Joannes Geertzen

Phantom pain and phantom sensations in upper limb amputees: an epidemiological study

&NA; Phantom pain in subjects with an amputated limb is a well‐known problem. However, estimates of the prevalence of phantom pain differ considerably in the literature. Various factors associated with phantom pain have been described including pain before the amputation, gender, dominance, and time elapsed since the amputation. The purposes of this study were to determine prevalence and factors associated with phantom pain and phantom sensations in upper limb amputees in The Netherlands. Additionally, the relationship between phantom pain, phantom sensations and prosthesis use in upper limb amputees was investigated. One hundred twenty‐four upper limb amputees participated in this study. Subjects were asked to fill out a self‐developed questionnaire scoring the following items: date, side, level, and reason of amputation, duration of experienced pain before amputation, frequencies with which phantom sensations, phantom pain, and stump pain are experienced, amount of trouble and suffering experienced, respectively, related to these sensations, type of phantom sensations, medical treatment received for phantom pain and/or stump pain, and the effects of the treatment, self medication, and prosthesis use. The response rate was 80%. The prevalence of phantom pain was 51%, of phantom sensations 76% and of stump pain 49%; 48% of the subjects experienced phantom pain a few times per day or more; 64% experienced moderate to very much suffering from the phantom pain. A significant association was found between phantom pain and phantom sensations (relative risk 11.3) and between phantom pain and stump pain (relative risk 1.9). No other factors associated with phantom pain or phantom sensations could be determined. Only four patients received medical treatment for their phantom pain. Phantom pain is a common problem in upper limb amputees that causes considerable suffering for the subjects involved. Only a minority of subjects are treated for phantom pain. Further research is needed to determine factors associated with phantom pain.

Impairments, disabilities and health related quality of life after treatment for breast cancer : a follow-up study 2.7 years after surgery

Purpose: The aim of this study was to assess impairments, disabilities and health related Quality of Life (QOL) after treatment of breast cancer and to analyse the relationship between treatment modalities, impairments, disabilities and health related QOL. Method: Fifty-five patients who underwent a modified radical mastectomy or a segmental mastectomy with axillary lymph node dissection were retrospectively assessed with a mean follow up of 2.7 years after treatment. Impairments were assessed by means of measuring active shoulder range of motion, grip strength, arm volume and pain. Disabilities were assessed by means of the Shoulder Disability Questionnaire (SDQ) and health related QOL was assessed by means of the RAND 36-item Health Survey (RAND-36). Setting: University Hospital Groningen (The Netherlands). Results: Pain (60%) and reduction of grip-strength (40%) were the most frequent impairments found. The prevalence of impaired range of motion and oedema was 9 – 16% respectively 15%. Mean group score of the SDQ was 33.7 (sd: 32.1) and mean scores of the RAND-36 differed significantly for physical functioning, vitality and health perception to that of a female norm group. Radiotherapy and chemotherapy were significant factors in the prediction of impaired range of motion. Pain and restricted range of motion explained 61% respectively 12% of the variance in disability (SDQ). In the prediction of health related QOL, pain, grip strength and arm volume were significant factors respectively in six, three and two domains. Conclusions: Pain is the most frequent assessed impairment after breast cancer treatment with strong relationship to perceived disability and health related QOL. Disability is mild and health related QOL (RAND-36) differed in three of the nine domains with a female norm group.

Treatment-Related Upper Limb Morbidity 1 Year after Sentinel Lymph Node Biopsy or Axillary Lymph Node Dissection for Stage I or II Breast Cancer

Background: In a prospective study, upper limb morbidity and perceived disability/activities of daily life (ADLs) were assessed before and 1 year after sentinel lymph node biopsy (SLNB) or axillary lymph node dissection (ALND).Methods: A total of 204 patients with stage I/II breast cancer (mean age, 55.6 years; SD, 11.6 years) entered the study, and 189 patients (93%) could be evaluated after 1 year. Fifty-eight patients (31%) underwent only SLNB, and 131 (69%) underwent ALND. Assessments performed before surgery (t0) and 1 year after surgery (t1), included pain, shoulder range of motion, muscle strength, upper arm/forearm circumference, and perceived shoulder disability/ADL.Results: Considerable treatment-related upper limb morbidity was observed. Significant (P < .05) changes between t0 and t1 were found in all assessments except strength of elbow flexors. Patients in the ALND group showed significantly more changes in the range of motion in forward flexion, abduction, and abduction/external rotation; grip strength and strength of shoulder abductors; circumference of upper arm and forearm; and perceived shoulder disability in ADLs compared with the SLNB group. Multivariate linear regression analysis showed that ALND could predict a decrease of range of motion in forward flexion, abduction, strength of shoulder abductors, grip strength, and shoulder-related ADLs and an increase in the circumference of the upper arm. Radiation of the axilla (19 patients) predicts an additional decrease in shoulder range of motion.Conclusions: One year after treatment of breast cancer, there is significantly less upper limb morbidity after SLNB compared with ALND. ALND is a predictor for upper limb morbidity.

Gait analysis in prosthetics: opinions, ideas and conclusions.

A review was performed of the literature of the last eleven years (1990–2000) with the topic: “clinical use of instrumented gait analysis in patients wearing a prosthesis of the lower limb”. To this end a literature search was performed in Embase, Medline and Recal. Forty-five (45) articles were identified for study from which 34 were reviewed. The reviews were divided into five subtopics: 1) adaptive strategies in gait (12 studies); 2) the influence of different parts of the prosthesis on gait (12 studies); 3) pressure measurements in the socket in gait studies (4 studies); 4) the influence of the mass of the prostheses on gait (5 studies); 5) energy considerations in gait (2 studies). A considerable part of the studies concerned the adaptive strategies of the amputee in walking and running and the evaluation of different prosthetic feet. All aspects and outcomes were reviewed concerning the clinical relevance.

Short-term morbidity of the upper limb after sentinel lymph node biopsy or axillary lymph node dissection for Stage I or II breast carcinoma.

The goals of sentinel lymph node biopsy (SLNB) are to improve axillary staging and reduce unnecessary axillary lymph node dissections (ALND), thereby reducing treatment‐related upper‐limb morbidity. In the current prospective study, short‐term upper‐limb morbidity was assessed after SLNB and/or ALND.

Multiple injuries: An overview of the outcome

To measure the functional outcome we analyzed 723 consecutive patients with multiple injuries (Abbreviated Injury Scale (AIS)/Injury Severity Score (ISS) > or = 16, mean ISS 30.1) treated at the University Hospital Groningen, the Netherlands, between 1985 and 1989. Age, sex, type of accident, AIS/ISS, discharge destination, length of hospital stay and functional outcome (measured by the Glasgow Outcome Scale) are described. The patients were young (mean age 33.4 years) and 186 died (25.7%) mainly because of severe head injuries. Half of the survivors could be discharged home and 29% were transferred to a rehabilitation center. Rehabilitation centers predominantly treat patients with severe injuries of the head or neck and extremities. These injuries, together with spinal cord injuries, appeared to be responsible for the majority of permanent disabilities. Although the functional outcome deteriorated linearly with increasing AIS/ISS, the final functional result was good: in the first half year after injury there was considerable recovery; after that there was further slight recuperation. Two years after injury, 68% had mild or no disabilities, 19% were moderately disabled, and 7% severely disabled.

Reliability and stability of the Roland Morris Disability Questionnaire : intra class correlation and limits of agreement

Purpose: To analyse test-retest reliability and stability of the Dutch language version of the Roland Morris Disability Questionnaire (RMDQ) in a sample of patients (n = 30) suffering from Chronic Low Back Pain (CLBP). Method: Patients filled out the Dutch language version of the RMDQ questionnaire twice, before starting the rehabilitation programme, with a 2-week interval. Intra Class Correlations (ICC), (one way random) was used as a measure for reliability and the limits of agreement were calculated for quantifying the stability of the RMDQ. An ICC of 0.75 or more was considered as an acceptable reliability. No criteria for limits of agreement were available. However, smaller limits of agreement indicate more stability because it indicates that the natural variation is small. Results: The Dutch RMDQ showed good reliability, with an ICC of 0.91. Calculating limits of agreement to quantify the stability, a large amount of natural variation ( ± 5.4) was found relative to the total scoring range of 0 to 24. Conclusion: The Dutch RMDQ proves to be a reliable instrument to measure functional status in CLBP patients. However, the natural variation should be taken into account when using it clinically.

Lower limb amputation Part 2: Rehabilitation - a 10 year literature review

Ten years after the ISPO consensus conference on amputation surgery, a search of relevant publications in the Rehabilitation-prosthetics-literature over the years 1990–2000 was performed. The main key-words in this research were: “lower limb, amputation, human and rehabilitation”. One hundred and four (104) articles were assessed by reading and from these the authors selected 24 articles. These articles are summarised, under several subheadings in this review article, focussing especially on quality of life, functional outcome and predictive factors.

Comparing self-report, clinical examination and functional testing in the assessment of work-related limitations in patients with chronic low back pain

Purpose. To compare the work-related limitations assessed using self-report, clinical examination and functional testing in patients with chronic low back pain (CLBP). Methods. Work-related limitations of 92 patients were assessed using self-report, clinical examination and functional testing. To obtain the assessed limitations the patient (self-report), the physician (clinical examination) and a trained evaluator (functional testing) completed a scorings form about the work-related limitations of the patient. The Isernhagen Work Systems Functional Capacity Evaluation (IWS FCE) was used to obtain the functional testing results. A κ value of more than 0.60, absolute agreement of more than 80% and ICC of more than 0.75 were considered as acceptable. Results. Little agreement and correlation among self-report, clinical examination and functional testing were found for the assessment of work-related limitations. Self-reported limitations were considerably higher than from those derived from clinical examination or functional testing. Additionally, the limitations derived from the clinical examination were higher than those derived from the IWS FCE. Conclusion. Comparing self-report, clinical examination and functional testing for assessing work-related limitations in CLBP patients showed large considerable differences in limitations. Professional health care workers should be aware of these differences when using them in daily practice.

Reflex sympathetic dystrophy of the upper extremity - a 5.5-year follow-up. Part II. Social life events, general health and changes in occupation

The aim of this retrospective long-term follow-up study was to describe the psychosocial aspects, such as social life events (SLE), around the causative event of reflex sympathetic dystrophy (RSD) and the psychological history of 65 patients, 3-9 years after RSD of the upper extremity. General health and long-term changes in occupation were assessed by means of a general health questionnaire (RAND-36) and a structured interview, respectively. SLE, with a life-change unit rate more than 35, was present in 32 patients. A psychological (or psychiatric) history was found in 22 patients. In total, 60% of the patients had a SLE and/or a psychological history. The pain scores of the RAND-36 among RSD patients differed significantly from those of the control group. 17 patients changed occupation after RSD. Nearly 30% of the patients had to stop work for more than one year. The results show a high coincidence between RSD and associated psychosocial disorders and this may play a role in intensifying and prolonging the symptomatology of RSD.