Physiother. Res. Int. 11: 191–203 (2006)Copyright © 2006 John Wiley & Sons, Ltd DOI: 10.1002/pri

Physiotherapy Research InternationalPhysiother. Res. Int. 11(4) 191–203 (2006)Published online in Wiley InterScience(www.interscience.wiley.com) DOI: 10.1002/pri.337

191

Functional ability in female leg ulcer patients — a challenge for physiotherapy

KIRSTI SKAVBERG ROALDSEN Department of Neurobiology, Care Sciences and Society, Division of Physiotherapy, Karolinska Institutet, Stockholm, Sweden; Sunnaas Reha-bilitation Hospital HF, Oslo, Norway

OLA ROLLMAN Department of Medical Sciences, Section of Dermatology and Venereol-ogy, University Hospital, Uppsala, Sweden

ERIK TOREBJÖRK Department of Neurobiology, Care Sciences and Society, Division of Physiotherapy, Karolinska Institutet, Stockholm, Sweden; Sunnaas Rehabilitation Hos-pital HF, Oslo, Norway

ELISABETH OLSSON Department of Neurobiology, Care Sciences and Society, Division of Physiotherapy, Karolinska Institutet, Stockholm, Sweden; Sunnaas Rehabilitation Hospital HF, Oslo, Norway

JOHAN KVALVIK STANGHELLE Sunnaas Rehabilitation Hospital HF, Oslo, Norway

ABSTRACT Background and Purpose. Venous leg ulceration represents a global health problem affecting predominantly elderly women. Traditionally, functional problems in this group of patients have attracted modest attention from wound care providers and physio-therapists. The aim of the present study was to describe and quantify disease consequences in female leg ulcer patients as a background for future physiotherapy interventions, using the nomenclature of the WHO International Classifi cation of Functioning, Disability and Health (ICF). Method. A prospective study was conducted in 34 women aged 60–85 years with current or previous venous leg ulcer as compared to 27 age-matched non-ulcer sub-jects. The outcome variables were pain, ankle range of motion, walking speed, walking endurance, self-perceived exertion, mobility, activities of daily living (ADL), physical activ-ity, general health, life satisfaction and use of walking aids and community services. Established instruments were utilized and categorized within ICF domains to provide a conceptual framework and basis for physiotherapeutic research. Results. Leg ulcer patients showed signifi cantly reduced values of ankle range of motion, walking speed and endurance, self-perceived exertion, mobility, ADL and physical activity level as compared to control subjects. Patients suffering from active ulceration were more negatively affected, and more of them had pain than post-ulcer fellows. By contrast, general health and life satisfaction were similarly rated by the two study groups. Conclusions. Elderly females in our study with chronic leg ulcer of venous aetiology had signifi cant mobility impair-ments, but the reasons and consequences of these impairments remain to be elucidated. The potential of preventive measures and physical rehabilitation to aid functioning and

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INTRODUCTION

Lower extremity venous insuffi ciency is the most common cause of recalcitrant leg ulcer-ation in Western societies (Callam et al., 1987; Baker et al., 1991; Nelzèn et al., 1991a, 1994; Lindholm et al., 1992). Traditionally, functional problems in this group of patients have attracted modest attention from wound care providers and physiotherapists.

The disease results from varicose veins, post-thrombotic valve injury or venous malformation and usually affects elderly women (Lindholm et al., 1992; Nelzèn et al., 1994). One study, however, suggests that more men than women suffer from venous insuffi ciency (Evans et al., 1999). By defi ni-tion, a chronic leg ulcer is located below the knee and has a duration of at least six weeks; yet much longer ulcer episodes and recur-rences are frequent among patients with venous insuffi ciency (Callam et al., 1987; Nelzèn et al., 1994).

Hitherto, clinical research in venous ulcer disease has concentrated mainly on circula-tory or wound care issues rather than physi-cal functioning of the individual. Despite the general clinical impression that patients often enter a non-healing state due to physi-cal inactivity and ankle stiffness, medical literature until the mid-1990s rarely focused on mobility and quality-of-life topics in chronic leg ulcers (Lindholm et al., 1993; Back et al., 1995). Above all, the potential benefi t of comprehensive advice and physi-cal rehabilitation in this disease category has not been thoroughly studied.

The aim of the present study was to describe and quantify disease consequences in elderly females with chronic leg ulcer-ation compared to an age-matched group as a background for future physiotherapy inter-ventions, using the International Classifi ca-tion of Functioning, Disability and Health (ICF) (WHO, 2001) as a conceptual model.

METHOD

Study design

A prospective study was conducted in 34 women aged 60–85 years with current or previous venous leg ulcer as compared to 27 age-matched non-ulcer subjects.

Subjects

Female leg ulcer patients attending the outpatient Department of Dermatology, Akademiska Hospital, Uppsala, Sweden, were consecutively invited to participate in the study. Only females with a diagnosis of venous leg ulceration with no or a minor arterial component, for example ankle–brachial pressure index (ABPI) above 0.7, were included. The diagnosis was based on medical history and clinical investigation. Exclusion criteria were clinically infected ulcer, acute ulcer (duration <3 months), diabetic or foot ulcers, acute ulcer pain and non-compliance.

In parallel to patient inclusion, dermatol-ogy patients referred to the same hospital unit were invited to participate as control

prospects of leg ulcer repair need to be investigated in future studies. Copyright © 2006 John Wiley & Sons, Ltd.

Key words: elderly women, mobility, physiotherapy, varicose ulcer

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subjects in the study. Inclusion criteria were: females aged 60–85 years with localized, mild to moderate skin disease, no history of leg ulcer or stasis dermatitis and no history or physical signs of arterial insuffi ciency of the legs (ABPI > 0.7).

Assessments

Impairments of body function and structures

Ulcer pain and global pain at present and during the preceeding week were recorded (yes/no) and pain intensity was recorded by use of a visual analogue scale (VAS) (Carls-son, 1993). Participants were asked whether or not pain was a problem. Current use of painkillers and experience of sleeping distur-bances attributed to pain were recorded.

Active ankle range of motion (ROM) (°) was determined by goniometry during maximal voluntary plantar fl exion and dor-sifl exion of both ankles (Miller, 1985). While in a reclined position with the knees slightly bent, the participants were instructed to exert maximal plantar fl exion then return to the starting position, and fi nally attempt maximum dorsifl exion of the ankle. In case of contractures, passive ROM was tested to determine whether muscle weakness or soft tissue or joint stiffness was limiting the achievement of full range of movement. Subjects were asked to report whether or not ankle mobility affected their walking abilities indoors, outdoors and during stair-climbing.

Activity limitations and participation restrictions

• Preferred walking speed (m/s) was cal-culated from a 20-m walk on level ground using a stopwatch (Butland et al., 1982).

• Walking endurance (m) was recorded by measuring the total distance walked in three minutes at preferred speed on a 20-m level ground distance (Butland et al., 1982).

• Perceived exertion was recorded after three minutes’ walking at preferred speed using the Borg Rating of Perceived Exer-tion Scale 6–20 (Borg RPE Scale) (Borg, 1982).

• ‘Timed Up & Go’ was measured using a stopwatch (Podsiadlo and Richardson, 1991).

• Self-rated mobility was graded as excel-lent, good, fair or poor.

The Barthel ADL Index (Mahoney and Barthel, 1965) was used by self-report to measure activities of daily living (ADL). A maximum score of 20 points refl ects time required and assistance needed in the basic physical functions which underlie normal living. Extended ADL was tested by use of the Functional Status Questionnaire (FSQ) (Jette et al., 1986), Part 1. A maximum of 52 points refl ect how health problems affect both basic ADL, such as self-care and walking, and extended ADL, such as house-hold work, shopping and participating in community activities.

Level of physical activity was assessed using the Grimby six-point classifi cation system, which is particularly designed for evaluating physical activity in elderly people (Grimby, 1986).

Contextual factors

The use of walking aids (indoors and out-doors) was noted, and the use of community services such as transport assistance and domestic help was assessed.

Satisfaction with current life was graded by use of a modifi ed Life Satisfaction Scale

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(LiSat) (Fugl-Meyer et al., 1991) that con-tains a global (satisfaction with life as a whole) and eight domain-specifi c questions related to different aspects of life. Two ques-tions were slightly modifi ed to fi t the study group. The two questions regarding sex and spouse were not asked as almost half of the informants were living alone. All but two subjects were retired and therefore ‘satisfac-tion with employment’ was defi ned as activ-ities performed from morning to late afternoon, and ‘satisfaction with leisure time’ was defi ned as activities performed after late afternoon and on weekends.

Self-rated global health was assessed using the question: ‘Would you say that your health is excellent, good, fair or poor?’ (Kaplan and Camacho, 1983). The

participants were also asked to state whether or not leg ulcer problems had adversely affected their self-rated health.

Procedure

All participants were clinically examined by the dermatologist. Symptoms and physical signs of venous stasis were recorded (see Table 1 below). A hand-held Doppler ultra-sound probe was used to measure the ABP index. The ulcer area was determined from acetate fi lm tracings (Etris et al., 1994) and digital image analysis (Olympus DP-Soft programme, Soft Imaging System GmbH, Germany).

Within three weeks from clinical exami-nation, interviewing and physical testing

TABLE 1: Characteristics of the study groups

Ulcer patients Control subjects p value (n = 34) (n = 27)

Demography (median (range)) age (years) 77 (60–85) 76 (62–85) NS body mass index (kg/m2) 24.6 (18.6–40.9) 24.8 (18.4–34.3) NSLeg ulcer disease (n) active leg ulcer 21 0 healed leg ulcer 13 0 lipodermatosclerosis 12 0 atrophie blanche 9 0 CVI 34 7 DVT 10 2 previous varicose surgery 12 5 NSGeneral disease cardio/cerebrovascular disease 6 5 NS musculoskeletal complaint 19 9 NS infl ammatory joint disease 2 3 NS orthopaedic surgery of lower extremity 16 2 <0.001 cancer 3 2 NS diabetes mellitus type II 1 3 NS pulmonary disease 5 5 NS visual or balance problem 7 9 NS other internal medical problem 9 14 NS

CVI = symptoms or signs of chronic venous insuffi ciency, superfi cial or deep, or both; DVT = history of deep venous thrombosis of the leg.

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was performed by the physiotherapist in a hospital-based laboratory for gait analysis. During functional testing, the ulcer patients maintained their current compression device. Walking tests were performed with partici-pants using their regular walking shoes and, if needed, indoor walking aids. No physical assistance was provided.

Ethics committee approval was obtained, and written informed consent was given by the participants prior to entry into the study.

Statistical analyses

Differences between the groups were compared with Mann–Whitney U test and Wilcoxon’s signed rank test for continuous variables. Mann–Whitney U tests were used for the variables pain, ROM, walking speed, walking endurance, ‘Timed Up & Go’ and ADL. Walking speed compared to reference values was tested with Wilcoxon’s signed rank test. For categorical values differences between groups were compared with Fisher’s exact test, (Borg’s RPE Scale, physical activity) and c2 test (self-rated mobility, walking aids, community services, satisfaction with life, self-rated global health). Data were reported in terms of medians and range. All statistical analyses were performed in SPSS (SPSS Inc., Chicago, IL, USA). A p value of <0.05 was considered statistically signifi cant.

RESULTS

Statistically signifi cant differences were found between the ulcer patient group and control subjects with regard to most para-meters tested. Therefore, where appropriate, the results for the ulcer patients group are presented either collectively or for the two subgroups (active ulcer patient group and healed ulcer patient group), respectively.

In total, 37 patients were enrolled during the 18 months of inclusion. Three dropped out due to intervening health problems or personal reasons. Thus, a convenience sample of 34 eligible individuals with active or healed leg ulcer formed the patient group.

Overall, 30/34 (88%) patients had a history of unilateral ulcer involvement, whereas 4/34 (12%) had bilateral involve-ment. The degree of venous insuffi ciency was classifi ed according to the classifi cation of chronic venous disease (CEAP) clinical grading system (Porter and Moneta, 1995). At the time of investigation, 21/34 (62%) patients had active ulceration (CEAP class 6), while the remaining patients had healed ulcers (CEAP class 5).

All but four ulcer patients used compres-sion devices: class I/II compression stocking (Mabs/Juzo, Mabs International, n = 6); short stretch elastic bandage (Comprilan, Smith & Nephew, n = 8); long stretch bandage (Wero, Tamro Medlab, n = 6); zink paste stocking (Zip Zoc, Smith & Nephew) plus self-adherent elastic bandage (Coban, 3M, n = 9); or multi-layer bandage (Profore, Smith & Nephew, n = 1). Three control subjects used class I compression stockings to control mild hypostatic oedema of the ankles.

Impairments of body structures and functions

Active ulcer patients reported more ulcer pain during the preceeding week than healed ulcer patients, 40 mm (0–60 mm) versus 0 mm (0–42 mm) (p < 0.001). More patients in the active ulcer group experienced pain as a problem, 14/21 (67%), than in the healed ulcer group, 3/13 (23%) (p = 0.035) and the control group, 7/27 (26%) (p = 0.005). In terms of global pain during the last week,

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the difference was signifi cant between the active and healed ulcer patient groups ( p < 0.001) and between the ulcer patient groups and the control group. In 22/34 (65%) ulcer patients and 10/27 (37%) control subjects pain was reported to cause sleeping distur-bance ( p = 0.018). Furthermore, 9/21 patients (43%) with active ulceration used pain killers on a regular basis as compared to 3/13 (23%) post-ulcer patients and 6/27 (22%) control subjects. The difference between ulcer patients and control subjects was signifi cant ( p = 0.005).

As all patients had reduced ankle ROM in both the ulcerated and the opposite leg, the median of each patient group was calcu-lated from the mean of both legs (Table 2).

Ankle plantar and dorsifl exion ROM was reduced in both the active and healed ulcer groups compared to the control group (Table 2). Seven of the ulcer patients (21%; four active and three healed) versus none of the control subjects had plantar fl exion contrac-ture (soft tissue or joint stiffness). There were no obvious differences in ankle ROM with regard to presence or absence of lipo-dermatosclerosis. None of the control sub-jects reported diffi culties in walking in- or outdoors, whereas 11 of the ulcer patients

(32%) reported indoor and 18 (53%) outdoor walking problems and problems walking up stairs, due to reduced ankle ROM. The dif-ference between ulcer patients and control subjects was signifi cant.

Activity limitations and participation restrictions

• Preferred walking speed was slower in the active ulcer group, 0.9 (0.4–1.2) m/s, compared to 1.1 (0.7–1.6) m/s in the healed ulcer group ( p = 0.027). The walking speed of each ulcer group was slower than that of the control group, 1.3 (0.9–1.8) m/s ( p < 0.05). Walking speed in the control group was within normal range of females of their age, while the ulcer group walked more slowly (Grimston et al., 1993).

• Walking endurance was less in the active ulcer group, 150 (60–200) m, compared with the healed ulcer group, 197 (116–260) m ( p = 0.008), and the control sub-jects, 210 (128–260) m ( p < 0.001). There were no statistically signifi cant differ-ences between the two latter groups.

• Perceived exertion was graded higher in the active ulcer group, 13 (11–15) ( p <

TABLE 2: Ankle range of motion

Ulcer patients Control subjects (C) p value

Active (A) Healed (H) (n = 27)

(n = 21) (n = 13)

Ankle range plantar fl exion 33 (10–49) 40 (31–55) 48 (36–65) AC <0.001 of motion HC 0.012 (°) AH 0.009 dorsifl exion 8 (−8 to 15) 10 (−9 to 14) 13 (5–20) AC 0.012 HC 0.002 AH NS

AC = active ulcer patients versus control subjects; HC healed ulcer patients versus control subjects; AH active ulcer patients versus healed ulcer patients; NS = not signifi cant.Figures represent median (range).

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0.001), and the healed ulcer group, 11 (10–15) ( p = 0.014), compared to the control group, 11 (7–15). There were no statistically signifi cant differences between the two patient groups.

• The only difference in the ‘Timed Up & Go’ was found between the active ulcer group, 13.1 (8.7–28.7) s, and the control group, 9.8 (6.9–13.1) s ( p < 0.001).

• Self-rated mobility was rated good or excellent by 10/34 (29%) of the ulcer patients compared to 22/27 (82%) of the controls (p < 0.001).

• In the Barthel ADL Index there was a statistically signifi cant difference between the active ulcer group, 19 (16–20) points, and the control group, 20 (18–20) points (p < 0.001). A full score on the Barthel ADL Index was found in 18/34 (53%) patients of the ulcer group, and in 25/27 (93%) of the control subjects. The remaining ulcer patients required some aids or personal support in everyday life; for example, showering assistance, walking aids and railings on stairs.

• In the Functional Status Questionnaire (Part 1), the active ulcer group had poorer values than the control group, 30 (22–43) points versus 42 (31–50) points ( p < 0.001). Unlike the control subjects, the

active ulcer patients reported problems such as carrying out physical efforts and participating in community activities.

• Physical activity was reported to be lower in the ulcer group than in the control group ( p < 0.001) (Table 3). Half of the ulcer patients (17/34) spent most of their time sitting compared to none in the control group, while the other half (17/34) participated in some kind of physical activities on a regular basis compared to all in the control group.

Contextual factors

Outdoor walking aids were used by 18/34 (53%) of the ulcer patients compared to one in the control group ( p < 0.001). Community transport service were utilized by 14/34 (42%) of the ulcer patients compared to two in the control group ( p = 0.003). For indoor ambulation 7/34 (21%) of the ulcer patients and one of the control subjects used a walking aid (NS).

The ulcer patients were less satisfi ed than the control subjects concerning health-related domains such as independence in every day life, daytime activities and contact with friends (Table 4). The active ulcer group was the least satisfi ed in terms of daytime activities ( p = 0.042). There was no

TABLE 3: Levels of physical activity

Activity Ulcer patients Control subjects (n = 34) (%) (n = 27) (%)

Hardly any physical activity — —Mostly sitting, sometimes a walk 17 (50) —Light exercise, 2–4 hours/week 13 (38) 13 (48)Moderate exercise, 1–2 hours/week 4 (12) 12 (44)Moderate exercise, >3 hours/week — 2 (7)Hard or very hard exercise — —

Figures represent number (%) of individuals.Statistically signifi cant difference between the groups ( p > 0.001).

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Physiother. Res. Int. 11: 191–203 (2006)Copyright © 2006 John Wiley & Sons, Ltd DOI: 10.1002/pri

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difference in satisfaction, however, with life as a whole between the ulcer group and the control group.

Self-rated global health was rated simi-larly by ulcer patients and control subjects. Thus, 25/34 (74%) of the ulcer patients and 22/27 (83%) of the control subjects judged their general health as good or excellent. When asked if the leg ulcer disease had adversely affected their general health, 15/34 (44%) of the ulcer patients answered ‘yes’.

DISCUSSION

Physical disability in chronic leg ulcer patients is a common notion encountered by experienced healthcare professionals. Few scientifi c studies, however, have tried to measure ankle mobility, walking perfor-mance or physical activity in patients and non-ulcer control subjects. The present study clearly demonstrates that venous leg ulcer disease was associated in our group with sig-nifi cant impairments, activity limitations and participation restrictions. However, despite obvious health problems, leg ulcer patients rated their global health and overall life satisfaction as good. The results have important implications for the understanding of comprehensive management and reha -bilitation services for this patient group, especially for physiotherapy. The two study groups were comparable with respect to slightly increased body mass index (BMI) indicating pre-obesity. However, overt obesity, which has been reported in venous ulcer patients (Nelzèn et al., 1994) was not a feature here. Epidemiological studies have also shown that the prevalence of diabetes and cardiovascular problems is increased in chronic leg ulcer patients (Margolis et al., 2004). In our study there was not an increased number of patients with cardiovascular diag-noses, probably due to the exclusion of male

patients. The single diabetic patient in this study had mild metabolic disease of short duration, which was probably of little relevance for her venous ulceration. Other medical problems were similarly distributed between our two study groups, except that a history of orthopaedic surgery or musculosk-eletal problem was more common in leg ulcer patients. This concurs with the report by Nelzèn et al. (1994) stating that more leg ulcer patients than expected had arthrosis or had undergone major surgery of the lower extrem-ities. Pain was a current problem in 67% of our patients with active ulceration, which is in agreement with Lindholm et al. (1993), Phillips et al. (1994) and Hofman et al. (1997). Nelzèn et al. (1994) reported that only 28% of their patients had pain at rest, and Tam and Moscella (1991) did not identify pain as a signifi cant problem at all. Thus, reports of ulcer pain in venous leg ulceration are incon-sistent. In the present study, 2/3 of the patients suffering from active ulceration had pain which required analgesics on a regular basis, while only 1/3 reported pain on the specifi c day of investigation. Hence our results comply with previous reports on the inadequacy of analgesic therapy in leg ulcer (Nelzèn et al., 1994; Hofman et al., 1997) and support the idea that ulcer pain in venous insuffi ciency is a substantial — though fl uctuating — problem related to a range of endogenous and external factors. As pointed out by Persoon et al. (2004), there is an obvious need for better recognition and relief of pain in venous leg ulcer.

Plantar fl exion and dorsifl exion were reduced in our patients, irrespective of their present ulcer state. A normal gait pattern is crucial for activation of the calf muscle pump. Accordingly, reduced ankle ROM performance contributes to calf muscle pump failure in patients with venous leg ulceration (Yang et al., 1999a, 1999b). Ankle

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dorsifl exion beyond the ‘neutral’ (90°) posi-tion in end-of-stance and swing phases, and plantar fl exion beyond neutral for push off are essential for normal walking (Back et al., 1995). Further to limited ankle mobility, 7/32 (21%) of our ulcer patients had plantar fl exion contracture. Patients with active ulcers had lower median plantar fl exion values than healed patients, supporting the fi ndings by Back et al. (1995).

Noteworthy was that patients with a history of unilateral ulcer disease had sig-nifi cant reductions of ankle ROM in the opposite extremity as well (that had never been affected by an ulcer). Since ankle prob-lems in one leg may infl uence ankle ROM in the opposite ankle, it is possible that joint dysfunction on the ulcer-bearing side may have caused secondary reductions in ankle ROM of the contralateral side. Taken together, our results suggest that the ulcer, or the adjacent tissue fi brosis, are not sole decisive factors for ankle stiffness and reduced muscle strength in chronic leg ulcer. For example, lengthy inactivity may be an important factor since local pain, oedema and compression devices (worn by 88% of our patients) may discourage or restrict the patient from physical exercise. Compression therapy is the gold standard in treatment of stasis ulcers, but the potential of long-term ankle dysfunction from bulky bandages and elastic stockings has to be elucidated. Also, diffi culties in fi nding appropriate walking shoes because of oedema or spacious wound care products may hinder outdoor walking. Concerns of skin breakdown or fear of ulcer deterioration caused by ankle movements may also hold back the patient from walking exercises (Hyde et al., 1999).

Since orthopaedic disorders other than ankle problems were over-represented in the leg ulcer group, such conditions may be of relevance for general mobility, as pointed

out by Callam et al. (1988). Thus, a diversity of local and general factors seem to push ulcer patients into physical passivity. Forth-coming studies in venous leg ulcer patients should try to specify the relative impact of mobility-restraining factors such as local tissue damage, pain and anxiety, orthopae-dic and other somatic problems, perceptive and habitual factors, and compression, including wound care products (Walshe, 1995; Chase et al., 1997; Hyde et al., 1999; Ebbeskog and Ekman, 2001). Whichever mechanisms involved, the vicious circle of poor mobility and delayed ulcer repair should be effectively counteracted (Franks et al., 1995).

The leg ulcer patients displayed a wide variety of activity limitations and participa-tion restrictions. In agreement with van Uden et al. (2005), we found that they had a lower preferred walking speed. We also found that walking endurance, basic- and self-rated mobility, and level of activity were reduced. In addition, ulcer patients had a higher degree of perceived exertion and needed more personal assistance and adap-tation to cope with daily living. Healing of an ulcer did not seem to reduce the mobility problems in a short-term perspective since patients with healed ulcer had comparable problems.

The value of combined physical activity and adequate compression therapy to reverse the effects of venous hypertension may be of importance in improving wound healing (Allen, 1990; Brooks et al., 2004). Brooks et al. (2004) found that full ankle movement and full mobility (without aid) reduced the risk of recurrence of ulcers. Clinical experi-ence also indicates that leg ulcer healing is more favourable in mobile patients. However, the studies of Nelzèn et al. (1991b) and Wissing et al. (1997) showed that a majority of leg ulcer patients are not very mobile.

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Physical activity should be encouraged since it may help to revert hypertension, promote wound healing, prevent ulcer recurrence and maintain physical fi tness. Pain, joint restric-tions and impaired muscle strength are prob-ably key features to deal with in order to avoid a reduced level of activity in leg ulcer patients. Hence, management of this cate-gory of patients should concentrate not only on ulcer healing but on pain prevention and exercise prescription to favour mobility function.

The frequent use of walking aids and use of community services for transport in the ulcer group indicates a high degree of func-tional disability in this group.

The ulcer patients in this study were less satisfi ed with daytime activities, contact with friends and independence in everyday life, which suggests that immobility, pain and time-consuming wound care restrain their life considerably. This is in agreement with Hyde et al. (1999) and Phillips et al. (1994), who reported that social isolation was common in this patient group. As opposed to Lindholm et al. (1993), who con-cluded that ulcer patients had reduced quality of life, we found no apparent dissatisfaction with life as a whole when compared to the control group. One possible explanation for this discrepancy is that the study by Lindholm and colleagues (1993) measured ‘health-related quality of life’, whereas we also asked for overall (i.e. unrelated to health) satisfaction with life. According to the ICF (WHO, 2001) personal factors such as individual psychological assets and other characteristics may have an infl uence on functioning by playing the role of a barrier or a facilitator, in this case more likely a facilitator.

Despite obvious health problems, the leg ulcer patients scored their self-rated health equally good as did the controls. This is in

agreement with Leinonen et al. (2001), who found that aging people adapt to changes in their objective and functional performance. When asking explicitly for changes in health, however, almost half of our patients claimed that their health had declined because of the leg ulcer.

IMPLICATIONS

This study has shed light on a neglected patient group and an underestimated health problem. Chronic venous leg ulceration in elderly women is associated with signifi cant mobility impairments, but the reasons and consequences of the disability remain to be elucidated. The potential of preventive mea-sures and physical rehabilitation to aid func-tioning and prospects of wound repair remain to be investigated in forthcoming studies.

It would seem important to offer these patients exercise treatment to prevent and reverse the functional disability and to eval-uate the effects of this new approach. There is a reason to believe that physiotherapists should be more involved in the treatment of these patients.

AKNOWLEDGEMENTS

The study was supported by grants from the Vårdal Foundation and the Medical Research Council in Stockholm, Sweden, the Sofi enlund Foundation and the Birgit & Rolf Sunnaas Memorial Fund/Sunnaas Rehabilitation Hospital, Oslo, Norway. The authors wish to thank the Department of Dermatology, the Department of Clinical Neurophysiology and the Department of Physiotherapy at the University Hospi-tal of Uppsala for their assistance in this study, and for the use of their facilities and equipment and Section of Biostatistics, Rikshospitalet, University of Oslo for statistical assistance.

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Address correspondence to: Kirsti Skavberg Roaldsen, Department Neurotec, Division of Physiotherapy, Karolinska Institutet, SE-14183 Huddinge, Sweden (E-mail: kirsti@mollsju.se).

(Submitted May 2005; accepted May 2006)