Biomedical subjects
Publications and source records attributed to J H Geertzen.
This retrospective study assessed the long-term outcome of brachial plexus neuropathy in 16 patients. The mean follow up was 8 years. Nine patients complained of persistent pain and muscle weakness, four had continuing problems with various activities of daily living and 11 had trouble with some housekeeping activities. Furthermore, eight of the patients had to change their occupation.
OBJECTIVE: To analyse perceived impairments, disability, job restrictions and job changes in subjects with a neurapraxia and neurotmesis of the ulnar nerve five years after trauma. DESIGN: Retrospective, descriptive follow-up study. SETTING: Department of Rehabilitation of a University Hospital. SUBJECTS: Sixteen subjects with a neurotmesis (NT-group) and 20 subjects with a neurapraxia (NP-group) were compared by means of a structured interview assessing perceived impairments and change in job and a questionnaire assessing disabilities (Groningen Activity Restriction Scale: GARS). RESULTS: The NP-group perceived significantly more pain, loss of strength and sensation, loss of dexterity and perceived more job-related restrictions than the NT-group. The NP-group had significantly higher scores on the GARS. There was a moderate correlation between the visual analogue score of the pain and the GARS in the NP- and NT-groups. No significant difference was found between the groups with respect to job changes. CONCLUSIONS: This study shows that subjects with a neurapraxia of the ulnar nerve perceive more impairments and disabilities compared with those subjects with a neurotmesis.
The clinical picture of reflex sympathetic dystrophy (RSD) is characterized by a combination of the triad: autonomic, motor and sensory changes. In this study, the grip strength is measured in 29 upper extremity RSD patients. We used the generalizability theory to assess the extent of the disagreement or differences (errors in measurement) within or between observers and interactions between observer-session and repetition of the measurements. The aims of our study were to determine the different sources of variation in grip strength tests and the smallest detectable differences (SDD) as well as the reliability of upper extremity grip strength tests in RSD patients. The main sources of variation of measurement errors were observer, patient/observer interactions and patient/session/observer interaction and a random source. We found that the generalizability theory is useful for estimating the sources of measurement error. Clinical examinations for muscle strength measurements, as a part of a total clinical examination, for example for a disability payment or worker's compensation in case of RSD patients should be done by more than one observer in more than one session and more than once.
OBJECTIVE: To determine to what extent stressful life events and psychological dysfunction play a role in the pathogenesis of Complex Regional Pain Syndrome type I (CRPS). DESIGN: A comparative study between a CRPS group and a control group. Stressful life events and psychological dysfunction evaluation was performed with a life event rating list and the Symptom Checklist-90 (SCL-90). SETTING: A university hospital. SUBJECTS: The CRPS group consisted of 24 patients with a history of upper extremity CRPS of less than 3 months. The control group consisted of 42 hand pathology patients waiting for elective hand surgery within the next 24 hours. MAIN OUTCOME MEASURES: Stressful life event rating was measured using the Social Readjustment Rating Scale. Psychological dysfunction was measured using the SCL-90. RESULTS: Stressful life events were experienced by 19 patients (79.2%) in the CRPS group and by 9 patients (21.4%) in the control group. This difference was significant. Testing of psychological dysfunction (SCL-90) in CRPS patients and the control group demonstrated some significant differences: male patients were more anxious than male controls; female patients were statistically more depressed, had feelings of inadequacy, and were emotionally less stable than female controls. In multivariate analysis, no significant differences were found across gender, age, or gender x group interactions. Of the SCL-90 dimensions, only insomnia correlated with the experienced stressful life events. CONCLUSION: Stressful life events are more common in the CRPS group, which indicates that there may be a multiconditional model of CRPS. The experience of stressful life events besides trauma or surgery are risk factors, not causes, in such a model.
OBJECTIVE: To quantify the amount of variation attributed to different sources of variation in measurement results of upper extremity range of motion, and to estimate the smallest detectable difference (SDD) between measurements in reflex sympathetic dystrophy (RSD) patients. DESIGN: Two observers each measured in two sessions the range of motion of several upper extremity joints of RSD patients participating in an outcome study. SETTING: Department of Rehabilitation of a university hospital. SUBJECTS: Twenty-nine upper extremity RSD patients. MAIN OUTCOME MEASURES: The range of motion of forward flexion and external rotation of the shoulder, extension, flexion and supination of the elbow, palmar, dorsiflexion and ulnar, radial deviation of the wrist of affected and nonaffected sides, using a two-armed goniometer and an inclinometer. The measurement results were analysed using an analysis of variance according to the generalizability theory. RESULTS: The results indicate that observer and patient-observer were important sources of variation. The random error was the most important source of variation. Averaged over all ranges of motion the observer contributed 3.9% to the total variation, patient-observer interactions contributed 5.2% and the random error 20.3%. The SDD was smallest for elbow flexion, 7.1 degrees and 9.6 degrees and was largest for external rotation of the shoulder, 24.8 degrees and 28.7 degrees. The SDD was smaller for the nonaffected side as compared to the affected side for the majority of ranges of motion except elbow extension, wrist dorsiflexion, and radial and ulnar deviation. CONCLUSION: Clinically, our results indicate that range-of-motion measurements in RSD patients are subject to considerable variation and indicate that results of medical examinations in order to assess disability on the basis of range-of-motion measurements are subject to the same variation.
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.
Since the improvement of surgical oncological operative procedures, anaesthesiology and intensive care facilities, forequarter amputations are being performed with increasing frequency and decreasing morbidity and mortality. This clinical note reports the rehabilitation and prosthetic management of a patient with an extensive forequarter amputation including pneumectomy.
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The aim of this retrospective and long-term follow-up study was to identify impairments resulting from reflex sympathetic dystrophy (RSD) of the upper extremity and to analyze the relationship between impairment and disability in RSD patients. The study group consisted of a referred sample of 65 RSD patients, with clinical signs in the upper extremity. RSD developed after fractures of the wrist or hand in 29 patients or after a carpal tunnel release in 9 patients. The mean interval between the RSD diagnosis and our evaluation was 5.5 (3-9) years (SD = 0.8). The main outcome measurements were the impairments assessed by standard physical examination. ADL and pain were quantified with a visual analogue scale (VAS). Pain was evaluated immediately before and after the physical examination and the perceived pain was determined in the week before the examination. Significant differences in impairments were found between the affected and the unaffected sides (p < 0.05). According to the AMA-guides, the impairments did not lead to disabilities. Significant correlations were found between VAS-ADL and VAS-pain in the last week prior to evaluation and full fist grip-strength. Pain seems to be the most disabling effect.
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.
Reflex sympathetic dystrophy (RSD) is characterized mostly by: (burning) pain, restricted range of motion, oedema and autonomic disturbances. Amputations in case of RSD patients should only be performed in cases of a dysfunctional limb, life threatening conditions such as untreatable infections or in cases in unbearable pain. The authors describe a patient in whom amputation became inevitable because of threatening infections.
This clinical note describes a 47-year-old man who had a traumatic amputation of the left lower leg. Two months after wearing a Kondylen Bettung Münster (KMB) prosthesis, he developed a compression neuropathy of the common peroneal nerve of this right leg after sitting cross-legged. This troublesome complication can be avoided by giving accurate information to the patient.
This clinical note describes the case of a nine-year-old girl with classical Volkmann's contracture of the left forearm. The report demonstrates the results and follow-up of conservative orthotic management used as a mode of treatment by a multidisciplinary team. When using an orthosis it is essential to check regularly to attain the desired result.
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.
OBJECTIVE: To describe the epidemiological data of a group of multiple injured patients. SETTING: University Hospital, Groningen. DESIGN: Retrospective, descriptive. PATIENTS AND METHODS: All multiple injured patients (HTI/ISS > 18), treated from 1985 to 1989 were analysed (932 cases). Age, sex, residence, type of accident, mortality, cause of death, ISS, length of hospital stay and destination after discharge are described. RESULTS: Generally speaking the multiple injured patients investigated were young and male. 75% of the injuries were caused by traffic accidents; occupants of cars run the highest risk of dying. Mortality (22%) is mainly determined by severe head injuries and increases with a higher ISS. The length of hospital stay averaged 22.5 days and compared with situations abroad is short. Half the patients could be discharged to their homes. Those who were transferred to a rehabilitation centre or a nursing home have a high ISS and mainly have severe injuries of the extremities. CONCLUSION: In view of the number of patients who could be discharged to their homes, the ultimate functional results look fair.
BACKGROUND: Isolated regional perfusion (IRP) of an extremity is a major operation. The therapeutic value for stage I melanoma is still controversial and is presently being investigated in a prospective, randomized study by the European Organization for Research and Treatment of Cancer. So far there are no reliable data available concerning the morbidity of IRP. Therefore, we performed a prospective, randomized study on this topic. METHODS: In a prospective study, a group of 97 patients with a stage I melanoma localized on an arm or leg were randomized for IRP with melphalan followed by wide excision (WE) and fasciotomy or for WE only. Morbidity was evaluated on the basis of the following parameters: duration of hospitalization, postoperative pain, postoperative performance, and grade of perfusion toxicity. At 12-month follow-up, a physical diagnostic examination was performed to measure the mobility of the joints, and the circumference and volume of the treated and untreated extremities. RESULTS: All the parameters, including the physical diagnostic examination, could be evaluated in 83 of the 97 patients (8 patients died of metastatic disease and 1 patient died of another disease before they could be investigated; 2 patients were in too poor physical condition due to metastases to be examined, and 3 patients were unable to participate for nonmedical reasons). Age and sex distribution were comparable in the various patient groups. Treatment mortality was 0%. There were no complications except for urine retention (one patient) and wound dehiscence (one patient). After IRP + WE of the lower limb, the period of hospitalization was an average of 1.9 days longer (p = 0.01) than for WE on the limb only. This difference was absent for the arm. Naturally after perfusion, there was a significant difference in toxic reactions (edema and pain) between the IRP + WE patients and the WE-only patients. However, at 12-month follow-up, the difference in morbidity between IRP + WE and WE-only patients was no longer present: Morbidity of joints and circumference of the limb were the same. A number of subjective complaints were encountered fairly often after IRP + WE (e.g., pricking sensations or pain during changes in the weather), which can possibly be explained by fibrosis caused by perfusion. These complaints were not quantified further because they did not hinder the patients' functioning. CONCLUSIONS: In a long term, IRP with fasciotomy does not cause any additional morbidity. Immediately after the operation, there was more morbidity as a result of the perfusion, which caused a 2-day-longer period of hospitalization in the patients with lower-limb perfusion compared with those who underwent WE only. These findings are in contrast to those in the literature, in which 25% limitation of motion in the ankle joint after perfusion is mentioned. One explanation may be that we always performed fasciotomy after perfusion to prevent (sub)clinical compression syndrome and avoid late fibrosis.
We report the results of two prospective studies of early treatment and psychological aspects in a series of 26 patients with sympathetic reflex dystrophy of the hand in which treatment was started within 3 months after diagnosis. Ismelin blocks is an often used therapy in sympathetic reflex dystrophy but a probable better therapy in the first stage of the dystrophy was also investigated. Thirteen patients were treated with Regional Intravenous Ismelin blocks and 13 other patients were treated with a hydroxyl radical scavenger, dimethylsulfoxide (DMSO). After 9 weeks there was a better result in the group treated with DMSO. This report also describes psychological research in a group of 24 dystrophy patients compared with a control group of 42 patients who underwent elective hand-surgery. Women dystrophy patients were more depressed and emotionally unstable. Eighty percent of all dystrophy patients had a recent life-event while only 20% of the control group members reported such an event. These two features seem to be independent. Early diagnosis in combination with early stress management training and a multidisciplinary treatment tends to be a very good solution.
Reflex sympathetic dystrophy is a chronic pain syndrome characterized by chronic burning pain, restricted range of motion, oedema and vasolability. Patients are difficult to treat and the prognosis is very often poor. This report emphasizes that an amputation in case of a reflex sympathetic dystrophy is mostly due to a too late recognition of this syndrome. In the international literature little is written about an amputation as a therapy for reflex sympathetic dystrophy. It is only mentioned as a therapy in the end stages of this syndrome. Sometimes a rejected amputation, as in this case report, can have a relatively good result. An early recognition of this pain syndrome produces the best possible outcome.