, Oulu, Finland.
| | - Juhani Määttä
- Medical Research Center Oulu, Oulu University Hospital, University of Oulu, P.O. Box 8000, FI-90014, Oulu, Finland; Research Unit of Health Sciences and Technology, University of Oulu, P.O. Box 8000, FI-90014, Oulu, Finland
| | - Eveliina Heikkala
- Medical Research Center Oulu, Oulu University Hospital, University of Oulu, P.O. Box 8000, FI-90014, Oulu, Finland; Research Unit of Population Health, University of Oulu, P.O. Box 8000, FI-90014, Oulu, Finland
| | - Jari Arokoski
- Department of Physical and Rehabilitation Medicine, Helsinki University Hospital, University of Helsinki, P.O. Box 4, FI-00014, Helsinki, Finland
| | - Jaro Karppinen
- Medical Research Center Oulu, Oulu University Hospital, University of Oulu, P.O. Box 8000, FI-90014, Oulu, Finland; Research Unit of Health Sciences and Technology, University of Oulu, P.O. Box 8000, FI-90014, Oulu, Finland; Finnish Institute of Occupational Health, FI-90032, Oulu, Finland; Rehabilitation Services of Wellbeing Services County of South Karelia, FI-53130, Lappeenranta, Finland
| | - Petteri Oura
- Medical Research Center Oulu, Oulu University Hospital, University of Oulu, P.O. Box 8000, FI-90014, Oulu, Finland; Research Unit of Health Sciences and Technology, University of Oulu, P.O. Box 8000, FI-90014, Oulu, Finland; Department of Forensic Medicine, University of Helsinki, P.O. Box 21, FI-00014, Helsinki, Finland; Forensic Medicine Unit, Finnish Institute for Health and Welfare, P.O. Box 30, FI-00271, Helsinki, Finland
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Heikkala E, Oura P, Määttä J, Karppinen J, Merikanto I. Pressure Pain Sensitivity and Chronotype: A Population-based Study of Middle-aged Finns. J Pain 2024:S1526-5900(24)00348-1. [PMID: 38242335 DOI: 10.1016/j.jpain.2024.01.338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 01/06/2024] [Accepted: 01/11/2024] [Indexed: 01/21/2024]
Abstract
Evening chronotype individuals experience pain more often than morning chronotypes, but relationships with pain sensitivity have rarely been studied. We examined whether chronotype is associated with pressure pain sensitivity, with special reference to mental health disorders, insomnia, and chronic musculoskeletal (MSK) pain as potential moderating factors. The study sample consisted of members of the Northern Finland Birth Cohort 1966 aged 46. Pressure pain threshold and tolerance were measured via the standardized protocol, categorized as lowest quartile versus others. Chronotype (morning [M; the reference], intermediate [I], and evening [E]) was defined using the Short Morningness-Eveningness questionnaire. Sex-stratified binary logistic regression models were separately adjusted for education, body mass index, long-term diseases (fully adjusted model), and for mental health disorders, insomnia, and chronic MSK pain (a residual confounding analysis). Interaction terms (Chronotype × Mental health/insomnia/chronic MSK pain) were tested. The study had 2,132 males and 2,830 females. The E-type males had 1.5-fold odds of having a low pain threshold (fully adjusted odds ratio [OR] 1.45, 95% confidence interval 1.05-2.00) and pressure pain tolerance (fully adjusted OR 1.47, 1.07-2.02), in comparison to M-types. Having a mental health disorder intensified the association with low pain threshold fourfold (4.06, 1.56-10.6). Being an E-type female was also associated with a low pain threshold, but the association was statistically nonsignificant (fully adjusted OR 1.18, .90-1.53). No statistically significant interactions were found among females. These results emphasize the role of chronotype in pain sensitivity and add an understanding of pain experience in light of innate circadian types. PERSPECTIVE: Male evening chronotypes are more sensitive to pain than morning chronotypes. Diagnosed mental health disorders in particular indicate a low pain threshold for evening chronotype males.
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Affiliation(s)
- Eveliina Heikkala
- Research Unit of Population Health, University of Oulu, Oulu, Finland; Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland; Wellbeing Services County of Lapland, Rovaniemi, Finland
| | - Petteri Oura
- Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland; Research Unit of Health Sciences and Technology, University of Oulu, Oulu, Finland
| | - Juhani Määttä
- Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland; Research Unit of Health Sciences and Technology, University of Oulu, Oulu, Finland
| | - Jaro Karppinen
- Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland; Research Unit of Health Sciences and Technology, University of Oulu, Oulu, Finland; Rehabilitation Services of South Karelia Social and Health Care District, Lappeenranta, Finland
| | - Ilona Merikanto
- Research Unit of Population Health, University of Oulu, Oulu, Finland; SleepWell Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland; Department of Public Health Solutions, Finnish Institute for Health and Welfare, Helsinki, Finland; Orton Orthopaedics Hospital, Helsinki, Finland
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Heikkala E, Oura P, Paananen M, Ho E, Ferreira P, Tanguay-Sabourin C, Karppinen J. Chronic disease clusters are associated with prolonged, bothersome, and multisite musculoskeletal pain: a population-based study on Northern Finns. Ann Med 2023; 55:592-602. [PMID: 36773018 PMCID: PMC9930817 DOI: 10.1080/07853890.2023.2177723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/12/2023] Open
Abstract
BACKGROUND Chronic diseases often accumulate with musculoskeletal (MSK) pain. However, less evidence is available on idiosyncratic patterns of chronic diseases and their relationships with the severity of MSK pain in general MSK pain populations. MATERIAL AND METHODS Questionnaire-based data on physician-diagnosed chronic diseases, MSK pain and its dimensions (frequency, intensity, bothersomeness, and the number of pain sites), and confounders were collected from the Northern Finland Birth Cohort 1966 at the age of 46. Latent Class Analysis (LCA) was used to identify chronic disease clusters among individuals who reported any MSK pain within the previous year (n = 6105). The associations between chronic disease clusters, pain dimensions, and severe MSK pain, which was defined as prolonged (over 30 d within the preceding year), bothersome (Numerical Rating Scale >5), and multisite (two or more pain sites) pain, were analyzed using logistic regression and general linear regression models, adjusted for sex and educational level (n for the full sample = 4768). RESULTS LCA resulted in three clusters: Metabolic (10.8% of the full sample), Psychiatric (2.9%), and Relatively Healthy (86.3%). Compared to the Relatively Healthy cluster, the Metabolic and Psychiatric clusters had higher odds for daily pain and higher mean pain intensity, bothersomeness, and the number of pain sites. Similarly, the odds for severe MSK pain were up to 75% (95% confidence interval: 44%-113%) and 155% (81%-259%) higher in the Metabolic and Psychiatric clusters, respectively, after adjustments for sex and educational level. CONCLUSIONS Distinct patterns of chronic disease accumulation can be identified in the general MSK pain population. It seems that mental and metabolic health are at interplay with severe MSK pain. These findings suggest a potential need to screen for psychiatric and metabolic entities of health when treating working-aged people with MSK pain.Key messagesThis large study on middle-aged people with musculoskeletal pain aimed to examine the idiosyncratic patterns of chronic diseases and their relationships with the severity of musculoskeletal pain. Latent class cluster analysis identified three chronic disease clusters: Psychiatric, Metabolic, and Relatively Healthy. People with accumulated mental (Psychiatric cluster) or metabolic diseases (Metabolic cluster) experienced more severe pain than people who were relatively healthy (Relatively Healthy cluster). These findings suggest a potential need to screen for psychiatric and metabolic entities of health when treating working-aged people with MSK pain.
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Affiliation(s)
- Eveliina Heikkala
- Research Unit of Population Health, University of Oulu, Oulu, Finland.,Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland.,Rovaniemi Health Center, Rovaniemi, Finland
| | - Petteri Oura
- Research Unit of Population Health, University of Oulu, Oulu, Finland.,Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Markus Paananen
- Research Unit of Population Health, University of Oulu, Oulu, Finland.,Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland.,Western Uusimaa Wellbeing Services County, Social and Health Care Services, Espoo, Finland
| | - Emma Ho
- Sydney Musculoskeletal Health, School of Health Sciences, Charles Perkins Centre, University of Sydney, Sydney, Australia.,Sydney Musculoskeletal Health, The Kolling Institute, School of Health Sciences, University of Sydney, Sydney, Australia
| | - Paulo Ferreira
- Sydney Musculoskeletal Health, School of Health Sciences, Charles Perkins Centre, University of Sydney, Sydney, Australia
| | - Christophe Tanguay-Sabourin
- Alan Edwards Pain Centre for Research on Pain, McGill University, Montreal, Canada.,Faculty of Medicine, Université de Montréal, Montreal, Canada
| | - Jaro Karppinen
- Research Unit of Population Health, University of Oulu, Oulu, Finland.,Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland.,Rehabilitation Services of South Karelia Social and Health Care District, Lappeenranta, Finland
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Tanguay-Sabourin C, Fillingim M, Guglietti GV, Zare A, Parisien M, Norman J, Sweatman H, Da-Ano R, Heikkala E, Perez J, Karppinen J, Villeneuve S, Thompson SJ, Martel MO, Roy M, Diatchenko L, Vachon-Presseau E. A prognostic risk score for development and spread of chronic pain. Nat Med 2023; 29:1821-1831. [PMID: 37414898 PMCID: PMC10353938 DOI: 10.1038/s41591-023-02430-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 05/31/2023] [Indexed: 07/08/2023]
Abstract
Chronic pain is a complex condition influenced by a combination of biological, psychological and social factors. Using data from the UK Biobank (n = 493,211), we showed that pain spreads from proximal to distal sites and developed a biopsychosocial model that predicted the number of coexisting pain sites. This data-driven model was used to identify a risk score that classified various chronic pain conditions (area under the curve (AUC) 0.70-0.88) and pain-related medical conditions (AUC 0.67-0.86). In longitudinal analyses, the risk score predicted the development of widespread chronic pain, the spreading of chronic pain across body sites and high-impact pain about 9 years later (AUC 0.68-0.78). Key risk factors included sleeplessness, feeling 'fed-up', tiredness, stressful life events and a body mass index >30. A simplified version of this score, named the risk of pain spreading, obtained similar predictive performance based on six simple questions with binarized answers. The risk of pain spreading was then validated in the Northern Finland Birth Cohort (n = 5,525) and the PREVENT-AD cohort (n = 178), obtaining comparable predictive performance. Our findings show that chronic pain conditions can be predicted from a common set of biopsychosocial factors, which can aid in tailoring research protocols, optimizing patient randomization in clinical trials and improving pain management.
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Affiliation(s)
- Christophe Tanguay-Sabourin
- Alan Edwards Centre for Research on Pain, McGill University, Montreal, Quebec, Canada.
- Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada.
- Department of Anesthesia, Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada.
| | - Matt Fillingim
- Alan Edwards Centre for Research on Pain, McGill University, Montreal, Quebec, Canada
- Department of Anesthesia, Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Gianluca V Guglietti
- Alan Edwards Centre for Research on Pain, McGill University, Montreal, Quebec, Canada
- Department of Anesthesia, Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
- Faculty of Dental Medicine and Oral Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Azin Zare
- Alan Edwards Centre for Research on Pain, McGill University, Montreal, Quebec, Canada
- Faculty of Dental Medicine and Oral Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Marc Parisien
- Alan Edwards Centre for Research on Pain, McGill University, Montreal, Quebec, Canada
- Department of Anesthesia, Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
- Faculty of Dental Medicine and Oral Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Jax Norman
- Alan Edwards Centre for Research on Pain, McGill University, Montreal, Quebec, Canada
- Faculty of Dental Medicine and Oral Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Hilary Sweatman
- Department of Neurology and Neurosurgery, McGill University, Montreal, Quebec, Canada
| | - Ronrick Da-Ano
- Alan Edwards Centre for Research on Pain, McGill University, Montreal, Quebec, Canada
- Faculty of Dental Medicine and Oral Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Eveliina Heikkala
- Research Unit of Population Health, University of Oulu, Oulu, Finland
- Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Jordi Perez
- Department of Anesthesia, Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
- Alan Edwards Pain Management Unit, McGill University Health Centre, Montreal, Quebec, Canada
| | - Jaro Karppinen
- Research Unit of Population Health, University of Oulu, Oulu, Finland
- Research Unit of Health Sciences and Technology, University of Oulu, Oulu, Finland
- Rehabilitation Services of Southern Karelia Social and Health Care District, Lappeenranta, Finland
| | - Sylvia Villeneuve
- Douglas Mental Health Institute Research Centre, McGill University, Montreal, Quebec, Canada
- McConnell Brain Imaging Center, Montreal Neurological Institute, McGill University, Montreal, Quebec, Canada
| | - Scott J Thompson
- Department of Anesthesiology, University of Minnesota, Minneapolis, MN, USA
| | - Marc O Martel
- Alan Edwards Centre for Research on Pain, McGill University, Montreal, Quebec, Canada
- Department of Anesthesia, Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
- Faculty of Dental Medicine and Oral Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Mathieu Roy
- Alan Edwards Centre for Research on Pain, McGill University, Montreal, Quebec, Canada
- Department of Anesthesia, Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
- Department of Psychology, McGill University, Montreal, Quebec, Canada
| | - Luda Diatchenko
- Alan Edwards Centre for Research on Pain, McGill University, Montreal, Quebec, Canada
- Department of Anesthesia, Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
- Faculty of Dental Medicine and Oral Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Etienne Vachon-Presseau
- Alan Edwards Centre for Research on Pain, McGill University, Montreal, Quebec, Canada.
- Department of Anesthesia, Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada.
- Faculty of Dental Medicine and Oral Health Sciences, McGill University, Montreal, Quebec, Canada.
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Heikkala E, Oura P, Ruokolainen O, Ala-Mursula L, Linton SJ, Karppinen J. The Örebro Musculoskeletal Pain Screening Questionnaire-Short Form and 2-year follow-up of registered work disability. Eur J Public Health 2023:7165278. [PMID: 37192056 DOI: 10.1093/eurpub/ckad079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2023] Open
Abstract
BACKGROUND The Örebro Musculoskeletal Pain Screening Questionnaire (ÖMPSQ) was developed to identify psychological and functioning-related risk factors among individuals with musculoskeletal pain at risk of work disability. This study aimed to examine whether the short version of the ÖMPSQ (ÖMPSQ-SF) can be used for this purpose, using registry-based outcomes. METHODS The ÖMPSQ-SF was completed by the members of the Northern Finland Birth Cohort 1966 at the age of 46 years (baseline). These data were enriched with national registers, including information on sick leaves and disability pensions (indicators of work disability). The associations between the ÖMPSQ-SF categories (low-, medium- and high risk) and work disability over a 2-year follow-up were analysed using negative binomial regression and binary logistic regression models. We made adjustments for sex, baseline education level, weight status and smoking. RESULTS Overall, 4063 participants provided full data. Of these, 90% belonged to the low-risk, 7% to the medium-risk and 3% to the high-risk group. Compared to the low-risk group, the high-risk group had a 7.5 [Wald 95% confidence interval (CI) 6.2-9.0] times higher number of sick leave days and 16.1 (95% CI 7.1-36.8) times higher odds of disability pension after adjustments in the 2-year follow-up. CONCLUSIONS : Our study suggests that the ÖMPSQ-SF could be used for predicting registry-based work disability at midlife. Those allocated to the high-risk group seemed to have a particularly great need of early interventions to support their work ability.
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Affiliation(s)
- Eveliina Heikkala
- Research Unit of Population Health, University of Oulu, Oulu, Finland
- Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
- Wellbeing Services, County of Lapland, Rovaniemi, Finland
| | - Petteri Oura
- Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
- Research Unit of Health Sciences and Technology, University of Oulu, Oulu, Finland
| | - Olli Ruokolainen
- Research Unit of Population Health, University of Oulu, Oulu, Finland
- Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Leena Ala-Mursula
- Research Unit of Population Health, University of Oulu, Oulu, Finland
| | - Steven J Linton
- Clinical Psychology, Center for Health and Medical Psychology, Örebro University, Örebro, Sweden
| | - Jaro Karppinen
- Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
- Research Unit of Health Sciences and Technology, University of Oulu, Oulu, Finland
- Finnish Institute of Occupational Health, Oulu, Finland
- Rehabilitation Services of South Karelia Social and Health Care District, Lappeenranta, Finland
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Mertimo T, Heikkala E, Niinimäki J, Blanco Sequeiros R, Määttä J, Kankaanpää M, Oura P, Karppinen J. The role of co-occurring insomnia and mental distress in the association between lumbar disc degeneration and low back pain related disability. BMC Musculoskelet Disord 2023; 24:293. [PMID: 37060071 PMCID: PMC10103434 DOI: 10.1186/s12891-023-06365-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 03/24/2023] [Indexed: 04/16/2023] Open
Abstract
BACKGROUND Lumbar disc degeneration (LDD) is associated with low back pain (LBP). Although both insomnia and mental distress appear to influence the pain experience, their role in the association between LDD and LBP is uncertain. Our objective was to investigate the role of co-occurring insomnia and mental distress in the association between LDD and LBP-related disability. METHODS A total of 1080 individuals who had experienced LBP during the previous year underwent 1.5-T lumbar magnetic resonance imaging, responded to questionnaires, and participated in a clinical examination at the age of 47. Full data was available for 843 individuals. The presence of LBP and LBP-related disability (numerical rating scale, range 0-10) were assessed using a questionnaire. LDD was assessed by a Pfirrmann-based sum score (range 0-15, higher values indicating higher LDD). The role of insomnia (according to the five-item Athens Insomnia Scale) and mental distress (according to the Hopkins Symptom Check List-25) in the association between the LDD sum score and LBP-related disability was analyzed using linear regression with adjustments for sex, smoking, body mass index, education, leisure-time physical activity, occupational physical exposure, Modic changes, and disc herniations. RESULTS A positive association between LDD and LBP-related disability was observed among those with absence of both mental distress and insomnia (adjusted B = 0.132, 95% CI = 0.028-0.236, p = 0.013), and among those with either isolated mental distress (B = 0.345 CI = 0.039-0.650, p = 0.028) or isolated insomnia (B = 0.207, CI = 0.040-0.373, p = 0.015). However, among individuals with co-occurring insomnia and mental distress, the association was not significant (B = -0.093, CI = -0.346-0.161, p = 0.470). CONCLUSIONS LDD does not associate with LBP-related disability when insomnia and mental distress co-occur. This finding may be useful when planning treatment and rehabilitation that aim to reduce disability among individuals with LDD and LBP. Future prospective research is warranted.
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Affiliation(s)
- Teija Mertimo
- Faculty of Medicine and Health Technology, Tampere University Hospital and University of Tampere, P.O. Box 607, Tampere, FI-33014, Finland.
- Research Unit of Population Health, Faculty of Medicine, University of Oulu, P.O. Box 5000, Oulu, FI- 90014, Finland.
| | - Eveliina Heikkala
- Research Unit of Population Health, Faculty of Medicine, University of Oulu, P.O. Box 5000, Oulu, FI- 90014, Finland
- Medical Research Center Oulu, Oulu University Hospital and University of Oulu, P.O. Box 5000, Oulu, FI-90014, Finland
| | - Jaakko Niinimäki
- Medical Research Center Oulu, Oulu University Hospital and University of Oulu, P.O. Box 5000, Oulu, FI-90014, Finland
- Research Unit of Medical Imaging, Physics and Technology, Faculty of Medicine, University of Oulu, P.O. Box 5000, Oulu, FI-90014, Finland
| | - Roberto Blanco Sequeiros
- Research Unit of Medical Imaging, Physics and Technology, Faculty of Medicine, University of Oulu, P.O. Box 5000, Oulu, FI-90014, Finland
- Department of Radiology, Turku University Hospital, Kiinamyllynkatu 4-8, Turku, FI-20520, Finland
| | - Juhani Määttä
- Medical Research Center Oulu, Oulu University Hospital and University of Oulu, P.O. Box 5000, Oulu, FI-90014, Finland
- Research Unit of Health Sciences and Technology, Faculty of Medicine, University of Oulu, P.O. Box 5000, Oulu, FI-90014, Finland
| | - Markku Kankaanpää
- Department of Rehabilitation and Psychosocial Support, Tampere University Hospital, P.O. Box 2000, Tampere, FI-33521, Finland
| | - Petteri Oura
- Medical Research Center Oulu, Oulu University Hospital and University of Oulu, P.O. Box 5000, Oulu, FI-90014, Finland
- Research Unit of Health Sciences and Technology, Faculty of Medicine, University of Oulu, P.O. Box 5000, Oulu, FI-90014, Finland
| | - Jaro Karppinen
- Medical Research Center Oulu, Oulu University Hospital and University of Oulu, P.O. Box 5000, Oulu, FI-90014, Finland
- Research Unit of Health Sciences and Technology, Faculty of Medicine, University of Oulu, P.O. Box 5000, Oulu, FI-90014, Finland
- Rehabilitation Services of South Karelia Social and Health Care District, Valto Käkelän katu 3, Lappeenranta, FI- 53130, Finland
- Finnish Institute of Occupational Health, Aapistie 1, Oulu, FI-90220, Finland
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Heikkala E, Jokelainen J, Mikkola I, Auvinen J, Hagnäs M. Recurrent prescription of sleep medication among primary care patients with type 2 diabetes: an observational study of real-world registry data. BMC Prim Care 2023; 24:90. [PMID: 37016350 PMCID: PMC10074898 DOI: 10.1186/s12875-023-02045-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 03/24/2023] [Indexed: 04/06/2023]
Abstract
BACKGROUND Little knowledge exists on the prevalence of recurrent sleep medication prescriptions among primary care patients with type 2 diabetes (T2D). Our aims were to examine the prevalence of recurrent sleep medication prescriptions and to elucidate the most often prescribed sleep medications in a Finnish primary care T2D population. METHODS The study examined 4,508 T2D patients who consulted a primary health care center between 2011 and 2019 in Rovaniemi, Finland. All the data were retrieved from patient records, and recurrent sleep medication was defined as two or more prescriptions within the study period. We used the Chi-square and Kruskal-Wallis tests to compare patients who did and did not have recurrent sleep medication prescriptions. RESULTS Altogether 28.1% of the T2D patients had been prescribed recurrent sleep medication. Benzodiazepine-like medication, melatonin, and mirtazapine were most often prescribed (to 56.9%, 44.4%, and 35.8%, respectively). Only 22.0% of the patients with recurrent sleep medication prescriptions had been diagnosed with a sleep disorder. CONCLUSIONS Recurrent sleep medication prescriptions are frequent among primary care T2D patients. It seems that sleep disorders are underdiagnosed in relation to this. Primary care clinicians should carefully estimate the need for sleep medication when treating T2D patients' sleep problems and emphasize the diagnostic patterns of sleep problems.
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Affiliation(s)
- Eveliina Heikkala
- Rovaniemi Health Center, Koskikatu 25, Rovaniemi, 96200, Finland.
- Research Unit of Population Health, University of Oulu, PO Box 5000, Oulu, 90015, Finland.
- Medical Research Center Oulu, University of Oulu and Oulu University Hospital, PO Box 5000, Oulu, 90014, Finland.
| | - Jari Jokelainen
- Arctic Biobank, Infrastructure for Population Studies, Faculty of Medicine, Northern Finland Birth Cohorts, University of Oulu, PO Box 5000, Oulu, 90015, Finland
| | - Ilona Mikkola
- Rovaniemi Health Center, Koskikatu 25, Rovaniemi, 96200, Finland
| | - Juha Auvinen
- Research Unit of Population Health, University of Oulu, PO Box 5000, Oulu, 90015, Finland
- Medical Research Center Oulu, University of Oulu and Oulu University Hospital, PO Box 5000, Oulu, 90014, Finland
| | - Maria Hagnäs
- Rovaniemi Health Center, Koskikatu 25, Rovaniemi, 96200, Finland
- Research Unit of Population Health, University of Oulu, PO Box 5000, Oulu, 90015, Finland
- Medical Research Center Oulu, University of Oulu and Oulu University Hospital, PO Box 5000, Oulu, 90014, Finland
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Heikkala E, Oura P, Karppinen J, Herbert A, Varis H, Hagnäs M, Mikkola I, Paananen M. Family structure and multisite musculoskeletal pain in adolescence: a Northern Finland Birth Cohort 1986 study. BMC Musculoskelet Disord 2023; 24:185. [PMID: 36906532 PMCID: PMC10007855 DOI: 10.1186/s12891-023-06294-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 03/06/2023] [Indexed: 03/13/2023] Open
Abstract
BACKGROUND Family structure is suggested to be associated with adolescent pain, but evidence on its association with multisite MS pain is sparse. The purpose of this cross-sectional study was to investigate the potential associations between family structure ('single-parent family', 'reconstructed family', and 'two-parent family') and multisite musculoskeletal (MS) pain in adolescence. METHODS The dataset was based on the 16-year-old Northern Finland Birth Cohort 1986 adolescents with available data on family structure, multisite MS pain, and a potential confounder (n = 5,878). The associations between family structure and multisite MS pain were analyzed with binomial logistic regression and modelled as unadjusted, as the evaluated potential confounder, mother's educational level, did not meet the criteria for a confounder. RESULTS Overall, 13% of the adolescents had a 'single-parent family' and 8% a 'reconstructed family'. Adolescents living in a single-parent family had 36% higher odds of multisite MS pain compared to adolescents from two-parent families (the reference) (Odds Ratio [OR]: 1.36, 95% Confidence Interval [CI]: 1.17 to 1.59). Belonging to a 'reconstructed family' was associated with 39% higher odds of multisite MS pain (OR 1.39, 1.14 to 1.69). CONCLUSION Family structure may have a role in adolescent multisite MS pain. Future research is needed on causality between family structure and multisite MS pain, to establish if there is a need for targeted support.
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Affiliation(s)
- Eveliina Heikkala
- Research Unit of Population Health, University of Oulu, PO Box 8000, 90014, Oulu, Finland. .,Medical Research Center Oulu, University of Oulu and Oulu University Hospital, 90014, Oulu, Finland. .,Wellbeing Services, County of Lapland, 96400, Rovaniemi, Finland.
| | - Petteri Oura
- Medical Research Center Oulu, University of Oulu and Oulu University Hospital, 90014, Oulu, Finland.,Research Unit of Health Sciences and Technology, University of Oulu, Oulu, Finland
| | - Jaro Karppinen
- Medical Research Center Oulu, University of Oulu and Oulu University Hospital, 90014, Oulu, Finland.,Research Unit of Health Sciences and Technology, University of Oulu, Oulu, Finland.,Rehabilitation Services of South Karelia Social and Health Care District, 53130, Lappeenranta, Finland
| | - Annie Herbert
- Department of Population Health Sciences, University of Bristol, Bristol, UK.,MRC Integrative Epidemiology Unit, University of Bristol, Oakfield House, Oakfield Grove, BS8 2BN, Bristol, UK
| | - Heidi Varis
- Research Unit of Population Health, University of Oulu, PO Box 8000, 90014, Oulu, Finland.,Wellbeing Services, County of Lapland, 96400, Rovaniemi, Finland
| | - Maria Hagnäs
- Research Unit of Population Health, University of Oulu, PO Box 8000, 90014, Oulu, Finland.,Medical Research Center Oulu, University of Oulu and Oulu University Hospital, 90014, Oulu, Finland.,Wellbeing Services, County of Lapland, 96400, Rovaniemi, Finland
| | - Ilona Mikkola
- Wellbeing Services, County of Lapland, 96400, Rovaniemi, Finland
| | - Markus Paananen
- Research Unit of Population Health, University of Oulu, PO Box 8000, 90014, Oulu, Finland.,Medical Research Center Oulu, University of Oulu and Oulu University Hospital, 90014, Oulu, Finland.,Primary Health Care Services, City of Espoo, 02070, Espoo, Finland
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9
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Heikkala E, Oura P, Ho E, Ferreira P, Paananen M, Karppinen J. Accumulation of long-term diseases is associated with musculoskeletal pain dimensions among middle-aged individuals with musculoskeletal pain. Eur J Pain 2023; 27:438-448. [PMID: 36560860 DOI: 10.1002/ejp.2070] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 12/15/2022] [Accepted: 12/17/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Long-term diseases often co-occur with musculoskeletal (MSK) pain. In middle-aged individuals with MSK pain, it remains unclear whether an accumulation (two or more) of long-term diseases is associated with MSK pain dimensions, including pain frequency, bothersomeness of pain, pain intensity and number of pain sites. METHODS This cross-sectional study included data from the Northern Finland Birth Cohort 1966 collected in 2012-2014 when the participants were 46 years of age. We included participants who reported having MSK pain during the previous year (collected retrospectively) and provided self-reported information related to MSK pain dimensions, long-term diseases and potential confounders (n = 4469). The association between long-term diseases and pain dimensions was modelled by general linear and logistic regression models, with beta (β) coefficients, odds ratios (ORs) and their 95% confidence intervals (CIs) being presented. Unadjusted models were followed by models adjusted for sex, educational level and smoking. RESULTS The presence of accumulated long-term diseases was associated with over two-fold higher odds of daily pain (adjusted OR 2.6, 95% CI 2.0-3.4) and significantly higher levels of bothersomeness of pain and pain intensity (adjusted β 1.1, 95% CI 0.9-1.4; adjusted β 1.0, 95% CI 0.8-1.1, respectively), relative to the absence of long-term diseases. Females with accumulated long-term diseases had a stronger relationship to number of pain sites than males. Associations between one long-term disease and pain dimensions were significant but smaller in magnitude. CONCLUSION There is a need for a better understanding of the relationships between accumulated long-term diseases and MSK pain. SIGNIFICANCE This study on middle-aged individuals with musculoskeletal pain showed that the presence of long-term diseases was clearly associated with pain frequency, bothersomeness of pain, pain intensity and number of pain sites. Compared with no long-term diseases, the association between accumulated (two or more) long-term diseases and pain dimensions was stronger than the association between one long-term disease and pain dimensions.
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Affiliation(s)
- Eveliina Heikkala
- Research Unit of Population Health, University of Oulu, Oulu, Finland
- Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
- Rovaniemi Health Center, Rovaniemi, Finland
| | - Petteri Oura
- Research Unit of Population Health, University of Oulu, Oulu, Finland
- Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Emma Ho
- Charles Perkins Centre Musculoskeletal Hub, School of Health Sciences, Faculty of Medicine, University of Sydney, Sydney, New South Wales, Australia
| | - Paulo Ferreira
- Charles Perkins Centre Musculoskeletal Hub, School of Health Sciences, Faculty of Medicine, University of Sydney, Sydney, New South Wales, Australia
| | - Markus Paananen
- Research Unit of Population Health, University of Oulu, Oulu, Finland
- Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
- Primary Health Care Services, Espoo, Finland
| | - Jaro Karppinen
- Research Unit of Population Health, University of Oulu, Oulu, Finland
- Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland
- Rehabilitation Services of South Karelia Social and Health Care District, Lappeenranta, Finland
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10
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Heikkala E, Merikanto I, Tanguay-Sabourin C, Karppinen J, Oura P. Eveningness is associated with persistent multisite musculoskeletal pain: a 15-year follow-up study of Northern Finns. The Journal of Pain 2022; 24:679-688. [PMID: 36513241 DOI: 10.1016/j.jpain.2022.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 11/30/2022] [Accepted: 12/02/2022] [Indexed: 12/14/2022]
Abstract
Chronotype, a phenotype representing a person's 24-hour circadian rhythm, has been increasingly acknowledged as playing a role in musculoskeletal (MSK) pain. Most prior research on chronotype and MSK pain have been based on cross-sectional data, and no study has explored multisite MSK pain (two or more pain locations) as the outcome. We drew the study sample from the 31- and 46-year data collections (baseline and follow-up, respectively) of the Northern Finland Birth Cohort 1966 and collected self-reported data on chronotype at follow-up (morning [M]-type, intermediate [I]-type, and evening [E]-type) and longitudinal multisite MSK pain trajectories (n=3,294). Multinomial logistic regression was used to estimate odds ratios (ORs) with 95% confidence intervals (CIs) in multisite MSK pain trajectories between the chronotypes. We conducted additional sensitivity analyses that 1) accounted for several confounders, and 2) examined the potential moderating role of sex, mental distress, and sleep disturbance status in the chronotype-multisite MSK pain associations. The E-types had two-and-a-half-times higher odds of multisite MSK pain at baseline and follow-up (OR 2.47, 95% CI 1.84-3.32) than the M-types. Having severe mental distress or poor sleep at baseline and follow-up, or sex did not change the strength of this association. Our examination of this longitudinal birth cohort study suggested that evening types, in comparison to morning types, are more likely to experience multisite MSK pain between ages 31 and 46 years. Chronotype should be recognized as a predictor of multisite pain and thus taken into account in the evaluation of a patient's risk for multisite pain. Perspective: This longitudinal study shows that evening types, compared to morning types, have higher odds of experiencing multisite MSK pain between ages 31 and 46 years. Chronotype should be considered while evaluating MSK patient's risk for persistent multisite pain symptoms.
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Affiliation(s)
- Eveliina Heikkala
- Research Unit of Population Health, University of Oulu, 90014 Oulu, Finland; Medical Research Center Oulu, University of Oulu and Oulu University Hospital, 90014 Oulu, Finland; Rovaniemi Health Center, 96200 Rovaniemi, Finland.
| | - Ilona Merikanto
- Research Unit of Population Health, University of Oulu, 90014 Oulu, Finland; SleepWell Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland; Department of Public Health Solutions, Finnish Institute for Health and Welfare, Helsinki, Finland; Orton Orthopaedics Hospital, Helsinki, Finland
| | - Christophe Tanguay-Sabourin
- Alan Edwards Pain Centre for Research on Pain, McGill University, Montreal, QC H3A 0G1, Canada; Faculty of Medicine, Université de Montréal, Montreal, QC H3T 1J4, Canada
| | - Jaro Karppinen
- Medical Research Center Oulu, University of Oulu and Oulu University Hospital, 90014 Oulu, Finland; Research Unit of Health Sciences and Technology, University of Oulu, 90014 Oulu, Finland; Rehabilitation Services of South Karelia Social and Health Care District, 53130 Lappeenranta, Finland
| | - Petteri Oura
- Medical Research Center Oulu, University of Oulu and Oulu University Hospital, 90014 Oulu, Finland; Research Unit of Health Sciences and Technology, University of Oulu, 90014 Oulu, Finland
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Heikkala E, Paananen M, Merikanto I, Karppinen J, Oura P. Eveningness intensifies the association between musculoskeletal pain and health-related quality of life: a Northern Finland Birth Cohort Study 1966. Pain 2022; 163:2154-2161. [PMID: 35135992 PMCID: PMC9578528 DOI: 10.1097/j.pain.0000000000002609] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 01/16/2022] [Accepted: 01/31/2022] [Indexed: 11/25/2022]
Abstract
ABSTRACT People with an evening (E)-type preference (ie, chronotype) experience musculoskeletal (MSK) pain and reduced health-related quality of life (HRQoL) more often than morning (M) types. Musculoskeletal pain is a well-established contributor to reduced HRQoL. This study aimed to evaluate whether eveningness amplifies the association between MSK pain and HRQoL in contrast to morningness. Questionnaire data on MSK pain dimensions (intensity, disability at work, number of pain sites [NPSs], and frequency), chronotype, covariates (sex, sufficiency of sleep duration, mental distress, and presence of coexisting diseases), and HRQoL (measured by 15D) were collected among 46-year-old individuals belonging to the Northern Finland Birth Cohort 1966 (N = 4257). Individuals without any MSK pain were excluded. General linear models were conducted to estimate the associations between chronotypes, MSK pain dimensions, and HRQoL. The interaction terms (chronotype × pain dimension) were tested in the models. There were 13% E-types and 43% M-types in the study sample. Each pain dimension and chronotype were related to HRQoL. In the sex-adjusted chronotype-specific models, the reduction in HRQoL in relation to pain appeared to be stronger among E-types than among M-types in respect to all pain dimensions. After adjustments, this was particularly seen in terms of NPS and pain frequency. Our findings suggest that eveningness intensifies the association between MSK pain and HRQoL, and, thus, they are indicative of E-types being more sensitive than M-types to the consequences of MSK pain. As such, MSK pain treatment and rehabilitation actions to improve HRQoL should be especially targeted at E-types.
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Affiliation(s)
- Eveliina Heikkala
- Center for Life Course Health Research, University of Oulu, Oulu, Finland
- Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Finland
- Rovaniemi Health Center, Rovaniemi, Finland
| | - Markus Paananen
- Center for Life Course Health Research, University of Oulu, Oulu, Finland
- Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Finland
- Primary Health Care Services, City of Espoo, Espoo, Finland
| | - Ilona Merikanto
- SleepWell Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Department of Public Health Solutions, Finnish Institute for Health and Welfare, Helsinki, Finland
- Orton Orthopaedics Hospital, Helsinki, Finland
| | - Jaro Karppinen
- Center for Life Course Health Research, University of Oulu, Oulu, Finland
- Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Finland
- Rehabilitation Services of South Karelia Social and Health Care District, Lappeenranta, Finland
| | - Petteri Oura
- Center for Life Course Health Research, University of Oulu, Oulu, Finland
- Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Finland
- Department of Forensic Medicine, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Forensic Medicine Unit, Finnish Institute for Health and Welfare, Helsinki, Finland
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12
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Heikkala E, Hagnäs M, Jokelainen J, Karppinen J, Ferreira P, Ferreira ML, Mikkola I. Association of musculoskeletal pain with the achievement of treatment targets for type 2 diabetes among primary care patients. Prim Care Diabetes 2022; 16:531-536. [PMID: 35523651 DOI: 10.1016/j.pcd.2022.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 04/19/2022] [Accepted: 04/21/2022] [Indexed: 11/30/2022]
Abstract
AIMS To assess the association of diagnosed musculoskeletal (MS) pain (low back, neck, shoulder, and knee pain; and the number of pain sites) with the achievement of targets for glycosylated haemoglobin A1c (HbA1c), low-density-lipoprotein cholesterol (LDL), and systolic blood pressure (SBP) among primary care patients with type 2 diabetes (T2D). METHODS The cross-sectional study population consisted of 3478 patients with a registry-based T2D diagnosis and available registry-based data on MS pain diagnoses, covariates, and outcomes between 2016 and 2019. Logistic regression analysis was used to evaluate the study aims. RESULTS Overall, 22% had at least one of the four types of MS pain, and 73%, 57%, and 51% achieved the treatment targets of HbA1c, LDL, and SBP, respectively. T2D patients with or without MS pain did not differ in their achievement of T2D treatment goals. Of pain locations, low back pain was associated with higher rates of achievement of the LDL target (OR 1.29, 95% CI 1.01-1.65), but the association was attenuated in the adjusted model. CONCLUSIONS MS pain was relatively prevalent among primary care patients with T2D, but did not influence the achievement of T2D treatment goals.
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Affiliation(s)
- Eveliina Heikkala
- Rovaniemi Health Center, Rovaniemi, Finland; Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland; Center for Life Course Health Research, University of Oulu, Oulu, Finland.
| | - Maria Hagnäs
- Rovaniemi Health Center, Rovaniemi, Finland; Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland; Center for Life Course Health Research, University of Oulu, Oulu, Finland
| | - Jari Jokelainen
- Center for Life Course Health Research, University of Oulu, Oulu, Finland
| | - Jaro Karppinen
- Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland; Center for Life Course Health Research, University of Oulu, Oulu, Finland; Rehabilitation Services of South Karelia Social and Health Care District, Lappeenranta, Finland
| | - Paulo Ferreira
- School of Health Sciences, Faculty of Medicine, University of Sydney, Sydney, New South Wales, Australia
| | - Manuela L Ferreira
- Faculty of Medicine and Health, Kolling Institute, School of Health Sciences, University of Sydney, Sydney, Australia
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13
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Abstract
STUDY DESIGN Cross-sectional. OBJECTIVE To study the associations between a family history of surgically treated low back pain (LBP) and adolescent LBP. SUMMARY OF BACKGROUND DATA A family history of LBP is related to adolescent LBP, but whether a family history of back surgery is relevant to adolescent LBP is not known. METHODS A subpopulation of the Northern Finland Birth Cohort 1986 was contacted when they were aged between 18 and 19years. The postal questionnaire asked the participants to report their LBP and a relative's (mother, father, sibling) LBP and back surgery, and to provide data on potential covariates. The association between a family history of LBP ("no family history of LBP," "family history of LBP but no surgery," and "family history of LBP and surgery") and adolescent LBP (no LBP, occasional LBP, and frequent LBP) were evaluated using logistic regression analysis with odds ratios (ORs) and 95% confidence intervals (CIs), adjusted for sex, smoking, and psychological distress. RESULTS Of the 1374 adolescents in the study, 33% reported occasional LBP and 9% frequent LBP. Both the "family history of LBP but no surgery" and "family history of LBP and surgery" categories were associated with frequent LBP (adjusted OR [aOR] 2.09, 95% CI 1.38-3.16; aOR 2.23, 95% CI 1.02-4.90, respectively). Occasional LBP was associated with the "family history of LBP and surgery" category. A subgroup analysis of adolescents with a family history of LBP found no statistically significant associations between family history of back surgery and adolescent LBP. CONCLUSION Our findings suggest that adolescents who report a family history of LBP have higher odds of frequent LBP irrespectively of a family history of back surgery.Level of evidence: 4.
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Affiliation(s)
- Eveliina Heikkala
- Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
- Center for Life Course Health Research, University of Oulu, Oulu, Finland
- Rovaniemi Health Center, Koskikatu 25, Rovaniemi, Finland
| | - Jaro Karppinen
- Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
- Center for Life Course Health Research, University of Oulu, Oulu, Finland
- Rehabilitation Services of South Karelia Social and Health Care District, Valto Käkelän katu 3, Lappeenranta, Finland
| | - Ilona Mikkola
- Rovaniemi Health Center, Koskikatu 25, Rovaniemi, Finland
| | - Maria Hagnäs
- Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
- Center for Life Course Health Research, University of Oulu, Oulu, Finland
- Rovaniemi Health Center, Koskikatu 25, Rovaniemi, Finland
| | - Petteri Oura
- Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
- Center for Life Course Health Research, University of Oulu, Oulu, Finland
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14
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Heikkala E, Oura P, Korpela T, Karppinen J, Paananen M. Chronotypes and disabling musculoskeletal pain: A Finnish birth cohort study. Eur J Pain 2022; 26:1069-1078. [PMID: 35258149 PMCID: PMC9310771 DOI: 10.1002/ejp.1931] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 02/03/2022] [Accepted: 03/06/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND It has been suggested that chronotype, the individual preference for 24-hour circadian rhythms, influences health. Sleep problems and mental distress are among the greatest risk factors for musculoskeletal (MS) pain. The aims of this study were first, to explore the associations between chronotypes and MS pain, with special reference to disabling MS pain, and second, to test whether mental distress and insomnia have a modifying role in the associations between chronotypes and MS pain. METHODS The dataset of 4,961 individuals was composed of Northern Finns surveyed on MS pain, chronotypes, and confounding factors (sex, insomnia, sleep duration, smoking, mental distress, occupational status, education level, and number of co-existing diseases) at 46 years. The relationships between chronotypes (evening [E], intermediate [I], and morning [M]) and MS pain were evaluated using multinomial logistic regression. To address the second aim, we included an interaction term (chronotype*mental distress, chronotype*insomnia) in the logistic model. RESULTS Compared to the M-types, both the E- and I-types had increased odds of suffering 'disabling pain' in the unadjusted model (odds ratio [OR] 1.79, 95% confidence interval [CI] 1.37-2.33; OR 1.54, 95% CI 1.29-1.84, respectively). However, the association remained statistically significant only after adjusting for all covariates among the I-types (OR 1.39, 95% CI 1.15-1.67). Neither mental distress nor insomnia was found to modify the chronotype-MS pain association. CONCLUSIONS The results highlight the importance of chronotypes for individuals' MS health but suggest the presence of confounding factors in the interplay between these factors.
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Affiliation(s)
- Eveliina Heikkala
- Center for Life Course Health Research, University of Oulu, Oulu, Finland.,Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland.,Rovaniemi Health Center, Rovaniemi, Finland
| | - Petteri Oura
- Center for Life Course Health Research, University of Oulu, Oulu, Finland.,Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Tuukka Korpela
- Center for Life Course Health Research, University of Oulu, Oulu, Finland.,Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Jaro Karppinen
- Center for Life Course Health Research, University of Oulu, Oulu, Finland.,Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland.,Rehabilitation Services of South Karelia Social and Health Care District, Lappeenranta, Finland
| | - Markus Paananen
- Center for Life Course Health Research, University of Oulu, Oulu, Finland.,Medical Research Center Oulu, University of Oulu and Oulu University Hospital, Oulu, Finland.,Primary Health Care Services, City of Espoo, Espoo, Finland
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15
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Mikkola I, Morgan S, Winell K, Jokelainen J, Frittitta L, Heikkala E, Hagnäs M. Association of personalised care plans with monitoring and control of clinical outcomes, prescription of medication and utilisation of primary care services in patients with type 2 diabetes: an observational real-world study. Scand J Prim Health Care 2022; 40:39-47. [PMID: 35148662 PMCID: PMC9090399 DOI: 10.1080/02813432.2022.2036458] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE To study the association of personalised care plans with monitoring and controlling clinical outcomes, prescription of cardiovascular and antihyperglycaemic medication and utilisation of primary care services in patients with type 2 diabetes (T2D). PATIENTS Primary care T2D outpatients from the Rovaniemi Health Centre. SETTING The municipal health centre, Rovaniemi, Finland. DESIGN A cross-sectional, observational, retrospective register-based study. The patients were divided into three groups: 'no care plan entries' (usual care); '1-2 care plan entries'; and '3 or more care plan entries'. MAIN OUTCOME MEASURES Monitoring of clinical and biochemical measures, achievement of treatment targets, prescription of cardiovascular and antihyperglycemic medication, and use of primary care services. RESULTS A total of 5104 patients with T2D (mean age 65.5 years (SD 12.4)), of which 67% had at least one care plan entry. Compared to usual care, the establishment of a care plan (either care plan group) was associated with better monitoring of glycosylated haemoglobin A1c, low-density-lipoprotein cholesterol, systolic blood pressure (sBP), and renal function, and there was more frequent prescription of all cardiovascular and antihyperglycemic medication. Patients in either care plan group were more likely to achieve sBP target (p < 0.05). Patients without a care plan had more unplanned primary care physician contacts compared to patients in care plan groups (p < 0.001). CONCLUSION Establishment of a care plan is associated with more intensive and focussed care of patients with T2D. The appropriate use of primary care resources is essential and personalised care plans may contribute to the treatment of patients with T2D.Key PointsCare planning aims to empower patients with type 2 diabetes. This study demonstrates that personalised care planning is associated withmore frequent monitoring for clinical outcomes,more frequent prescription of cardiovascular and antihyperglycemic medication andmore frequent utilisation of planned diabetes consultations when compared to usual care.
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Affiliation(s)
- Ilona Mikkola
- Rovaniemi Health Centre, Rovaniemi, Finland
- CONTACT Ilona Mikkola , P.O. Box 8216, RovaniemiFI-96101, Finland
| | - Simon Morgan
- Elermore Vael General Practice, Elermore Vale, Australia
| | | | - Jari Jokelainen
- Infrastructure for Population Studies, Faculty of Medicine, University of Oulu, Oulu, Finland
- Unit of General Practice, Oulu University Hospital, Oulu, Finland
| | - Lucia Frittitta
- Endocrinology, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
- Diabetes, Obesity and Dietetic Center, Garibaldi-Nesima Medical Center, Catania, Italy
| | | | - Maria Hagnäs
- Rovaniemi Health Centre, Rovaniemi, Finland
- Endocrinology, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
- Diabetes, Obesity and Dietetic Center, Garibaldi-Nesima Medical Center, Catania, Italy
- Center for Life Course Health Research, University of Oulu, Oulu, Finland
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16
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Heikkala E, Mikkola I, Jokelainen J, Timonen M, Hagnäs M. Multimorbidity and achievement of treatment goals among patients with type 2 diabetes: a primary care, real-world study. BMC Health Serv Res 2021; 21:964. [PMID: 34521389 PMCID: PMC8442281 DOI: 10.1186/s12913-021-06989-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 09/07/2021] [Indexed: 12/15/2022] Open
Abstract
Background Type 2 diabetes (T2D), with its prevalence and disability-causing nature, is a challenge for primary health care. Most patients with T2D are multimorbid, i.e. have one or more long-term diseases in addition to T2D. Multimorbidity may play a role in the achievement of T2D treatment targets, but is still not fully understood. The aims of the present cross-sectional, register-based study were to evaluate the prevalence and the most common patterns of multimorbidity among patients with T2D; and to study the potential associations between multimorbidity and treatment goal achievement, including measurements of glycosylated haemoglobin A1c (HbA1c), low-density lipoprotein (LDL) and systolic blood pressure (sBP). Methods The study population consisted of 4545 primary care patients who received a T2D diagnosis between January 2011 and July 2019 in Rovaniemi Health Centre, Finland. Data on seven long-term concordant (T2D-related) diseases, eight long-term discordant (non-T2D-related) diseases, potential confounders (age, sex, body mass index, prescribed medication), and the outcomes studied were collected from patients’ records. Logistic regression models with odds ratios (ORs) and 95 % confidence intervals (CIs) were assessed to determine the associations between multimorbidity and the achievement of treatment targets. Results Altogether, 93 % of the patients had one or more diseases in addition to T2D, i.e. were considered multimorbid. Furthermore, 21 % had only concordant disease(s) (Concordant subgroup), 8 % had only discordant disease(s) (Discordant subgroup) and 64 % had both (Concordant and discordant subgroup). As either single diseases or in combination with others, hypertension, musculoskeletal (MS) disease and hyperlipidaemia were the most prevalent multimorbidity patterns. Being multimorbid in general (OR 1.32, CI 1.01–1.70) and belonging to the Concordant (OR 1.45, CI 1.08–1.95) and Concordant and discordant (OR 1.31, CI 1.00–1.72) subgroups was associated with achievement of the HbA1c treatment target. Belonging to the Concordant and discordant subgroup was related to meeting the LDL treatment target (OR 1.31, CI 1.00–1.72). Conclusions Multimorbidity, including cardiovascular risk and the musculoskeletal disease burden, was extremely prevalent among the T2D patients who consulted primary health care. Primary care clinicians should survey the possible co-existence of long-term diseases among T2D patients to help maintain adequate treatment of T2D.
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Affiliation(s)
- Eveliina Heikkala
- Rovaniemi Health Center, Koskikatu 25, 96200, Rovaniemi, Finland. .,Medical Research Center Oulu, University of Oulu and Oulu University Hospital, PO Box 5000, 90014, Oulu, Finland. .,Center for Life Course Health Research, University of Oulu, PO Box 5000, 90015, Oulu, Finland.
| | - Ilona Mikkola
- Rovaniemi Health Center, Koskikatu 25, 96200, Rovaniemi, Finland
| | - Jari Jokelainen
- Center for Life Course Health Research, University of Oulu, PO Box 5000, 90015, Oulu, Finland
| | - Markku Timonen
- Center for Life Course Health Research, University of Oulu, PO Box 5000, 90015, Oulu, Finland
| | - Maria Hagnäs
- Rovaniemi Health Center, Koskikatu 25, 96200, Rovaniemi, Finland.,Medical Research Center Oulu, University of Oulu and Oulu University Hospital, PO Box 5000, 90014, Oulu, Finland.,Center for Life Course Health Research, University of Oulu, PO Box 5000, 90015, Oulu, Finland
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Heikkala E, Ala-Mursula L, Taimela S, Paananen M, Vaaramo E, Auvinen J, Karppinen J. Accumulated unhealthy behaviors and psychosocial problems in adolescence are associated with labor market exclusion in early adulthood - a northern Finland birth cohort 1986 study. BMC Public Health 2020; 20:869. [PMID: 32503491 PMCID: PMC7275307 DOI: 10.1186/s12889-020-08995-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 05/27/2020] [Indexed: 12/26/2022] Open
Abstract
Background The relevance of health-related behaviors to exclusion from the labor market in early adulthood remains poorly studied in relation to the magnitude of the problem. We explored whether adolescents’ accumulated unhealthy behaviors and psychosocial problems are associated with later labor market exclusion, and whether multisite musculoskeletal pain (MMSP) impacts these relations. Methods We gathered questionnaire data on unhealthy behaviors and psychosocial problems and MMSP among adolescents aged 15 to 16 belonging to the Northern Finland Birth Cohort 1986. The findings were combined with registry data on unemployment, employment and permanent work disability during a five-year follow-up between the ages of 25 and 29 (n = 6692). In the statistical modeling we used education, family leave and socioeconomic status of childhood family as potential confounders, as well as latent class and logistic regression analyses. Results The Externalizing behavior cluster associated with over one year of unemployment (RR 1.64, CI 1.25–2.14) and permanent work disability (OR 2.49, CI 1.07–5.78) in the follow-up among the men. The Sedentary cluster also associated with over one year (RR 1.41, CI 1.13–1.75) and under one year of unemployment (RR 1.25, CI 1.02–1.52) and no employment days (RR 1.93, CI 1.26–2.95) among the men. Obese male participants were at risk of over one year of unemployment (RR 1.50, CI 1.08–2.09) and no employment days (RR 1.93, CI 1.07–3.50). Among the women, the Multiple risk behavior cluster related significantly to over one year of unemployment (RR 1.77, CI 1.37–2.28). MMSP had no influence on the associations. Conclusions Unhealthy behavior patterns and psychosocial problems in adolescence have long-term consequences for exclusion from the labor market in early adulthood, especially among men. Simultaneously supporting psychological well-being and healthy behaviors in adolescence may reduce labor market inclusion difficulties in the early phase of working life.
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Affiliation(s)
- Eveliina Heikkala
- Medical Research Center Oulu, University of Oulu and Oulu University Hospital, PO Box 5000, 90014, Oulu, Finland. .,Rovaniemi Health Center, Koskikatu 25, 96200, Rovaniemi, Finland.
| | - Leena Ala-Mursula
- Center for Life Course Health Research, University of Oulu, Aapistie 5B, 90150, Oulu, Finland
| | - Simo Taimela
- Department of Orthopedics and Traumatology, Helsinki University Hospital, Töölö hospital, Topeliuksenkatu 5, 00260, Helsinki, Finland.,Clinicum, Department of Orthopedics and Traumatology, University of Helsinki, PO Box 266, 00029 HUS, Helsinki, Finland
| | - Markus Paananen
- Medical Research Center Oulu, University of Oulu and Oulu University Hospital, PO Box 5000, 90014, Oulu, Finland
| | - Eeva Vaaramo
- Intrastructure for Population Studies, Faculty of Medicine, University of Oulu, Aapistie 5B, 90150, Oulu, Finland
| | - Juha Auvinen
- Medical Research Center Oulu, University of Oulu and Oulu University Hospital, PO Box 5000, 90014, Oulu, Finland.,Oulunkaari Health Center, Piisilta 1, 90110, Ii, Finland
| | - Jaro Karppinen
- Medical Research Center Oulu, University of Oulu and Oulu University Hospital, PO Box 5000, 90014, Oulu, Finland.,Center for Life Course Health Research, University of Oulu, Aapistie 5B, 90150, Oulu, Finland.,Finnish Institute of Occupational Health, Aapistie 1, 90220, Oulu, Finland
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Heikkala E, Paananen M, Taimela S, Auvinen J, Karppinen J. Associations of co‐occurring psychosocial and lifestyle factors with multisite musculoskeletal pain during late adolescence—A birth cohort study. Eur J Pain 2019; 23:1486-1496. [DOI: 10.1002/ejp.1414] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 04/26/2019] [Accepted: 05/05/2019] [Indexed: 12/11/2022]
Affiliation(s)
- Eveliina Heikkala
- Medical Research Center Oulu University of Oulu and Oulu University Hospital Oulu Finland
- Rovaniemi Health Center Rovaniemi Finland
| | - Markus Paananen
- Medical Research Center Oulu University of Oulu and Oulu University Hospital Oulu Finland
| | - Simo Taimela
- Department of Orthopedics and Traumatology Helsinki University Hospital, Töölö hospital Helsinki Finland
- Clinicum, Department of Orthopedics and Traumatology University of Helsinki Helsinki Finland
| | - Juha Auvinen
- Medical Research Center Oulu University of Oulu and Oulu University Hospital Oulu Finland
- Oulunkaari Health Center Ii Finland
| | - Jaro Karppinen
- Medical Research Center Oulu University of Oulu and Oulu University Hospital Oulu Finland
- Center for Life Course Health Research University of Oulu Finland
- Finnish Institute of Occupational Health Oulu Finland
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Mikkonen P, Heikkala E, Paananen M, Remes J, Taimela S, Auvinen J, Karppinen J. Accumulation of psychosocial and lifestyle factors and risk of low back pain in adolescence: a cohort study. Eur Spine J 2015; 25:635-42. [PMID: 26070550 DOI: 10.1007/s00586-015-4065-0] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Revised: 04/19/2015] [Accepted: 06/07/2015] [Indexed: 11/28/2022]
Abstract
PURPOSE Low back pain (LBP) is common already in adolescence, and many risk indicators including both psychosocial and lifestyle factors have been recognized. Our purpose was to assess whether the co-occurrence of psychosocial (externalizing and internalizing) problems and lifestyle factors (leisure time physical activity, sedentary behaviour, sleep, smoking, and overweight/obesity) associate with LBP at 16 years cross-sectionally or with new LBP at 18-year follow-up. METHODS The study population, drawn from the Northern Finland Birth Cohort 1986, consisted of 1625 participants (712 boys and 913 girls) who completed a questionnaire on potential explanatory factors at 16 years and on LBP at 16 and 18 years. The outcome measure was 'reporting LBP' or 'consultation for LBP' during the past 6 months. Latent Class Analysis (LCA) was utilized to study the co-occurrence of the explanatory factors. RESULTS Among both genders, four clusters were found. Externalizing behaviour problems were associated with 'reporting LBP' (RR 1.5, boys 1.4, girls) and 'consultation for LBP' (RR 1.6 for both genders) at baseline among both genders. In addition, the cluster of multiple risk behaviours was associated with both 'reporting LBP' (RR 1.3) and 'consultation for LBP' (RR 2.5) and the obese cluster with 'consultation for LBP' (RR 1.7) among girls. Externalizing behaviour problems at 16 years predicted 'consultation for LBP' at 18 years among girls (RR 3.6). CONCLUSIONS Our results stress the role of psychosocial factors in reporting and seeking care for adolescent LBP.
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Affiliation(s)
- Paula Mikkonen
- Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland.
| | - Eveliina Heikkala
- Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Markus Paananen
- Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Jouko Remes
- Finnish Institute of Occupational Health, Statistics and Health Economics, Oulu, Finland
| | - Simo Taimela
- Department of Public Health, University of Helsinki, Helsinki, Finland
| | - Juha Auvinen
- Institute of Health Sciences, University of Oulu, Oulu, Finland
| | - Jaro Karppinen
- Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland.,Finnish Institute of Occupational Health, Health and Work Ability, and Disability Prevention Centre, Oulu, Finland
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Heikkala E, Remes J, Paananen M, Taimela S, Auvinen J, Karppinen J. Accumulation of lifestyle and psychosocial problems and persistence of adverse lifestyle over two-year follow-up among Finnish adolescents. BMC Public Health 2014; 14:542. [PMID: 24884444 PMCID: PMC4057560 DOI: 10.1186/1471-2458-14-542] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2013] [Accepted: 05/23/2014] [Indexed: 03/14/2023] Open
Abstract
BACKGROUND Adolescent'psychosocial problems associate with unhealthy behaviors, but data on co-occurring patterns is sparse. We investigated 1) whether adolescents could be categorized into meaningful subgroups with respect to psychosocial and lifestyle factors, 2) whether the prevalence of physical inactivity, overweight and smoking vary within the subgroups and 3) whether these unhealthy behaviors persist in a two-year follow-up. METHODS The study was based on a subgroup of the 1986 Northern Finland Birth Cohort, which consisted of adolescents who replied to a postal questionnaire at 16 years (n = 6792) and a subgroup of this sample at 18 years (n = 1552). Latent class analysis (LCA) was performed to establish clusters at 16 years. RESULTS Smoking co-existed with emotional and behavioral problems in both genders. Boys with the most inactive lifestyle slept poorly, whereas multiple problems co-occurred among girls. Those with a high body mass index (BMI) separated as groups of their own. Different combinations of adverse lifestyle and emotional and behavioral problems were relatively common in both sexes as only 51% of boys and 67% of girls belonged to the reference cluster with low probability for these findings. Physical inactivity, high BMI and smoking tended to persist over the two-year follow-up. CONCLUSIONS It seems that lifestyle and psychosocial factors divide adolescents into distinct subgroups in which unhealthy lifestyle patterns remain between the ages of 16 and 18. This may indicate problems in other life areas and expose them to an increased risk of future health problems.
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Affiliation(s)
- Eveliina Heikkala
- Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Aapistie 1, 90220 Oulu, Finland.
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