W.H. Eisma

Quality of life in patients with diabetic foot ulcers

PURPOSE To compare Quality of Life (QoL) between diabetic patients with (former or present) and without foot ulcers. METHODS Two patient groups of comparable age, sex distribution, type distribution and duration of diabetes were studied. Fourteen patients with former or present, but clinically stable diabetic foot ulcers (DFUs) were studied. The control group was 24 unknown patients with DFUs. None of the participants had other diabetic complications or conditions that would potentially affect QoL. A diabetic foot risk score and QoL were assessed. QoL was scored with the RAND-36, the Barthel Score (ADL) and the Walking and Walking Stairs Questionnaire (WSQ). RESULTS Marked and significant differences were found in physical functioning (p < 0.001), social functioning (p < 0.05), physical role (p < 0.001) and health experience (p < 0.05) between the two groups with the RAND-36 and the four subscales of the WSQ (all p < 0.001). On all these scales, QoL was significantly poorer in the study group. A correlation was found between the risk scores and QoL (physical functioning and physical role Spearmans r: -0.66, -0.56 and WSQ -0.63, -0.64, -0.67 and 0.71, respectively). CONCLUSION Presence or history of DFUs has a large impact on physical role, physical functioning and mobility. Physical impairments especially influenced QoL. Probably, QoL can be increased by providing attention that will enhance mobility and by giving advice about adaptations and special equipment.Purpose: To compare Quality of Life (QoL) between diabetic patients with (former or present) and without foot ulcers. Methods: Two patient groups of comparable age, sex distribution, type distribution and duration of diabetes were studied. Fourteen patients with former or present, but clinically stable diabetic foot ulcers (DFUs) were studied. The control group was 24 unknown patients with DFUs. None of the participants had other diabetic complications or conditions that would potentially affect QoL. A diabetic foot risk score and QoL were assessed. QoL was scored with the RAND-36, the Barthel Score (ADL) and the Walking and Walking Stairs Questionnaire (WSQ). Results: Marked and significant differences were found in physical functioning (p < 0.001), social functioning (p < 0.05), physical role (p < 0.001) and health experience (p < 0.05) between the two groups with the RAND-36 and the four sub scales of the WSQ (all p 0.001). On all these scales, QoL was significantly poorer in the study group. A correlation was found between the risk scores and QoL (physical functioning and physical role Spearmans r: 0.66, 0.56 and WSQ 0.63, 0.64, 0.67 and 0.71, respectively). Conclusion: Presence or history of DFUs has a large impact on physical role, physical functioning and mobility. Physical impairments especially influenced QoL. Probably, QoL can be increased by providing attention that will enhance mobility and by giving advice about adaptations and special equipment.

Energy storage and release of prosthetic feet Part 1: biomechanical analysis related to user benefits

The energy storing and releasing behaviour of 2 energy storing feet (ESF) and 2 conventional prosthetic feet (CF) were compared (ESF: Otto Bock Dynamic Pro and Hanger Quantum; CF: Otto Bock Multi Axial and Otto Bock Lager). Ten trans-tibial amputees were selected. The study was designed as a double-blind, randomised trial. For gait analysis a VICON motion analysis system was used with 2 AMTI force platforms. A special measuring device was used for measuring energy storage and release of the foot during a simulated step. The impulses of the anteroposterior component of the ground force showed small, statistically non-significant differences (deceleration phase: 22.7–23.4 Ns; acceleration phase: 17.0–18.4 Ns). The power storage and release phases as well as the net results also showed small differences (maximum difference in net result is 0.03 J kg−1). It was estimated that these differences lead to a maximum saving of 3% of metabolic energy during walking. It was considered unlikely that the subjects would notice this difference. It was concluded that during walking differences in mechanical energy expenditure of this magnitude are probably not of clinical relevance. Ankle power, as an indicator for energy storage and release gave different results to the energy storage and release as measured with the special test device, especially during landing response. In the biomechanical model (based on inverse dynamics) used in the gait analysis the deformation of the material is not taken into consideration and hence this method of gait analysis is probably not suitable for calculation of shock absorption.

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.

Epidemiology of lower limb amputees in the north of the Netherlands: Aetiology, discharge destination and prosthetic use

The aim of this study was to give a retrospective review of all lower limb amputations performed in the 3 northern provinces of the Netherlands in 1991–1992. Assembled data were compared with the existing information in the National Medical Register (NMR) over the same period. With the participation of all regional hospitals, 473 lower limb amputations from transpelvic to transmetatarsal level were identified. Of the amputations 94% were performed for vascular pathology, 3% for trauma, and 3% for oncologic reasons. After surgery a prosthesis was provided to 48% of the amputees. The actual number of performed amputations exceeds the number of amputations registered by the NMR by 9%. Incidence rates of lower limb amputations in the Netherlands are 18–20/100,000 over the last 12 years. These numbers are lower than in other areas and show no sharp decrease in frequency compared with other countries in Western Europe.

Major trauma in young and old : What is the difference?

OBJECTIVE To evaluate the differences in mortality and long-term outcome between young and elderly patients with multiple injuries. DESIGN Retrospective and descriptive. MATERIALS AND METHODS Over a 5-year period (from January 1985 to January 1990) all the consecutive young (20 to 29 years, n = 167) and elderly (> or = 60 years, n = 121) patients with an Abbreviated Injury Scale score/Injury Severity Score of > or = 16 treated at the University Hospital Groningen (the Netherlands) were reviewed. Age, sex, mechanisms of injury, Abbreviated Injury Scale score, Injury Severity Score, mortality, duration of artificial ventilation, hospitalization, and intensive care treatment and discharge destination were analyzed. Long-term outcome was determined using the Glasgow Outcome Scale. MEASUREMENTS AND MAIN RESULTS Motorized vehicles were the leading cause of injury in both groups. Mortality in the young was lower than in the elderly (19.6% versus 38.8%); all elderly with an Injury Severity Score of > or = 50 died. Nearly all deaths in young and elderly were caused by severe brain injuries (83.8% versus 74.4%). Deaths related to multiple organ failure were not observed in the young and were rare in the elderly. The surviving young and elderly could be discharged home in equal percentages and their functional outcome 2 years after injury did not differ essentially. CONCLUSION We did not find any valid argument to treat severely injured elderly patients any differently from their younger counterparts, which implies that the increased trauma care cost is also justified for severely injured elderly.

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.

Participation and satisfaction after spinal cord injury: results of a vocational and leisure outcome study

Study design:Survey.Objectives:Insight in (1) the changes in participation in vocational and leisure activities and (2) satisfaction with the current participation level of people with spinal cord injuries (SCIs) after reintegration in society.Design:Descriptive analysis of data from a questionnaire.Setting:Rehabilitation centre with special department for patients with SCIs, Groningen, The Netherlands.Subjects:A total of 57 patients with traumatic SCI living in the community, who were admitted to the rehabilitation centre two to 12 years before the current assessment.Main outcome measures:Changes in participation in activities; current life satisfaction; support and unmet needs.Results:Participation expressed in terms of hours spent on vocational and leisure activities changed to a great extent after the SCI. This was mainly determined by a large reduction of hours spent on paid work. While 60% of the respondents successfully reintegrated in work, many changes took place in the type and extent of the job. Loss of work was partially compensated with domestic and leisure activities. Sports activities were reduced substantially. The change in participation level and compensation for the lost working hours was not significantly associated with the level of SCI-specific health problems and disabilities. As was found in other studies, most respondents were satisfied with their lives. Determinants of a negative life satisfaction several years following SCI were not easily indicated. Reduced quality of life was particularly related to an unsatisfactory work and leisure situation.Conclusions:Most people with SCI in this study group were able to resume work and were satisfied with their work and leisure situation.

Walking speed of normal subjects and amputees: aspects of validity of gait analysis

This study investigated some aspects of the validity of walking speed recording in 15 normal subjects, 16 trans-femoral amputees and 8 knee disarticulation amputees. The variability and test-retest reliability of walking speed and the influence of simultaneous recording of EMG and goniometry on comfortable and fast walking speeds were studied. The variability between sessions was mainly determined by the variance within each session. The variance of speed within sessions while walking with fast speed, was higher when walking without equipment than when walking with equipment. The variances of speed within sessions of the normal subjects were higher than those for both amputee groups. The test-retest reliability, expressed by the intra-class correlation coefficient, was good: between 0.83 and 0.98. The speed when walking without equipment was significantly higher both in normal subjects and amputees than the speed when.walking with equipment.

Relationship between impairments, disability and handicap in reflex sympathetic dystrophy patients: a long-term follow-up study

Objective: To determine the relationship between impairments, disability and handicap in reflex sympathetic dystrophy (RSD) patients. Design: A long-term follow-up study of upper extremity RSD patients. Setting: A university hospital. Subjects: Sixty-five patients, 3–9 years (mean interval 5.5 years) after RSD of the upper extremity (mean age 50.2 years). Main outcome measures: Impairments: range of motion, moving two point discrimination, muscle strength of the hand and pain were measured. Disability was assessed with the Groningen Activity Restriction Scale (GARS) and handicap was assessed with three subscales (social functioning, role limitations due to physical problems and role limitations due to emotional problems) of the RAND-36. Results: After RSD of the upper extremity, 62% of the patients are limited in activities of daily living (ADL) and/or instrumental ADL (IADL). Pain and restrictions in forward flexion of the shoulder, thumb opposition and grip strength are the most important impairments limiting ADL and IADL. Patients with limitations in ADL and IADL are significantly more handicapped than patients without limitations. Pain is the most important factor contributing to handicap. Conclusion: The relationship between impairments and disability and between disability and handicap in RSD patients is weak to moderate. Pain is the most important factor leading to disability and handicap.

Mobility of people with lower limb amputations: scales and questionnaires: a review

Objective and design: A systematic literature review to compare mobility scales used for lower limb amputees. A literature search was carried out by computerized search of biomedical literature including Medline and Embase. The studies included were published between 1978 and 1998 and including the following keywords: amputation, artificial limbs, prosthesis, lower limb, activities of daily living, mobility. Results: Thirty-five studies were identified; 19 had a measurement of separate levels of mobility comparable to each other. Sixteen studies used ordinal and ratio scales without separate levels of mobility. The widest range of measurement found was the scale from ‘walking with prosthesis without a walking aid’ to ‘totally confined to bed’. The Stanmore Harold Wood mobility scale was published most frequently. None of the 35 studies presented give a continuous measurement of mobility. Conclusion: A multitude of measurement scales and questionnaires are available for differ in methods and measuring range. Measuring mobility by a scale has been shown to have limitations. Several authors did extensive research but they all measure only a number of aspects of mobility. Consensus about the measurement of mobility of lower limb amputees is not available in the recent literature.