Work physical therapy and rehabilitation ergonomics: A review and discussion of the scope of the areas

Purpose. There has been a recent development of the work physical therapy area in Brazil. The relationship between work physical therapy and rehabilitation ergonomics needs to be highlighted to avoid segregation and fragmentation of these complementary fields. For these reasons, the purpose of this article was to review and clarify the scope of the areas of work physical therapy and rehabilitation ergonomics.

Method. The available literature discussing the roles of the areas of interest was critically reviewed.

Results. Both areas are concerned with workers' health and safety and they complement each other.

Conclusions. Work physical therapy can be considered as rehabilitation ergonomics practiced by physical therapists with their specific interests. Hopefully, this paper will contribute to further interaction between the areas of work physical therapy and rehabilitation ergonomics not only in Brazil but worldwide. This may contribute to improved occupational disability prevention and rehabilitation.     

A nursing perspective on the relationship between nursing and allied health in inpatient rehabilitation

Purpose. To generate a deeper understanding of contextual factors influencing nursing's contribution to inpatient rehabilitation units in Australia.

Method. Grounded theory informed by the theoretical perspective of symbolic interactionism. Data were generated by interviews with nurses and observation of their everyday practice.

Results. Nursing and allied health work in inpatient rehabilitation was segregated by divided and dividing work practices. Several contextual conditions contributed to the segregation. These were 'limited acknowledgment of nursing's complex role', 'divisive work practices' and 'discontinuous teamwork'. Segregation limited the extent to which nurses could contribute to patient rehabilitation.

Conclusion. The delivery of multi-professional inpatient rehabilitation is complex. By focusing efforts to ameliorate segregation, progress can be made towards optimizing the contribution of all disciplines to patient rehabilitation.     

Predictors of assistive technology use: the importance of personal and psychosocial factors

Objective. To validate an assistive technology (AT) baseline and outcomes measure and to quantify the measure's value in determining the best match of consumer and AT considering consumer ratings of their subjective quality of life, mood, support from others, motivation for AT use, program/therapist reliance, and self-determination/self-esteem.

Design. Prospective multi-cohort study.

Setting. Vocational rehabilitation offices and community.

Participants. Over 150 vocational rehabilitation counselors in 25 U.S. states with one consumer each receiving new AT.

Interventions. Counselor training in the Matching Person and Technology (MPT) Model and consumer completion of the MPT measure, Assistive Technology Device Predisposition Assessment (ATD PA).

Main outcome measures. Total and subscale scores on the ATD PA as well as counselor-completed questionnaires.

Results. ATD PA items differentiated consumer predispositions to AT use as well as AT and user match. There were no significant differences due to gender, physical locality, or age within this sample of working-age adult consumers. Vocational rehabilitation counselors exposed to training in the MPT Model achieved enhanced AT service delivery outcomes.

Conclusions. The ATD PA is a valid measure of predisposition to use an AT and the subsequent match of AT and user. Rehabilitation practitioners who use the ATD PA will achieve evidence-based practice and can expect to see enhanced AT service delivery outcomes.     

'It was hard but you did it': the co-production of 'work' in a clinical setting among spinal cord injured adults and their physical therapists

Purpose. This paper focuses on what takes place during the rehabilitation of spinal cord injured (SCI) adults. It analyses the cardinal rehabilitation task of transforming the compromised, limited and injured corporeal style of newly injured adults (best described phenomenologically as an 'I cannot do' or ' I no longer can') into a new style of embodiment, one in which 'I am newly abled'. This transformation is not a passive, surrendering experience. Rather, as informants repeatedly noted, 'rehabilitation is hard work'. This paper examines that 'work'.

Method. This paper draws from observational and interview data collected over an 18-month period in a metropolitan rehabilitation centre in the Midwestern United States. It presents an exemplar case of a clinical setting, that between a physical therapist and her SCI client.

Results. The interactional and meaning-making nature of clinical encounters are explicated, revealing the collaborative and situational constitution of rehabilitation work.

Conclusions. Experience-near, phenomenologically informed, research is shown to be a valuable way of understanding rehabilitation practices and how they might affect inpatients and staff.     

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.     

Reliability and construct validity of the client-centred rehabilitation questionnaire

Purpose. A key component in assessing the performance of rehabilitation services is the client's perspective. The purpose of this paper is to report on the development of a publicly available measure of client-centred rehabilitation (CCRQ) that can be used for discriminative and evaluative purposes.

Method. Mixed qualitatative and quantitative methods were used. Phase 1: Identification of seven domains of client-centred rehabilitation based on a literature review, focus groups with clients, and review by content experts. Phase 2: Item generation for the seven conceptually derived subscales and cognitive interviews with inpatient rehabilitation patients. Phase 3: Psychometric testing for internal reliability, test-retest reliability and discriminative construct validity using data from a mailed, self-administered survey to 1568 patients discharged from two large inpatient rehabilitation facilities.

Results. The seven conceptually derived subscales all have strong internal (0.72 - 0.87) and test-retest reliability (0.74 - 0.85). Discriminative construct validity is demonstrated by the ability of subscales to identify significant differences between programs within two rehabilitation facilities.

Conclusions. The results for the reliability and validity of this measure support its value for use in clinical and quality improvement work as well as research.     

The role of the spiritual dimension of the self as the prime determinant of health

Purpose. To present a clinical commentary on the relationship of spirituality to healthcare for those with chronic physical conditions.

Method. A spiritually based theory of self-identity was presented, based on selected literature to identify the process of health attainment for those with chronic conditions. The resultant Health Change Process Theory was then discussed in relation to relevant empirical research and the implications for rehabilitation practice were outlined.

Results. The development of a resilient, intrinsic, spiritually based concept of self was found to be pivotal to health outcomes in rehabilitation. This was then incorporated within a Health Change Process Theory to explain and predict the course followed by people with chronic disorders to achieve health.

Conclusion. The Health Change Process Theory provides an inclusive framework within which acute and chronic rehabilitation healthcare can be merged to maximise health outcomes. Nevertheless, a need remains to develop a quantitative measure of individual holistic health, based on this theory, to facilitate its use in rehabilitation practice. This paper forwards an explanation for the process that people experiencing chronic physical disabilities undergo as they achieve health. A concept of self that identifies the spiritual core as the component that determines the constancy and continuity of self as a whole which is necessary for health is presented as the basis of the rehabilitative health process.     

How can a work rehabilitation process be improved?--a qualitative study from the perspective of social insurance officers

Purpose: The aim of this study is to describe social insurance officers' experiences of a work rehabilitation process at a rehabilitation centre in the northern parts of Sweden. In Sweden the social insurance company has a key role to coordinate all efforts concerning work rehabilitation planning between all rehabilitation actors.

Method: Ten social insurance officers at the social insurance company in a city in northern Sweden were interviewed using a narrative approach about their experiences of work rehabilitation processes in general. The interviews were analysed by qualitative content analysis with a focus on their experiences of goals, content and results of a work rehabilitation process.

Results: The social insurance officers' experiences of how a work rehabilitation process could be improved were described in six categories; (1) Early identification of problems, needs and interventions (2) clear goal formulations, (3) a focus on psychosocial factors (4) a greater variety of possible interventions, (5) activating employers to a higher extent in work rehabilitation and (6) a closer cooperation and information exchange with other rehabilitation actors.

Conclusions: It is possible to improve a work rehabilitation process by focusing on early identification of problems, needs and interventions, with a variety of interventions to choose between and with clear goal formulations and recognizing psychosocial factors in the process. To activate employers to a higher extent in work rehabilitation and to make the information exchange between rehabilitation actors more frequent may also improve work rehabilitation processes.     

Survey of the current status of cancer rehabilitation in Japan

Purpose. To elucidate the current status of cancer rehabilitation in institutions nationwide.

Method. A questionnaire survey regarding the current status of cancer rehabilitation in 1693 healthcare institutions was conducted by mail. The survey first asked whether rehabilitation was being conducted for cancer patients and, in facilities in which it was being conducted, it then asked about the content of the rehabilitation, the stage of the cancer patients, etc. Facilities in which cancer rehabilitation was not being conducted were surveyed in regard to whether there was a need for cancer rehabilitation.

Results. Valid replies were obtained from 1045 (62.0%) institutions and 864 (82.7%) of them conducted rehabilitation for cancer patients. A high proportion of the content of the rehabilitation was found to be related to physical function. Activities of daily living guidance and training were also found to be conducted in a high proportion. Low proportions of the facilities conducted content that was specialized for cancer. Of the 181 facilities in which rehabilitation was not being conducted for cancer patients, 171 (94.5%) replied that they felt that rehabilitation was needed for cancer patients.

Conclusions. Based on the results of this fact-finding survey it will be necessary to consider strategies for popularizing and developing rehabilitation programmes for cancer patients in Japan.     

Disability prevention and communication among workers, physicians, employers, and insurers--current models and opportunities for improvement

Purpose: To review prevailing models of disability management and prevention with respect to communication, and to suggest alternative approaches.

Method: Review of selected articles.

Results: Effective disability management and return to work strategies have been the focus of an increasing number of intervention programmes and associated research studies, spanning a variety of worker populations and provider and business perspectives. Although primary and secondary disability prevention approaches have addressed theoretical basis, methods and costs, few identify communication as a key factor influencing disability outcomes. Four prevailing models of disability management and prevention (medical model, physical rehabilitation model, job-match model, and managed care model) are identified. The medical model emphasizes the physician's role to define functional limitations and job restrictions. In the physical rehabilitation model, rehabilitation professionals communicate the importance of exercise and muscle reconditioning for resuming normal work activities. The job-match model relies on the ability of employers to accurately communicate physical job requirements. The managed care model focuses on dissemination of acceptable standards for medical treatment and duration of work absence, and interventions by case managers when these standards are exceeded. Despite contrary evidence for many health impairments, these models share a common assumption that medical disability outcomes are highly predictable and unaffected by either individual or contextual factors. As a result, communication is often authoritative and unidirectional, with workers and employers in a passive role.

Conclusion: Improvements in communication may be responsible for successes across a variety of new interventions. Communication-based interventions may further improve disability outcomes, reduce adversarial relationships, and prove cost-effective; however, controlled trials are needed.     

Theoretical aspects of goal-setting and motivation in rehabilitation

Purpose: The purpose of this article is to provide rehabilitation theorists and researchers with an introduction to some key theories of goals and motivation from the field of social cognition and to argue for increased dialogue between the two disciplines.

Method: The use of goals and goal-setting in rehabilitation is briefly surveyed and the somewhat ambivalent attitude toward the concept of motivation in the rehabilitation literature is highlighted. Three major contributors to the study of goals and motivation from the field of social cognition are introduced and their work summarized. They include: (i) Deci and Ryan's Self-Determination Model; (ii) Emmons' work on goals and personal strivings, and (iii) Karniol and Ross' discussion of temporal influences on goal-setting.

Results: It is argued that there is a need for a greater emphasis upon theory development in rehabilitation research and that closer collaboration between researchers in rehabilitation and social psychology offers considerable promise. Instances where the three theories from social cognition might have relevance to clinical rehabilitation settings are described. Some possible directions for research are also briefly sketched.

Conclusion: Both rehabilitation and social cognition have much to gain from increased dialogue.     

Scoring systems to evaluate elderly patients with hip fractures

Purpose: To report about different scales and scoring systems used to evaluate elderly patient with hip fracture during the acute post-fracture phase and during post-operative rehabilitation.

Methods and results: Report of the different scales from a literature review.

Conclusions: Standard validated scales are one of the tools to perform such an evaluation process as objectively as possible and to evaluate surgical, medical and rehabilitative management in these elderly patients. These scales are only a complementary tool, and they cannot replace physical examination. However, these validated tools are probably more accurate than just clinical impression. The appropriate combination of clinical experience and these scales may well contribute to a better care of elderly patients with hip fractures.     

Cognitive-behavioural stimulation protocol for severely brain-damaged patients in the post-acute stage in developmental age

Purpose. To present a cognitive-behavioural stimulation (CBS) protocol designed to help severely damaged patients in the early post-acute stage by describing the underlying methodology and assessing its efficacy compared to traditional rehabilitation methods. This protocol combines multisensory stimulation and cognitive-behavioural techniques to elicit and intensify the occurrence of adaptive responses and reduce maladaptive behavioural patterns.

Methods. A control group and an experimental group - both evaluated with the Levels of Cognitive Functioning Assessment Scale (LOCFAS) - were compared at the beginning of the rehabilitation programme and at the end of it. The control group consisting of patients assessed and treated before receiving the CBS protocol was enrolled in a traditional rehabilitation programme (only physical therapy and speech therapy). Besides the traditional therapy, the experimental group also received the CBS protocol.

Results. Patients on the CBS protocol show a greater improvement and are therefore more responsive than the control group after the 16-week remediation programme. The mean LOCFAS improvement of the experimental group is more marked during the first month of rehabilitation and is associated to the entry LOCFAS level, while in the control group the improvement on LOCFAS is considered to be 'spontaneous' and is associated to the aetiology of the brain damage.

Conclusions. Our results show a better initial outcome for patients receiving the CBS protocol.     

Medico-legal and ethical aspects in the management of wandering patients following brain injury: questionnaire survey

Background. Different methods are often used to deter head injury patients, who have a tendency to wander, from leaving the rehabilitation wards. The extent to which these patients could be restrained is controversial. Despite the fact that the majority of these patients lack mental capacity, Mental Health Act sections are rarely invoked. Under common law, informal patients should have the right to refuse treatment and to leave the hospital whenever they like.

Objective. To examine the current practice in the management of wandering patients following brain injury in rehabilitation units in the UK and to formulate practical guidelines based on this common practice.

Methods. A postal survey in the form of a structured questionnaire was sent to 58 consultants in Rehabilitation Medicine and Neuropsychologists based at different neurological rehabilitation units in the UK.

Results. A total of 30 clinicians (52%) completed the questionnaire. One-to-one supervision was the method most commonly used to manage wandering patients (83%) followed by implementation of a structured daily routine (73%) and the use of different medications (70%). Only 17% would lock the door without giving the patient lock combination/key and another 17% would physically restrain the patient without invoking mental health act (MHA) section; 60% would consider MHA section with great variability in the mental health team response time and the place where patient is managed once under MHA section.

Conclusions. The questionnaire showed great variations in the methods and the medico-legal framework used in the management of wandering patients. There was, however, a tendency to avoid physical restraint which may reflect the recognition of the unlawfulness of detaining informal patients.     

The impact of psychological factors in recovery following surgery for hip fracture

Purpose. To increase awareness of psychological factors in recovery from hip fracture and to describe strategies that can be used to help patients in the process of recovery.

Method and results. Psychological theory, case examples and clinical observation are used to propose three frameworks for understanding the psychological factors which can impede recovery. Indication of key strategies for assessment and intervention which can be used in rehabilitation services is provided.

Conclusions. An understanding of the psychological factors which can impede recovery in hip fracture is important for all professionals involved in rehabilitation. Psychologists can provide consultation and support for staff working in physical rehabilitation and can work directly with cases where there is complexity. There is still relatively little known about this important area and further research is needed to provide a clear evidence base.     

Physical therapy education and provision in Cambodia: A framework for choice of systems for development projects

Purpose. Rehabilitation agencies, policy makers and donors are faced with the choice of the level of rehabilitation provider to promote in developing countries. This is particularly the case after conflict when new systems are considered and the need for rehabilitation becomes a priority. The complete decimation of medical services in Cambodia highlights the effects of both social change and development agency impact on the establishment of rehabilitation services. This paper discusses the factors that led to the development of four types of physical therapy provider levels in Cambodia with the goal of providing a framework for these decisions.

Methods. Case study analysis utilizing interviews, site analysis and literature review.

Results. There are four levels of physical therapy provider systems that were initiated at different stages of the rebuilding of the country. Rehabilitation workers were trained during the war in refugee camps and afterwards in rehabilitation centers, professional physical therapists were trained in a university programme after the conflict ceased and community follow-up workers and community-based rehabilitation workers were trained to address some of the geographic accessibility issues. Factors that affected the different systems include the post-conflict development agency philosophy, instructor availability and training, financial support, high school education standards, geographic and rural/urban distribution and cost and time for training. The community-based rehabilitation and community follow-up models also address referral systems and social and vocational support.

Conclusions. The comparison of the different types of provider and the initiating or driving forces that led to development of these systems are discussed in order to provide agencies which are planning to implement training of rehabilitation providers in developing countries with a decision-making framework. A combined system is the optimal approach; however, the choice of which type of provider level to promote will differ according to political stability, stage of development, presence of trained educators, rural vs. urban need, funding agency philosophy and educational standards in the country.     

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.     

Learning to eat after radiation therapy for throat cancer

Purpose: The initial purpose was to find more expedient ways for learning to eat for personal rehabilitation. The secondary purposes were to inform other radiation therapy patients and to inform clinicians and therapists involved in rehabilitation of throat cancer patients.

Method: This is an account of personal experiences of the author who is a throat cancer survivor. This rehabilitation engineer, and his social worker wife, systematically sought and found more effective ways for learning to eat again.

Results: More effective approaches for discovering, preparing, presenting and consuming food by recovering throat cancer patients were identified.

Conclusion: The rehabilitation process for patients with radiation damage to the throat can be enhanced through simple methods and dedicated efforts of the patients themselves.     

Quality assessment in rehabilitation centres: the indicator system 'Quality Profile'

Purpose: An indicator system for measuring the quality of rehabilitation centres ('Quality Profile' of rehabilitation centres) is presented. The implementation of the concept is explained with the aid of results regarding structural, process and outcome quality in 26 cardiac and orthopaedic rehabilitation centres.

Method: In each centre, structural, process and outcome quality, including patient and employee satisfaction, are measured. Process quality is determined by means of a peer review procedure that includes examination of 20 randomly selected cases on the basis of discharge reports and therapy plans. The medical outcome is measured by a prospective study with three measurement time points and a sample of approx. N = 200 patients per centre.

Results: Overall, the level of quality of the medical rehabilitation in the institutions participating in the study must be considered high. However, on almost all quality dimensions, even after a risk adjustment there are clear differences between centres, which point to the usefulness of benchmarking analyses and the need for improvements in quality in some centres.

Conclusions: The indicator system presented is a starting-point for comprehensive, comparative measurement of the quality of in-patient rehabilitation centres that, with regard to its principles, also appears applicable to other areas of health care.