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Latijnhouwers, D.A.J.M.; Hoogendoorn, K.G.; Nelissen, R.G.H.H.; Putter, H.; Vlieland, T.P.M.V.; Gademan, M.G.J.; LOAS Study Grp 2023

Adherence to the Dutch recommendation for physical activity: prior to and after primary total hip and knee arthroplasty

Article / Letter to editor

open access

PurposeTo determine the course of adherence to physical activity (PA) recommendation in hip/knee osteoarthritis patients before and after hip/knee arthroplasty (THA/TKA). Moreover, we explored... Show morePurposeTo determine the course of adherence to physical activity (PA) recommendation in hip/knee osteoarthritis patients before and after hip/knee arthroplasty (THA/TKA). Moreover, we explored predictors for non-adherence 12 months postoperatively.Materials and methodsPrimary THA/TKA were included in a multicenter observational study. Preoperatively and 6/12 months postoperatively, patients reported engagement in moderate-intensity PA in days/week in the past 6 months (PA-recommendation (& GE;30 min of moderate-intensity & GE;5 days/week)). We included predictors stratified by preoperative adherence: sex, age, BMI, comorbidities, smoking, living/working status, season, mental health, HOOS/KOOS subscales before and 6 months postoperatively, and 6-month adherence.Results(1005 THA/972 TKA) Preoperatively, 50% of the population adhered. Adherence increased to 59% at 6 and 12 months. After 12 months, most patients remained at their preoperative PA level, 11% of the preoperative adherers decreased, while 20% of the preoperative non-adherers increased their PA level. In all different groups, adherence to the PA recommendation at 6 months was identified as a predictor (OR-range: 0.16-0.29). In addition, BMI was identified as predictor in the THA adherent (OR = 1.07; 95%CI [1.02-1.15]) and TKA non-adherent groups (OR = 1.08; 95%CI [1.03-1.12]). THA non-adherent group not having paid work (OR = 0.53; 95%CI [0.33-0.85]), and in the TKA adherent group, lower KOOS subscale symptoms (OR = 1.03; 95%CI [1.01-1.05]) were associated with non-adherence.ConclusionsMajority of patients remained at their preoperative PA level. Non-adherence at 6 months was highly predictive for 12-month non-adherence. Show less

Allonsius, F.; Kloet, A.J. de; Markus-Doornbosch, F. van; Vlieland, T.P.M.V.; Holst, M. van der 2023

A longitudinal follow-up study of parent-reported family impact and quality of life in young patients with traumatic and non-traumatic brain injury

Article / Letter to editor

open access

PurposeBrain injuries (traumatic-/nontraumatic, TBI/nTBI) in young patients may lead to problems e.g., decreased health-related quality of life (HRQoL), and causes family impact. Knowledge... Show morePurposeBrain injuries (traumatic-/nontraumatic, TBI/nTBI) in young patients may lead to problems e.g., decreased health-related quality of life (HRQoL), and causes family impact. Knowledge regarding the family impact and the relationship with patients' HRQoL over time is scarce. This follow-up study describes family impact/HRQoL and their mutual relationship in young patients (5-24 years) after TBI/nTBI.Materials and methodsParents of patients that were referred to outpatient rehabilitation completed the PedsQL (TM) Family-Impact-Module questionnaire to assess the family impact and the parent-reported PedsQL (TM) Generic-core-set-4.0 to assess patients' HRQoL (lower scores: more family impact/worse HRQoL). Questionnaires were completed at the time of referral to rehabilitation (baseline) and one/two years later (T1/T2). Linear-mixed models were used to examine family impact/HRQoL change scores, and repeated-measure correlations (r) to determine longitudinal relationships.ResultsTwo-hundred-forty-six parents participated at baseline, 72 (at T2), median patient's age at baseline was 14 years (IQR:11-16), and 181 (74%) had TBI. Mean (SD) PedsQL (TM) Family-Impact-Module score at baseline was 71.7 (SD:16.4) and PedsQL (TM) Generic-core-set-4.0: 61.4 (SD:17.0). Over time, PedsQL (TM) Family-Impact-Module scores remained stable, while PedsQL (TM) Generic-core-set-4.0 scores improved significantly(p < 0.05). A moderately strong longitudinal correlation was found between family impact&HRQoL (r = 0.51).ConclusionsFamily impact does not tend to decrease over time but remained a considerable problem, although patients' HRQoL improved. Next to focusing on patients' HRQoL, it remains important to consider family impact and offer family support throughout rehabilitation. Show less

Meijeren-Pont, W. van; Arwert, H.; Volker, G.; Fiocco, M.; Achterberg, W.P.; Vlieland, T.P.M.V.; ... ; Stroke Cohort Outcomes REhabil (SCORE) Study Group 2023

The trajectory of pain and pain intensity in the upper extremity after stroke over time: a prospective study in a rehabilitation population

Article / Letter to editor

open access

Purpose: To assess the presence of upper extremity pain after stroke over time and the course of its intensity in patients with persistent pain. Materials and methods: Patients with stroke... Show morePurpose: To assess the presence of upper extremity pain after stroke over time and the course of its intensity in patients with persistent pain. Materials and methods: Patients with stroke completed a question on the presence of upper extremity pain (yes/no) and rated its intensity with a visual analogue scale (0-10) at 3, 18, and 30 months after starting multidisciplinary rehabilitation. The presence of upper extremity pain and its intensity over time were analysed with Generalized Estimating Equations models and Linear Mixed Models, respectively. Results: 678 patients were included. The proportions of patients reporting upper extremity pain were 41.8, 36.0, and 32.7% at 3, 18, and 30 months, respectively, with the decline in proportions reaching statistical significance (odds ratio 0.82, 95% confidence interval 0.74-0.92, p < 0.001). At all time points, in those reporting pain the median intensity was 5.0 (interquartile ranges (IQR) 4.0-7.0 at 3 and 3.0-6.0 at 18 and 30 months). In the 73 patients with persistent pain, there was no significant change in intensity over time. Conclusions: The proportion of patients reporting upper extremity pain after stroke was considerable, despite a significant decrease in 2.5 years. In patients reporting persistent pain, the intensity did not change over time. Show less

Sarac, C.; Nelissen, R.G.H.H.; Holst, M. van der; Malessy, M.J.A.; Pondaag, W. 2022

Differences in the perspectives of functioning and health in the ICF model between patients with brachial plexus birth injury and their parents versus healthcare professionals

Article / Letter to editor

open access

Purpose To explore and compare the perspectives of patients and their parents (PPs) with a brachial plexus birth injury (BPBI) with those of health care professionals (HCPs). Materials and methods... Show morePurpose To explore and compare the perspectives of patients and their parents (PPs) with a brachial plexus birth injury (BPBI) with those of health care professionals (HCPs). Materials and methods We conducted a study using a questionnaire among PPs and HCPs. Importance of different outcome categories was scored on a Likert scale. Items were linked to corresponding categories of the International Classification of Functioning, Disability and Health. Means were compared using analysis of variance (ANOVA). Results Data were collected from 184 patients and 65 HCPs. We found a difference in 7/14 outcome categories between joint PP groups and HCPs. Parents scored outcome evaluation categories as more important than patients, categories filled out together by patient and parent scored in between (p < 0.05). The majority of PPs and HCPs rated outcome assessment as important in more domains than "Body functions" and "Body structures". The biggest difference was found in the importance of evaluation of pain. Conclusions Outcome assessment in the domains "Activities and participation" and "Environmental factors" was rated as important by both PPs and HCPs. Evaluation of pain was more often scored as important by PPs. Different domains seem to be underestimated by HCPs and need more attention during consultation. Show less

Egmond, E.E A. van; Gorp, D.A.M. van; Jongen, P.J.; Klink, J.J.L. van der; Reneman, M.F.; Arnoldus, E.P.J.; ... ; Hiele, K. van der 2021

Self-reported work productivity in people with multiple sclerosis and its association with mental and physical health

Article / Letter to editor

open access

Egmond, E.E.A. van; Gorp, D.A.M. van; Jongen, P.J.; Klink, J.J.L. van der; Reneman, M.F.; Arnoldus, E.P.J.; ... ; Hiele, K. van der 2021

Self-reported work productivity in people with multiple sclerosis and its association with mental and physical health

Article / Letter to editor

open access

Purpose This study aimed to identify mental health, physical health, demographic and disease characteristics relating to work productivity in people with multiple sclerosis (MS). Methods In this... Show morePurpose This study aimed to identify mental health, physical health, demographic and disease characteristics relating to work productivity in people with multiple sclerosis (MS). Methods In this cross-sectional study, 236 employed people with MS (median age = 42 years, 78.8% female) underwent neurological and neuropsychological assessments. Additionally, they completed questionnaires inquiring about work productivity (presenteeism: reduced productivity while working, and absenteeism: loss of productivity due to absence from work), mental and physical health, demographic and disease characteristics. Multiple linear and logistic regression analyses were performed with presenteeism and absenteeism as dependent variables, respectively. Results A model with mental and physical health factors significantly predicted presenteeism F(11,202) = 11.33, p < 0.001, R-2 = 0.38; a higher cognitive (p < 0.001) and physical impact (p = 0.042) of fatigue were associated with more presenteeism. A model with only mental health factors significantly predicted absenteeism; chi(2)(11)=37.72, p < 0.001, with R-2 = 0.27 (Nagelkerke) and R-2 = 0.16 (Cox and Snell). Specifically, we observed that more symptoms of depression (p = 0.041) and a higher cognitive impact of fatigue (p = 0.011) were significantly associated with more absenteeism. Conclusions In people with MS, both cognitive and physical impact of fatigue are positively related to presenteeism, while symptoms of depression and cognitive impact of fatigue are positively related to absenteeism. Show less

Egmond-van Dam, J.C. van; Vlieland, T.P.M.V.; Kuipers, I.M.; Blom, N.A.; Harkel, A.D.J. ten 2021

Improvement of physical activity levels in children and adolescents after surgery for congenital heart disease: preferences and use of physical therapy

Article / Letter to editor

open access

Purpose After surgery for congenital heart disease in children and adolescents, an active lifestyle is important to achieve and maintain good physical fitness. This study aimed to describe physical... Show morePurpose After surgery for congenital heart disease in children and adolescents, an active lifestyle is important to achieve and maintain good physical fitness. This study aimed to describe physical activity, as well as the use of patients' and parents' preferences for rehabilitative care after surgery for congenital heart disease. Methods This cross-sectional study included patients aged 4-16 years old, who had undergone surgery for congenital heart disease 2 years prior to the study onset. Patients and/or parents were invited to complete questionnaires on physical activity, and on their preferences for, and -use of, rehabilitative care after surgery. Results Forty-five of the 92 eligible patients and/or parents completed the questionnaires. The median age of the children was 12.2 years (IQR 7.8-16.1). Two children (4%) met the recommendations for taking part in moderate physical activity and 13 (29%) having done so for vigorous physical activity. Postoperatively 15 children (33%) had had physical therapy in primary care. More than 50% of the patients/parents would have preferred to have had more information on physical activity and to have taken part in an individual exercise program delivered during their primary care. Conclusion The majority of eligible patients do not meet public health recommendations for engaging in physical activity and do not use physical therapy after surgery for congenital heart disease. The majority of patients and parents preferred more information as well as individual physical therapy treatments. Show less

Heus, I.; Weezenberg, D.; Severijnen, S.; Vlieland, T.V.; Holst, M. van der 2020

Measuring treatment outcome in children with developmental coordination disorder: responsiveness of six outcome measures

Article / Letter to editor

open access

Purpose:Although measuring outcome of rehabilitation in children with Developmental Coordination Disorder is considered important no consensus exists on which instruments to use. An important... Show morePurpose:Although measuring outcome of rehabilitation in children with Developmental Coordination Disorder is considered important no consensus exists on which instruments to use. An important attribute of a measurement instrument would be that it is sensitive to clinical changes. The aim of this prospective, observational study was therefore to investigate the responsiveness of six potentially suitable instruments. Methods:Forty-one children (34 boys, median age 7.8 years, Inter Quartile Range: 7.2-9.2) receiving multidisciplinary rehabilitation treatment for Developmental Coordination Disorder were included (mean treatment time: 32.8 h, Standard Deviation 7.3). The following instruments were applied before and after rehabilitation: Movement-Asessment-Battery-Children-2 (MABC-2), Canadian Occupational Performance Measure (COPM), Systematic detection writing problems (SOS-2-NL), DCD-daily, Behaviour Rating Inventory of Executive Function (BRIEF), and TNO-AZL children's Quality of Life questionnaire (TACQOL)). Change-scores (paired t-test/Wilcoxon-test) and responsiveness (Effect-sizes and Standardized-Response-Means) were calculated. Results:Significant differences over time were found for the Canadian Occupational Performance Measure, DCDdaily and Movement-Asessment-Battery-Children-2 (p < 0.05). The responsiveness of these instruments was moderate-high (Canadian Occupational Performance Measure-performance Effect-Size:1.70/Standardized-Response-Mean:1.81, Canadian Occupational Performance Measure-satisfaction Effect-Size:1.65/Standardized-Response-Mean 1.53; DCDdaily-total-score Effect-Size:0.40/Standardized-Response-Mean:0.62, DCDdaily-Quality-score Effect-Size:0.74/Standardized-Response-Mean:0.89, DCDdaily-time-score Effect-Size:0.21/Standardized-Response-Mean:0.43; MABC-2-total-score Effect-Size:0.42/Standardized-Response-Mean:0.43, MABC-2-Ball-skills-score Effect-Size:0.33/Standardized-Response-Mean:0.36). Systematic detection of writing problems (SOS-2-NL), Behaviour Rating Inventory of Executive Function (BRIEF) and TNO-AZL children's Quality of Life questionnaire (TACQOL) were not responsive to change. Conclusion:Although the Movement-Asessment-Battery-Children-2 test is the most widely used instrument when measuring rehabilitation outcome in Developmental Coordination Disorder, the Canadian Occupational Performance Measure and DCDdaily seem to be more responsive and constitute a valuable addition. Show less

Gartner, F.R.; Marinus, J.; Hout, W.B. van den; Vleggeert-Lankamp, C.; Stiggelbout, A.M. 2020

The cervical radiculopathy impact scale: development and evaluation of a new functional outcome measure for cervical radicular syndrome

Article / Letter to editor

open access

Objective:To develop and validate an outcome scale for the cervical radicular syndrome and to build a mapping, predicting EQ-5D utility from the new scale. Study design and setting:An item pool was... Show moreObjective:To develop and validate an outcome scale for the cervical radicular syndrome and to build a mapping, predicting EQ-5D utility from the new scale. Study design and setting:An item pool was developed based on literature and patient and clinician interviews. Item selection was based on symptomatology, factor analysis, and internal consistency. We assessed: (a) test-retest reliability by standard error of measurement and intraclass correlation coefficients; (b) construct validity by testing 22 hypotheses on relationships with existing measures and known-group differences. For the mapping, performance was assessed by mean absolute error and root mean squared error. Results:A total of 254 patients with cervical radicular syndrome completed the first questionnaire, 61 stable patients a retest. Item selection led to a 21-item questionnaire consisting of three subscales: Symptoms, Energy and postures, and Actions and activities. Standard error of measurement values ranged from 6.7 to 11.2 on a 0 to 100 scale. All subscales showed good reliability (intraclass correlation coefficients: 0.84, 0.87, and 0.94). All hypotheses for construct validity were confirmed. A linear utility mapping was preferred, with reasonable statistical performance. Conclusion:We developed a reliable and valid cervical radicular syndrome specific outcome scale, called the Cervical Radiculopathy Impact Scale (CRIS). This new questionnaire may facilitate (cost-)effectiveness studies in this field. Show less

Stokman-Meiland, D.C.M.; Groeneveld, I.F.; Arwert, H.J.; Pas, S.L. van der; Meesters, J.J.L.; Mishre, R.R.D.; ... ; Goossens, P.H. 2020

The course of depressive symptoms in the first 12 months post-stroke and its association with unmet needs

Article / Letter to editor

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Aim:To describe the course of depressive symptoms during the first 12 months post-stroke and its association with unmet needs. Methods:A prospective cohort study among stroke patients admitted to... Show moreAim:To describe the course of depressive symptoms during the first 12 months post-stroke and its association with unmet needs. Methods:A prospective cohort study among stroke patients admitted to inpatient rehabilitation. Depressive symptoms were assessed 3, 6, and 12 months post-stroke using the Hospital Anxiety and Depression Scale, and categorized into three trajectories: no (all times <8), non-consistent (one or two times >= 8), or persistent (all times >= 8) depressive symptoms. Unmet needs were assessed using the Longer-Term Unmet Needs questionnaire. Multivariable logistic regression analyses were used to investigate the association between depressive symptoms and unmet needs. Results:One hundred and fifty-one patients were included, of whom 95 (62.9%), 38 (25.2%), and 18 (11.9%) had no, non-consistent, or persistent depressive symptoms, respectively. Depressive symptoms three months post-stroke persisted in 43.9% and recurred in 19.5% of patients during the first 12 months post-stroke. Depressive symptoms were significantly associated with the occurrence and number of unmet needs (odds ratio 6.49;p = 0.003 and odds ratio 1.28;p = 0.005, respectively). Conclusions:Depressive symptoms three months post-stroke were likely to persist or recur during the first 12 months post-stroke. Depressive symptoms are associated with unmet needs. These results suggest that routine monitoring of depressive symptoms and unmet needs should be considered post-stroke. Show less

Geerse, D.J.; Roerdink, M.; Marinus, J.; Hilten, J.J. van 2020

Assessing walking adaptability in stroke patients

Article / Letter to editor

open access

Purpose: The ability to adapt walking is important for safe ambulation. Assessments of impairments in walking adaptability with the Interactive Walkway may aid in the development of individualized... Show morePurpose: The ability to adapt walking is important for safe ambulation. Assessments of impairments in walking adaptability with the Interactive Walkway may aid in the development of individualized therapy strategies of stroke patients. The Interactive Walkway is an overground walkway with Kinect v2 sensors for a markerless registration of full-body kinematics, which can be augmented with (gait-dependent) visual context to assess walking adaptability. This study aims to evaluate the potential of the Interactive Walkway as a new technology for assessing walking adaptability in stroke patients. Materials and methods: 30 stroke patients and 30 controls performed clinical tests, quantitative gait assessments and various walking-adaptability tasks on the Interactive Walkway. Outcome measures were compared between stroke patients and controls to examine known-groups validity. Pearson's correlation coefficients were calculated to assess the relationship between walking-adaptability outcomes and commonly used clinical test scores of walking ability and spatiotemporal gait parameters of unconstrained walking. Results: Good known-groups validity for walking-adaptability outcomes was demonstrated. In addition, the vast majority of walking-adaptability outcomes did not or only moderately correlate with clinical test scores of walking ability and unconstrained walking parameters. Conclusion: Interactive Walkway walking-adaptability outcomes have good known-groups validity and complement standard clinical tests and spatiotemporal gait parameters. Show less

Krogt, H. van der; Kouwijzer, I.; Klomp, A.; Meskers, C.G.M.; Arendzen, J.H.; Groot, J.H. de 2020

Loss of selective wrist muscle activation in post-stroke patients

Article / Letter to editor

open access

Purpose: Loss of selective muscle activation after stroke contributes to impaired arm function, is difficult to quantify and is not systematically assessed yet. The aim of this study was to... Show morePurpose: Loss of selective muscle activation after stroke contributes to impaired arm function, is difficult to quantify and is not systematically assessed yet. The aim of this study was to describe and validate a technique for quantification of selective muscle activation of wrist flexor and extensor muscles in a cohort of post-stroke patients. Patterns of selective muscle activation were compared to healthy volunteers and test-retest reliability was assessed. Materials and methods: Activation Ratios describe selective activation of a muscle during its expected optimal activation as agonist and antagonist. Activation Ratios were calculated from electromyography signals during an isometric maximal torque task in 31 post-stroke patients and 14 healthy volunteers. Participants with insufficient voluntary muscle activation (maximal electromyography signal <3SD higher than baseline) were excluded. Results: Activation Ratios at the wrist were reliably quantified (Intraclass correlation coefficients 0.77-0.78). Activation Ratios were significantly lower in post-stroke patients compared to healthy participants (p < 0.05). Conclusion: Activation Ratios allow for muscle-specific quantification of selective muscle activation at the wrist in post-stroke patients. Loss of selective muscle activation may be a relevant determinant in assigning and evaluating therapy to improve functional outcome. Show less

Pont, W.; Groeneveld, I.; Arwert, H.; Meesters, J.; Mishre, R.R.; Vlieland, T.V.; ... ; SCORE-study Grp 2020

Caregiver burden after stroke: changes over time?

Article / Letter to editor

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Introduction and aim: Many caregivers of stroke patients experience a high burden. This study aims to describe the course of burden in individual caregivers in the first year after stroke. Methods:... Show moreIntroduction and aim: Many caregivers of stroke patients experience a high burden. This study aims to describe the course of burden in individual caregivers in the first year after stroke. Methods: This study is part of the Stroke Cohort Outcomes of REhabilitation study, a multicentre, longitudinal cohort study including consecutive stroke patients admitted to two rehabilitation facilities. Caregivers were asked to complete the Caregiver Strain Index and questions on their sociodemographic characteristics 6 and 12 months post admission. Patients' sociodemographic and clinical characteristics were extracted from medical records. Results: A total of 129 caregivers were included, 72 completed the Caregiver Strain Index twice. Of them, 19 (26.4%) were men, median age 59 (range 27-78) years. A consistently high or low burden was reported by 15 (20.8%) and 49 (68.1%), respectively, whereas 8 (11.1%) reported a high burden at either 6 (n = 3) or 12 months (n = 5). Discussion: In the majority of caregivers of stroke patients the perceived caregiver burden is consistent over time. However, as in 11.1% caregiver burden changes from 6 to 12 months, caregiver burden should be measured repeatedly until 12 months after stroke. Caregivers living together with a patient who suffered a haemorrhagic stroke seem to be more at risk for a high burden. Show less

Egmond, E.E.A. van; Van Gorp, D.; Honan, C.; Heerings, M.; Jongen, P.; Van der Klink, J.; ... ; Hiele, K. van der 2019

A Dutch validation study of the Multiple Sclerosis Work difficulties questionnaire in relapsing remitting multiple sclerosis

Article / Letter to editor

open access

Stoop, D.F.; Vries-Bouwstra, J.K. de; Vlieland, T.P.V. 2019

Quality of life and strain among caregivers of patients with systemic sclerosis

Article / Letter to editor

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Graaf, J.A. de; Mierlo, M.L. van; Post, M.W.M.; Achterberg, W.P.; Kappelle, L.J.; Visser-Meily, J.M.A. 2018

Long-term restrictions in participation in stroke survivors under and over 70 years of age

Article / Letter to editor

open access

Holst, M. van der; Groot, J.; Steenbeek, D.; Pondaag, W.; Nelissen, R.G.H.H.; Vlieland, T.P.M.V. 2018

Participation restrictions among adolescents and adults with neonatal brachial plexus palsy: the patient perspective

Article / Letter to editor

open access

Otterman, N.; Veerbeek, J.; Schiemanck, S.; Wees, P. van der; Nollet, F.; Kwakkel, G. 2017

Selecting relevant and feasible measurement instruments for the revised Dutch clinical practice guideline for physical therapy in patients after stroke

Article / Letter to editor

open access

Meide, H. van der; Gorp, D. van; Hiele, K. van der; Visser, L. 2017

“Always looking for a new balance”: toward an understanding of what it takes to continue working while being diagnosed with relapsing-remitting multiple sclerosis

Article / Letter to editor

open access

Background: The aim of this study was to gain insight into the meaning of work in the everyday lives of people with relapsing-remitting multiple sclerosis, and the barriers and facilitators to staying in work.Methods: Nineteen employed adults diagnosed with relapsing-remitting multiple sclerosis participated in narrative interviews. All interviews were transcribed and coded for thematic analysis.Results: For people with relapsing-remitting multiple sclerosis, continuing to work was a precarious balancing act. Five themes influenced this balance: becoming familiar with the disease, adjusting expectations, having an understanding and realistic line manager, seeing work as meaningful life activity and strategic considerations.Conclusions: People receiving a diagnosis of relapsing-remitting multiple sclerosis have to refamiliarize themselves with their own body in a meaningful way to be able to continue their work. Rehabilitation professionals can support them herein by taking into account not merely functional capabilities but also identity aspects of the body. Medication that stabilizes symptoms supports making the necessary adjustments. A trusting relationship with the line manager is vital for this adaptation process. Additionally, a match between being adequately challenged by work, while still having the capacity to meet those work demands, is needed, as is long-term financial stability.

Implications for rehabilitation
Rehabilitation professionals can support employees with relapsing-remitting multiple sclerosis by taking into account not merely functional capabilities but also identity aspects of the body.
A trusting relationship with the line manager, including a timely disclosure of the diagnosis, is vital for people with relapsing-remitting multiple sclerosis to remain at work.
For people with relapsing-remitting multiple sclerosis, there is a delicate balance between being adequately challenged by work while still having the capacity to meet work demands.

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Peter, W.; Wees, P.J. van der; Verhoef, J.; Jong, Z. de; Bodegom-Vos, L. van; Hilberdink, W.K.H.A.; ... ; Vlieland, T.P.M.V. 2015

Effectiveness of an interactive postgraduate educational intervention with patient participation on the adherence to a physiotherapy guideline for hip and knee osteoarthritis: a randomised controlled trial

Article / Letter to editor

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