Both protocols of providing rehabilitation services turned out to be equally effective, but the conventional orthopedic ... 3,623) using the available direct cost data. Conclusion ... to shorten the time of recovery and the length of hospital stay, and ...
Arthritis Care & Research Vol. 63, No. 3, March 2011, pp 335–341 DOI 10.1002/acr.20398 © 2011, American College of Rheumatology
ORIGINAL ARTICLE
Economic Evaluation of Multidisciplinary Rehabilitation After Primary Total Knee Arthroplasty Based on a Randomized Controlled Trial ¨ NEN,3 ANNA-MAIJA KAUPPILA,1 HARRI SINTONEN,2 PASI ARONEN,2 PASI OHTONEN,3 EERO KYLLO 4 AND JARI P. A. AROKOSKI
Objective. To conduct an economic evaluation of a multidisciplinary, biopsychosocial outpatient rehabilitation program implemented 2– 4 months after total knee arthroplasty (TKA), compared with conventional orthopedic care. Methods. After surgery, 86 patients were randomized to a multidisciplinary rehabilitation group (n ⴝ 44) or a conventional orthopedic care group (n ⴝ 42). Alongside the randomized controlled trial, we estimated the costs of rehabilitation, health care resource use, and community support. Information about resource use was collected by means of a questionnaire together with data from hospital records. The primary outcome (effectiveness) measure was change in self-reported functional capacity and the secondary measure was quality-adjusted life years (QALYs) gained during the 12-month followup. Cost-effectiveness was assessed from between-group differences in costs, change in functional capacity, and QALYs gained. Results. Both protocols of providing rehabilitation services turned out to be equally effective, but the conventional orthopedic care protocol was unequivocally cost saving: the saving was €1,830 per patient (95% confidence interval ⴚ548, 3,623) using the available direct cost data. Conclusion. Multidisciplinary rehabilitation for unselected osteoarthritis patients in the subacute period of recovery after TKA is not a cost-effective use of health care resources. Similar rehabilitation protocols cannot be recommended for clinical pathways of TKA in the future.
INTRODUCTION The number of total knee replacements performed each year is increasing in developed countries (1–3). Osteoarthritis (OA) is the most common reason for joint replaceISRCTN: 74292386. Supported in part by funding from the Oulu University Hospital. 1 Anna-Maija Kauppila, MD: Oulu University Hospital and Oulu Deaconess Institute, Oulu, Finland; 2Harri Sintonen, PhD, Pasi Aronen, MSocSci: University of Helsinki, Helsinki, Finland; 3Pasi Ohtonen, MSc, Eero Kyllo¨nen, MD, PhD: Oulu University Hospital, Oulu, Finland; 4Jari P. A. Arokoski, MD, PhD: Kuopio University Hospital and University of Kuopio, Kuopio, Finland. Dr. Sintonen is the developer and copyright holder of the 15D and receives royalties (less than $10,000) from Coronaria Impact Oy for the license of the electronic version of the 15D. Address correspondence to Anna-Maija Kauppila, MD, PL 25, 90029 OYS, Oulu, Finland. E-mail: anna-maija. kauppila@oulu.fi. Submitted for publication April 11, 2010; accepted in revised form October 26, 2010.
ment surgery, and in Finland, OA accounted for 90% of 10,438 primary total knee replacement procedures performed in 2006 (3). Although a majority of patients experience marked improvement in pain, physical function, and quality of life after total knee arthroplasty (TKA) (4,5), all of the significant defects in muscle strength, aerobic fitness, and quality of life do not spontaneously resolve after surgery (6 – 8). Therefore, it is essential that patients receive effective rehabilitation. Following total knee replacement, it is unclear which method of rehabilitation is superior in terms of patientrelated outcome and cost of care. Comparison of the results of previous studies is complicated due to the heterogeneity of their content, outcome measurements, and study design. Recent studies have questioned the intensity and progression of previously used postoperative exercise programs (7,9,10), and more progressive, high-intensity exercises have been recommended to augment the return to near-normal levels of activity and function after surgery (7). Limited health care resources have created a demand for more efficient delivery of care. Clinical pathways and accelerated interventions have been implemented in order 335
336 to shorten the time of recovery and the length of hospital stay, and to reduce costs after joint replacement surgery (11). In a recent Danish trial, an accelerated perioperative care and rehabilitation intervention after TKA turned out to be as effective as but less costly than standard care (12). So far, only a few other studies, representing guidance and physiotherapy, have reported the cost-effectiveness of rehabilitation programs in connection with total knee replacement surgery (13–16). It has been suggested that rehabilitation programs, which are based on biopsychosocial philosophy and which integrate exercise and self-management interventions, could be effective for knee OA patients (17). Limited evidence exists on the effectiveness of early multidisciplinary rehabilitation after TKA (18). We have reported the results of a biopsychosocial, multidisciplinary, outpatient rehabilitation program in the subacute period of recovery after surgery, compared with conventional orthopedic care. In both groups, the results showed equal, significant improvement in functional capacity and health-related quality of life (HRQOL) 12 months after TKA (19). This report details an economic evaluation of the two rehabilitation programs.
SUBJECTS AND METHODS Design, participants, and ethics. Full details of the prospective, randomized controlled trial have been published previously (19). In brief, the trial was conducted to compare an outpatient, center-based multidisciplinary rehabilitation program completed 2– 4 months after primary TKA and conventional orthopedic care that included a standard amount of physiotherapy. The trial was conducted to detect differences in functional recovery, improvement in HRQOL, and the use of rehabilitation services during the 1-year followup. The subjects had to be knee OA patients, 60 – 80 years of age, who were scheduled for elective, primary unilateral TKA at Oulu University Hospital, and who participated in the study voluntarily. The exclusion criteria were: severe cardiovascular or pulmonary disease (New York Heart Association class III–IV) (20), severe dementia (Mini-Mental State Examination ⬍18) (21), rheumatoid arthritis, primary TKA scheduled as a treatment of an acute trauma of the knee, planned use of a special endoprosthesis, and a major postoperative complication as a contraindication for intensive rehabilitation (i.e., hemarthrosis, fracture, or infection of the operated knee joint; deep vein thrombosis; acute myocardial infarction; pulmonary embolism; and stroke). The study protocol was approved by the Ethics Committee of the Oulu University Hospital in December 2001. Written consent for participation was obtained from each patient. Interventions. All of the patients received conventional orthopedic care according to hospital protocols. Physiotherapy included preoperative guided exercises, a daily guided exercise program on the surgical ward, and a guided subsequent exercise program at a 2-month outpatient control visit to an orthopedic surgeon. Instructions for exercises to be completed daily were given. Outpatient
Kauppila et al control visits to an orthopedic surgeon were arranged 2, 6, and 12 months after surgery. The need for further rehabilitation was assessed at each visit. Therefore, additive outpatient rehabilitation interventions might have been included in the conventional care. In the subacute recovery period, knee joint effusion, pain, and movement limitations are expected to be improved, enabling the practice of more intense exercises. Therefore, the multidisciplinary rehabilitation program in the Department of Physical Medicine and Rehabilitation at Oulu University Hospital started 2– 4 months after TKA. The program was completed as an outpatient course lasting 10 days, and each course consisted of up to 8 patients. The aim of the program was to improve the patients’ quality of life and functional capacity by improving lower extremity strength, increasing lower extremity joint mobility, improving endurance, and motivating the patients to carry out a regular exercise program and weight control. Finally, the aim of the program was to offer psychosocial support, especially through peer support. Two physiotherapists, a physician specialized in physical medicine and rehabilitation, an orthopedic surgeon, a psychologist, a nutritionist, and a social worker were included in the multidisciplinary team. A detailed description of the rehabilitation programs is presented elsewhere (19). The interventions were provided between November 2002 and January 2006. We hypothesized that the multidisciplinary rehabilitation program would yield faster attainment of functional recovery than would conventional orthopedic care 1 year after surgery. Outcome measures. In both groups, the outcomes were assessed preoperatively and 2, 6, and 12 months after surgery. The primary outcome measure was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) function subscale score at the 12-month followup. We used a function scale that asks 17 questions about difficulties with functioning. Each question is graded on a visual analog scale ranging from 0 to 100 mm. Higher scores represent greater limitations in function. To score the function scale, we calculated the mean of the item scores (22). The secondary outcome measures were: the WOMAC subscale score for function at the 2- and 6-month followup periods; at all followup periods the 15D score, which is a generic, 15-dimensional, standardized, self-administered instrument that measures HRQOL and that can be used both as a profile and a single-index score measure (the maximum score is 1 [no problems in any dimension] and the minimum score is 0 [equal to being dead] [23]); the WOMAC composite score and subscale scores of pain and stiffness (22); and the results of objectively measured physical performance, based on a 15meter walk test (24), a stair test (25), and isometric strength of the knee (26), measured with the Lido Active Multijoint Rehabilitation System (Loredan Biomedical). Resource use and unit costs. Information about health care resource use and community support was collected by means of a questionnaire. Data collected included the number of visits to a general practitioner and a private
Cost of Multidisciplinary Rehabilitation After Primary TKA consultant; visits to a nurse in public health care; the number of outpatient visits to a central hospital; the number of inpatient days at a community health center ward, Oulu University Hospital, and other hospitals; the number of individual and group physiotherapy visits; the number of inpatient days in rehabilitation; and the number of public health care nursing and home help service visits. The preoperative questionnaire covered 1 month before surgery, and the following questionnaires covered the periods since the previous measurement. In addition, the number of outpatient visits to Oulu University Hospital (the only central hospital in the study area) and the number of inpatient days at communal health center wards and Oulu University Hospital were collated from hospital records for each patient. The unit costs of inpatient stay, outpatient health care services, and community support were obtained from the publication Healthcare Unit Costs in Finland in 2006 (27). The unit cost of the multidisciplinary rehabilitation course was based on the detailed internal accounting system of Oulu University Hospital. The unit cost of inpatient rehabilitation for veterans was obtained from the State Treasury. Since 87 (99%) of the 88 patients were retired, productivity costs due to days of sick leave were not included. The costs therefore represent the 1-year direct health care and social service costs. All of the costs are expressed in Euros (€) at the 2006 price level. Statistical methods. Summary statistics are expressed as the mean ⫾ SD or as the median with interquartile ranges (IQRs). The Mann-Whitney U test was used to compare the distribution of variables between the study groups for continuous variables and the Fisher’s exact test was used for categorical variables. Two-tailed significance levels are reported. The mixed-model approach was used to analyze repeated outcome measurements in all 4 assessment points using combined covariance patterns and a random coefficient model (28). The covariance structures tested were variance components, first-order autoregressive, heterogeneous first-order autoregressive, and spatial exponential, and the one with the smallest Akaike’s information criterion was chosen. The reported P value for time ⫻ group indicates time– group interaction. The mixed-model approach takes into account all available data, i.e., patients with incomplete data were not excluded from the analyses. Therefore, the analyses of the outcome measures were performed according to the intent-to-treat (ITT) principle. Statistical analysis was performed using SPSS, version 14.0, and SAS, version 9.1.3, statistical software. Effectiveness was measured by the change in both the time-weighted WOMAC function score and the number of quality-adjusted life years (QALYs) gained during the followup. In a secondary analysis, effectiveness was measured by the difference in self-reported pain and objectively measured physical performance. Cost-effectiveness was assessed from between-group differences in costs, change in functional capacity, and QALYs gained within 12 months of followup.
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RESULTS Participants and dropouts. Of the 88 patients (66 women) who met the trial eligibility requirements, 44 patients were randomly allocated to the multidisciplinary rehabilitation group and 42 patients to the conventional orthopedic care group, which was defined as the control group. Two patients were excluded because their operation was canceled. The baseline mean ⫾ SD age was 70.7 ⫾ 5.5 years, the mean ⫾ SD WOMAC function score was 60.7 ⫾ 18.2 mm, the mean ⫾ SD 15D score was 0.806 ⫾ 0.097, and the mean duration of symptoms was 9.6 years (range 1–50 years). Preoperatively, 17 patients (39%) in the multidisciplinary rehabilitation group and 13 patients (31%) in the control group lived alone (P ⫽ 0.5), 2 patients (5%) in the multidisciplinary rehabilitation group and 3 patients (7%) in the control group used home nursing (P ⫽ 0.7), and 4 patients (9%) in the multidisciplinary rehabilitation group and 4 patients (10%) in the control group used home help services (P ⬎ 0.9). In spite of the randomization, comorbid illnesses were more common (1 patient [2%] in the multidisciplinary rehabilitation group versus 9 patients [21%] in the control group did not have any other comorbid illnesses besides OA in other joints [P ⫽ 0.02]) and the patients’ global assessment of disease severity (mean ⫾ SD 73.9 ⫾ 24.6 versus 66.9 ⫾ 22.6; P ⫽ 0.008) was worse in the multidisciplinary rehabilitation group than in the control group. Otherwise, the preoperative characteristics of the groups were comparable at baseline (data not shown). Eight patients in the multidisciplinary rehabilitation group and 3 patients in the control group were excluded during the followup period. Questionnaire data on health care costs were available from 41 patients (93%) in the multidisciplinary rehabilitation group and 40 (95%) in the control group at the 2-month followup, from 34 patients (77%) in the multidisciplinary rehabilitation group and 38 (90%) in the control group at the 6-month followup, and from 35 patients (80%) in the multidisciplinary rehabilitation group and 35 (83%) in the control group at the 12-month followup. Therefore, the direct health care and social service costs of 36 patients (82%) in the multidisciplinary rehabilitation group and 39 patients (93%) in the control group were included in the final analyses. The WOMAC composite score (mean ⫾ SD 69.8 ⫾ 17.6 mm versus 59.0 ⫾ 16.6 mm; P ⫽ 0.04), function score (mean ⫾ SD 70.2 ⫾ 18.3 mm versus 59.0 ⫾ 17.8 mm; P ⫽ 0.005), and pain score (mean ⫾ SD 70.4 ⫾ 20.3 mm versus 57.6 ⫾ 17.9 mm; P ⫽ 0.05) were higher among the patients lost to followup than among those who completed the study. Otherwise, there were no significant differences in preoperative characteristics between the patients who completed the study and those who did not (data not shown). Outcome measures. Self-reported functional capacity, quality of life, and the results of physical performance tests improved significantly in both groups. Table 1 shows that no difference was found between the groups in any outcome measure at any assessment point during the study
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Table 1. Changes in self-reported functional capacity, health-related quality of life, and objectively measured physical performance in the study groups during the 1-year followup*
WOMAC function, mm‡ WOMAC composite score, mm‡ WOMAC pain, mm‡ WOMAC stiffness, mm‡ 15D score 15-meter walk test, seconds Stairs up, seconds Stairs down, seconds Peak torque extension (affected side), Nm Relative peak torque extension (affected side), Nm/kg
MRG (n ⴝ 36)
Control group (n ⴝ 39)
P time ⴛ group†
⫺32.4 ⫾ 26.4 ⫺32.8 ⫾ 24.9 ⫺36.8 ⫾ 25.8 ⫺26.2 ⫾ 30.6 0.034 ⫾ 0.090 ⫺3.7 ⫾ 7.1 ⫺4.2 ⫾ 5.9 ⫺5.8 ⫾ 9.7 13.2 ⫾ 35.5 0.21 ⫾ 0.45
⫺32.8 ⫾ 20.1 ⫺33.2 ⫾ 18.8 ⫺35.7 ⫾ 20.4 ⫺29.2 ⫾ 35.3 0.035 ⫾ 0.079 ⫺3.2 ⫾ 2.6 ⫺3.5 ⫾ 3.7 ⫺4.2 ⫾ 4.2 11.4 ⫾ 30.7 0.16 ⫾ 0.35
0.4 0.4 0.4 ⬎ 0.9 0.8 0.3 0.5 0.2 ⬎ 0.9 0.6
* Values are the mean ⫾ SD. The change is given as the final (12-month) score minus the preoperative score. MRG ⫽ multidisciplinary rehabilitation group; WOMAC ⫽ Western Ontario and McMaster Universities Osteoarthritis Index. † P value given as a result of the mixed-model, with time– group interaction and all 4 assessment points considered. ‡ WOMAC scores were graded on a visual analog scale ranging from 0 –100 mm. Higher scores represent greater limitations in function.
period, i.e., the rehabilitation protocols were equally effective (Table 1). Health care resource use and community support. Table 2 provides an overview of the items of resource use, unit costs (27), mean costs by item of resource, and the mean total direct cost. The mean direct total cost using the available cost data was €12,950 (median €12,018, IQR €10,293–15,759) in the multidisciplinary rehabilitation group (n ⫽ 36) and €11,120 (median €9,522, IQR €8,524 –
11,091) in the control group (n ⫽ 39). The mean direct total cost of rehabilitation services was €2,005 (median €1,792, IQR €1,607–2,224) in the multidisciplinary rehabilitation group and €490 (median €123, IQR €0 – 678) in the control group. Economic evaluation. When effectiveness was measured by the change in the time-weighted WOMAC function score, the intervention resulted in a mean decrement of 2.61 (95% confidence interval [95% CI] ⫺5.9, 10.4) in
Table 2. Items of resource use, their unit costs, amount of resource use, mean ⴞ SD costs, and associated total costs based on the patients for whom the resource use data were available* Total usage (no. of visits)
No. of inpatient days at a university hospital No. of inpatient days at a community health center ward No. of inpatient days at other hospitals General practitioner visits in public health care No. of outpatient visits to a university hospital Visits to a private consultant Nurse visits in public health care Multidisciplinary rehabilitation program Physiotherapist visits No. of inpatient days in rehabilitation for veterans Group physiotherapy visits Public health care home nursing visits Public health care home help service visits Total knee arthroplasty Direct total costs Total costs
Mean ⴞ SD costs, €
Unit cost, €
MRG (n ⴝ 36)
Control group (n ⴝ 39)
MRG (n ⴝ 36)
900.3† 193.3†
54‡ 154‡
25‡ 138‡
1,350 ⫾ 2,168 827 ⫾ 1,373
577 ⫾ 1,281 661 ⫾ 1,494
613.8† 81.5† 198.0† 80.8† 26.9† 1,607§ 61.7† 123.7¶
2 51 42‡ 8 35 36 167 24
1 61 42‡ 6 30 0 246 14
34 ⫾ 143 115 ⫾ 119 231 ⫾ 297 18 ⫾ 52 26 ⫾ 41 1,433 ⫾ 164 286 ⫾ 362 87 ⫾ 360
16 ⫾ 98 127 ⫾ 148 213 ⫾ 292 12 ⫾ 35 21 ⫾ 34 0 389 ⫾ 521 44 ⫾ 277
35 86 194 36
74 640# 318 39
31 ⫾ 102 102 ⫾ 267 152 ⫾ 400 8,090 12,950 ⫾ 3,011 466,197
56 ⫾ 240 699 ⫾ 4,199 230 ⫾ 1,262 8,090 11,120 ⫾ 5,950 433,663
29.7† 42.6† 28.2† 8,089.6†
Control group (n ⴝ 39)
* The unit costs are expressed in Euros at the 2006 price level. MRG ⫽ multidisciplinary rehabilitation group. † The source for the unit costs was Hujanen et al (27). ‡ Number of visits collated from hospital records for each patient. § The unit cost of multidisciplinary rehabilitation is based on the detailed internal accounting system of Oulu University Hospital. ¶ The source for the unit cost of inpatient rehabilitation for veterans was the State Treasury. # One patient used 616 home nursing visits during the followup.
Cost of Multidisciplinary Rehabilitation After Primary TKA function. When effectiveness was measured by the number of QALYs gained during the followup, the intervention resulted in a mean QALY decrement of ⫺0.0192 (95% CI ⫺0.0620, 0.0246). Both protocols of providing rehabilitation services turned out to be equally effective, but the conventional orthopedic care protocol was unequivocally cost saving. The saving was €1,830 per patient (95% CI ⫺548, 3,623) using the available direct cost data.
DISCUSSION To our knowledge, this is the first study evaluating the costs of a multidisciplinary rehabilitation program completed 2– 4 months after primary TKA, compared with conventional orthopedic care that included a standard amount of physiotherapy. Equal, significant improvement in HRQOL and functional capacity was found in both groups, but conventional care was clearly cost saving. The saving in direct health care and social service costs was €1,830 per patient, but there is rather wide variation around this mean. The strengths of the trial are its prospective, randomized, controlled design and its clinical relevance. Effectiveness was primarily analyzed by assessing change both in self-reported functional capacity, HRQOL, and objectively measured physical performance; cost-effectiveness was assessed from between-group differences in costs, change in functional capacity, and QALYs gained. All of the instruments and tests that were used were standard and validated, and the analyses of outcome measures were performed according to the ITT principle. Imputing of the missing total direct cost data was not included in the cost-effectiveness analyses. During the followup period, 8 patients in the multidisciplinary rehabilitation program group and 3 patients in the conventional orthopedic care group were excluded according to the study protocol. Preoperatively, they reported more severe limitations in their functional capacity than the patients who completed the study, but there was no difference in their use of health care resources or social services. The results on the cost-effectiveness of the two different protocols of rehabilitation were very clear: conventional orthopedic care was unequivocally cost saving. Therefore, although imputing of the missing cost data was not included in the analyses, it more than likely did not bias the results in any truly significant way. Although the questionnaire data on health care resource use and community support were not available for all of the patients at each followup, the overall response rate of approximately 85% is reasonably high. We collated from hospital records the data on inpatient stays at Oulu University Hospital and communal health center wards as well as outpatient visits to Oulu University Hospital for each of the analyzed 75 patients, which minimized the missing data. Inaccurate recall due to memory and cognitive impairment is a concern in elderly patients, and it may have affected the results of the present study. However, none of the patients in the study population had significant memory problems, 87 (99%) of them lived independently, and at baseline,
339 they all were light users of health care and social support services. Therefore, we do not believe short-term recall of resource utilization was inaccurate or biased in any direction. By using the available data on providing rehabilitation services after surgery, the saving was €1,515 per patient in favor of the control group. The cost of the multidisciplinary intervention was €1,607, expressed at the 2006 price level, which mainly explains the mean difference in direct total cost of €1,830 between the groups. There were rather large differences in the mean costs of some items of resource use, but the differences were not statistically significant at any assessment point, probably due to wide variance, which is also reflected in the wide variance in the total cost. There was also rather wide variation in incremental effectiveness, measured in two ways. Wide variation in both costs and effectiveness suggests that with some combinations of patient characteristics, i.e., in some subgroups, the result of intervention can be different from that shown by the means. However, the data are too small to enable identifying what such groups might be. The process of TKA care varies significantly across and within health care settings (29). In the US, complex combinations of health insurance payers influence the process of care. It is quite common to use inpatient rehabilitation with extended-care facilities and home physiotherapy after an acute hospital stay (29). Like in the UK (29), Australia (29,30), and The Netherlands (31), patients in Finland are predominantly treated in the acute hospital system with greater use of outpatient physiotherapy than inpatient, multidisciplinary rehabilitation with extendedcare facilities, including occupational therapy. Physiotherapists not only supervise patients to improve muscle strength, joint mobility, and endurance, but also to advise them to perform activities of daily living. Even the need for possible assistive devices or home adaptations is usually evaluated by a physiotherapist rather than an occupational therapist. Therefore, visits to occupational therapists were not included in the questionnaire on health care resource use and community support in the present study. OA is a complex interaction of biopsychosocial and economic effects. Therefore, it has been suggested that integrated rehabilitation programs including both exercise and self-management interventions could be efficient for patients with knee OA (17). Although the latest programs have turned out to be cost effective (32), many earlier programs have been found too long, complex, and expensive (17). Self-management interventions generally include advice and education about healthy lifestyles, pain management, joint protection, problem solving, and planning skills. Both exercise and self-management interventions were also included in the present multidisciplinary rehabilitation program. Furthermore, we used mainly group physiotherapy, which has been demonstrated to be cost effective for patients with chronic knee pain (32). However, when interpreting the results of the present study, one can question whether the program was too complex, which undoubtedly raised the cost of the intervention. On the basis of the latest findings and suggestions (6,7,9), one can also question whether the exercises lacked optimal intensity and progression, which could have af-
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fected the results of the achieved improvement and recovery, i.e., effectiveness. The rehabilitation program lasted 10 days over a period of 2 weeks, which may have been too short a period, considering the original aim of the program. In a few studies that have reported positive results of rehabilitation after TKA, the time period of the programs was longer than it was in the present study (9,15,16). In conclusion, for unselected knee OA patients, the multidisciplinary rehabilitation program implemented 2– 4 months after primary TKA was as effective as conventional orthopedic care that included a standard amount of physiotherapy, but conventional orthopedic care was undoubtedly cost saving. Therefore, similar multidisciplinary rehabilitation protocols cannot be recommended in clinical pathways for TKA in the future.
9.
10. 11. 12.
13.
ACKNOWLEDGMENTS
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We thank Martti Ha¨ma¨la¨inen, PhD, and Juhana Leppilahti, PhD, for their guidance in planning the study, and Pertti Siira, PT, and Vesa Laine, MSc, for providing the physical performance tests.
15.
AUTHOR CONTRIBUTIONS All authors were involved in drafting the article or revising it critically for important intellectual content, and all authors approved the final version to be published. Dr. Kauppila had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study conception and design. Kauppila, Sintonen, Aronen, Ohtonen, Kyllo¨nen, Arokoski. Acquisition of data. Kauppila, Kyllo¨nen, Arokoski. Analysis and interpretation of data. Kauppila, Sintonen, Aronen, Ohtonen, Kyllo¨nen, Arokoski.
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17. 18.
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