Limb Problems Research Articles

Fifteen-year follow-up of upper limb function in children with moderate to severe traumatic brain injury

To describe the impaired fine-motor skills in patients with traumatic brain injury acquired in childhood. A total of 165 patients with traumatic brain injury, aged 0-17 years, injured during the period 1987-1991, were identified. Fifteen years post-injury a questionnaire was sent to the patients. Twenty-six of the subjects had upper limb problems, 15 of whom agreed to participate and 12 attended an evaluation. The Sollerman test was administered. This test consists of 20 activities, of which 7 hand-grips were used (pulp-pinch, lateral pinch, tripod pinch, 5-finger pinch, diagonal, transverse and spherical volar grip). Each sub-test was scored from 0 to 4 points. Each task must be performed within 20 s. The maximum score was 80. Bimanual fine motor skills were classified by Bimanual Fine Motor Function (BFMF). BFMF consists of 5 levels of function of each hand. Level I is normal function, level II-V means subnormal function in an increasing grade. Co-ordination, spasticity, 2PD and stereognosis were also measured. All patients had subnormal results on the Sollerman test. Fifty-eight percent had abnormal scores on the BFMF test. The Sollerman test seemed to be reliable at picking up hand motor problems, as all subjects who reported such problems scored subnormally. This is in contrast to the BFMF test findings, where only 60% of our group scored subnormally.

Foot Plantar Pressure Measurement System: A Review

Foot plantar pressure is the pressure field that acts between the foot and the support surface during everyday locomotor activities. Information derived from such pressure measures is important in gait and posture research for diagnosing lower limb problems, footwear design, sport biomechanics, injury prevention and other applications. This paper reviews foot plantar sensors characteristics as reported in the literature in addition to foot plantar pressure measurement systems applied to a variety of research problems. Strengths and limitations of current systems are discussed and a wireless foot plantar pressure system is proposed suitable for measuring high pressure distributions under the foot with high accuracy and reliability. The novel system is based on highly linear pressure sensors with no hysteresis.

24. Myasthenia gravis after vaccination

Introduction: The accessory peroneal nerve (APN) is an anatomic variation that can potentially cause disturbance in electrodiagnostic (EDX) studies. This anomaly is detected by nerve conduction studies. There are no recent studies regarding the prevalence of this anatomic variation. Objectives: To determine the presence and prevalence of the APN in an EDX medicine clinic. Methods: In a cross-sectional descriptive study that took place from March 2009 to July 2010, 230 cases comprising 460 legs were referred for EDX studies of upper limb problems. Compound muscle action potentials and nerve conduction velocities of the deep peroneal nerve were measured by needle electromyography by stimulating the DPN at the knee, ankle, and lateral malleolous areas accordingly and recording from the extensor digitorum brevis muscle. Results: The study population included 120 females (52%) and 110 (47%) males with a mean age of 42.1 13.5 years. The APN was detected in 28 patients (12%). Ten (17.9%) had bilateral APN and in the remaining 18 cases (82.1%), the APN was unilateral. Gender distribution was similar, which means half of the cases (14 patients) belonged to each gender. Conclusion: The prevalence of the APN in this study was 12.2% (17.9% bilateral and 82.1% unilateral).

22. Correlation of nerve conduction parameters in diagnosing ulnar neuropathy at the elbow

Introduction: The accessory peroneal nerve (APN) is an anatomic variation that can potentially cause disturbance in electrodiagnostic (EDX) studies. This anomaly is detected by nerve conduction studies. There are no recent studies regarding the prevalence of this anatomic variation. Objectives: To determine the presence and prevalence of the APN in an EDX medicine clinic. Methods: In a cross-sectional descriptive study that took place from March 2009 to July 2010, 230 cases comprising 460 legs were referred for EDX studies of upper limb problems. Compound muscle action potentials and nerve conduction velocities of the deep peroneal nerve were measured by needle electromyography by stimulating the DPN at the knee, ankle, and lateral malleolous areas accordingly and recording from the extensor digitorum brevis muscle. Results: The study population included 120 females (52%) and 110 (47%) males with a mean age of 42.1 13.5 years. The APN was detected in 28 patients (12%). Ten (17.9%) had bilateral APN and in the remaining 18 cases (82.1%), the APN was unilateral. Gender distribution was similar, which means half of the cases (14 patients) belonged to each gender. Conclusion: The prevalence of the APN in this study was 12.2% (17.9% bilateral and 82.1% unilateral).

23. Facial palsy after vaccination

Introduction: The accessory peroneal nerve (APN) is an anatomic variation that can potentially cause disturbance in electrodiagnostic (EDX) studies. This anomaly is detected by nerve conduction studies. There are no recent studies regarding the prevalence of this anatomic variation. Objectives: To determine the presence and prevalence of the APN in an EDX medicine clinic. Methods: In a cross-sectional descriptive study that took place from March 2009 to July 2010, 230 cases comprising 460 legs were referred for EDX studies of upper limb problems. Compound muscle action potentials and nerve conduction velocities of the deep peroneal nerve were measured by needle electromyography by stimulating the DPN at the knee, ankle, and lateral malleolous areas accordingly and recording from the extensor digitorum brevis muscle. Results: The study population included 120 females (52%) and 110 (47%) males with a mean age of 42.1 13.5 years. The APN was detected in 28 patients (12%). Ten (17.9%) had bilateral APN and in the remaining 18 cases (82.1%), the APN was unilateral. Gender distribution was similar, which means half of the cases (14 patients) belonged to each gender. Conclusion: The prevalence of the APN in this study was 12.2% (17.9% bilateral and 82.1% unilateral).

People with patellofemoral osteoarthritis have smaller hip muscle volumes than healthy controls

Purpose: The patellofemoral joint (PFJ) is a frequently affected by the osteoarthritis (OA) process and contributes significantly to the OA-related pain and reduced physical function. Due to the unique biomechanics of the PFJ, it is likely that rehabilitation strategies tailored to PFJ OA will optimise clinical outcomes. However, currently there is limited knowledge of the modifiable impairments associated with PFJOA, which could be targeted in rehabilitation programs. Hip muscle dysfunction has been proposed to influence PFJ stress and hence, may play a role in the development or progression of PFJOA. Specifically, weakness of hip abductor muscles may result in excessive femoral adduction, which may increase contact pressure in the lateral PFJ. Therefore, the aim of this study was to compare the volumes of the primary hip-abductors (gluteus medius, gluteus minimus and tensor fasciae latae) of individuals with PFJOA, with those of healthy controls.Methods: 50 individuals with radiographic evidence of PFJ OA and symptoms stereotypical of PFJ involvement, aged > 40 years and 13 people aged > 40, with no lower limb problems were recruited. Magnetic Resonance (MR) images of the hip region were obtained. The cross-sectional area of the hip-abductor muscles were manually segmented from each axial MR slice, and were used to calculate muscle volume. A test-retest reliability study was performed to assess the intra-investigator reliability of this procedure. The muscle volumes of were normalised to body weight and analyses were performed with and without gender as a co-variate.Results: There were no differences in participant characteristics between the PFJ OA group (female 40 (63%); age 55 ± 10 yrs; height 1.69±0.09m; weight 76±13 kg) and control group (female 10 (62%); age 52±6yrs; height 1.68±0.10; weight 71±13kg). The techniques for assessing muscle volume were shown to be reliable (ICC ≥ 0.997). Comparisons of mean normalised muscle volumes revealed significant between-group differences for gluteus medius (mean difference: 95% confidence interval 0.47: 0.08 to 0.86 cm3.kg-1; p = 0.02), gluteus minimus (0.21; 0.09 to 0.33 cm3.kg-1; p = 0.001) and tensor fasciae latae (0.23; 0.03 to 0.42 cm3.kg-1; 0.024). Inclusion of gender as a covariate did not change the significant findings.Conclusions: Individuals with PFJOA had significantly smaller gluteus medius, gluteus minimus and tensor fasciae latae muscles when compared with healthy control individuals. As muscle volume is directly related to peak isometric force output, smaller muscles will tend to be weaker. It is unclear whether hip-abductor weakness is a cause or an effect of PFJOA. Regardless, the present study provides several directions for future research on this relationship

Clinical staging of type 2 diabetes: The time has come

Clinical staging of type 2 diabetes: The time has come

Effects of foot orthoses: How important is the practitioner?

Foot orthoses (FO) are commonly used in the treatment of numerous lower limb problems, pains and injuries. Whilst many studies report their positive effects, and most practitioners would confirm those findings, the available information appears to be anecdotal. As such, the exact mechanisms in which FO work are not fully understood. Therefore, a need exists to study the influence of the inter-practitioner variability in the assessment of orthoses performance. This investigation is central to the understanding of the performance variations in custom-made foot orthoses (CFO). Eleven practitioners took part in the study. Each practitioner completed a clinical assessment of one subject, after which a pair of foot orthoses was manufactured based on casts of the subject's feet using a neutral non-weight bearing plaster cast. Ten trials per condition were recorded during which kinematic and kinetic data were collected. CFO did not have any systematic significant effects (p<0.05) on any kinetic except for the right-leg peak active force. In addition, systematic kinematic effects could be observed mainly for the sagittal plane for forefoot-to-hindfoot and hindfoot-to-tibia peak angles. The results from this study demonstrate that inter-practitioner variability is a major factor in orthotic intervention in treating a single patient and for a specific pathology. It is therefore strongly recommended to use caution when drawing general conclusions from research studies using custommade foot orthoses. The results suggest that CFO effects can differ between limbs. More importantly, their effects are also practitioner-dependant. Great caution should be used when comparing studies on CFO with different practitioners as conclusions could vastly differ.

Hunt &amp; Marshall’s Clinical Problems in Surgery

This precise and thorough textbook provides a fresh insight into problem-based learning. An integrated approach is presented that allows the development of an organised and logical system for solving clinical problems encountered by patients. The informative text encourages the reader to acquire a focused history, complete a detailed physical examination and then develop a differential diagnosis and relevant management plan. Such a problem-orientated clinical approach is invaluable for the inexperienced and is recommended for anyone preparing for examinations at undergraduate and postgraduate levels. The book is organised into nine chapters, which cover regional problems such as abdomen and gut problems, limb problems and urogenital problems. An additional four chapters are devoted to more general aspects of surgery including common medical problems in surgical patients, post-operative problems, intensive care and trauma. A broad range of topics is covered in an accurate and up-to-date manner. The text is well written and easy to read. Each chapter focuses on the problem presented by the patient and then describes the clinical reasoning necessary for diagnosis and formulating a tailored treatment pathway. Pattern recognition of common surgical diseases is presented in a succinct and easily learnt style with useful tables and diagrams. There are no colour photographs but the black and white photographs and radiographs complement the text. Many line diagrams are included and these are simple and informative. The book also includes valuable advice on recording progress notes, reviewing unwell patients, writing discharge summaries and presenting case histories. The appeal of this book is broad and it will be useful to medical students and those preparing for postgraduate exams, as well as doctors wishing to refine their clinical surgical skills. The problem-orientated approach is a useful tool and is expertly presented by the authors.

Eficacia del tratamiento con férula tipo INMOYBA en niños con torsión tibial interna y externa

Introduction Rotational problems of the lower limbs are one of the most common causes of pediatric orthopedics consultation. There is considerable controversy regarding conservative treatment. The aim of our study is to assess the effectiveness of the INMOYBA type brace for the treatment of tibial torsion. Material and methods A retrospective descriptive study was performed including the patients referred to our Child Rehabilitation Unit who were diagnosed with pathological tibial torsion and treated with INMOYBA type splint for nighttime use. We collected sociodemographic variables and rotational profile. Measurements were made just before starting treatment with the splint and six months after its removal. Thigh-foot angle (TFA) was also obtained on removal of the splint. Results The correction produced in the initial TFA compared to the removal one was 14.38° on the left and 13.08° on the right, this being statistically significant. When the removal TFA was compared with the final value, correction was even greater. A reduction was obtained when the internal and external rotation of the hip was correlated before and after treatment as well as dorsal and plantar flexion. The latter was statistically significant. Conclusion The use of INMOYBA-type night splint appears to be effective for the treatment of both internal and external tibial torsion. It would be advisable to ascertain whether the decrease in plantar flexion produced is due to the use of this type of brace or if it is associated to the natural evolution.

A path of perpetual resilience: Exploring the experience of a diabetes-related amputation through grounded theory

Little research has been done on the experience of diabetes-related amputation. The aim of this study was to allow amputees to describe their experiences of amputation and to generate grounded theory that will lead health professionals towards a more comprehensive understanding of the realities of post-amputation life. Unstructured interviews were conducted with five participants with a diabetes-related amputation living in a rural setting, and their respective carers. The interviews were analysed using Grounded Theory methods. Data analysis revealed three categories: ‘imposed powerlessness’, ‘adaptive functionality’ and ‘endurance’. The impact of participant’s amputations were influenced by continuing limb problems post-amputation and co-existing complications affecting their physical function. Medical errors and lack of awareness of the risks for diabetic amputations resulted in uncertainty and fear. The participants’ sense of grief, loss and shock post operatively continued later as they came to terms with their awkwardness of movement, yet they moved forward developing their own sense of hope through a coping process that revealed remarkable ability to endure and exert control over lives that seemed to be at the whim of an ongoing disease process. The substantive theory resulting from this grounded theory study was conceptualised as ‘A Path of Perpetual Resilience’. It is important that psychosocial and not just physical adjustment is considered an indicator for determining outcomes for these people, and that future care involves strategies to promote this. A greater sample size is required to determine if these findings are transferable to the general diabetes-related amputation population.

The role of circumflex femoral veins in the saphenofemoral junction incompetence: a case report

A 31 year-old female patient, an opera singer, came for a consultation, mainly for aesthetic problems of the lower limbs. An asymptomatic bilateral P-point pelvic shunt was demonstrated by the EchoDoppler, while no nutcracker syndrome was detected. The examination demonstrated a medial circumflex femoral vein (MCFV), going into the common femoral vein and then into the great saphenous vein (GSV). The Valsalva manoeuvre showed the GSV terminal valve incompetence. A dilated MCFV vein at the level of the saphenofemoral junction was the source of the reflux through the GSV, while the external iliac vein was competent. GSV reflux with Valsalva was present only in the lying position. Flow in the MCFV was directed toward the CFV during and after the Valsalva. The examination shows clearly that a GSV reflux can sometimes occur in absence of iliac reflux. Circumflex femoral veins (medial and lateral) are anatomical variations, but common findings during ordinary EchoColourDoppler investigations of the venous system of the lower limbs.

The Incidence of Wound Complications Related to Negative Pressure Wound Therapy Power Outage and Interruption of Treatment in Orthopaedic Trauma Patients

Negative pressure wound therapy (NPWT) using the Vacuum Assisted Closure system is an invaluable tool for use on patients with complex limb and soft tissue problems. Recently, the manufacturer (Kinetic Concepts, Inc, San Antonio, TX) made significant modifications to the NPWT platform, including computer software, battery, alarming systems, electric cord and plug apparatus, and others. Since these modifications, we have seen several cases in which the NPWT device has powered off resulting in an unrecognized interruption of therapy. We sought to evaluate the conditions and clinical effects, if any, to orthopaedic trauma patients who experienced an interruption of NPWT therapy when the device powers off. Retrospective study of consecutive patients. Two neighboring regional trauma centers. One hundred twenty-three consecutive orthopaedic trauma patients treated with NPWT by two orthopaedic trauma surgeons between May and November 2008. Patient/injury, treatment, and perioperative clinical outcomes data (with emphasis on wound complications such as infection, graft loss, and unscheduled surgery) were collected from medical records and wound care databases. Twelve patients (10%) had problems with the NPWT device powering off causing an unrecognized interruption of therapy. Eleven patients underwent early (less than 6 hours) wound débridement and reapplication of NPWT after detection, of which nine required unplanned surgery. Seven of the 12 patients recognized as having failed NPWT of this type ultimately experienced wound complications, including five deep infections and both patients being treated with an Integra graft (loss of graft). We have seen substantial problems in orthopaedic trauma patients treated with the NPWT, in which the device has powered off resulting in an unrecognized interruption of therapy. This has resulted in atypically unhealthy-appearing wounds, unplanned surgeries for débridement, and most importantly, an increased incidence of wound complications, including infection and graft loss (P < 0.05).

Getting the signal to noise ratio right in the management of diabetes in primary care: time to stratify risk and focus on outcomes rather than process

We need to consider how to improve the signal-tonoise ratio in managing the lower limb in diabetes and stratification of risk is an option. Stratifying risk is likely to be helpful, though probably as part of a package of other measures. Whilst the combination of risk stratification and pay-for-performance has improved care in cardiovascular disease, it did not result in instant optimal management - gaps in quality and technical implementation issues remain.13,14 Although the effectiveness of P4P remains a matter of debate;15 there are indicators that introducing P4P has improved intermediate markers in the quality of care in diabetes.16 Previous studies have suggested that the introduction of a shared information system is associated with improving care in diabetes.17 However, caution is needed in deciding whether this represents cause and effect.18 As incorporation into P4P indicators improves data recording there maybe scope to include stratification of risk of lower limb problems and appropriate referral into P4P indicators. It is also possible that other professional groups might be more effective in detecting changes in the foot in people with diabetes. In Salford a care pathway which involves paper based assessment by podiatrists is associated with a substantial fall in the rate of amputation.19 The purpose of informatics is how to better use data and information to improve the quality of care.20 The ongoing rise, or at best lack of any fall, in the rate of amputationin diabetesis achallenge for us all. Sharing information, stratifying risk, and providing the right care are critical. We also need to explore how P4P might help achieve better outcomes. Improving the signal to noise ratio by focussing care on higher risk individuals and providing feedback about outcomes, in this case rates of amputation, are recommended as the next steps to improve quality. © 2011 PHCSG, British Computer Society.

M1457: Clinical Presentation and Management of Afferent Limb Syndrome in Pancreatic Cancer Patients Following Pancreaticoduodenectomy and Adjuvant Therapy

Information on afferent limb syndrome (ALS) following pancreaticoduodenectomy (PD) for pancreatic cancer (PC) is limited. We evaluated the incidence, clinical presentation, and management of afferent limb problems in PC patients who have had PD at our institution over a 14-year period (1995-2009).

Frequency and Severity of Self-Reported Upper Extremity Impairments, Activity Limitations, and Participation Restrictions Following Breast Cancer Treatment

Objective: Upper quarter impairments, activity limitations, and participation restrictions have been commonly reported in breast cancer survivors. However, use of a standardized tool to assess the frequency and severity of these problems has not been performed. Therefore, we sought to identify the type and severity of upper limb problems following breast cancer treatment, and the impact of those impairments on self-reported participation in daily activities. Methods: 76 participants completed a survey regarding their cancer treatment and any upper extremity complaints during that time. If they reported current problems with the affected arm, they were asked to complete the Disabilities of the Shoulder Arm and Hand (DASH) Outcome Measure. Results: 96% of respondents indicated upper extremity problems related to cancer treatment, most commonly: arm weakness (59%), lymphedema (53%), pain (52%), stiffness (21%), and frozen shoulder (20%). Of those reporting problems, only 33% received physical therapy intervention. Mean DASH score was 24 (SD = 18), indicating mild to moderate disability. Conclusion: Problems in the upper extremity are common following breast cancer treatment. Some of these problems, even if rated as mildly disabling, are long-lasting and lead to self-reported activity limitations and participation restrictions. Few women with these complaints received physical therapy intervention.

Environmental and demographic risk factors for poor welfare in working horses, donkeys and mules in developing countries

Over 85% of equids live in developing countries, where they are usually used for work. We aimed to identify environmental factors associated with potential welfare problems in working equids, helping target welfare interventions towards the most vulnerable animals. Over 5 years, non-invasive behavioural and physical data were collected from 5481 donkeys, 4504 horses, and 858 mules across nine developing countries. Hoof and limb problems were over 90% prevalent, and 85% of equids were thin. Older, thinner animals had the most problems, and species differences in susceptibility were found. Equids used to transport people by cart, to carry goods by pack, or to work in bricks kilns had more problems than other equids. Rural equids had more problems than urban ones, but urban equids had more lesions, and were more aggressive towards observers. Equids were significantly thinner when climates were warmer. These results should aid the development and targeting of specific welfare interventions.

Upper limb musculoskeletal abnormalities and poor metabolic control in diabetes

Introduction An increased prevalence of musculoskeletal disease is recognised in diabetes and is a common source of disability. It is known to predominantly affect the upper limbs especially the hand and shoulder. The relationship with other complications of diabetes and glycaemic control is uncertain. We designed this study to clarify these relationships, and to assess differences between types 1 and 2 diabetes. Methods We identified a group of 96 people with established diabetes and examined them for the presence of locomotor disease focussing on the upper limbs. We recorded the mean HbA1c and the presence of diabetic complications, together with the health assessment questionnaire (HAQ) score. We explored correlations between locomotor disease and these variables using logistic regression. We compared data between type 1 and type 2 diabetics and contrasted the amalgamated data with that of a matched control population of medical out patients using Students t tests. Results Locomotor disease was present in 75% of diabetics with the upper limb the commonest site for abnormalities. This prevalence was significantly higher than that seen in the controls (53%) [ p = 0.02]. Shoulder capsulitis (25%), carpal tunnel syndrome (20%), tenosynovitis (29%), limited joint mobility (28%) and Dupuytrens contracture (13%) were the most frequent findings and were much commoner than in controls. Capsulitis usually coexisted with other upper limb abnormalities and best predicted the presence of retinopathy and/or neuropathy. The mean HbA1c was significantly higher in patients with combined shoulder and hand problems (9.1%) than in those with no upper limb problems (8.0%) [ p = 0.018]. The pattern of results was similar in type 1 and type 2 diabetes, although the prevalence of abnormalities and mean HAQ were significantly greater in type 2 patients, which may be in part a function of their greater mean age. Conclusion Upper limb locomotor abnormalities are very common in diabetes and are associated with worse glycaemic control and more diabetic complications. Assessment of upper limb locomotor disease in diabetes should include an estimate of glycaemic control and a search for other complications.

Massive transfusion and surgical management of iatrogenic aortic laceration associated with cystocentesis in a dog

A 4-year-old 29-kg (63.8-lb) spayed female Husky crossbred was referred for emergency treatment because of catastrophic hemorrhagic shock following attempts at cystocentesis for investigation of suspected urinary tract infection. On arrival at the hospital, clinicopathologic assessments revealed rapidly decreasing PCV and worsening hypoproteinemia, compared with findings immediately prior to referral. The dog had severe hyperlactemia. Ultrasonography revealed the presence of free fluid in the abdomen; the fluid appeared to be blood (determined via abdominocentesis). Urgent surgical exploration was undertaken. Two small lacerations in the ventral aspect of the abdominal aorta just dorsal to the bladder were identified and repaired. Multiple transfusions of packed RBCs (5 units) and fresh frozen plasma (3 units) were administered, and autotransfusion of blood (1.2 L) from the abdomen was performed. The dog recovered well from surgery and anesthesia, but developed signs of severe pain and swelling of both hind limbs, which were attributed to reperfusion injury following aortic occlusion during surgery. Treatment included administration of S-adenosylmethionine (23 mg/kg [10.5 mg/lb], PO, q 24 h) and analgesia; 5 days after surgery, the hind limb problems had resolved and treatments were discontinued. In the dog of this report, aortic laceration secondary to cystocentesis was successfully treated with a combination of surgery and massive transfusion; the development of reperfusion injury was an interesting and reversible complication of surgery. The possibility of damage to intra-abdominal structures should be investigated if a dog becomes acutely ill after cystocentesis.

Musculoskeletal Impairments in the Norwegian Working Population: The Prognostic Role of Diagnoses and Socioeconomic Status

Population-based, 5-year prospective cohort study. To assess the incidence of musculoskeletal disorders (MSDs) in sickness absence longer than 8 weeks in Norway, and to identify diagnostic and socioeconomic predictors of the transition to disability pension (DP). MSDs are prevalent and of major concern for sickness absence. Previous epidemiological studies are largely cross-sectional and based on self-reports, often with low response rates, selection, and reporting bias. Prospective studies with physician-verified diagnoses might be a better approach. Thirty-seven thousand nine hundred forty-two females and 26,307 males with an episode of sickness absence >8 weeks in 1997, certified with a MSD were followed up for 5 years. Diagnostic and sociodemographic data were obtained from a national database. Cases were divided into 9 diagnostic subgroups, based on the International Classification of Primary Health Care. Survival analysis was performed with granting of DP as the endpoint, in the full sample and for diagnostic subgroups. Over all 20% of cases obtained DP during follow-up. Among those aged 50 to 62 and among those with only basic education 46% obtained DP. DP rates were highest for osteoarthrosis (47%), rheumatoid arthritis (46%), and myalgia/fibromyalgia (38%). Fractures/injuries had the lowest rate. Controlled for age, education and income, relative risk of DP was 1.5 (95% CI: 1.4-1.6) for upper limb problems, 2.0 (95% CI: 1.8-2.1) for back problems, 2.8 (95% CI: 2.5-3.1) for osteoarthrosis, 3.3 (95% CI: 3.0-3.6) for myalgia/fibromyalgia, and 4.2 (95% CI: 3.9-4.7) for rheumatoid arthritis, compared to "fractures and injuries." Age, diagnoses, and socioeconomic variables were important predictors of an adverse outcome among workers with a sickness absence of 8 or more weeks. Further research is needed to determine whether differentiated follow-up strategies might prevent permanent disability.