Long term treatment related upper limb morbidity and quality of life after sentinel lymph node biopsy for stage I or II breast cancer.

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 physical- and 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.

Vocational perspectives after spinal cord injury.

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.

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.

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 (t(0)) and 1 year after surgery (t(1)), 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 t(0) and t(1) 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.

Vocational reintegration following spinal cord injury: expectations, participation and interventions.

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.

Long-term outcome of equestrian injuries in children.

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.

Long-term disabilities and handicaps following sports injuries: outcome after outpatient treatment.

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.

Long-term outcome of sports injuries: results after inpatient treatment.

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.

Late morbidity after treatment of breast cancer in relation to daily activities and quality of life: a systematic review.

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.

[Clinical treatment of equestrian injuries in Groningen, 1990-1998: serious long-term effects]. / Klinisch behandelde paardrijletsels in Groningen, 1990-1998: ernstige langetermijngevolgen.

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.

Symptom scoring systems to diagnose distal polyneuropathy in diabetes: the Diabetic Neuropathy Symptom score.

AIMS: To provide one of the diagnostic categories for distal diabetic polyneuropathy,several symptom scoring systems are available, which are often extensive and lack in validation. We validated a new four-item Diabetic Neuropathy Symptom (DNS) score for diagnosing distal diabetic polyneuropathy. METHODS: We compared score characteristics of the generally accepted Neuropathy Symptom Score (NSS) with the DNS score, and tested construct validity,predictive value and reproducibility with the Diabetic Neuropathy Examination score, Semmes-Weinstein monofilaments and Vibration Perception Threshold(clinical standards) in 73 patients with diabetes (24 Type 1, 49 Type 2;43 male/30 female; mean age 57 years (19-90);mean diabetes duration 15 years (1-43)). RESULTS: Correlation between NSS and DNS score was high (Spearman r= 0.88). Patient scores were more differentiated on the DNS score. The relation of the NSS and DNS scores, respectively, with clinical standards was good (Spearman r= 0.21-0.60). Reproducibility of the DNS score was high (Cohen weighted kappa 0.78-0.95). The DNS score was easier to perform in clinical practice. CONCLUSIONS: The DNS is validated, fast and easy to perform, with a high predictive value when screening for diabetic polyneuropathy.

[Bicycle spoke injuries in children: accident details and consequences]. / Spaakverwondingen bij kinderen: toedracht en gevolgen.

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.

Factors related to successful job reintegration of people with a lower limb amputation.

OBJECTIVE: To study demographically, amputation-, and employment-related factors that show a relationship to successful job reintegration of patients after lower limb amputation. DESIGN: Cross-sectional study. SETTING: University hospital. PATIENTS: Subjects had an acquired unilateral major amputation of the lower limb at least 2 years before, were aged 18 to 60 years (mean, 46yr), and were living in the Netherlands. All 322 patients were working at the time of amputation and were recruited from orthopedic workshops. INTERVENTION: Questionnaires sent to subjects to self-report (1) demographic and amputation information and (2) job characteristics and readjustment postamputation. Questionnaire sent to rehabilitation specialists to assess physical work load. MAIN OUTCOME MEASURES: Demographically related (age, gender); amputation-related (comorbidity; reason and level; problems with stump, pain, prosthesis use and problems, mobility, rehabilitation); and employment-related (education, physical workload) information about the success of job reintegration. RESULTS: Job reintegration was successful in 79% and unsuccessful in 21% of the amputees. Age at the time of amputation, wearing comfort of the prosthesis, and education level were significant indicators of successful job reintegration. Subjects with physically demanding jobs who changed type of job before and after the amputation more often successfully returned to work than subjects who tried to stay at the same type of job. CONCLUSIONS: Older patients with a low education level and problems with the wearing comfort of the prosthesis are a population at risk who require special attention during the rehabilitation process in order to return to work. Lowering the physical workload by changing to another type of work enhances the chance of successful reintegration.

Evaluation of a screening and prevention programme for diabetic foot complications.

Foot complications in diabetes can be decreased by preventive measures. The authors evaluated the current diabetic foot screening and prevention programme of the diabetes outpatient clinic of their university hospital, by assessing the presence of risk factors for the development of foot disorders and the preventive measures taken. Fifty (50) diabetic patients not known to have foot complications were selected at random. Risk factors and preventive measures were inventarised with the Coleman risk-categorization system and the Preventive Measures Scale, respectively. Sixty per cent (60%) of the patients were at risk of developing diabetic foot complications. The preventive measures were low in these patients. Patient knowledge was insufficient and behaviour even worse. Basal preventive shoe adaptations were absent in most patients at risk. No relation between risk category and the preventative status was found. Cross-sectional examination at a university outpatient clinic showed serious risk profiles for foot complications, which were not balanced by the application of generally accepted preventive measures. At the outpatient clinic, screening should be optimised.

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 Spearman's 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.

Extensibility and stiffness of the hamstrings in patients with nonspecific low back pain.

OBJECTIVE: To investigate the extensibility and stiffness of the hamstrings in patients with nonspecific low back pain (LBP). DESIGN: An experimental design. SETTING: A university laboratory for human movement analysis in a department of rehabilitation medicine. PARTICIPANTS: Forty subjects, a patient group (20) and a healthy control group (20). INTERVENTIONS: Subjects laid supine on an examination table with a lift frame, with left leg placed in a sling at the ankle. Straight leg raising, pulling force, and activity of hamstring and back muscles were recorded with electrodes. Patients indicated when they experienced tension or pain. MAIN OUTCOME MEASURES: The lift force, leg excursion, pelvic-femoral angle, first sensation of pain, and the electromyogram of the hamstrings and back muscles measured in an experimental straight-leg raising set-up. RESULTS: The patient group showed a significant restriction in range of motion (ROM) and extensibility of the hamstrings compared with the control group. No significant difference in hamstring muscle stiffness can be assessed between both groups. CONCLUSION: The restricted ROM and the decreased extensibility of the hamstrings in patients with nonspecific LBP is not caused by increased muscle stiffness of the hamstrings, but determined by the stretch tolerance of the patients.

Employment status, job characteristics, and work-related health experience of people with a lower limb amputation in The Netherlands.

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.

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.

Measurement of severity of sports injuries: an epidemiological study.

OBJECTIVE: To evaluate the severity of sports injuries in relation to the severity of injuries due to other causes and in relation to type of sport, using generally applied measures of injury severity. SUBJECTS: A total of 12403 patients, 4-50 years old, who were treated in the trauma department of the Groningen University Hospital for a sports injury, from January 1990 until January 1997. METHOD: All patients treated because of an injury entered the study. A distinction was made between injuries caused by playing sports, home and leisure accidents, traffic accidents and violence. The severity of the injuries was assessed by using the criteria of rate of admission, Injury Severity Scale (ISS). Finally the sports injuries were analysed with regard to type of sport. RESULTS: In total, 57760 injuries were registered. After injuries due to home and leisure accidents (44%; 25228) sports injuries (21%; 12 403) were the most frequent cause of injury. Of the patients with a sports injury, 7.9% (980) were admitted, which is more than with home and leisure accidents (6.7%; 1690) but less than with traffic accidents (21.5%; 2202) and violence (9.3%; 364). In a majority of cases, admission was related to a limited number of types of sport. The mean ISS of sports injuries was low, as with injuries following home and leisure accidents and violence. The percentage of sports injuries with an ISS higher than or equal to 16 and the percentage mortality were both low in comparison to injuries due to violence or traffic accidents. CONCLUSIONS: Sports injuries rank second highest in terms of cause of injury, after home and leisure accidents; and rank third in terms of severity, after traffic accidents and violence. Even though the ISS is low, sports injuries may have serious consequences.

Diabetic neuropathy examination: a hierarchical scoring system to diagnose distal polyneuropathy in diabetes.

OBJECTIVE: Existing physical examination scoring systems for distal diabetic polyneuropathy (PNP) do not fulfill all of the following criteria: validity, manageability, predictive value, and hierarchy The aim of this study was to adapt the Neuropathy Disability Score (NDS) to diagnose PNP in diabetes so that it fulfills these criteria. RESEARCH DESIGN AND METHODS: A total of 73 patients with diabetes were examined with the NDS. Monofilaments and biothesiometry were used as clinical standards for PNP to modify the NDS. RESULTS: A total of 43 men and 30 women were studied; mean duration of diabetes was 15 years (1-43), and mean age was 57 years (19-90). A total of 24 patients had type 1 diabetes, and 49 patients had type 2 diabetes. Clinically relevant items were selected from the original 35 NDS items (specific item scored positive in >3 patients). The resulting 8-item Diabetic Neuropathy Examination (DNE) score could accurately predict the results of the clinical standards and is strongly hierarchical (H value 0.53). The sensitivity and specificity of the DNE at a cut-off level of 3 to 4 were 0.96 and 0.51 for abnormal monofilament scores, respectively. For abnormal vibration perception threshold scores, these values were 0.97 and 0.59, respectively. Reproducibility as assessed by inter- and intrarater agreement was good. CONCLUSIONS: The DNE is a sensitive and well-validated hierarchical scoring system that is fast and easy to perform in clinical practice.