Rehabilitation medicine in countries of Central/Eastern Europe

Purpose. To describe attributes of rehabilitation medicine common to the five countries of Central Eastern Europe (CEE) and their implications for future challenges.

Methods. Critical collection and study of pertinent data on evolvement and present state of rehabilitation medicine in CEE countries by a coordinated team of rehabilitation experts from each of the relevant countries.

Results. CEE countries are similar in their need for rehabilitation medicine, its evolvement, present state and current practice. Settings largely emerged without strategic planning on the national level and lagged behind those in Central and Western Europe both in time and content.

Conclusion. The framework that evolved in all except Slovenia is not appropriate to needs. In order to meet future challenges all five CEE countries need the incorporation of inpatient, outpatient and community-based rehabilitation into one system.     

The system for medical rehabilitation in Croatia

Purpose.?To describe the framework for medical rehabilitation in Croatia and to discuss its influence on the practice of the specialty.

Methods.?Collection, analysis and interpretation of data pertaining to the need for medical rehabilitation in the country and to its elements of structure, process and outcome of care.

Results.?The practice of medical rehabilitation in Croatia has evolved without strategic planning on the national level and therefore without a designed system. This lack in the present framework causes shortcomings in all three elements of rehabilitation care and impedes the advancement of the specialty.

Conclusion.?Medical rehabilitation in Croatia needs a national strategic plan for a three-level system that incorporates inpatient, outpatient and community-based rehabilitation.     

Integrating physical medicine and rehabilitation into the curriculum of Iranian medical students

Purpose. To evaluate the attitude of interns toward Physical Medicine and Rehabilitation (PM&R) and design a PM&R curriculum for medical students with continued medical education programmes and workshops based on the needs and interest of Iranian medical community.

Method. Eighty questionnaires were distributed to the medical interns on the last day after attendance in the PM&R ward after participating in a one-month outpatient and inpatient course including 12 lectures.

Results. Out of 80 participants, 34 (42.5%) were female and 46 (57.5%) were male. All the participants believed participating in a rehabilitation course was necessary; 52 (65%) believed that participating in a separate course of PM&R was necessary, and 28 (35%) believed that rehabilitation of each field of medicine should be presented in its course. A significant percentage (31.4%) of the participants were interested in continuing their education in PM&R specialty.

Conclusion. The enthusiasm of the medical students towards PM&R is a promising sign toward progress of PM&R in Iran which must be directed through a strong effort of physiatrists through setting up appropriate educational programmes for medical students and continued medical education programme s in the universities.     

Psychological comorbidity in medical rehabilitation--the need for education

Purpose. Prevalence of comorbid mental disorders in rehabilitation patients is high. In spite of the bio-psycho-social approach in rehabilitation, recognition and treatment rates of comorbid mental disorders during rehabilitation are low. The purpose of the study was to raise specific information about current clinical practice concerning comorbid mental disorders and training needs of rehabilitation personnel.

Method. 435 questionnaires were sent out to medical personnel in 54 rehabilitation hospitals in south-west Germany.

Results. Psychologists in rehabilitation spend most of their time on counselling (45%) and group interventions (29%). Physicians and psychologists both feel highly responsible for recognizing mental disorders and motivating patients to seek aftercare. Screeners are rarely used by psychologists and physicians. Seventy-six percent of the participants would take part in specific training sessions. High training needs were stated for affective, anxiety and somatoform disorders. A specific training session for mental health in rehabilitation should last at least half a day and cover affective, anxiety and somatoform disorders.

Conclusions. Taking these results into account, it is possible to put together a training program in diagnostics of comorbid mental disorders, which fits the needs of the professionals.     

The work of rehabilitation

Purpose. To describe three years of activity of a rehabilitation unit and to make comparisons between clients who receive different levels of active rehabilitation.

Method. A retrospective study set in an inpatient rehabilitation facility located in Dunedin, New Zealand, examining 874 inpatient admissions over three financial years (2000 - 2002). Outcome measures include Functional Independence Scores (FIM) at admission and discharge, length of stay, weekly gains in FIM scores, and changes in FIM sub-scores.

Results. Assessment and rehabilitation patients made significant FIM gains in comparison to assessment only and social relief (respite care) patients. Assessment and rehabilitation patients showed greater gains in the Physical dimensions of the FIM in comparison to the Cognitive although this is probably a function of different scaling. Floor and ceiling effects were not present in the FIM.

Conclusions. The interdisciplinary rehabilitation program brings about real functional and cognitive gains in a range of patients as measured with the FIM. This adds to the considerable body of research which documents FIM gains and further provides evidence that physical and cognitive gains differ.     

Health behavior change models and theories: contributions to rehabilitation

Purpose. This article highlights the importance of health behavior change (HBC) theory, and its relevance to rehabilitation research and practice.

Method. An extensive review of HBC-related literature pertinent to rehabilitation was conducted, focusing on the potential impact of these theories and models in enhancing long-term results of rehabilitation with regard to lifestyle change and health promotion, and outlining the benefits of incorporating HBC themes into rehabilitation practice. For our purposes, the HBC concept is based on initiation and maintenance of health behaviors, functioning, wellness, and self-management of chronic conditions or disabilities within an environmental context. While comparing and contrasting three widely known theories of HBC, the contributions of these theories to rehabilitation research and practice are discussed.

Results. Three propositions are put forward: (1) HBC variables should regularly be used as outcome measures in evidence-based rehabilitation research; (2) there should be a better understanding of the role of the rehabilitation provider as a facilitator in eliciting healthy behaviors; and (3) there is a need to expand the HBC concept into a more comprehensive view encompassing a person's functioning within the environmental context.

Conclusions. A conceptual merger between HBC theories and rehabilitation practice can have major implications for individuals with disabilities, their functioning, health, and well-being.     

Pain perception during the rehabilitation phase following traumatic hip fracture in the elderly is an important prognostic factor and treatment tool

Purpose. To evaluate the role of pain perception on admission to geriatric rehabilitation on the functional recovery after rehabilitation treatment in elderly patients with hip fracture and on the length of stay.

Method. One hundred and sixty-five community dwelling elderly 65-year-old and over (mean age of 78 years), following recent operated traumatic hip fracture without clinical evidence for another acute medical or surgical condition were assessed regarding age, sex, chronic medical conditions, pre-fracture functional status, type of fracture and of operation, pain perception, and cognitive status. Pain was measured using the Visual Analogue Score (VAS). Functional status was measured using the Functional Independence Measurement (FIM). Activities of Daily Living (ADL) were assessed using the Katz index.

Results. The average VAS score on admission was 7.38 ± 1.20 and on discharge 3.67 ± 1.18. Pain on admission inversely correlated to family support, function prior to fracture and cognitive status on admission, and correlated positively with depressed mood. With every increase of one point in VAS on admission above 4 points, the FIM on discharge decreased by 8.77 and the length of stay increased by 4.76 days.

Conclusions. Pain intensity may add a valuable dimension for the prognostic evaluation of the patients with hip fractures. Inadequate early patient assessment and associated treatment impact on the patients' functional outcome, prolonged duration of rehabilitation treatment, and therefore, in addition to socio-economic effect, increase the cost to the local health care setting.     

The Papworth Early Rehabilitation Programme: vocational outcomes

Background. There are 2.7 million people in the UK receiving incapacity benefits, costing approximately £18 billion pa. Government has adopted a policy of helping claimants back into work, through structured vocational rehabilitation schemes. There are no published results of vocational rehabilitation services in the UK. We present the results of the Papworth Trust vocational rehabilitation programme. Depending on the severity of their disability, the 'Early Rehab Programme' aims to get people on incapacity benefits: (a) into employment, (b) fit for and seeking work, (c) involved in voluntary work, (d) education, or (e) able to live independently.

Methods. Retrospective chart survey and telephone follow up.

Setting. Cambridgeshire.

Results. Since 1995, 274 people attended for a preliminary interview, of which 107 subsequently started a full rehab programme. Eighty-seven were male and 20 female. Half had been unemployed for more than two years. Ninety-four completed the programme, of whom 53 had gained employment, 33 were 'work ready' and four were doing voluntary work. At long-term follow-up, 52 were employed, 12 were in voluntary work, and 7 had retired on medical grounds.

Conclusions. This programme demonstrates that long-term Incapacity Benefit recipients can return to sustained employment, as shown in those who participated in the Papworth Trust's vocational rehabilitation programme.     

A comparison of a hospital-based and two home-based rehabilitation programmes

Purpose. This paper compares the service models of three different types of rehabilitation programmes provided in Victoria, Australia: One hospital-based and two types of rehabilitation in the home (RITH).

Method. Nine focus group interviews were conducted with multidisciplinary staff working in rehabilitation teams in one hospital-based and eight RITH programmes. Additional data were collected for 164 clients and 75 carers from eight of these programmes at admission, discharge and three months post discharge. Interviews were conducted with 32 clients and 14 carers.

Results. The criteria for admission and model of rehabilitation adopted in the three programmes were similar. There were differences in programme aims, characteristics of the clients admitted and the type and level of therapy clients received, both between hospital and home-based programmes and between the three programmes. In general, staff and clients saw the home as providing a relevant context that enabled individualized, goal directed therapy for medically stable rehabilitation clients. The hospital offered an opportunity to socialize with others and specialized equipment.

Conclusions. Results of this study suggest clients and carers require a mix of hospital and home-based rehabilitation that is able to respond to their needs and preferences at each phase of the rehabilitation continuum.     

Purposes and mechanisms of goal planning in rehabilitation: the need for a critical distinction

Purpose. To determine a preliminary typology of purposes and mechanisms ascribed to goal planning in rehabilitation. To demonstrate the importance of making a critical distinction between these different purposes and mechanisms when reviewing or designing research on goal planning in rehabilitation.

Method. A search of Medline, Embase, PsychINFO and CINAHL for articles on goal planning in rehabilitation. Articles were only included if they were about patient populations and made explicit statements regarding the function or purpose of goal planning in rehabilitation. Thematic analysis was used to qualitatively synthesise the purposes and mechanisms of goal planning described in the literature.

Results. Four major purposes for undertaking goal planning in rehabilitation are identified: (1) to improve patient outcomes (as determined by standardised outcome measures), (2) to enhance patient autonomy, (3) to evaluate outcomes, and (4) to respond to contractual, legislative or professional requirements. The first of these purposes is associated with four distinct mechanisms with the remaining three purposes appearing to relate to one underlying mechanism.

Conclusions. This typology offers one approach for critically engaging with the wide-ranging issues in goal planning. Debate stemming from this work could facilitate systematic reviews of this area as well as guide research and application to practice.     

Falling between two stools; how a weak co-operation between the social security and the unemployment agencies obstructs rehabilitation of unemployed sick-listed persons

Purpose. To explore significant factors behind the weak co-operation between local social insurance and unemployment agencies impairing the rehabilitation of unemployed sick-listed persons.

Method. Individual, semi-structured face-to-face interviews with main actors directly involved in the sick-listing and rehabilitation process were conducted in the year 2000. In all 39 persons were interviewed: 25 professionals (physicians, public employment and social insurance officers) and 14 clients. Data were analysed according to Grounded theory method.

Results. The majority of unemployed sick-listed persons were declared too sick to work and were erased from the unemployment registers. This measure weakened the incentives for co-operation between the two main rehabilitation actors. The implication was that the unemployed sick-listed persons lost the opportunity of the co-ordinated rehabilitation they were entitled to. Three significant factors behind this process were identified by the main actors: indistinct regulation of co-operation, shifting political goals over time and conflicting goals between agencies; the last factor mainly a consequence of the other two.

Conclusions. The findings suggest that labour market changes and manifest political goals influence the rehabilitation efforts giving low priority to difficult-to-place individuals such as unemployed sick-listed persons. In fact, a labour market problem turns into a medical problem. The hypothesis needs further testing in quantitative studies.     

Toward a cognitive-affective model of goal-setting in rehabilitation: is self-regulation theory a key step?

Purpose: The aim of this article is to argue that self-regulation theory might offer a useful model for clinical practice, theory-building and empirical research on goal-setting in rehabilitation.

Method: Relevant literature on goal-setting and motivation in rehabilitation is considered and some problematic issues for current practice and future research are highlighted. Carver and Scheier's self-regulation theory and its application to rehabilitation research is examined.

Results: It is argued that self-regulation theory offers a robust theoretical framework for goal-setting and one in which the salient concepts of motivation and emotion are prominent.

Conclusions: Self-regulation theory offers a potentially useful heuristic framework for rehabilitation research.     

Theory development and a science of rehabilitation

Purpose. This article considers the role of theory and theory building in science and specifically in rehabilitation. It is argued that rehabilitation has tended to value theory testing over theory building and some evidence is presented for this.

Method. Some general questions concerning the role of theory in scientific progress are discussed including: What is a theory? What is the role of theory in science? What makes a good scientific theory? How does theoretical change occur in science? Where relevant these questions are discussed in terms of examples from clinical rehabilitation research.

Results. Two important issues arising from the preceding discussion are then considered. First is the question of whether a general or unifying theory of rehabilitation is a desirable goal. The second concerns how we might begin to develop a coherent programme of theory building in rehabilitation.

Conclusion. More time spent on rehabilitation theory building may enhance the fruits of empirical theory testing.     

Effectiveness of workplace rehabilitation interventions in the treatment of work-related low back pain: a systematic review

Purpose. A systematic review was conducted to evaluate the effectiveness of workplace rehabilitation interventions for injured workers with low back pain (LBP).

Method. MEDLINE, CINAHL (Cumulative Index to Nursing and Allied Health Literature), EMBASE, and AMED (Allied and Complementary Medicine) were searched from 1982 to 2005 for peer-reviewed studies of rehabilitation interventions that were provided at the workplace to workers with musculoskeletal work-related LBP. Methodological quality appraisal and data extraction were conducted by five reviewers.

Results. Of a total of 1,224 articles that were identified by the search, 15 articles, consisting of 10 studies, were of sufficient quality to be included in the review. The best evidence was that clinical interventions with occupational interventions as well as early return to work/modified work interventions were effective in returning workers to work faster, reducing pain and disability, and decreasing the rate of back injuries. Ergonomic interventions also were found to be effective workplace interventions.

Conclusion. The need for further research in this area is necessary to reduce the burden of back pain on employees and their families, employers, and the health care system.     

Rehabilitation approaches in fibromyalgia

Purpose. This paper provides an overview of the evidence for the principal approaches taken to the rehabilitation of patients with fibromyalgia (FM): exercise, psychologically-based approaches, multimodal approaches, self-management approaches, and complementary and alternative therapies.

Method. A review of current published evidence.

Results. Owing to factors such as methodological shortcomings of existing studies, and the lack of evidence on individual modalities, it is difficult to draw definitive conclusions as to which is the most appropriate rehabilitation approach in FM. However, there is growing evidence for the role of exercise training, and clear indications that if appropriately prescribed, this can be undertaken without adverse effects. Similarly, psychologically-based interventions such as cognitive-behavioural therapy have received some support from the literature. Evidence for other interventions is more equivocal.

Conclusions. It appears that a combination of interventions, in a multimodal approach (e.g., exercises combined with education and psychologically-based interventions) is the most promising means of managing patients with FM.     

An introduction to the Korean Employment Promotion Agency for the Disabled

Purpose. The main aim of this article is to provide an introduction to the Korean Employment Promotion Agency for the Disabled (KEPAD), and to provide comparative thought regarding government-based vocational rehabilitation service delivery between South Korea and the USA.

Method. Relevant literature is considered, and current issues and comparative discussion in practice are highlighted.

Results. Introductory information in terms of organization, eligibility, services and programmes are presented. In addition, practical problems associated with the KEPAD system and a cross-cultural analysis is elaborated, comparing the USA and South Korean vocational rehabilitation systems.

Conclusion. KEPAD has successfully derived public support and acknowledgement of its national responsibility in ensuring vocational rehabilitation services for persons with disabilities. The KEPAD system demonstrates a unique approach in implementing vocational rehabilitation services by providing various benefits for both employers and persons with disabilities. However, considerable cautiousness in terms of cross-cultural analyses is required for international application. Furthermore, successive research of rehabilitation infrastructure is warranted.     

Prophylaxis of venous thromboembolism during early inpatient rehabilitation after acquired brain injury: how guidelines change management

Purpose. To establish guidelines for prophylaxis of venous thromboembolism (VTE) in younger adults undergoing early inpatient rehabilitation following acquired brain injury (ABI).

Method. A two-phase (phase 1: retrospective; phase 2: prospective) observational study was carried out involving patients admitted to an inpatient neurological rehabilitation unit during a 40-month period. In phase 1, VTE prophylaxis was prescribed on an ad hoc basis. In phase 2, prophylaxis was considered in accordance with guidelines agreed locally. The prescribing behaviour in each phase of the study was compared using a VTE risk stratification tool based on expert opinion and a review of the literature.

Results. Data were obtained on 94 patients in phase 1 and 23 patients in phase 2. During phase 1, the prophylactic prescribing behaviour of the referring hospitals and our unit after admission were similar ( p = 0.13). In phase 2, our prescribing behaviour had changed compared with that of the referring hospitals, with a significant increase in the proportion of patients on appropriate treatment ( p = 0.01) and a decrease in the numbers under-treated ( p = 0.002). We were also significantly less likely to under-treat ( p = 0.005) and more likely to over-treat ( p = 0.004) after admission during phase 2 compared with phase 1, whilst practice was variable in patients at moderate risk.

Conclusions. Guidelines modify behaviour. They must stratify risk, particularly to avoid inconsistencies in the management of patients at moderate risk. There is a need to establish national guidelines for VTE prophylaxis during early inpatient rehabilitation after ABI; these guidelines should include a risk stratification tool.     

Gender differences in amputation outcome

Purpose. To assess the influence of gender on the success of limb-fitting after amputation.

Methods. One-hundred and five successive in-patients admitted to an amputee rehabilitation ward were followed to assess the success of limb-fitting at discharge. The influence of demographic, clinical and social factors on the success of lower limb-fitting was assessed using linear regression analysis and group comparisons.

Results. There were 35 (33%) women in a cohort of 105 successive admissions. Men and women were comparable in terms of age, length of stay, medical comorbidity and level of amputation. Women were less likely to be successfully fitted with a prosthetic limb at discharge than men (42.9% vs 68.6%, p = 0.011), and more women lived alone (57.1% vs 38.6%, p = 0.021). Linear regression revealed that gender was an independent significant factor in the success of limb-fitting; age, level and cause of amputation, co-morbidity and length of stay were not significant factors.

Conclusions. Women were less likely to be successfully fitted with a lower limb prosthesis after amputation.     

Reading to stroke unit patients: perceived impact and potential of an innovative arts based therapy

Objective. This study investigated the delivery of an arts based intervention to stroke patients and sought users' and professionals' views of any perceived benefits.

Setting. The study was undertaken on the stroke rehabilitation ward of a London teaching hospital.

Design. Semi-structured interviews were carried out with 21 patients, 3 health care professionals and 5 reading service personnel. Observation sessions were carried out weekly for the 10-month duration of the project. Data were analysed using the Framework method.

Intervention. The reading service, run by Interact, a registered charity, aims to entertain, stimulate and engage patients. Readers are professional actors trained to work specifically with stroke patients. Interact provide a selection of reading materials or alternatively patients provide their own material.

Results. Participants' accounts suggested that the service met its aim of providing entertainment and stimulation. Additionally, there was some evidence that taking part in the reading service was associated with participants' emotional well being, the processes of adjusting to hospitalisation and to their engagement in rehabilitation therapies. Hospital staff acknowledged the service benefited patients with regard to spiritual, emotional/psychological needs. However they maintained that the service, as entertainment rather than therapy, was of minor importance.

Conclusion. This arts based intervention was welcomed by patients and seemed to address some needs not met in the current configuration of care. These findings suggest that interventions such as the reading service point to ways in which it is possible to enhance the rehabilitation environment and perhaps facilitate better outcomes for stroke patients.