Construct Validity of Functional Capacity Evaluation in Patients with Whiplash-Associated Disorders.

PURPOSE: The construct validity of functional capacity evaluations (FCE) in whiplash-associated disorders (WAD) is unknown. The aim of this study was to analyse the validity of FCE in patients with WAD with cultural differences within a workers' compensation setting. METHODS: 314 participants (42% females, mean age 36.7 years) with WAD (grade I and II) were referred for an interdisciplinary assessment that included FCE tests. Four FCE tests (hand grip strength, lifting waist to overhead, overhead working, and repetitive reaching) and a number of concurrent variables such as self-reported pain, capacity, disability, and psychological distress were measured. To test construct validity, 29 a priori formulated hypotheses were tested, 4 related to gender differences, 20 related associations with other constructs, 5 related to cultural differences. RESULTS: Men had significantly more hand grip strength (+17.5 kg) and lifted more weight (+3.7 kg): two out of four gender-related hypotheses were confirmed. Correlation between FCE and pain ranged from -0.39 to 0.31; FCE and self-reported capacity from -0.42 to 0.61; FCE and disability from -0.45 to 0.34; FCE and anxiety from -0.36 to 0.27; and FCE and depression from -0.41 to 0.34: 16 of 20 hypotheses regarding FCE and other constructs were confirmed. FCE test results between the cultural groups differed significantly (4 hypotheses confirmed) and effect size (ES) between correlations were small (1 hypothesis confirmed). In total 23 out of 29 hypotheses were confirmed (79%). CONCLUSIONS: The construct validity for testing functional capacity was confirmed for the majority of FCE tests in patients with WAD with cultural differences and in a workers' compensation setting. Additional validation studies in other settings are needed for verification.

Measurement Properties of the Spinal Function Sort in Patients with Sub-acute Whiplash-Associated Disorders.

PURPOSE: To extensively analyze the measurement properties the Spinal Function Sort (SFS) in patients with sub-acute whiplash-associated disorders (WAD). METHODS: Three-hundred-two patients with WAD were recruited from an outpatient work rehabilitation center. Internal consistency was assessed by Cronbach's α. Construct validity was tested based on eight a priori hypotheses. Structural validity was measured with principal component analysis (PCA). Test-retest reliability and agreement was evaluated in a sub sample (n = 32) using intraclass correlation coefficient (ICC) and limits of agreement (LoA). The predictive validity of SFS for future work status at 1, 3, 6, and 12 months follow-up was determined by area under the curve (AUC) of receiver operating characteristics. Non-return to work (N-RTW) was defined with two cut-off points: workcapacity <50 and <100 %. RESULTS: N-RTW decreased from 50%, 1 month follow-up, to 14%, 12 months follow-up. Cronbach's α was 0.98, PCA revealed evidence for unidimensionality. ICC was 0.86, LoA was ±33 points. Seven out of eight hypotheses for construct validity were not rejected. AUC reduced with a longer follow-up from 0.71 for 1 month to 0.61 at 12 months, for cut-off point <50%. For cut-off point <100% these values were 0.71 and 0.59. CONCLUSION: In patients with sub-acute WAD test-retest reliability, internal consistency, construct- and structural validity of the SFS were adequate. LoA were substantial. Sensitivity to accurately predict N-RTW was poor. The predictive validity of the SFS for N-RTW of patients with sub-acute WAD from an outpatient work rehabilitation setting was only sufficient for the short term (1 month).

Barriers to and facilitators of sports participation for people with physical disabilities: a systematic review.

Most people with physical disabilities do not participate in sports regularly, which could increase the chances of developing secondary health conditions. Therefore, knowledge about barriers to and facilitators of sports participation is needed. Barriers and facilitators for people with physical disabilities other than amputation or spinal cord injuries (SCI) are unknown. The aim of this study was to provide an overview of the literature focusing on barriers to and facilitators of sports participation for all people with various physical disabilities. Four databases were searched using MeSH terms and free texts up to April 2012. The inclusion criteria were articles focusing on people with physical disabilities, sports and barriers and/or facilitators. The exclusion criteria were articles solely focusing on people with cognitive disabilities, sensory impairments or disabilities related to a recent organ transplant or similar condition. Fifty-two articles were included in this review, with 27 focusing on people with SCI. Personal barriers were disability and health; environmental barriers were lack of facilities, transport and difficulties with accessibility. Personal facilitators were fun and health, and the environmental facilitator was social contacts. Experiencing barriers to and facilitators of sports participation depends on age and type of disability and should be considered when advising people about sports. The extent of sports participation for people with physical disabilities also increases with the selection of the most appropriate sport.

Barriers and facilitators of sports in Dutch Paralympic athletes: An explorative study.

The purpose of this study was to gain insight in barriers and facilitators of sports in paralympic athletes. An online questionnaire was distributed through the Netherlands Olympic Committee and National Sports Confederation to determine personal and environmental barriers and facilitators of sports participation. The International Classification of Functioning, Disability and Health model and theory of planned behavior were used to respectively categorize the results in environmental and personal factors, and attitude, subjective norm and perceived behavioral control. Seventy-six Dutch Paralympic athletes completed the questionnaire (51% response rate). Barriers and facilitators experienced by ambulant and wheelchair athletes were compared. Most frequently mentioned personal barrier was dependency of others (22%), while most frequently mentioned environmental barrier was lack of sports facilities (30%). Wheelchair athletes mentioned more barriers (median = 3, interquartile range: 0.5-6), than ambulant athletes (median = 1.0,interquartile range:0.0-3.0, P = 0.023). One-third of the athletes did not experience any barriers. Most frequently mentioned personal facilitators to initiate sports participation were fun (78%), health (61%), and competition (53%). Most frequently mentioned environmental facilitator was social support (40%). This study indicated that barriers of sport were mostly environmental, while facilitators were usually personal factors. Attitude and subjective norm were considered the most important components for intention to participation in sports. The facilitators outweighed the barriers and kept the athletes being active in sports.

Reliability of clinician rated physical effort determination during functional capacity evaluation in patients with chronic musculoskeletal pain.

INTRODUCTION: Functional capacity evaluation (FCE) can be used to make clinical decisions regarding fitness-for-work. During FCE the evaluator attempts to assess the amount of physical effort of the patient. The aim of this study is to analyze the reliability of physical effort determination using observational criteria during FCE. METHODS: Twenty-one raters assessed physical effort in 18 video-recorded FCE tests independently on two occasions, 10 months apart. Physical effort was rated on a categorical four-point physical effort determination scale (PED) based on the Isernhagen criteria, and a dichotomous submaximal effort determination scale (SED). Cohen's Kappa, squared weighted Kappa and % agreement were calculated. RESULTS: Kappa values for intra-rater reliability of PED and SED for all FCE tests were 0.49 and 0.68 respectively. Kappa values for inter-rater reliability of PED for all FCE tests in the first and the second session were 0.51, and 0.72, and for SED Kappa values were 0.68 and 0.77 respectively. The inter-rater reliability of PED ranged from κ = 0.02 to κ = 0.99 between FCE tests. Acceptable reliability scores (κ > 0.60, agreement ≥80 %) for each FCE test were observed in 38 % of scores for PED and 67 % for SED. On average material handling tests had a higher reliability than postural tolerance and ambulatory tests. CONCLUSION: Dichotomous ratings of submaximal effort are more reliable than categorical criteria to determine physical effort in FCE tests. Regular education and training may improve the reliability of observational criteria for effort determination.

Short and long term mortality rates after a lower limb amputation.

OBJECTIVE: To determine mortality rates after a first lower limb amputation and explore the rates for different subpopulations. METHODS: Retrospective cohort study of all people who underwent a first amputation at or proximal to transtibial level, in an area of 1.7 million people. Analysis with Kaplan-Meier curves and Log Rank tests for univariate associations of psycho-social and health variables. Logistic regression for odds of death at 30-days, 1-year and 5-years. RESULTS: 299 people were included. Median time to death was 20.3 months (95%CI: 13.1; 27.5). 30-day mortality = 22%; odds of death 2.3 times higher in people with history of cerebrovascular disease (95%CI: 1.2; 4.7, P = 0.016). 1 year mortality = 44%; odds of death 3.5 times higher for people with renal disease (95%CI: 1.8; 7.0, P < 0.001). 5-years mortality = 77%; odds of death 5.4 times higher for people with renal disease (95%CI: 1.8; 16.0,P = 0.003). Variation in mortality rates was most apparent in different age groups; people 75-84 years having better short term outcomes than those younger and older. CONCLUSIONS: Mortality rates demonstrated the frailty of this population, with almost one quarter of people dying within 30-days, and almost half at 1 year. People with cerebrovascular had higher odds of death at 30 days, and those with renal disease and 1 and 5 years, respectively.

Reliability and safety of functional capacity evaluation in patients with whiplash associated disorders.

INTRODUCTION: Whiplash-associated disorders (WAD) are a burden for both individuals and society. It is recommended to evaluate patients with WAD at risk of chronification to enhance rehabilitation and promote an early return to work. In patients with low back pain (LBP), functional capacity evaluation (FCE) contributes to clinical decisions regarding fitness-for-work. FCE should have demonstrated sufficient clinimetric properties. Reliability and safety of FCE for patients with WAD is unknown. METHODS: Thirty-two participants (11 females and 21 males; mean age 39.6 years) with WAD (Grade I or II) were included. The FCE consisted of 12 tests, including material handling, hand grip strength, repetitive arm movements, static arm activities, walking speed, and a 3 min step test. Overall the FCE duration was 60 min. The test-retest interval was 7 days. Interclass correlations (model 1) (ICCs) and limits of agreement (LoA) were calculated. Safety was assessed by a Pain Response Questionnaire, observation criteria and heart rate monitoring. RESULTS: ICCs ranged between 0.57 (3 min step test) and 0.96 (short two-handed carry). LoA relative to mean performance ranged between 15 % (50 m walking test) and 57 % (lifting waist to overhead). Pain reactions after WAD FCE decreased within days. Observations and heart rate measurements fell within the safety criteria. CONCLUSIONS: The reliability of the WAD FCE was moderate in two tests, good in five tests and excellent in five tests. Safety-criteria were fulfilled. Interpretation at the patient level should be performed with care because LoA were substantial.

Influence of efforts of employer and employee on return-to-work process and outcomes.

BACKGROUND: Research on disability and RTW outcome has led to significant advances in understanding these outcomes, however, limited studies focus on measuring the RTW process. After a prolonged period of sickness absence, the assessment of the RTW process by investigating RTW Effort Sufficiency (RTW-ES) is essential. However, little is known about factors influencing RTW-ES. Also, the correspondence in factors determining RTW-ES and RTW is unknown. The purpose of this study was to investigate 1) the strength and relevance of factors related to RTW-ES and RTW (no/partial RTW), and 2) the comparability of factors associated with RTW-ES and with RTW. METHODS: During 4 months, all assessments of RTW-ES and RTW (no/partial RTW) among employees applying for disability benefits after 2 years of sickness absence, performed by labor experts at 3 Dutch Social Insurance Institute locations, were investigated by means of a questionnaire. RESULTS: Questionnaires concerning 415 cases were available. Using multiple logistic regression analysis, the only factor related to RTW-ES is a good employer-employee relationship. Factors related to RTW (no/partial RTW) were found to be high education, no previous periods of complete disability and a good employer-employee relationship. CONCLUSIONS: Different factors are relevant to RTW-ES and RTW, but the employer-employee relationship is relevant for both. Considering the importance of the assessment of RTW-ES after a prolonged period of sickness absence among employees who are not fully disabled, this knowledge is essential for the assessment of RTW-ES and the RTW process itself.

Feasibility and short-term effects of Activity Coach+: a physical activity intervention in hard-to-reach people with a physical disability.

PURPOSE: Existing physical activity interventions do not reach a considerable proportion of physically disabled people. This study assessed feasibility and short-term effects of Activity Coach+, a community-based intervention especially targeting this hard-to-reach population. METHODS: Feasibility was determined by reach, dropouts, and compliance with the protocol. Physical activity was measured with the Activ8 accelerometer and the adapted SQUASH questionnaire. Health outcomes were assessed by body composition, blood pressure, hand grip force, 10-metre walk test, 6-minute walk test, and the Berg Balance Scale. The RAND-36, Exercise Self-Efficacy Scale, Fatigue Severity Scale, and IMPACT-S were administered. Measurements were performed at baseline and after 2 and 4 months. Changes over time were analysed by Friedman tests. RESULTS: Twenty-nine participants enrolled during the first 4 months, of whom two dropped out. Intervention components were employed in 86-100% of the participants. Physical activity did not change after the implementation of Activity Coach+. Body mass index (p = 0.006), diastolic blood pressure (p = 0.032), walking ability (p = 0.002), exercise capacity (p = 0.013), balance (p = 0.014), and vitality (p = 0.049) changed over time. CONCLUSIONS: Activity Coach + is feasible in a community setting. Indications for effectivity of Activity Coach + in hard-to-reach people with a physical disability were found.Implications for rehabilitationActivity Coach + was able to reach physically disabled people living in community, a population that is assumed hard-to-reach.Activity Coach + was feasible in a population of persons with a physical disability that was heterogeneous with respect to age and (severity of) disability.The current study provides the first indications for the beneficial health effects of Activity Coach + in hard-to-reach people with a physical disability.

Are consumers satisfied with the use of prosthetic sports feet and the provision process? A mixed-methods study.

BACKGROUND: Special feet connected to a prosthesis, prosthetic sports feet, enable athletes with a lower limb amputation to run. The selection of a prosthetic sports feet is usually based on body weight and preferred sports performance. The selection of a prosthetic sport feet is also based on clinicians who likely have limited experience due to a small number of athletes with a lower limb amputation. HYPOTHESIS: Athletes with a lower limb amputation are not satisfied with the use and service associated with prosthetic sports feet due to a lack of prosthetic sports feet provision guidelines, poorer function of prosthetic sports feet compared to the anatomical foot and ankle, and limited experience of clinicians. EVALUATION OF HYPOTHESIS: A mixed-methods study in 16 athletes with a lower limb amputation using a prosthetic sport foot from Össur or Otto Bock, included semi-structured interviews and quantitative analysis. Three dimensions of prosthetic sports feet were investigated: 1) use, 2) provision process, and 3) cosmetics. Qualitative data were analyzed to identify factors influencing consumer satisfaction. Quantitative data were analyzed to investigate satisfaction and perceived relative importance of the dimensions. RESULTS: Participants were satisfied with the prosthetic sports feet use. However, they were not satisfied with the process prior to provision. The prosthetic sport feet use was perceived as the most important dimension. Sports performance was the critical element in the prosthetic sports feet use and was influenced by stability, confidence and fear, safety, focus, energy return, and comfort. Cosmetics were unimportant. Motivation to purchase the prosthetic sports feet was the key element for the prosthetic sports foot acquisition. Satisfaction about the process prior to provision was negatively influenced by poor support of professionals during rehabilitation, the complexity and duration of the purchase process, and lack of information and accessibility of prosthetic sports feet. CONCLUSION: The most important dimension of the prosthetic sports feet was its use, which was directly influenced by performance. To further increase the satisfaction with prosthetic sports feet, clinicians should establish how to meet the desired sports performance level of athletes with a lower limb amputation. Improving the process prior to the provision process may increase satisfaction. We suggest increasing the support of professionals during rehabilitation and training through cooperation between involved services, organizing prosthetic sports feet try-out sessions, and increase the accessibility of the prosthetic sports feet. In this way, individuals with a lower limb amputation may become and stay more physically active and participate in sports.

Relationship between psychological factors and performance-based and self-reported disability in chronic low back pain.

Cross sectional study, performed in an outpatient university based pain rehabilitation setting. To analyze the relationship between psychological factors (psychosocial distress, depression, self efficacy, self-esteem, fear of movement, pain cognitions and coping reactions) and performance-based and self-reported disability, as measured with a Functional Capacity Evaluation (FCE) and the Roland Morris Disability Questionnaire (RMDQ), in patients with chronic low back pain (CLBP). It has been suggested that a strong relationship exists between psychological factors and disability in patients with CLBP. In former research disability was often measured by self-report and seldom performance-based. Study sample consisted of 92 patients with CLBP admitted for multidisciplinary rehabilitation. Prior to treatment, all patients completed questionnaires to measure psychological factors and self-reported disability, and performed an FCE to measure performance-based disability. Correlation coefficients between psychological variables and FCE and self-reported disability were calculated. Multivariate linear regression analyses were performed with self-reported or performance based disability measures as outcome variables, and psychological measures as predictor variables. Out of 42 relations analyzed, 5 were statistically significant. This concerned one significant correlation between kinesiophobia and a subtest of FCE, and four correlations between psychological factors and RMDQ. No correlation was significant after the Bonferroni correction was applied (P < 0.001). The strength of significant correlations ranged from r = -0.33 to r = 0.25. The multivariate analysis revealed that psychological variables measured in this study could explain 19% of the variance of self-reported disability, with kinesiophobia being the only psychological variable that contributed significantly. The suggested strong relationship between psychological factors and performance-based and self-reported disability could not be confirmed in this study. This may implicate that the relationship between psychological factors and disability in patients with CLBP is not as unambiguous as suggested.

Decision making process for amputation in case of therapy resistant complex regional pain syndrome type-I in a Dutch specialist centre.

Deciding for an amputation in case of complex regional pain syndrome type I (CRPS-I) is controversial. Evidence for favorable or adverse effects of an amputation is weak. We therefore follow a careful and well-structured decision making process. After referral of the patient with the request to amputate the affected limb, it is checked if the diagnosis CRPS-I is correct, duration of complaints is more than 1 year, all treatments described in the Dutch guidelines have been tried and if consequences of an amputation have been well considered by the patient. Thereafter the patient is assessed by a multidisciplinary team (psychologist, physical therapist, anesthesiologist-pain specialist, physiatrist and vascular surgeon). During a multidisciplinary meeting professionals summarize their assessment. Pros and cons of an amputation are discussed, taking into account level of amputation and expectations about post amputation functioning of patient and team. Based on assessments and discussion a consensus based decision is formulated and the patient is informed. If it is decided that an amputation is to be performed, the amputation will follow shortly. If it is decided not to amputate, the decision is extensively explained to the patient. Incidence of patients suffering from therapy resistant CRPS-I referred for amputation is low and because referred patients are strongly in favor of an amputation, a randomized controlled trial will be difficult to perform. Hence level of evidence in favor or against an amputation will remain low. We therefore report our decision making process to facilitate discussion about this difficult and delicate matter.

Efficacy of intrathecal baclofen delivery in the management of severe spasticity in upper motor neuron syndrome.

In the treatment of patients with severe spasticity, intrathecal administration of baclofen (ITB) was introduced in order to exert its effect directly at the receptor sites in the spinal cord, and have better therapeutic efficacy with smaller drug doses compared to oral antispasmodic medications. Apart from our own research in Groningen, a review is performed to present and discuss the efficacy of ITB in patients with spasticity and hypertonia as symptoms of the upper motor neuron syndromes. The majority of the ITB studies describe proven efficacy in the reduction of spasticity and spasms in short-term and long-term follow-up. Functional improvements in daily care, hygiene, pain, etc are described but not often with reliable and validated instruments. A few studies reported significant improvement in walking performance in ambulant patients. The studies that have been done on the efficacy of ITB in relation to quality of life (QOL) showed some evidence of improvement. Future research is needed on fine tuning in the ITB therapy using functional assessment instruments.

[Clinical practice guideline 'Complex regional pain syndrome type I']. / Richtlijn 'Complex regionaal pijnsyndroom type I'.

The development and treatment ofthe complex regional pain syndrome type I (CRPS-I) are a subject of much discussion. Using the method for the development ofevidence-based guidelines, a multidisciplinary guideline for the diagnosis and treatment of this syndrome has been drawn up. The diagnosis of CRPS-I is based on the clinical observation of signs and symptoms. For pain treatment, the WHO analgesic ladder is advised up to step z. In case of pain ofa neuropathic nature, anticonvulsants and tricyclic antidepressants may be considered. For the treatment ofinflammatory symptoms, free-radical scavengers (dimethylsulphoxide or acetylcysteine) are advised. In order to enhance peripheral blood flow, vasodilatory medication may be considered. Percutaneous sympathetic blockades may be used for a cold extremity ifvasodilatory medication produces insufficient effect. To decrease functional limitations, standardised physiotherapy and occupational therapy are advised. To prevent the occurrence of CRPS-I after wrist fractures, the use of vitamin C is recommended. Adequate perioperative analgesia, limitation of operation time and limited use of bloodlessness are advised for the secondary prevention of CRPS-I. Use of regional anaesthetic techniques can also be considered in this connection.

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.

Chronic pain in rehabilitation medicine.

In this paper the chronicity of pain in non-specific pain syndromes is discussed. Experts in the study of pain with several professional backgrounds in rehabilitation are the authors of this paper. Clinical experience and literature form the basis of the paper. Non-specific low back pain and Complex Regional Pain Syndrome type I (CRPS-I) are discussed in the light of chronic pain. Many definitions of chronic pain exist. Yellow flags are important factors to identify possible chronic pain. In the acute phase of a non-specific pain complaint one should try to identify possible psychosocial inciting risk factors. Behavioural and cognitive treatment seems to be effective for chronic pain patients.

Back pain and backpacks in children: biomedical or biopsychosocial model?

Public press, professional organisations and journals have been sending alarming messages about the rising prevalence of back pain in school age children. Carrying backpacks has been suggested as one of the key factors contributing to back pain in children. The basic assumption based on the biomedical model is that the maturing spine cannot handle the mechanical load of the backpack sufficiently. A review of the evidence in the professional literature, however, revealed very limited evidence to support this assumption. On the contrary, the literature does suggest that psychological and social factors may be of greater importance to explain back pain in children. We conclude this clinical commentary postulating that the public, children and their parents are better served with a more modest and balanced perspective of the professionals, and propose that back pain in children (as it is in adults) should be viewed from a biopsychosocial model.

Material handling performance of patients with chronic low back pain during functional capacity evaluation: a comparison between three countries.

PURPOSE: Functional Capacity Evaluations (FCEs) are batteries of tests designed to measure patients' ability to perform work-related activities. Although FCEs are used worldwide, it is unknown how patients' performances compare between countries or settings. This study was performed to explore similarities and differences in FCE performance of patients with chronic low back pain (CLBP) between three international settings that utilize the same FCE protocol. METHODS: Standardized FCEs were performed on three cohorts of patients with CLBP: A sample from an outpatient rehabilitation context in The Netherlands (n = 121), a Canadian sample in a Worker's Compensation context (n = 273), and a Swiss sample in an inpatient rehabilitation context (n = 170). Patients were undergoing FCE as part of their usual clinical care. Means and standard deviations of maximum performance on the FCE material handling items were calculated and differences compared using ANOVA. Multivariable linear regression was used to determine the relationship between country of origin and FCE performance while controlling for potential confounders including, age, sex, duration of back pain problems, and self-reported pain and disability ratings. RESULTS: Compared to the Dutch sample, the mean performance of patients in the Canadian and Swiss samples was consistently lower on all FCE items. This association remained statistically significant after controlling for potential confounders. CONCLUSIONS: Considerable differences were observed between settings in maximum weight handled on the various FCE items. Future FCE research should examine the effects of a number of potentially influential factors, including variability in evaluator judgements across settings, the evaluator-patient interaction and patients' expectations of the influence of FCE results on disability compensation.

Work status and chronic low back pain: exploring the International Classification of Functioning, Disability and Health.

PURPOSE: Exploring which variables are related to work status in patients with chronic low back pain (CLBP), classified according to the International Classification of Functioning, Disability and Health (ICF). METHOD: Ninety-two patients with CLBP filled out questionnaires inquiring after health status, impairments in body functions/structures, limitations in activities of daily living (ADL), participation in work, environmental and personal factors. Additionally, patients performed tests to measure physical fitness and performance of work-related activities. Univariate analyses were performed to investigate whether differences exist between working and non-working patients. Logistic linear regression analysis was performed to explain work status from the variables of functioning. RESULTS: Non-working patients had a lower self-reported physical and mental health, lower physical fitness, more self-reported limitations in ADL, lower education, more depressive symptoms and higher psycho neuroticism than working patients. Self-reported physical and mental health and educational level correctly classified 84.5% of the patients as working or non-working. Performance of work-related activities was not significantly related with work-status. CONCLUSIONS: The relation between work status and CLBP is multidimensional, as was illustrated by using the bio-psychosocial model of the ICF. Patients with a low educational level, a low self-reported physical or mental health were more likely to be non-working. Self-reported limitations and physical and mental health are more important in explaining work status than objective measurements of performance.

Development of clinical guidelines for the prescription of orthoses in patients with neurological disorders in The Netherlands.

The objective of this study was to develop guidelines for the prescription of ankle-foot, knee, wrist-hand and elbow orthoses for patients with neurological disorders. The study is part of a more comprehensive study focusing on the development of clinical guidelines for the prescription of these orthoses in a wider patient population. Evidence from literature (reviews, randomized controlled trials with good quality), information from literature with a lower degree of evidence and information from structured interviews with experts in the field of orthotics, form the basis of statements presented in a Delphi procedure. The Delphi technique was used to gain consensus on statements published on the Internet. A group of experts in the field of orthotics and neurological disorders was asked to give their opinion on 41 statements. Statements with a general agreement of at least 75% were accepted. Statements with less general agreement were rewritten and the experts could react in a second and possibly in a third round. Afterwards, an opinion-based workshop was organized in which participants could react on preliminary guidelines and on Delphi-statements with between 65% and 75% agreement. Consensus on 32 statements was gained during the three rounds and the opinion-based workshop. These statements form the basis of the consensus based clinical guidelines for the prescription of orthoses in patients with neurological disorders.