Background: In a prospective study, long term upper-limb morbidity, perceived disabilities in activities of daily life (ADL) and quality of life (QOL) were assessed before and 2 years after sentinel lymph node biopsy (SLNB) or axillary lymph node dissections (ALND) for breast cancer. Methods: Two hundred and four patients with stage I/II breast cancer, mean age 55.6 years (SD: 11.6) entered the study and 181 patients (89%) could be evaluated after 2 years. Fifty-seven patients underwent SLNB (31%) and 124 patients underwent an ALND (69%). Assessments included pain, shoulder range of motion, muscle strength, arm volume, perceived shoulder disability in ADL and QOL. Results: Significant (P!0.05) changes between before and 2 years after surgery were found in almost all assessments of shoulder function, ADL and several QOL subscales. Patients in the ALND group showed significant more changes in range of motion (ROM), grip strength, arm volume, ADL and QOL physicaland role functioning, pain and sleeplessness and arm symptoms compared to the SLNB group. Multivariate linear regression analysis showed that ALND could predict decrease of ROM, grip strength, ADL and physical functioning (QOL) and increase of arm volume, pain and arm symptoms score (QOL). Radiation on the axilla predicts an additional decrease in shoulder ROM and increase of arm volume. Conclusion: Two years after surgery for breast cancer, patients show significantly less treatment related upper limb morbidity, perceived disability in ADL and worsening of QOL after SLNB compared with ALND. q 2005 Elsevier Ltd. All rights reserved.

Objective: To give insight into the vocational situation several years after a traumatic spinal cord injury (SCI) and describe the personal experiences and unmet needs; to give an overview of health and functional status per type of SCI and their relationship with employment status.Design: Descriptive analysis of data from a questionnaire.Setting: Dutch rehabilitation centre with special department for patients with spinal cord injuries.Subjects: Fifty-seven patients with a traumatic SCI, aged 18-60 years, admitted to the rehabilitation centre from 1990 to 1998.Main measures: Questionnaire with items related to vocational outcome, job experiences, health and functional status.Results: Of 49 patients who were working at the moment of SCI 60% currently had a paid job. Vocational outcome was related to a higher educational level. A significant relation between the SCI-specific health and functional status and employment was not found. The respondents who changed to a new employer needed more time to resume work, but seemed more satisfied with the job and lost fewer working hours than those who resumed work with the same employer. In spite of reasonable to good satisfaction with the current work situation, several negative experiences and unmet needs were reported.Conclusions: Despite a high participation in paid work following SCI, the effort of the disabled worker to have and keep a job should not be underestimated.

Objectives: To examine children's reports of their health-related quality of life (HRQoL) following paediatric traffic injury, to explore child and parental post-traumatic stress, and to identify children and parents with adverse outcomes. Design: Prospective cohort study. Assessments: shortly after the injury, three months and six months post injury. Setting: Department of Traumatology, University Hospital. Subjects: Fifty-one young traffic injury victims aged 8-15 years. Main measures: TNO-AZL Children's Quality of Life questionnaire and the Impact of Event Scale. Results: Short-term adverse changes in the child's HRQoL were observed for the child's motor functioning and autonomy. At three months, 12% of the children and 16% of the parents reported serious post-traumatic stress symptoms. Increased stress at three months, or across follow-up, was observed among hospitalized children, children with head injuries, and children injured in a motor vehicle accident. Parental stress was related to low socioeconomic status and the seriousness of the child's injury and accident (hospitalization, head injury, serious injury, motor vehicle involved, others injured). Conclusions: The children reported only temporary effects in their motor functioning and autonomy. Post-traumatic stress symptoms following paediatric traffic injury were not only experienced by the children, but also by their parents.

Study design: Survey. Objectives: To explore the process of reintegration in paid work following a traumatic spinal cord injury (SCI), including the role of early expectations of individual patients regarding return to work, indicators of success of job reintegration and a description of reintegration interventions and barriers. Setting: Dutch rehabilitation centre with special department for patients with spinal cord injuries. Methods: Descriptive analysis of data gathered by a mailed questionnaire, which was returned by 57 persons (response 83%) with traumatic SCI, aged 18–60 years, and data of earlier expectations reported by the individual patients during the rehabilitation admission following SCI from 1990 to 1998. Results: Of 49 respondents who were employed at the moment of the SCI, 45% expected to be able to resume work. These positive expectations were associated with a higher educational level. In 67%, return to work was successful. The chance to reintegrate successfully was better if the patient expected to resume work. Logistic regression analysis did not reveal other significant indicators. About one-third of the 49 respondents working preinjury followed vocational retraining, which was successful for most of them so far. In the majority of work situations modifications have been made, such as job adaptations and reduction of working hours. Several unmet needs regarding reintegration interventions were also reported. Conclusions: Positive expectations regarding resumption of work after a SCI are an important indicator of successful reintegration in work. An active role of the rehabilitation team is recommended in drawing up a vocational reintegration plan to prepare the patient, the employer and professionals involved in the reintegration process.

PURPOSE:To investigate the possible development of long-term disabilities arising from paediatric equestrian injuries.METHOD:All patients, aged 17 years or younger, treated in a hospital setting because of an equestrian injury during a five-year period received a questionnaire. A reference population and healthy friends served as controls.RESULTS:Four years post-injury, 41 of the 100 respondents still experienced disabilities following the injury. The median Injury Severity Score was 4. Absenteeism from school lasted 2 weeks, and from horse riding, 4 months. Compared to the reference population, the results of the Child Health Questionnaire were poorer considering most of its subscales. In comparison with the friends, the patients only scored lower on 'physical functioning'. The risk factors concerning poor long-term outcomes were being an advanced rider, sustaining injuries other than fractures of the extremities or sustaining subsequent injuries following the riding accident.CONCLUSIONS:Although equestrian injuries in children are minor to moderate in their severity, these injuries are significant considering that a large proportion of patients experience long-term disabilities.

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.

BACKGROUND: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.METHODS:The study comprised 204 patients with Stage I/II breast carcinoma. Mean patient age was 55.6 years (standard deviation, 11.6). Sixty-six patients (32%) underwent SLNB only, and 138 (68%) underwent a Level I-II ALND. Assessment (preoperative [t0] and 6 weeks postoperative [t1]) included evaluation of shoulder range of motion, muscle strength, grip strength, pain, upper/forearm circumference, shoulder disability, and activities of daily life (ADL).RESULTS:Considerable treatment-related upper-limb morbidity was observed. Significant (P < 0.001) changes were found for pain, range of motion in forward flexion, abduction and abduction/external rotation, strength of shoulder abductors and elbow flexors, and in perceived disability in ADL. However, no significant difference in change of upper-limb function and ADL was found between the SLNB and ALND groups.CONCLUSIONS:Significant short-term treatment-related upper-limb morbidity exists after SLNB or ALND. There is no significant difference in short-term treatment-related morbidity between SLNB and ALND.

Objective: To investigate whether sports injuries result in long-term disabilities and handicaps and to establish variables with a prognostic value for the occurrence of these long-term consequences.Materials and methods: All patients older than 17 years of age and admitted to the University Hospital Groningen because of a sports injury were entered in the study. By filling in a questionnaire 1 - 4 years after the injury an inventory was made of the long-term consequences.Main outcome measures: Absenteeism from work and sports, experienced disabilities or handicaps and the Sickness Impact Profile 68 (SIP68).Results: Out of 306 patients 229 (75%) returned a completed questionnaire. Sixty-seven per cent of the working population had been unfit for work up to one year, whereas 4% still had not resumed work. Absenteeism from sports was also considerable; nearly half of the population did not participate in sports for more than a year. Furthermore, 32% of the patients still experienced disability or handicap following the injury. This finding is in agreement with the results of the SIP68 ( odds ratio 6.8; confidence interval (95% CI): 3.51 - 13.08). Two prognostic variables could be distinguished: 'gender' and 'type of sport'. Long-term consequences occur more often in women ( p < 0.03) and with playing outdoor soccer, horse riding or skiing ( p < 0.01).Conclusions: Sports injuries can lead to long-term disabilities and handicaps. The variables 'gender' and 'type of sport' were of prognostic significance.

Purpose : The aim was to investigate whether long-term disabilities and handicaps arise from a sports injury requiring outpatient treatment and to identify the potential risk factors. Method : A representative sample was taken from a population of patients treated as outpatients due to a sports injury. The selected patients were sent a questionnaire, 2 - 5 years after the injury. Result : Thirty-nine percent of the patients studied were unable to work for up to 1 month after the injury, 19% were not able to work for up to 3 months and another 5% could not work for a maximum of 8 months. Participation in sporting activities was hampered for up to 1 year in 76% of the patients and 11% had not resumed sports participation at all. In addition, 20% of the population stated that they still suffered from disabilities and handicaps following the sports injury. The outcome of the SIP68 underlines these results. Nine percent of the patients had a sumscore larger than 0. The variables which could be identified as risk factors were the body region: knee and sex: female. Conclusions : Sports injuries requiring outpatient treatment can lead to long-term disabilities and handicaps, especially in patients with knee injuries and injuries in women. On average these consequences are less severe than those associated with inpatients; however, this finding is of great value since the number of outpatients is much higher than in patients admitted to a hospital.

AIMS Breast cancer treatment may result in long-term upper limb morbidity: reduced range of motion of the shoulder, muscle weakness of the arm and hand, lymph edema, pain and numbness. Relationship of this late morbidity with activities of daily life (ADL) and quality of life (QOL) is infrequently described and the strength of this relationship is not clear. METHODS A systematic review was performed to evaluate the results of studies, analyzing late morbidity of breast cancer treatment in relationship with ADL and/or QOL. A literature search over the last 20 years (1980-2000) was performed in the databases MEDLINE, EMBASE, PSYCHLIT and CANCERLIT. Methodological quality of selected articles was assessed and additional, aspects of treatment related late morbidity and the relationship to ADL and/or QOL were summarized. RESULTS From the 1642 yielded articles 15 fulfilled our primary selection criteria. Only six articles could be selected due to the inappropriate methodological quality. There was high variation in prevalence of pain (12-51%), impairments in range of motion (2-51%), edema (6-43%) and decreased muscle strength (17-33%). Four articles reported significant relationships between late morbidity of the upper limb and perceived disabilities in ADL/QOL. The strength of these relationships was rather low. CONCLUSIONS Few studies investigated the relationship between late morbidity of the upper limb after treatment of early breast cancer and ADL/QOL. Significant relationship between late morbidity and restrictions of daily activities and poorer QOL was reported, however, the strength of this relationship was rather low.

OBJECTIVE:To determine whether equestrian injuries result in long-term residual symptoms and to establish the risk factors for these outcomes.DESIGN:Retrospective, descriptive.METHOD:A total of 88 patients older than 17 years of age who had been admitted to the Department of Surgery, University Hospital Groningen during the period 1990-1998 because of an equestrian injury were included in the study. After an average period of five years an inventory was made using the Sickness Impact Profile 68 (SIP68), if absenteeism from work or sport and disabilities or handicaps were experienced. Following this the risk factors for the occurrence of long-term effects were investigated.RESULTS:The response was 65/88 (74%). Equestrian injuries often resulted in long-term effects: 35% of the patients had a SIP68 score > 0.11% were permanently unfit for work, 25% no longer participated in sport as an effect of the injury and 43% still experienced some form of disability or handicap; on average this was all 5 years after the injury. The type of injury (notably intracranial, fracture), body region (notably trunk), and the injury severity score (ISS) were significantly correlated with the occurrence of long-term effects.CONCLUSION:Equestrian injuries which required clinical treatment were serious in nature and often resulted in disabilities and handicaps.

OBJECTIVE: To describe the accident details and the effects of bicycle-spoke accidents on the physical and psychosocial functioning of children. DESIGN: Retrospective, descriptive. METHODS: The parents of 87 children aged between 1-12 who came to the central casualty department at the Groningen University Hospital with bicycle-spoke injuries during the period 1 January 1998 to 31 October 1999, were asked to complete a questionnaire on the accident details, the quality of life and the functional health status (behaviour) of their child in January 2000. RESULTS: Eighty-seven children fulfilled the inclusion criteria: 44 boys and 43 girls, with a mean age of 4.4 years (SD: 1.6, range: 1.4-10.2). Fifty-nine parents filled out the questionnaire (68%). A quarter of the children had been transported in a bicycle-seat (25%) and half of the children (51%) were seated on the carrier without any foot supports. Twenty-four percent of the bicycles were equipped with unbroken coat guards. The younger children (1-5 years of age) had significantly lower scores regarding motor functioning compared with the reference group (p < 0.001). The study population did not have significantly lower scores for the other quality of life domains compared with the reference groups. Eight parents (14%) attributed behavioural problems to the bicycle-spoke accident. CONCLUSION: Not all children were fully recovered one year after the bicycle-spoke accident. The sequelae included physical as well as behavioural aspects of functioning. The bicycles lacked adequate protective measures

OBJECTIVE:To describe the health-related quality of life (HRQoL) of young traffic victims and to identify those children who are at high risk of a reduced HRQoL. METHODS:Retrospective analysis of data obtained from a registration system and from questionnaires completed by 211 parents of young traffic victims who attended the department of traumatology in 1996 and 1997. RESULTS:The overall group of young traffic victims experienced a lower HRQoL sumscore compared with the reference population (p = 0.001). A total of 48 parents (23%) attributed their child's reduced HRQoL specifically to the traffic accident. The socioeconomic status (SES) of the father (p = 0.018) and the Injury Severity Score (p < 0.001) emerged as significant predictors of traffic-related HRQoL. CONCLUSION:Children of low SES parents and severely injured children are at particularly high risk of a reduced HRQoL following a traffic accident. However, not solely severely injured and hospitalized young traffic victims may suffer a diminished HRQoL but traffic-related injuries of minor or moderate severity may cause substantial problems as well.

OBJECTIVE:To describe the accident details and the effects of bicycle-spoke accidents on the physical and psychosocial functioning of children.DESIGN:Retrospective, descriptive.METHODS:The parents of 87 children aged between 1-12 who came to the central casualty department at the Groningen University Hospital with bicycle-spoke injuries during the period 1 January 1998 to 31 October 1999, were asked to complete a questionnaire on the accident details, the quality of life and the functional health status (behaviour) of their child in January 2000.RESULTS:Eighty-seven children fulfilled the inclusion criteria: 44 boys and 43 girls, with a mean age of 4.4 years (SD: 1.6, range: 1.4-10.2). Fifty-nine parents filled out the questionnaire (68%). A quarter of the children had been transported in a bicycle-seat (25%) and half of the children (51%) were seated on the carrier without any foot supports. Twenty-four percent of the bicycles were equipped with unbroken coat guards. The younger children (1-5 years of age) had significantly lower scores regarding motor functioning compared with the reference group (p < 0.001). The study population did not have significantly lower scores for the other quality of life domains compared with the reference groups. Eight parents (14%) attributed behavioural problems to the bicycle-spoke accident.CONCLUSION:Not all children were fully recovered one year after the bicycle-spoke accident. The sequelae included physical as well as behavioural aspects of functioning. The bicycles lacked adequate protective measures.

Objective: To provide an epidemiological overview of the characteristics of injured children and to compare hospitalized and nonhospitalized injured children to identify predictors of hospitalization and, with that, possible predictors of disablement. Design: Retrospective analysis of data obtained from a computerized trauma registration system and medical records. Setting: Department of Traumatology, University Hospital Groningen, the Netherlands. Subjects: Children (0–19 years) injured in 1996 and 1997 ( n = 5057). Results: The majority of children were injured in home and leisure accidents (53%) and sustained minor injuries. Only 55 (1%) children were severely injured (Injury Severity Score (ISS) 3 16). Overall, 512 (10%) patients required hospitalization, 19 children were referred to a rehabilitation centre, and 24 children died due to their injuries. The majority of these patients were injured in traffic. Compared with the group of nonhospitalized patients, the group of hospitalized patients consisted of more males and traffic victims, were more severely injured, and sustained more head/neck, spine, and thorax and abdomen injuries. Nonhospitalized patients incurred proportionally more upper and lower extremity injuries. The ISS, the body region of most severe injury, and injury cause (traffic accidents) were significant predictors of hospitalization. Conclusions: Young traffic victims, severely injured children in terms of high ISS scores, and children with injuries affecting the head/neck/face or thorax/abdomen carry the highest risk of hospitalization.

OBJECTIVES:To describe indicators of job dissatisfaction among amputee employees and to compare job satisfaction and health experience of working amputee employees with that of control subjects.DESIGN:A cross-sectional study, mailed questionnaire.SETTING:Patients were recruited by the orthopedic workshops of the Netherlands.PARTICIPANTS:One hundred forty-four patients who had an acquired unilateral major amputation of the lower limb at least 2 years before, were aged 18 to 60 years (mean age, 43y), and were living and working in the Netherlands. One hundred forty-four control subjects matched for age, gender, and type of job.INTERVENTIONS:Not applicable.MAIN OUTCOME MEASURES:Statistical analysis of responses to a questionnaire regarding patient characteristics and amputation-related factors, amputee patients' opinions about their work and the social atmosphere at work, and their general health (RAND 36-Item Health Survey [RAND-36]).RESULTS:People with an amputation had greater job satisfaction (70%) than did the able-bodied control group (54%). The wish for (better) modifications in the workplace and the presence of comorbidity were significantly related to job dissatisfaction in people with limb loss. Amputee employees were less often hindered by the failures of others and by fluctuations in temperature. People with limb loss showed a worse physical health experience than controls on the RAND-36.CONCLUSIONS:The vocational satisfaction of people with limb loss may be improved by better workplace modifications, depending on the functional capabilities of the person and the functional demands of the job; improvement may also be achieved by vocational rehabilitation programs, especially for those with an amputation in combination with other morbidity. Despite experiencing more health problems, the amputee group expressed greater job satisfaction than the able-bodied group, reflecting a great appreciation of job reintegration by people with a lower-limb amputation.

Schoppen T, Boonstra A, Groothoff JW, de Vries J, Göeken LNH, Eisma WH. Employment status, job characteristics, and work-related health experience of people with a lower limb amputation in The Netherlands. Arch Phys Med Rehabil 2001;82:239-45. Objectives: To describe the occupational situation of people with lower limb amputations in The Netherlands and to compare the health experience of working and nonworking amputee patients with a nonimpaired reference population. Design: Cross-sectional study in which patients completed a questionnaire about their job participation, type of job, workplace adjustments to their limb loss, their position in the company, and a general health questionnaire. Setting: Orthopedic workshops in The Netherlands with a population of lower limb amputees. Patients: Subjects were recruited from orthopedic workshops in the Netherlands. They ranged in age from 18 to 60 years (mean, 44.5yr) and had a lower limb amputated at least 2 years (mean, 19.6yr) before this study. Main Outcome Measures: A self-report questionnaire, with 1 part concerning patient characteristics and amputation-related factors, and the other concerning job characteristics, vocational handicaps, work adjustments, and working conditions; and a general health questionnaire (RAND-36) to measure health status. Results: Responses were received from 652 of the 687 patients (response rate, 95%) who were sent the questionnaire. Sixty-four percent of the respondents were working at the time of the study (comparable with the employment rate of the general Dutch population), 31% had work experience but were not presently working, and 5% had no work experience. After their amputations, people shifted to less physically demanding work. The mean delay between the amputation and the return to work was 2.3 years. Many people wished their work was better adjusted to the limitations presented by their disability and they mentioned having problems concerning possibilities for promotion. Seventy-eight percent of those who stopped working within 2 years after the amputation said that amputation-related factors played a role in their decision. Thirty-four percent said that they might have worked longer if certain adjustments had been made. The health experience of people who were no longer working was significantly worse than that of the working people with amputations. Conclusions: Although amputee patients had a relatively good rate of job participation, they reported problems concerning the long delay between amputation and return to work, problems in finding suitable jobs, fewer possibilities for promotion, and problems in obtaining needed workplace modifications. People who had to stop working because of the amputation showed a worse health experience than working people.