Effects on work resumption of a co-operation project in vocational rehabilitation. Systematic,multi-professional,client-centred and solution-oriented co-operation

Purpose.?The present aim was to evaluate the effect of systematic multi-professional co-ordinated rehabilitation (the Stockholm Co-operation Project) on the number of days’ sick leave during the first and second half-years after the rehabilitation co-ordination period, compared to the year before. Another aim was to evaluate the economic effects at national level.

Method.?A matched-pairs design was used. The study group was based on 64 rehabilitees employed by a public employer in Stockholm, who took part in a systematic multi-professional co-operation project. To obtain pairs, the 64 individuals were individually matched with 64 people who received conventionally organised rehabilitation. Thus, there were 128 subjects altogether.

Results.?The study group had substantially less sick leave days per month than the comparison group during the second half-year after the rehabilitation co-ordination period. The effect was even greater in a subgroup with more previous sick leave. During the first half-year after the intervention the comparison group had relatively more sick leave. No effect was found for a subgroup with less previous sick leave. The economic benefit of the intervention was estimated to €1,278 per month and person based on the whole group, and to €2,405 per month and person based on those with more sick leave.

Conclusions.?People who undergo co-ordinated rehabilitation have more working days after the intervention period than those with conventional rehabilitation. This way for rehabilitation actors to co-operate gives better outcomes for rehabilitation cases with long previous sick leave, but not for cases with less previous sick leave. It also generates economic gains at several levels.     

Quality of life and maintenance of improvements after early multimodal rehabilitation: a 5-year follow-up

Purpose. There is a paucity of long-term evaluations on rehabilitation of musculoskeletal disorders, e.g., neck, shoulder or back pain. The aim of this study was to assess quality of life and the effect of early multimodal rehabilitation on 91 patients with musculoskeletal pain and disability at a 5-year follow-up.

Method. The follow-up assessment, which included questions on pain, function, quality of life, perceived health, sick leave and psychosomatic symptoms, was performed 5 years after the assessment of baseline status.

Results. Improvements in pain, perceived health and psychosomatic symptoms were maintained at the 5-year follow-up. In addition, improvements in function, quality of life, and level of acceptable pain were significant in comparison to baseline. At the time of the baseline assessment all patients were on sick leave (13% were on partial sick leave). At the 5-year follow-up, 58% of the patients were at work part or full time. The results show that those working differed significantly from those not working at the 5-year follow-up on almost all variables, indicating that those working enjoy better health. The most salient prognostic factors for return to work were perceived health and educational level at the time of the baseline evaluation.

Conclusions. These results show that treatment improved quality of life and the effects were basically maintained at 5 years. Work capacity as reflected in return to work increased greatly (81%) at a 1-year follow-up and was substantial (58%) at the 5-year follow-up. Moreover, perceived health and educational levels were important prognostic factors. Finally, the fact that patients working reported better health underscores the probable importance of return to work. Our results imply that it may be feasible to obtain long-term benefits from such a primary care-based intervention.     

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.     

Self-rated health as a predictor of return to work among employees on long-term sickness absence

Aims. The aim of the present study is to identify self-rated health predictors of return to work (RTW) within the study population as a whole as well as in three subgroups, namely musculoskeletal complaints, other physical health complaints, and psychological complaints.

Methods. The study was based on a sample of 862 employees on sickness absence (maximum duration of 12 weeks). The employees filled out a baseline questionnaire and were subsequently followed until the tenth month after listing sick. Cox proportional hazards regression analyses were used to identify determinants of RTW.

Results. For the study population as a whole type of complaint, earlier sickness absence, subjective severity of complaints and several RAND-36 subscales were predictive of RTW. Furthermore, the RAND-36 subscales physical functioning, physical role limitations, mental health, and health change were predictive of RTW among employees with musculoskeletal complaints. For employees with other physical health problems subjective severity of complaints and the RAND-36 subscales physical and social functioning, general health perception, and health change were associated with RTW. Finally, with regard to the group with psychological complaints the RAND-36 subscales mental health and general health perception predicted RTW.

Conclusion. Several aspects of self-rated health predict RTW for employees on long-term sickness absence. Variables related to functional status predict RTW for employees with physical complaints in contrast to psychological problems.     

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.     

Can the results 6 months after anterior cervical decompression and fusion identify patients who will have remaining deficit at long-term?

Purpose. There is no knowledge if short-term outcome in patients after anterior cervical decompression and fusion (ACDF) can be used to identify which patients have remaining deficit in long term. This study investigates if 6-month outcome with a broad assessment after ACDF with a cervical intervertebral fusion cage can be a guide for the 3-years outcome.

Method. A prospective study. Questions about background data, pain, numbness, neck specific disability, distress, sick leave, health, symptom satisfaction and effect of and satisfaction with surgery were asked 28 patients 3 years after ACDF. Measurements have earlier been obtained before and 6 and 12 months after ACDF.

Results. Compared with the results before surgery patients had improved in pain intensity (p = 0.001), neck pain (0.001), numbness (p = 0.02) and were more 'satisfied' with having their neck problems (p = 0.01). Except for a worsening in expectations of surgery fulfilled (p = 0.04) there were no significant differences between 6-month and 3-year outcome. Three years after ACDF about two-thirds of the patients had remaining deficit with regard to pain intensity, Neck Disability Index, Distress and Risk Assessment Method and general health. According to the parameters studied 50 - 78% of those who at the 6-month follow-up were without deficit were still healthy at the 3-year follow-up. For patients with deficit at 6-month follow-up, still 83 - 100% had deficit 3 years after surgery.

Conclusions. Despite a rather small study obtained the stability of 6-month and 3-year results indicates that short-term results might be sufficient for evaluating effects of the treatment. Since the patients in this study clearly demonstrate broad problems array of development of more structured multi-professional rehabilitation models including exercises which improve neck muscle strength, endurance and proprioception need to be introduced.     

Vocational training integrated into inpatient psychosomatic rehabilitation--short and long-term results from a controlled study

Purpose. The aim of this study was to determine the impact of a vocational training programme on short- and long-term results after psychosomatic rehabilitation.

Method. 1,590 inpatients were screened for vocational integration. A high-risk group of 266 patients was randomly assigned to the vocational training programme plus psychosomatic treatment; treatment- as- usual served as a control condition. An occupational training was conducted at local companies, closely integrated into psychosomatic treatment. Vocational attitudes and adjustment were studied at intake, discharge, three, 12 and 24 month follow-ups.

Results. More than half of the study participants were unemployment and/or long-term work-disabled harbouring strong negative attitudes toward return to work. Forty-six percent of the intervention group declined from participation, but complied with follow-up investigation. At discharge, participants of the vocational training programme had become more optimistic regarding resuming work. One year following discharge, participants of the training programme reported less absence from work. After 24 months, vocational adjustment had improved considerably among programme participants, and declined among controls and refusers.

Conclusion. An intensive vocational training programme is effective in promoting positive attitudes to work, reducing work disability and promoting return-to-work. However, a randomized design may be not optimal; evaluation necessitates long-term follow-up.     

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.     

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.     

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.     

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.     

Referral of patients with neuromuscular disease to occupational therapy, physical therapy and speech therapy: usual practice versus multidisciplinary advice

Purpose. To compare the volume of occupational therapy (OT), physical therapy (PT) and speech therapy (ST) as currently received by patients with neuromuscular diseases with the volume of OT, PT and ST recommended by a multidisciplinary team.

Method. The use of OT, PT and ST was studied retrospectively and prospectively in a reference group (n = 106) receiving usual care and in an intervention group (n = 102) receiving advice based on multidisciplinary assessments. A cost analysis was made and the implementation of the advice was evaluated at 6 months.

Intervention. Multidisciplinary assessments consisted of a single consultation by OT, PT and ST each, followed by a multidisciplinary meeting and integrated advice.

Outcome variables. Volume (frequency times duration) of therapy, relative over- and underuse of therapy and costs of therapy and intervention.

Results. Compared to the multidisciplinary advice, there was 40% underuse of OT among patients with neuromuscular disease. For PT, there was 32% overuse and 22% underuse; for ST, there was neither over- nor underuse. Some 40% of patients received once-only advice regarding ST compared to 27% regarding OT and 19% regarding PT. The costs of the multidisciplinary advice were estimated at €245 per patient. If fully implemented, our multidisciplinary approach would result in a mean cost savings of €85.20 per patient. The recommended therapy had, however, been implemented only partially at 6 months follow-up.

Conclusions. Some patients with a neuromuscular disease do not receive any form of allied healthcare, whereas they should. Among patients with neuromuscular disease who do receive some form of allied healthcare, quite a few receive these treatments for too long periods of time. Ways need to be developed to improve implementation of the multidisciplinary advice and to obtain a more favourable balance between its costs and benefits.     

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.     

Locus of control and regional differences in sickness absence in Sweden

Purpose. The aim of this study was to investigate if there are differences in locus of control (LOC), at a societal level, between two residential areas in Sweden with substantial differences in sickness absence.

Method. A postal questionnaire was sent to 1500 randomly selected men and women aged 20 - 64 years. Five hundred questionnaires were sent to people living in Stromsund (a sparsely populated municipality in northern Sweden with high rates of sickness absence) and 1000 questionnaires to people in the Swedish capital of Stockholm, which has a low rate of sickness absence.

Results and conclusion. A comparison of LOC in the two study areas supported our hypothesis to a certain extent, external locus being more prominent in Stromsund. When physical and mental health and income were considered, however, the differences disappeared. Consequently, this study did not support the opinion that differences in sickness absence can be explained by LOC at a societal level.     

Applicability of a toolkit for geriatric rehabilitation outcomes

Purpose. To field test the applicability of a multidimensional toolkit for geriatric rehabilitation outcomes which includes nine standardized tools. Applicability is defined as context- and population-specific pragmatic qualities of an assessment tool such as respondent and examiner burden, score distribution and format compatibility.

Method. A sample of 48 older adults representing four diagnostic groups, as well as 26 caregivers, were assessed at home in the first month after discharge from intensive rehabilitation (T1) and 2 months later (T2). Pre-determined qualitative and quantitative applicability criteria were coded and compared at T1 and T2, as well as responsiveness.

Results. A higher respondent burden was found for three self-report tools, as well as a ceiling effect on social functioning tools. Respondent burden, examiner burden and score distribution remained stable or diminished at T2. Format compatibility deteriorated only for the mobility test due to a higher proportion of non ambulatory participants (17%). Low to moderate associations between the tools corroborated that they were not redundant (r_Pearson ≤ 0.77). Responsiveness estimates confirmed that mean scores were stable between T1 and T2.

Conclusion. Overall, the toolkit was found to be applicable at home after geriatric rehabilitation. Modifications are proposed to further improve its applicability. This study highlighted practical aspects that could alleviate the burden on research participants and facilitate the use of those tools for community follow-up for clinical and research purposes.     

The QE Health Scale (QEHS): assessment of the clinical reliability and validity of a spiritually based holistic health measure

Purpose. To assess the clinical reliability and validity of a holistic health measure, the QE Health Scale (QEHS), for use with people with physical disabilities.

Method. A test-retest design saw the QEHS administered and compared with established measures of health at admission and discharge from three-week inpatient rehabilitation programmes. Data was analysed by factor and correlation analysis. Clinician-reported credibility and usefulness of the theoretical basis of the QEHS, the QEHS itself, and Patient Profiles derived from the QEHS were also used to evaluate clinical validity.

Results. The QEHS was judged to possess satisfactory reliability and validity.

Conclusion. The QEHS is a clinically reliable, valid, credible and useful holistic health instrument to facilitate client-centred therapeutic interventions, inform decision-making and evaluate outcomes for people with physical disabilities.     

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.     

Simulation-based executive cognitive assessment and rehabilitation after traumatic frontal lobe injury: a case report

Purpose. To investigate whether identifying specific deficits after brain injury can lead to a more focused and potentially effective cognitive rehabilitation technology.

Method. Cognitive simulation assessment was undertaken in a 47-year-old man with trauma-related prefrontal damage and persisting occupational and cognitive-behavioral difficulties at 15 months post brain injury.

Results. Results revealed significant difficulties in measured levels of activity, initiative, information utilization, response flexibility, and effective decision-making strategies which accorded well with his real-life complaints despite normal neuropsychological test scores. This profile of findings was then used to design a two-stage intervention program. The first stage focused on participant education and awareness about his simulation-based problem solving difficulties. In the second stage specific goals were formulated to improve problem solving impairments that were then the target of weekly training sessions using pertinent decision-making and problem-solving vignettes. A parallel version of the cognitive simulation assessment was undertaken post-cognitive training (3 months after initial assessment) and revealed significant improvements in targeted executive cognitive-behavioral areas.

Conclusion. Results of this cognitive rehabilitation probe supported the feasibility and validity of undertaking a cognitive simulation approach to identify residual executive function deficits after traumatic brain injury, even with a normal neuropsychological test profile. Further studies are needed to establish the reliability, generalizability and maintenance of such gains.     

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.