Responsiveness of generic and disease-specific health-related quality of life instruments to venous ulcer healing

The aim of the study was to evaluate the responsiveness of the Short Form Health Survey, the EuroQol 5 Dimension questionnaire, and the Charing Cross Venous Ulcer Questionnaire (CXVUQ) to venous ulcer healing. Participants had health-related quality of life measured at baseline and 12 weeks. Standardized response means were calculated to assess the responsiveness of the instruments to change in an ulcer state (healed vs. unhealed). Three hundred and sixty-eight participants completed the questionnaires at baseline and 360 at 12 weeks. One hundred and ninety-three participants (54%) had healed at 12 weeks. The standardized response means ranged from −0.01 to 0.47 for Short Form Health Survey, 0.10–0.31 for EuroQol 5 Dimension questionnaire, and −0.21 to −0.92 for CXVUQ. Differences between healed and unhealed participants at 12 weeks were significantly different for three of the eight domains on Short Form Health Survey and on all domains for the CXVUQ. There were no significant differences between the groups on the EuroQol 5 Dimension questionnaire scales. CXVUQ was more responsive than the generic instruments to change in ulcer status over 12 weeks for measuring health-related quality of life of patients with venous ulceration.     

Intermittent claudication: Symptom severity versus health values

Objective: The objective of this study was to obtain health values from patients with intermittent claudication with five different instruments and to study the construct validity of these measures of health-related quality of life by examining their relation with symptom severity. Methods: We included all patients with intermittent claudication who participated in an exercise program of the Department of Internal Medicine at our university hospital (n = 92). Health value instruments included the verbal rating scale, time trade-off, standard gamble, EuroQol, and the Health Utilities Index (Mark III). Symptom-free walking distance was used as a measure of symptom severity. Results: For all instruments the average health values in groups of patients with a symptom-free walking distance ≤150 m were lower than the average values in patients with a greater walk distance, but the differences for the time trade-off and the standard gamble were small, and only the differences for the verbal rating scale and the EuroQol were statistically significant. At the individual patient level considerable heterogeneity was seen, and the statistical association of the symptom-free walking distance with health values varied from poor to moderate (Spearman rank correlations, 0.03 to 0.48; p values, 0.003 to 0.78). Conclusion: At least for the verbal rating scale and the EuroQol, the results of our study provide evidence of the validity of the various health value instruments in a population of patients with peripheral arterial occlusive disease. (J Vasc Surg 1998;27:422-30.)     

Improvement of the walking ability in intermittent claudication due to superficial femoral artery occlusion with supervised exercise and pneumatic foot and calf compression: a randomised controlled trial.

OBJECTIVES: To compare the effect of unsupervised exercise, supervised exercise and intermittent pneumatic foot and calf compression (IPC) on the claudication distance, lower limb arterial haemodynamics and quality of life of patients with intermittent claudication. METHODS: Thirty-four eligible patients with stable intermittent claudication were randomised to IPC (n = 13, 3h/d for 6 months), supervised exercise (n = 12, three hourly sessions/week for 6 months) or unsupervised exercise (n = 9). In each patient, initial claudication distance (ICD), absolute claudication distance (ACD), resting ankle brachial pressure index (ABPI), and resting hyperaemic calf arterial inflow were measured before, 6 weeks, 6 months and 1 year after randomisation. Quality of life was assessed with the short form (SF)-36, walking impairment (WIQ) and intermittent claudication questionnaires (ICQ). RESULTS: Compared with unsupervised exercise, both IPC and supervised exercise, increased ICD and ACD, up to 2.83 times. IPC increased arterial inflow (p < 0.05 at 6 weeks) and ABPI. Supervised exercise decreased arterial inflow and increased ABPI (p < 0.05 at 6 months). Unsupervised exercise had no effect on arterial inflow or ABPI. IPC improved significantly the ICQ score and the speed score of the WIQ, while supervised exercise improved the WIQ claudication severity score. At 1 year clinical effectiveness of supervised exercise and IPC was largely preserved. CONCLUSIONS: IPC, by augmenting leg perfusion, achieved improvement in walking distance comparable with supervised exercise. Long-term results in a larger number of patients will provide valuable information on the optimal treatment modality of intermittent claudication.     

Validation of the Dutch version of the Walking Impairment Questionnaire

ObjectivesThe Walking Impairment Questionnaire (WIQ) is a frequently used questionnaire to evaluate patients with intermittent claudication (IC). The aim of this study is to validate the Dutch WIQ for the European situation using the metric system.DesignValidation study.MaterialsAfter translation and cultural adaptation of the WIQ, 130 patients with IC completed the Dutch WIQ, the RAND-36, and the EuroQol questionnaire. Walking distances were determined by treadmill testing.MethodsCorrelations between the WIQ, the two quality of life questionnaires, and walking distances were calculated to determine validity. Reliability and internal consistency were determined using the intraclass correlation coefficient (ICC) and Cronbach's alpha, respectively.ResultsSignificant correlations were found between the WIQ and the absolute claudication distance (ACD) (0.52), EuroQol (0.33) and seven domains of the RAND-36. Test–retest reliability expressed by the ICC was 0.89. The internal consistency determined by Cronbach's alpha was 0.92 for the total WIQ score. Furthermore, a lower WIQ score corresponds to a shorter ACD.ConclusionsThis study shows that the Dutch version of the WIQ using the European metric system is a valid, reliable and clinically relevant instrument for assessing walking impairment in patients with intermittent claudication.     

The effect of metabolic syndrome components on exercise performance in patients with intermittent claudication

PURPOSE: To determine the effect of metabolic syndrome components on intermittent claudication, physical function, health-related quality of life, and peripheral circulation in patients with peripheral arterial disease (PAD), and to identify the metabolic syndrome components most predictive of each outcome measure. METHODS: Patients limited by intermittent claudication with three (n = 48), four (n = 45), or five (n = 40) components of metabolic syndrome were studied. Patients were assessed on PAD-specific measures consisting of ankle-brachial index (ABI), initial claudication distance, absolute claudication distance, physical function measures, health-related quality of life, and calf blood flow and transcutaneous oxygen tension responses after 3 minutes of vascular occlusion. RESULTS: Initial claudication distance (mean +/- SD) progressively declined (P = .019) in those with three (203 +/- 167 m), four (124 +/- 77 m), and five (78 +/- 57 m) metabolic syndrome components, and absolute claudication distance progressively declined (P = .036) in these groups as well (414 +/- 224 m vs 323 +/- 153 m vs 249 +/- 152 m, respectively). Furthermore, compared with patients with only three components of metabolic syndrome, those with all five components had impaired values (P < .05) for peak oxygen uptake, ischemic window, 6-minute walk distance, self-perceived walking ability and health, daily physical activity, health-related quality of life on six of eight domains, calf hyperemia, and calf ischemia after vascular occlusion. Abdominal obesity was the predictor (P < .05) of exercise performance during the treadmill and 6-minute walk tests, as well as physical activity. Elevated fasting glucose was the predictor (P < .05) of peripheral vascular measures, self-perceived walking ability and health, and health-related quality of life. CONCLUSION: PAD patients with more metabolic syndrome components have worsened intermittent claudication, physical function, health-related quality of life, and peripheral circulation. Abdominal obesity and elevated fasting glucose are the metabolic syndrome components that are most predictive of these outcome measures. Aggressively treating these metabolic syndrome components may be particularly important in managing symptoms and long-term prognosis of PAD patients.     

Response to exercise rehabilitation in smoking and nonsmoking patients with intermittent claudication

BACKGROUND: The purpose was to compare the changes in claudication pain, ambulatory function, daily physical activity, peripheral circulation, and health-related quality of life following a program of exercise rehabilitation in smoking and nonsmoking patients with peripheral arterial disease (PAD) limited by intermittent claudication.Methods and results Thirty-nine smokers (63 +/- 4 pack-year smoking history; mean +/- SE) and 46 nonsmokers (former smokers who had a 51 +/- 7 pack-year smoking history who quit 14 +/- 2 years prior to investigation) completed the study. The 6-month exercise rehabilitation program consisted of intermittent treadmill walking to near maximal claudication pain 3 days per week, with progressive increases in walking duration and intensity during the program. Measurements were obtained on each patient before and after rehabilitation. Following exercise rehabilitation the smokers and nonsmokers had similar improvements in these measures, as initial claudication distance increased by 119% in the smokers (P <.001) and by 97% in the nonsmokers (P <.001), and absolute claudication distance increased by 82% (P <.001) and 59% (P <.001) in the smokers and nonsmokers, respectively. Furthermore, exercise rehabilitation improved (P <.05) ambulatory function, daily physical activity, peripheral circulation, and health-related quality of life in the smokers and nonsmokers. CONCLUSION: Exercise rehabilitation is an effective therapy to improve functional independence in both smoking and nonsmoking patients with PAD limited by intermittent claudication. Therefore, smokers with intermittent claudication are prime candidates for exercise rehabilitation because their relatively low baseline physical function does not impair their ability to regain lost functional independence to levels similar to nonsmoking patients with PAD.     

Quality of life after infrainguinal bypass grafting surgery. Dutch Bypass Oral Anticoagulants or Aspirin (BOA) Study Group

PURPOSE: The purpose of this study was to compare quality of life in patients with and without various ischemic complications after infrainguinal bypass grafting surgery for occlusive vascular disease. METHODS: A sample of patients (n = 746) randomized in the Dutch BOA study (n = 2645), a multicenter trial that compared the effectiveness of oral anticoagulant therapy with aspirin in the prevention of infrainguinal bypass graft occlusions, was entered in this study. On the basis of clinical outcomes of the trial, the patients were grouped as follows: patients with patent grafts (n = 409); patients with nontreated graft occlusions, subdivided into an asymptomatic group (n = 32) and a symptomatic group (n = 65); patients with subsequent revascularizations (n = 194); patients with amputations (n = 36); and patients with failed secondary revascularizations followed by secondary amputation (n = 38). In case an outcome event occurred, the patients were regrouped accordingly. Every half year, the patients completed a Short Form-36 and a EuroQol questionnaire. A multilevel model was used for repeated measure analysis. RESULTS:The mean follow-up time was 21 months. The quality of life in patients with nontreated asymptomatic occlusions was roughly similar to the quality of life in patients with patent grafts. Patients with symptomatic nontreated occlusions had the lowest outcome with regard to pain as compared with the other groups. Furthermore, physical and social functioning was lower for these patients than for patients with patent grafts. Revascularizations, successful or not, negatively affected pain, social functioning, and physical and emotional role. After successful revascularization, some improvement was observed in pain, physical and social functioning, and general and mental health as compared with the group with nontreated symptomatic occlusions. Amputation deteriorated physical functioning strikingly, especially after failed secondary revascularization. These patients also had the lowest scores of all the groups in the dimensions of social functioning, physical and emotional role, and mental health. EuroQol score showed deterioration of quality of life after all events, except for asymptomatic occlusions. The same patterns emerged if we stratified our analysis according to the indication for the initial operation: claudication or limb salvage. Quality of life was constant over time in all the groups in the observed period. CONCLUSION: Quality of life in patients with asymptomatic occluded grafts is similar to quality of life in patients with patent grafts. Revascularization of symptomatic occluded grafts improves quality of life to a certain extent. Amputation, in particular after failed secondary revascularization, seemed to be the lowest possible outcome. The results of the Short Form-36 and EuroQol measurements were in line with the clinical expectations. The association of disease severity with scores on the instruments supports the construct validity of these outcome measures for an objective assessment of quality of life in controlled studies.     

The PADHOC Device is a Better Guide to the Actual Incapacity Suffered by Claudicants than the Gold Standard Constant Load Treadmill Test

BACKGROUND: The Constant Load Treadmill Test (CLTT) is currently the primary method used to measure walking impairment in patients with peripheral vascular disease. The aim of this study was to compare the CLTT and PADHOC device as assessments of walking impairment. METHODS: 55 patients with intermittent claudication underwent a CLTT and a Double Physiological Walking Test (DPWT) using the PADHOC device. Health-related quality of life was measured using the Short Form 36 and the Claudication Scale. RESULTS: The initial claudication and maximum walking distance from the first part of the DPWT showed the best correlation with domains of pain and physical function. CONCLUSIONS: The DPWT is more representative of the functional incapacity experienced by patients with intermittent claudication. We believe that the PADHOC is a suitable alternative to the CLTT in the assessment of this patient group.     

Exercise performance in patients with peripheral arterial disease who have different types of exertional leg pain

OBJECTIVE: This study compared the exercise performance of patients with peripheral arterial disease (PAD) who have different types of exertional leg pain. METHODS: Patients with PAD were classified into one of four groups according to the San Diego Claudication Questionnaire: intermittent claudication (n = 406), atypical exertional leg pain causing patients to stop (n = 125), atypical exertional leg pain in which patients were able to continue walking (n = 81), and leg pain on exertion and rest (n = 103). Patients were assessed on the primary outcome measures of ankle-brachial index (ABI), treadmill exercise measures, and ischemic window. RESULTS: All patients experienced leg pain consistent with intermittent claudication during a standardized treadmill test. The mean (+/- SD) initial claudication distance (ICD) was similar (P = .642) among patients with intermittent claudication (168 +/- 160 meters), atypical exertional leg pain causing patients to stop (157 +/- 130 meters), atypical exertional leg pain in which patients were able to continue walking (180 +/- 149 meters), and leg pain on exertion and rest (151 +/- 136 meters). The absolute claudication distance (ACD) was similar (P = .648) in the four respective groups (382 +/- 232, 378 +/- 237, 400 +/- 245, and 369 +/- 236 meters). Similarly, the ischemic window, expressed as the area under the curve (AUC) after treadmill exercise, was similar (P = .863) in these groups (189 +/- 137, 208 +/- 183, 193 +/- 143, and 199 +/- 119 AUC). CONCLUSION: PAD patients with different types of exertional leg pain, all limited by intermittent claudication during a standardized treadmill test, were remarkably similar in ICD, ACD, and ischemic window. Thus, the presence of ambulatory symptoms should be of primary clinical concern in evaluating PAD patients regardless of whether they are consistent with classic intermittent claudication.     

The role of pedometers in the assessment of intermittent claudication.

OBJECTIVES: to evaluate the role of pedometers in the assessment of patients with intermittent claudication by comparing them with treadmill testing, post-exercise ankle brachial pressure index (ABPI) and physical function questionnaires. PATIENTS AND METHODS: fifty patients with intermittent claudication were prospectively assessed by treadmill examination measuring maximum walking distance (MWD) and post-exercise ABPI. Three physical function questionnaires: (1) Medical Outcome Study Short Form-36 (MOS SF-36), Physical Function (PF). (2) MOS SF-36 Role limitation due to Physical Problems (RP). (3) Walking Impairment Questionnaire (WIQ) were completed. Pedometers were used for one week and the daily average number of steps taken by each patient recorded. Pedometers scores were compared with MWD, post-exercise ABPI and physical function questionnaires scores using Spearman correlation test. RESULTS: pedometers estimation of daily physical activity moderately correlated with MWD (Rho=0.35, p=0.01), post-exercise ABPI (Rho=0.35, p=0.01), MOS-SF 36 PF (Rho=0.31, p=0.02), MOS-SF RP (Rho=0.28, p=0.05) and with WIQ (Rho=0.42, p=0.003). CONCLUSIONS: they moderately correlate with treadmill testing, post-exercise ABPI, and with physical function questionnaires. Pedometers may provide a simple and cheap alternative for the assessment of physical and functional disability in intermittent claudication.     

Lack of relationship between gait parameters and physical function in peripheral arterial disease

OBJECTIVE: Physical function is limited in patients with peripheral arterial disease who are symptomatic with intermittent claudication (PAD-IC). When patients with PAD-IC experience claudication, previous reports have described gait abnormalities, including alterations in step length and cadence. This study tested the hypothesis that patients with PAD-IC would have a decrease in usual and maximal walking speed and that this alteration in gait parameters would contribute to their decreased physical function scores, even in the absence of claudication. The aims were to evaluate usual and maximal walking speed and gait parameters (step length, cadence and toe out angle) in subjects with PAD-IC and control subjects with similar baseline activity levels. METHOD: A cross-sectional study of 25 subjects with PAD-IC compared with 26 age-matched controls was conducted in a research laboratory in an academic medical center. Study subjects were similar in age, gender, and physical activity status. Subjects with PAD-IC had an ankle-brachial index <0.90 in at least one leg and reported symptoms of intermittent claudication that limited walking ability. Subjects in either group were excluded if they used assistive devices to walk or were limited in walking ability by orthopedic, neurologic, cardiac, or pulmonary symptoms. Gait parameters were assessed at the onset of walking (before the development of claudication pain in the PAD-IC group) at self-selected and maximal walking speeds during which step and stride characteristics were collected. Subjects completed a physical activity recall, a Short Form questionnaire (SF-36), and a 6-minute walk that was limited by claudication in the PAD-IC group. RESULTS: During gait testing, no patient with PAD-IC developed claudication. There were no significant differences between the PAD-IC and control groups in usual or maximal walking speed or other gait variables (step length, cadence, stride width, toe out angle). In contrast, the SF-36 physical function score was reduced 15.2 percentage points (P < .02) and the summary physical component score was reduced 6.7 percentage points in the PAD-IC group compared with controls (P = .002). In addition, the 6-minute walk distance was significantly less in the PAD-IC group than in the control group by 308.8 feet (P < .001). A series of bivariate analyses demonstrated that PAD-IC was the best predictor of reduced physical function, whereas no gait parameter was associated with reduced physical function. CONCLUSION: Patients with PAD-IC have significantly reduced 6-minute walk distance and reduced physical function by questionnaire scores that was not explained by any effects of PAD-IC on walking speed and selected gait parameters assessed before the onset of claudication pain.     

The effect of exercise intensity on the response to exercise rehabilitation in patients with intermittent claudication

PURPOSE: The purpose of this randomized trial was to compare the efficacy of a low-intensity exercise rehabilitation program vs a high-intensity program in changing physical function, peripheral circulation, and health-related quality of life in peripheral arterial disease (PAD) patients limited by intermittent claudication. METHODS: Thirty-one patients randomized to low-intensity exercise rehabilitation and 33 patients randomized to high-intensity exercise rehabilitation completed the study. The 6-month exercise rehabilitation programs consisted of intermittent treadmill walking to near maximal claudication pain 3 days per week at either 40% (low-intensity group) or 80% (high-intensity group) of maximal exercise capacity. Total work performed in the two training regimens was similar by having the patients in the low-intensity group exercise for a longer duration than patients in the high-intensity group. Measurements of physical function, peripheral circulation, and health-related quality of life were obtained on each patient before and after the rehabilitation programs. RESULTS: After the exercise rehabilitation programs, patients in the two groups had similar improvements in these measures. Initial claudication distance increased by 109% in the low-intensity group (P < .01) and by 109% in the high-intensity group (P < .01), and absolute claudication distance increased by 61% (P < 0.01) and 63% (P < .01) in the low-intensity and high-intensity groups, respectively. Furthermore, both exercise programs elicited improvements (P < .05) in peak oxygen uptake, ischemic window, and health-related quality of life. CONCLUSION: The efficacy of low-intensity exercise rehabilitation is similar to high-intensity rehabilitation in improving markers of functional independence in PAD patients limited by intermittent claudication, provided that a few additional minutes of walking is accomplished to elicit a similar volume of exercise.     

Metabolic syndrome impairs physical function, health-related quality of life, and peripheral circulation in patients with intermittent claudication

PURPOSE: This study was conducted to (1) examine the effect of metabolic syndrome on intermittent claudication, physical function, health-related quality of life, and peripheral circulation in patients with peripheral arterial disease (PAD), and (2) determine whether peripheral vascular function was predictive of intermittent claudication and physical function in patients with metabolic syndrome. METHODS: Patients limited by intermittent claudication and who had metabolic syndrome (n = 133) were compared with those without metabolic syndrome (n = 201). Patients were assessed on metabolic syndrome characteristics, PAD-specific measures consisting of ankle/brachial index and claudication distances, physical function measures, health-related quality of life, and calf blood flow and transcutaneous oxygen tension responses after 3 minutes of vascular occlusion. RESULTS: Initial claudication distance (mean +/- SD) was 29% shorter (P = .018) in patients with metabolic syndrome than in the controls (128 +/- 121 meters vs 180 +/- 166 meters), and absolute claudication distance was 22% shorter (P = .025) in those with metabolic syndrome (319 +/- 195 meters vs 409 +/- 255 meters). Furthermore, patients with metabolic syndrome had lower peak oxygen uptake (P = .037), a shorter 6-minute walk distance (P = .027), lower values on six domains of health-related quality of life (P < .05), reduced calf hyperemia (P = .028), and greater calf ischemia (P < .001) after vascular occlusion. In the group with metabolic syndrome, calf ischemia was correlated with initial claudication distance (r = 0.30, P = .004), absolute claudication distance (r = 0.40, P < .001), and peak oxygen uptake (r = 0.52, P < .001). CONCLUSION: Metabolic syndrome worsens intermittent claudication, physical function, health-related quality of life, and peripheral circulation in patients with PAD. Calf ischemia in those with metabolic syndrome was predictive of intermittent claudication and physical function. The additive burden of metabolic syndrome thus places patients who are limited by intermittent claudication at an even greater risk for living a functionally dependent lifestyle. Aggressive risk-factor modification designed to treat components of metabolic syndrome should be evaluated for efficacy in modifying physical and vascular function in patients with intermittent claudication.     

Symptoms, disability, and quality of life in patients with carpal tunnel syndrome

We used validated outcome instruments to measure symptoms, disability, and health-related quality of life in 58 patients with carpal tunnel syndrome (CTS). The patients completed the CTS instrument before and 6 weeks, 3 months, and 6 months after surgery and the Short Form-36 (SF-36) before and 3 months after surgery. The size of clinical change detected by each outcome measure was estimated by the standardized response mean (mean change/ standard deviation of the change). Large improvement was observed for the CTS symptom scale (mean standardized response, 1.4-1.9) and function scale (0.8-1.1). Improvement in SF-36 scales was large for pain (1.0) and moderate for physical role, mental health, and the physical component summary (0.5-0.6). Compared with the general population SF-36 norms (n = 2,181), CTS patients had significantly worse scores for physical functioning, physical role, pain, vitality, and the physical component summary before surgery. After surgery, SF-36 scores had normalized except for physical role and the physical component summary.     

The value of patient activity level in the outcome of total hip arthroplasty

Commonly used total hip arthroplasty scores take into account pain, function, walking, and range of motion. The purpose of this study was to evaluate the value of patient activity level as part of the outcome of total hip arthroplasty. Using linear regression analysis, the relationship between patient activity level (University of California Los Angeles activity score), the Harris Hip Score, and the Short Form-12 health survey was evaluated in 152 patients (mean age, 58.7 years) with a mean follow-up 5.2 years (range, 2-21 years). The University of California Los Angeles activity scale had an R(2) value of 0.39 and 0.19 to the Short Form-12 physical and mental components, respectively, and 0.32 to the Harris Hip Score. By evaluating patient activity level, one obtains important qualitative information in assessing the clinical outcome after total hip arthroplasty.     

Walking and cycling tests in neurogenic and intermittent claudication

The walking and cycling tolerance of 19 patients with neurogenic claudication and 11 with intermittent claudication was assessed, first in the upright and then in 30 degrees of flexion, repeating the tests on a second day. The flexed posture improved the walking and cycling distance, respectively, in 11 and six patients with neurogenic claudication. In two of the 11 patients, this posture significantly improved by more than 100% of both walking and cycling distances. In addition, one patient had claudication pain when he was walking, but could cycle unlimited distance. Only one of the patients with intermittent claudication could walk or cycle further in the flexed position. Although some patients with neurogenic claudication increase their walking distance by flexing forwards, we conclude that posture-related walking and cycling are insufficiently sensitive tests to distinguish between neurogenic and intermittent claudication.     

The ischemic window: a method for the objective quantitation of the training effect in exercise therapy for intermittent claudication.

Twenty-two patients with intermittent claudication were prospectively enrolled in a 12-week program of supervised, graded treadmill exercise therapy. Severity and distribution of arterial occlusive disease were ascertained by noninvasive determination of segmental lower extremity blood pressures and waveforms. No attempt was made to modify risk factors for atherosclerotic occlusive disease. The exercise-induced reduction of the ankle pressure and its recovery were recorded over time, and the area under this curve, the "ischemic window," represents the severity of the ischemic deficit. Absolute systolic ankle pressure, ankle-brachial index, maximum walking time, claudication pain time, and the ischemic window were measured before and after exercise training in all subjects. Maximum walking time and claudication pain time increased 659% and 846%, respectively, among the 19 patients completing the 12-week program (p = 0.001; p = 0.0002). These patients underwent a mean reduction of 58.7% in the ischemic window after a standardized workload (p less than 0.05), and this correlated with the degree of symptomatic improvement. Absolute ankle pressure and ankle-brachial index were unchanged after exercise training. This study confirms the utility of supervised exercise therapy in the treatment of intermittent claudication. The ischemic window is a useful method for quantifying the ischemic deficit produced by exercise and provides a reproducible means of documenting functional improvement in patients undergoing exercise training.     

Improvement in Quality of Life After Laparoscopic Sleeve Gastrectomy

Few studies have investigated changes in health-related quality of life (HRQOL) in surgical patients who have undergone a laparoscopic sleeve gastrectomy. Prospective data were obtained from 78 consecutive patients undergoing laparoscopic sleeve gastrectomy (LSG; mean age, 42.4 years; mean body weight, 131 kg; mean body mass index (BMI), 47 kg/m(2) (24.4% of superobese patients)). Two HRQOL questionnaires were administered preoperatively and 12 months postsurgery: the generic Medical Outcomes Study Short Form-36 and the weight-specific IWQOL-Lite questionnaire. Excess weight loss at 12 months was 57.18%. No mortality was recorded. HRQOL scores revealed a significant improvement in all areas of both questionnaires. However, changes in HRQOL were not associated consistently with amount of weight loss. Laparoscopic sleeve gastrectomy is an effective and safe procedure, with positive changes in health-related quality of life as well as weight reduction. A fruitful area for future research is the investigation of long-term changes in HRQOL after LSG.     

Long-term subjective and objective outcome after primary repair of traumatic facial nerve injuries

Although traumatic facial nerve paralysis is a severe handicap, there are no follow-up studies evaluating outcome after primary repair of traumatic facial nerve injuries. From May 1988 to August 2005, 27 patients (mean age, 27 years) were operated for traumatic facial nerve lesions (mean number of affected branches, 2.2). End-to-end facial nerve repair was always performed. All patients were invited to our outpatient clinic for standardized questionnaires (Facial Disability Index, Short Form-36 Health Survey), physical examination (Sunnybrook Facial Grading System), and clinical photographs. Sixteen patients participated in the follow-up study (mean, 9.2 years). Mean Facial Disability Index Physical and Social scores were 86 and 81, respectively, indicating good subjective facial functioning. The mean Sunnybrook Facial Grading System score was 74 indicating adequate facial functioning. Mean physical and mental health scores (Short Form-36 Health Survey) were comparable with normative data. Primary end-to-end repair of traumatic facial nerve injuries results in good long-term objective and subjective functional and emotional outcome.     

Assessing the reliability and responsiveness of 5 shoulder questionnaires

The purpose of this study was to compare the test-retest reliability and responsiveness of 5 different shoulder questionnaires in a simple of patients with shoulder pain. Ninety-nine patients completed the following shoulder questionnaires on 2 occasions: Subjective Shoulder Rating Scale, Simple Shoulder Test, Modified-American Shoulder and Elbow Surgeons Form, Shoulder Severity Index, and the Shoulder Pain and Disability Index. The Short Form-36 was also included. Test-retest reliability was assessed with intraclass correlation coefficients. Standardized response means were calculated to assess responsiveness. This procedure was done on 33 subjects who underwent rotator cuff surgery or total shoulder arthroplasty and who believed that they had improved between testings. All questionnaires had acceptable reliability (coefficients >0.75) except the Subjective Shoulder Rating Scale (coefficient = 0.71) and were more responsive (0.65 < Standardized response mean < 1.23) than the Short Form-36 (0.08 < Standardized response mean < 0.43) except for pain (0.91). In this longitudinal study a direct comparison of 5 shoulder questionnaires was carried out. We found the Subjective Shoulder Rating Scale to have lower reliability and responsiveness. The other 4 questionnaires including 1 developed to measure whole extremity function (Modified American Shoulder and Elbow Surgeons Form) rather than the shoulder only were comparable with good reliability and responsiveness. The results indicate that the shoulder questionnaires were more sensitive to change in patients with shoulder pain than the generic questionnaire (Short Form-36), and both types of questionnaires should be used in outcome evaluations.