Predictors of return to work after inpatient cardiac rehabilitation under workers' compensation plan

Vocational reintegration is one of the major goals of cardiac rehabilitation. 70 % of blue-collar workers under 50 years of age resume their job after in-patient cardiac rehabilitation. 10 % are hindered to do so by cardiac problems. Specific measures exist that may facilitate work resumption. As these measures should be started as soon as possible there is a need for predictors of return to work which can be obtained easily and at an early stage. Subjects of this prospective study were 650 patients (10 % female) under 50 years of age who participated in an in-patient cardiac rehabilitation programme under the workers' pension insurance scheme. At the beginning of programme participation, problems in work resumption as expected by the patient and by his physician were obtained, as well as depression and anxiety scores (HADS-D). Physicians' and patients' expectations concerning problems in resuming work turn out to be significant predictors of the vocational situation of the male patients six months following medical rehabilitation. The depression score obtained at the outset of the programme is the only predictor of return to work in female patients.     

Prediction of "intent", "discrepancy with intent", and "discrepancy with nonintent" for the patient with chronic pain to return to work after treatment at a pain facility.

OBJECTIVE: We previously determined that "intent" to return to work post pain facility treatment is the strongest predictor for actual return to work. The purposes of the present study were the following: to identify variables predicting "intent"; to predict membership in the "discrepant with intent" group [those chronic pain patients (CPPs) who do intend to return to work but do not]; and to predict membership in the "discrepant with nonintent" group (those CPPs who do not intend to return to work but do). DESIGN: A total of 128 CPPs completed a series of rating scales and yes/no questions relating to their preinjury job perceptions and a question relating to "intent" to return to the same type of preinjury job post-pain facility treatment. These CPPs were part of a grant study for prediction of return to work, and therefore their work status was determined at 1, 3, 6, 12, 18, 24, and 30 months posttreatment. Preinjury job perceptions and other demographic variables were utilized using stepwise discriminant analysis to identify variables predicting "intent" and predicting membership in the "discrepant with intent" and "discrepant with nonintent" groups. SETTING: Pain facility (multidisciplinary pain center). PATIENTS: Consecutive low back pain CPPs, mean age 41.66+/-9.54 years, with the most frequent highest educational status being high school completion (54.7%) and 60.2% being worker compensation CPPs. RESULTS: "Intent" was predicted by (in decreasing order of probability) postinjury job availability variables, job characteristic variables, and a litigation variable. "Discrepant with intent" was predicted by (in decreasing order of probability) for the 1-month follow-up time point, postinjury job availability variables, pain variables, a litigation variable, and a function perception variable, and for the final follow-up time point, pain variables only. "Discrepant with nonintent" was predicted by (in order of decreasing probability) for the 1-month follow-up time point, a job availability variable, a demographic variable, and a functional perception variable, and for the final follow-up time point a pain variable and a job availability variable. The percentage of CPPs correctly classified by each of these analyses was as follows: "intent" 81.25%, "discrepant with intent" 87.01% (at 1-month follow-up) and 74.03% (final follow-up), "discrepant with nonintent" 92.16% (at 1-month follow-up) and 75.00% (final follow-up). CONCLUSIONS: CPPs intentions of returning to their preinjury jobs are mainly determined by job availability and job characteristic variables but surprisingly not by pain variables. However, the results with "discrepant with intent" and "discrepant with nonintent" groups indicate that actual return to work is determined by an interaction between job availability variables and pain variables with pain variables predominating for long-term outcome.     

Vocational integration after a two-year retraining measure in vocational retraining centres--a prognostic model

BACKGROUND: Vocational rehabilitation aims at occupational reintegration of the clients. This article focuses on several key results of an evaluation study on rehabilitative vocational training programmes. A central research goal was to identify prognostic factors for successful vocational integration. METHOD: Three vocational retraining centres (Berufsf?rderungswerke) participated in this cohort study with five waves of measurement. Data gathering on process and outcome quality of the two-year training programmes was based on client-surveys (questionnaires). A prognostic model for occupational integration one year after the training measure was developed, based on questionnaire data gathered at the beginning of the training courses. RESULTS: One year after completion of their training 55% of the participants had returned to a job (dependent or self-employed). The logistic regression model for prognosis of return to work showed six relevant variables, and occupational integration as well as nonintegration 12 months after training could be predicted in 77%. Regional unemployment rates revealed to be the most important predictive variable for job reintegration. Other significant variables were: control beliefs, educational level, pain, perceived social support, and occupational field. Neither marital status nor level of disability (GdB) proved predictive for return to work. The variables age and gender were significant only in the univariate analysis. DISCUSSION AND CONCLUSION: A set of variables could be identified as predictive for return to work after a two-year vocational training measure. Some variables, such as control beliefs or perceived social support, may indicate possibilities for specific supportive interventions.     

The impact of psychologically different patient groups on outcome after a vocational rehabilitation program for long-term spinal pain patients

A better knowledge of differential treatment outcomes for subgroups of chronic spinal pain patients may, for instance, help clinicians in treatment planning or pain researchers in treatment outcome research. The purpose of this prospective study was to evaluate the predictive validity of a subgroup classification based on the Swedish version of the (West Haven Yale) Multidimensional Pain Inventory, the MPI-S. Patients referred to a vocational rehabilitation program were classified into one of three groups, labeled 'adaptive copers', 'dysfunctional' patients, and 'interpersonally distressed' patients, and followed over an 18-month follow-up period. The outcome variables were absence from work (defined as sick listing plus early retirement), general health status, and utilization of health care resources. To our knowledge, the predictive validity of the MPI subgroups has not been evaluated regarding sick listing and early retirement after rehabilitation. As hypothesized, the results showed that the 'dysfunctional' patient group had significantly more registered absences from work and reported higher utilization of health care, over the follow-up period compared to the 'adaptive copers'. Furthermore, as hypothesized, the 'interpersonally distressed' and 'dysfunctional' patient groups report a poorer general health status than the 'adaptive copers' over the whole follow-up period. However, contrary to our hypothesis, the proportion of improved patients did not differ significantly between the subgroups. Altogether, the predictive validity of the MPI-S subgroup classification was mainly confirmed. The clinical implications of this study suggest that the matching of treatment to patient needs may enhance treatment outcome, reduce pain and suffering among chronic spinal pain patients and facilitate a better health economic allocation of treatment resources.     

Disability measurement in persons with back pain: a validity study of spinal range of motion and velocity

OBJECTIVE: To evaluate the criterion validity and responsiveness to change of spine kinematic variables to assess disability in patients with low back pain. DESIGN: Blinded comparison between spine kinematic variables, Oswestry disability questionnaire scores, and work status. SETTING: Multidisciplinary occupational rehabilitation clinic of a university hospital. PATIENTS: Population-based cohort of 111 patients with subacute work-related back pain who were absent from regular work for more than 4 weeks because of back pain. INTERVENTIONS: This study was part of a population-based randomized clinical trial. Patients were randomized to 4 different methods of management: usual care, rehabilitation, ergonomics, or rehabilitation and ergonomics. MAIN OUTCOME MEASURES: Oswestry disability questionnaire, kinematic analysis of the spine during flexion and extension of the trunk, and work status were collected at weeks 4, 12, 24, and 52 after the back accident. RESULTS: Kinematic variables were poorly to moderately related to work status and Oswestry questionnaire scores. Kinematic variables were also unresponsive to change in work status and Oswestry questionnaire scores over time. CONCLUSION: Spine kinematics during flexion and extension of the trunk do not appear to be a valid measure of disability in patients with subacute and chronic back pain.     

Return to work after low voltage electrical injury

Low voltage electrical injury is associated with minor or no cutaneous burns and its symptoms rarely appear on initial examination. The purpose of this study was to determine the ability to return to work among patients with low voltage electrical injury. A retrospective hospital chart review was conducted among patients with low voltage electrical injury admitted to the outpatient burn clinic of a rehabilitation hospital between January 1, 2002 and March 21, 2006. Symptoms at follow-up visits and return to work status were compared between patients with electrical contact injuries and those with electrical flash injuries using Student's t-test and chi analysis with a P < 0.05 considered significant. Values are presented as mean +/- SD. Forty patients were treated for low voltage electrical injury, and all injuries occurred at work. There were 34 men (85%) and 6 women (15%) with a mean age of 37.3 +/- 11.2 years and a mean total body surface area burned of 13.0% +/- 17.6%. Most patients had neurological (92.5%), psychological (90.0%), and musculoskeletal (72.5%) symptoms, which were documented on average 303.7 days after injury. Twenty-five (62.5%) patients had electrical contact injury and 15 (37.5%) patients had electrical flash injuries. Patients with electrical contact injuries were younger (34.2 +/- 9.9 years vs 42.4 +/- 11.6 years, P = 0.030), complained of more psychological symptoms (25 vs 11, P = 0.006), more neurological symptoms (25 vs 12, P = 0.020), and more fatigue (10 vs 1, P = 0.022) than patients with electrical flash injuries. Twenty-three patients (57.5%, 14 electrical contact and 9 electrical flash) attempted to return to work on average 107.7 days after injury, but only 13 patients (32.5%, six electrical contact and seven electrical flash) successfully returned to work 59.38 days after injury. Of them 7 (53.8%) return to the same job, 5 (38.5%) returned to a modified job, and 1 (7.7%) to a new job. Low voltage electrical injury can significantly impact a patient's ability to return to work because of the psychological, neurological, and musculoskeletal symptoms, which are observed. Recognition of low voltage injury as a potentially permanent source of symptoms is important and has to date not been well established. More effective preventive measures should be implemented at work to reduce the risk of these injuries.     

Motivation and return to work among the long-term sicklisted: an action theory perspective

Purpose : The purpose of this study is to enlighten motivation and return to work among the long-term sicklisted.

Method : Data are from a mail questionnaire answered by 185 people living in the Stockholm metropolitan area in Sweden. All subjects were on long-term sick leave owing to back or neck symptoms, they were 18 - 55 years of age and had an employer. A part of the questionnaire was based on an action theory perspective emphasising the respondent's own view of his or her present and future situation. People answered structured questions about what kind of work they wanted, if they thought they could get such a work and if they thought they could manage this type of work. All three aspects are of importance in the study of motivation. A follow-up of the employment status of the respondents was made about two years after the questionnaire had been answered. The relationships between their plans and employment status were studied.

Results : The results show that our questions had good predictive validity, i.e. there were clear correlations between the answers and employment status two years later. It was shown that wanting to return to work is connected to one's view of own possibilities. What a person wants is not an isolated opinion, but clearly connected with the other aspects, particularly own competence ('can manage').

Conclusion : It is concluded that the action theory approach could be developed into an instrument for 'action analysis' that could be used in work with vocational rehabilitation. Such a development is now under way.     

Motivation and return to work among the long-term sicklisted: an action theory perspective

Purpose : The purpose of this study is to enlighten motivation and return to work among the long-term sicklisted. Method : Data are from a mail questionnaire answered by 185 people living in the Stockholm metropolitan area in Sweden. All subjects were on long-term sick leave owing to back or neck symptoms, they were 18 - 55 years of age and had an employer. A part of the questionnaire was based on an action theory perspective emphasising the respondent's own view of his or her present and future situation. People answered structured questions about what kind of work they wanted, if they thought they could get such a work and if they thought they could manage this type of work. All three aspects are of importance in the study of motivation. A follow-up of the employment status of the respondents was made about two years after the questionnaire had been answered. The relationships between their plans and employment status were studied. Results : The results show that our questions had good predictive validity, i.e. there were clear correlations between the answers and employment status two years later. It was shown that wanting to return to work is connected to one's view of own possibilities. What a person wants is not an isolated opinion, but clearly connected with the other aspects, particularly own competence ('can manage'). Conclusion : It is concluded that the action theory approach could be developed into an instrument for 'action analysis' that could be used in work with vocational rehabilitation. Such a development is now under way.     

Improved work ability and return to work following vocational multidisciplinary rehabilitation of subjects on long-term sick leave.

OBJECTIVE: To evaluate a vocational multidisciplinary rehabilitation programme for patients on long-term sick leave with respect to their work ability and return to work. METHODS: A multidisciplinary rehabilitation programme was administered to an intervention group of 183 patients on long-term sick leave (mean 12.2 months). Effects of the treatment were compared with a control group (n = 96) recruited from the national sickness insurance record of patients on sick leave of 6-12 months duration (mean 11.5 months). Perceived work ability, return to work, background factors and psychosocial aspects of work were assessed on the basis of questionnaires at baseline and after 4 months. RESULTS: Perceived work ability of the intervention group improved significantly after 4 months compared with the control group (p < 0.01). In the intervention group, 80% had returned to work compared with 66% in the control group (p = 0.06). Return to work after 4 months was predicted by good work ability at baseline, improved work motivation, improved work ability at follow-up and increased rumours of change in the workplace (R2 26.1-38.6%, p < 0.05). CONCLUSION: This multidisciplinary rehabilitation programme significantly improved perceived work ability compared with treatment as usual.     

Workers' disability and return to work.

A severe injury on the job often results in a medical recovery period requiring either a temporary or long-term absence from work. Rehabilitation interventions emphasizing return to work may facilitate recovery and prevent workers from becoming unemployed. A review of the current literature suggests a direct relationship between workers' demographic and disability-related characteristics, early referral to rehabilitation and successful return to work. This article describes findings from a research study designed to investigate factors associated with the return to work of injured workers. Data from 200 workers' compensation cases from a large automobile manufacturing employer in the state of Michigan were analyzed in terms of workers' demographics and other characteristics including type and severity of injury, cause of injury, type of medical intervention received, disability status, worker's job experience and wages before injury; disability costs to employer; the provision of vocational rehabilitation services; and return-to-work outcomes. Variables found to be significantly related to return to work outcomes included workers' age, education, wages before injury, job seniority and severity of the injury. Workers who successfully returned to work had higher seniority in their jobs, more education and were paid higher wages. Workers whose injuries were more severe and longer lasting, were less likely to return to work. Back impairments appeared to be a particular risk factor for return to work regardless of vocational rehabilitation intervention.     

Relationship between the margin of manoeuvre and the return to work after a long-term absence due to a musculoskeletal disorder: an exploratory study

Purpose.?The application of the margin of manoeuvre (MM) concept in work rehabilitation is new. It allows for variations in both health status and work demands, and the interaction between the two, to be taken into account. The objective of this exploratory study was to document the relationship between the presence of an MM in the workplace and the return to work (RTW), after a long-term absence.

Methods.?This study used the data collected during an earlier study that sought to identify the dimensions and indicators of the MM. The data were analysed on three levels, and the convergences and divergences in the MM indicators and dimensions in relation to the RTW were grouped accordingly.

Results.?Eleven workers and five clinicians participated in this study. The results support the proposition that the presence of a sufficient MM in the workplace is associated with RTW of individuals at the end of a rehabilitation programme despite a long-term absence (n == 6), and conversely, that its absence would appear to be associated with a non-return to work (n == 4).

Conclusions.?A better understanding of this concept will help further the development of a tool to assist clinicians in their task of assessing a worker's capacity to return to a given job.     

The effectiveness of psychological interventions for the rehabilitation of low back pain: a randomized controlled trial evaluation.

Forty-five low back pain patients were randomly assigned to either a standard inpatient rehabilitation program or the standard program with additional psychological components. The standard program emphasized education, support, and physical reconditioning through exercise. Patients receiving the psychological program were given additional training in relaxation and other coping skills and received contingent reinforcement for exercise. Both programs included reduction of medication intake and an emphasis on family involvement after discharge. Measures of functional status were taken prior to the program, at discharge from the 3-week inpatient program, and at a 6-month follow-up appointment. These data revealed that patients improved their overall functioning at discharge and maintained these gains at the follow-up assessment. A similar pattern of findings was obtained for self-reported pain and interference. Furthermore, 81% of the patients had returned to work or were engaged in active job retraining by the follow-up. Using a conservative measure of full-time return to the same or an equivalent job, 57% were employed by the follow-up. Patient improvement, however, was not differentially affected by treatment group assignment, suggesting that the psychological treatment failed to add to the effectiveness obtained by the standard rehabilitation program. Results are discussed in the context of improving patient outcomes from rehabilitation for low back pain.     

Development and validation of a prognosis model for predicting work capacity after rehabilitation based on routinely collected parameters

For efficient rehabilitation it is important to identify, as early as possible, the patients likely to be successfully returned to work after rehabilitation. The aim of this pilot study was to develop a statistical model for predicting this return as reliably as possible. The model uses only information readily available at the beginning of rehabilitation. A multiple regression analysis with backward elimination was used from a routine data base and identified 8 variables of prognostic value. The model offers a comfortable possibility to predict the probability of return to work of a patient on the basis of routinely registered data. The prognosis was found correct in 68% of those returning to work after rehabilitation (sensitivity) and in 80% of those who did not (specificity). Further work to improve the model for prognosis in rehabilitation research is considered reasonable.     

Medical rehabilitation in long-term disability

Based on data from a prospective observational cohort study the following article attempts to answer two key questions of rehabilitation research in Germany: (1) What are the utilization rates of rehabilitation measures in patients with long-term work-incapacity due to low-back pain? (2) In this group of patients: does participation in rehabilitation programs correlate with return to work? Patients with long-term work-incapacity due to low-back pain report a severely impaired health status (measured by FFbH, SF-36, numeric rating scale for pain intensity) which calls for comprehensive medical treatment and rehabilitation. 40.5% of study patients received first time medical rehabilitation between three months and one year after the beginning of long-term work-incapacity, 20.5% between one year and two years after the beginning of long-term work-incapacity. These figures were not influenced by age. Considering the severity of impairment we judge these rates as being quite low. There was no positive correlation found between utilization of medical rehabilitation measures or any other medical treatment and return to work. A positive correlation was observed for utilization of first time medical rehabilitation between three months to one year after the beginning of long-term work-incapacity and functional capacity. This effect was demonstrable for patients 50 years of age or younger. CONCLUSIONS: (1) In our cohort utilization of medical rehabilitation measures in patients with low-back pain and long-term work-incapacity is quite low. This suggests a considerable amount of underutilization. (2) In order to avoid underutilization the process of accessing medical rehabilitation within the German health care system should be critically reviewed. (3) In the given context of high unemployment rates and the German early pensioning system the use of "return to work" as the main criterion to judge effectiveness of rehabilitation measures remains debatable.     

Validation of a model for evaluating outcome after traumatic brain injury

OBJECTIVE: To validate a model that examines the contribution of premorbid variables, injury severity, and functional and cognitive status to outcome 1 year after traumatic brain injury (TBI). DESIGN: Cross-validation study using a larger, national, prospective, longitudinal sample. SETTING: Acute inpatient rehabilitation hospitals at Traumatic Brain Injury Model Systems centers. PARTICIPANTS: Two sample populations followed through acute rehabilitation to 1 year after TBI. The original sample included 107 patients, and the cross-validation sample included 294 patients. Participants were predominantly young men who had experienced moderate to severe TBI in motor vehicle crashes. INTERVENTIONS: Acute medical and rehabilitation care. MAIN OUTCOME MEASURES: Disability Rating Scale, Community Integration Questionnaire, and return to employment. RESULTS: Structural equation modeling was used to compare the fit of the data to a path analysis developed through clinical use and previous research. Both samples provided adequate goodness of fit, supporting the model's validity. Injury severity affected cognitive and functional status, and cognitive and functional status significantly influenced 1-year outcome. Premorbid factors and injury severity did not directly influence outcome. CONCLUSIONS: Both samples supported the proposed model, which was cross-validated. Injury severity indirectly influences outcome through its effects on cognitive and functional status. Although treatment to decrease injury severity is obviously important, concentrated rehabilitation interventions aimed at improving patients' cognitive and functional status may have a more significant impact on 1-year outcome and should be the focus of future research.     

Factors related to successful job reintegration of people with a lower limb amputation

OBJECTIVE: To study demographically, amputation-, and employment-related factors that show a relationship to successful job reintegration of patients after lower limb amputation. DESIGN: Cross-sectional study. SETTING: University hospital. PATIENTS: Subjects had an acquired unilateral major amputation of the lower limb at least 2 years before, were aged 18 to 60 years (mean, 46yr), and were living in the Netherlands. All 322 patients were working at the time of amputation and were recruited from orthopedic workshops. INTERVENTION: Questionnaires sent to subjects to self-report (1) demographic and amputation information and (2) job characteristics and readjustment postamputation. Questionnaire sent to rehabilitation specialists to assess physical work load. MAIN OUTCOME MEASURES: Demographically related (age, gender); amputation-related (comorbidity; reason and level; problems with stump, pain, prosthesis use and problems, mobility, rehabilitation); and employment-related (education, physical workload) information about the success of job reintegration. RESULTS: Job reintegration was successful in 79% and unsuccessful in 21% of the amputees. Age at the time of amputation, wearing comfort of the prosthesis, and education level were significant indicators of successful job reintegration. Subjects with physically demanding jobs who changed type of job before and after the amputation more often successfully returned to work than subjects who tried to stay at the same type of job. CONCLUSIONS: Older patients with a low education level and problems with the wearing comfort of the prosthesis are a population at risk who require special attention during the rehabilitation process in order to return to work. Lowering the physical workload by changing to another type of work enhances the chance of successful reintegration.     

Predictors for return to work after spinal cord injury: a 3-year multicenter analysis

OBJECTIVE: To examine the ability of the Motor Index Score (MIS), in combination with demographic variables, to predict return to work during a 3-year period for individuals with spinal cord injury (SCI). METHODS: Prospectively collected data, between 1986 and 1995, submitted to the National Spinal Cord Injury Statistical Center were analyzed to determine the prediction of return to work utilizing variables of education, ethnicity, age, marital status, gender, and MIS. Individuals, aged 18 to 65 yrs, employed at the time of their injury, were evaluated at discharge from rehabilitation and at 1 (YR1), 2 (YR2), and 3 (YR3) years postinjury (sample sizes of 1,857, 1,486, and 1,177, respectively). RESULTS: The most important predictors of return to work were education, MIS, ethnicity, and age at onset of SCI. These variables resulted in a high rate of accuracy for predicting across all 3 yrs (YR1, 81%; YR2, 82%; YR3, 77%). CONCLUSIONS: The ability to predict return to work after SCI was shown utilizing MIS and demographic variables, with nearly 80% accuracy. This suggests that return to work after SCI is a dynamic process, with the level of importance of each variable changing with time postinjury.     

Therapeutic programmes focusing on job related problems - which psychosomatic patients should participate?

The necessity to offer special therapeutic programmes focusing on job related problems in psychosomatic rehabilitation has become increasingly evident. Which patients should participate in such programmes? This question has not yet been discussed with regard to its theoretical and methodological implications. In clinical practice the decision has been based on the therapists evaluation. 105 patients, consecutively admitted in a psychosomatic hospital were interviewed with a screening questionnaire about their job related strains and the perceived interaction between symptomatology and job. According to the literature guidelines for inclusion of psychosomatic patients to a special work hardening programme were used. Therapists were asked to independently assign their patients to the programme. The overlap between the two procedures was small. While the guidelines focussed on a high level of job strain and the patient's motivation for a job-related therapeutic approach, the therapists' decision was based on duration of inability to work, impairments at work due to the symptoms, conflicts with colleagues at work and the patient's ability to perceive problems in a differentiated manner. Considering the problem of inclusion-criteria for a work hardening programme, the highly complex constellations behind routine therapeutic decisions in psychosomatic rehabilitation became evident. To integrate medical diagnosis, symptomatology, psychological models, job strain, the patient's social situation and values, is a neglected but important goal of rehabilitation sciences and should be a base for a concept guiding the development, evaluation and establishment of work related therapeutic programmes.