Rehabilitation with intensive attention training early after acquired brain injury promotes better long-term status on health-related quality of life, daily activities, work ability and return to work.

OBJECTIVE: To describe long-term effects on activity, participation, and quality of life (i) at different post-injury starting time points of attention training and (ii) of two different types of rehabilitation with attention training in patients after stroke or traumatic brain injury; and to describe their functioning level. DESIGN: 2 years after rehabilitation intervention, comparisons were made in one cohort receiving attention training subacute (< 4 months) or post-acute (4-12 months) and in one cohort with two different training methods, a process-based and an activity-based method respectively. PATIENTS: 100 patients were recruited from our earlier RCT study. They had mild to moderate stroke or traumatic brain injury with relatively limited symptomatology, and all had moderate to severe attention impairment. METHODS: A questionnaire-based interview: EuroQol 5 dimensions, Occupational Gaps Questionnaire, Work Ability Index, self-assessed work status, self-reported employment conditions, sick leave, and experienced cognitive limitations in work performance. RESULTS: An advantage for patients receiving subacute attention training regarding daily activities, work ability and returning to work. CONCLUSION: The results indicate that subacute rehabilitation with attention training (< 4 months) is preferable compared to post-acute intervention (4-12 months). There were only minor differences between the training methods.

Variability in patient characteristics and service provision of interdisciplinary pain rehabilitation: A study using the Swedish national quality registry for pain rehabilitation.

OBJECTIVE: To describe the organization, content and dosage of interdisciplinary pain rehabilitation, and the differences in degree of severity of problems of patients admitted to clinical units reporting to a Swedish national quality pain registry, grouped according to unit size and possible affiliation with a university hospital. METHODS: Reports from 31 out of 39 clinical units in Sweden, on inclusion processes, organization, content and dosage of interdisciplinary pain rehabilitation, and patient-reported data from a Swedish national quality pain registry at assessment for interdisciplinary pain rehabilitation were analysed. RESULTS: the number of patients treated annually at each unit ranged from 3 to 340. In 17 units, teams comprised 5 professionals. Dosage of interdisciplinary pain rehabilitation ranged from 20-180 h per patient in total. Patients at the university-hospital units scored the highest levels of symptoms and lowest levels of health-related quality of life. Units used similar sets of inclusion criteria, and several treatments, such as education, self-training and psychological interventions, were used by most units. CONCLUSION: When interpreting outcome data from registries, aspects other than rehabilitation outcomes must be considered. The interpretation of outcomes from quality registries would be facilitated if data, in addition to assessments and patient-reported outcomes, also includes standardized descriptions of the reporting clinical units.

Preliminary ICF core set for patients with myalgic encephalomyelitis/chronic fatigue syndrome in rehabilitation medicine.

OBJECTIVE: To create and evaluate a preliminary ICF Core Set for myalgic encephalomyelitis/chronic fatigue syndrome using a team-based approach. DESIGN: Observational study. SUBJECTS/PATIENTS: A total of 100 consecutive patients (mean age 45 years (standard deviation (SD) 9 years)) were assessed by a rehabilitation team and included in the study. METHODS: A preliminary International Classification of Functioning, Disability and Health (ICF) Core Set was created, based on literature studies, and on discussion forums between the team and the researchers. Patients were assessed by a rehabilitation medicine team regarding impairments in body function, activity limitations, and restrictions in participation. RESULTS: Clinical assessments of the component Body Functions found impairments in energy, fatigue, physical endurance, fatigability, sleep and pain in 82-100% of patients. At least half of the patients had impairments in higher cognitive functions, attention, and emotions, as well as sound and light hypersensitivity, general hyper-reactivity and thermoregulatory functions. For the component Activity/Participation, the most frequent limitations and restrictions were in doing housework (93%), assisting others (92%), acquisition of goods and services (90%), remunerative employment (87%), handling stressful situations (83%), preparing food (83%), recreation and leisure (82%), informal socializing (78%) and carrying out daily activities (77%). The most frequent degrees of impairments/limitations/restrictions assessed were light and moderate, except for remuneative employment, for which restrictions were severe. CONCLUSION: Using unconventional methods, this study sets out a preliminary ICF Core Set list for patients with myalgic encephalomyelitis/chronic fatigue syndrome. Further studies are required to improve and test this Core Set in myalgic encephalomyelitis/chronic fatigue syndrome populations.

Daily management of attention dysfunction two-four years after brain injury and early cognitive rehabilitation with attention process training: a qualitative study.

The evaluation of intensive cognitive training is usually based on neuropsychological tests and questionnaires. A study of the subjective experience of cognitive training would provide another type of valuable information concerning the effects of rehabilitation. We used grounded theory methods to explore the experience and management of attention dysfunction in daily life two-four years after brain injury. Data were collected by in-depth interviews of 14 adults with moderate-to-mild attention dysfunction after stroke or traumatic brain injury, and working part time or full time at the time of the interviews. The group received 20 hours of attention process training within the context of multidisciplinary rehabilitation early after brain injury. Data were analysed by open coding with constant comparison. The management of attention dysfunction was described by the informants as a dynamic process where strategies are continuously refined and flexibly adjusted as awareness and metacognitive knowledge increases. This process is regulated by situation-dependent factors. Attention process training might provide a suitable starting point for the identification of problem areas, improved specific goalsetting and stimulated self-training. The model describes the dynamic nature of the process, the ongoing struggle, self-training and search for feedback.

Burn survivors' pulmonary and muscular impairment, exercise tolerance and return-to-work following medical-vocational rehabilitation: A long-term follow-up.

OBJECTIVE: To follow up the long-term outcome in return-to-work (RTW) rate in burn-injury patients, and to determine the degree of impairment in pulmonary and muscular function and exercise tolerance. DESIGN: A prospective, longitudinal follow-up study without a control group. PATIENTS: Twenty-five burn-injury patients referred for medical-vocational rehabilitation. METHODS: Return-to-work rate was followed after completed medical-vocational rehabilitation. Pulmonary function was evaluated with spirometry, diffusing capacity and radio spirometry. Exercise capacity was determined using a bicycle ergometer. Muscle functions evaluated in the arms and legs were: isokinetic torque, isometric strength, endurance and muscular strength utilization. RESULTS: Return-to-work rate was 87%. During bicycle exercise tests the patients, on average, reached their expected workloads. The dominating lung func-tion abnormality observed on lung scintigraphy was delayed wash-out time of inhaled radioactive xenon gas, suggesting airway obstruction. All tests of shoulder-flexor and knee-extensor muscle function showed large minimum-maximum differences. Mean isometric endurance of shoulder flexors was lower than mean of references, and isokinetic knee extensor torques were slightly lower. CONCLUSION: High return-to-work rates can be achieved after burn injury requiring hospital-ward care. Despite measurable impairments in muscle strength/endurance and pulmonary function in a substantial proportion of these patients, overall normal bicycle exercise capacity was observed except for a few cases.

Relationship between sleep disturbance, pain, depression and functioning in long-term sick-listed patients experiencing difficulty in resuming work.

OBJECTIVE: To describe the frequency of reported sleeping, depression and pain problems, the severity of these problems and the degree of self-estimated difficulties in mental functions and activities in relation to the sleep disturbance and pain category group in patients on long-term sick-leave. DESIGN: Cross-sectional study. PATIENTS: A total of 1206 patients experiencing difficulty in resuming work. METHODS: Patient examinations by specialists in psychiatry, orthopaedic surgery and rehabilitation medicine. Validated questionnaires, including status regarding depression, sleep, pain and functioning were used. RESULTS: The prevalence of sleep disturbance was 83%; 74% of the patients with moderate/severe sleep disturbance also had moderate/severe pain problems and 26% had no/mild pain problems. Fifty-seven percent of the patients with no/mild sleep disturbance and 83% of the patients with moderate/ severe sleep disturbance also had depression. The degree of difficulty in performing the 6 selected International Classification of Functioning, Disability and Health activities and mental functions was higher for the category with moderate/severe sleep problems, compared with those with no/mild sleep problems. CONCLUSION: To optimize rehabilitation for patients on long-term sick-leave experiencing difficulties in returning to work, the results indicate a need also to focus attention on sleep problems and not only on pain and depression. This may entail the planning of measures to improve decision-making and concentration and alleviate lassitude, fatigability, sadness and pessimistic thoughts.

Using a profile of a modified Brief ICF Core Set for chronic widespread musculoskeletal pain with qualifiers for baseline assessment in interdisciplinary pain rehabilitation.

AIM: To describe the use of a "workable" visual profile of function and disability, based on a modified Brief International Classification of Functioning, Disability and Health (ICF) Core Set for chronic widespread pain, for initial assessments in a clinical setting of interdisciplinary pain rehabilitation teams. METHOD: The Brief ICF Core Set was slightly adapted to meet the needs of an interdisciplinary rehabilitation medicine team working in a university outpatient clinic and admitting patients referred from primary care. The Core Set categories were made measurable by means of eg, assessment instruments and clinical investigations. The resulting profile was given a workable shape to facilitate rapid understanding of the initial assessment outcome. RESULTS: Individual patients showed different profiles of problems and resources, which facilitated individual rehabilitation planning. At the level of the study group, the profiles for the Core Set component Body Functions showed that most patients had severe impairment in the sensation of pain and exercise tolerance categories of function, but most had resources in the motivation and memory categories of function. Likewise, for the component Activities, most patients had limitations in lifting and carrying objects and remunerative employment, but most had resources in intimate relationships and family relationships. At first, the use of the modified Brief ICF Core Set in the team conference was rather time consuming, but after a couple of months of experience, the team assessment took approximately 30 minutes to complete per patient. CONCLUSION: The profile of the modified Brief ICF Core Set for chronic widespread pain served as a common platform, facilitating cooperation between the rehabilitation team members and providing a uniform language, which helped in structuring the clinical work. The profile also provided an easily accessible, overall view of the patient's problems and resources, which helped in understanding the functioning situation of the patient.

ICF Core Set for vocational rehabilitation: results of an international consensus conference.

PURPOSE: Vocational rehabilitation (VR) programs aim to facilitate work participation. However, there is no universal framework to describe the functioning of individuals who participate in VR. The objective of this paper is to report on the Core Set for VR based on the International Classification of Functioning, Disability and Health (ICF) by the World Health Organization (WHO). METHODS: A formal decision-making and consensus-based process was conducted based on the evidence from four preparatory studies. Twenty-three international experts chosen by WHO Region and expertise in VR attended the consensus conference. RESULTS: Ninety ICF categories were included in the comprehensive Core Set (activities and participation = 40, environmental factors = 33, body functions = 17), while the brief Core Set included 13 second-level categories (activities and participation = 6, environmental factors = 4, body functions = 3). CONCLUSIONS: The expert opinion and evidence-based Core Set could serve as an international standard for what to measure and report concerning functioning of individuals in VR. The Core Set could also provide a common language among clinicians, researchers, insurers, and policymakers in the implementation of successful VR. Further testing and validation studies are encouraged.

Differences in symptoms, functioning, and quality of life between women on long-term sick-leave with musculoskeletal pain with and without concomitant depression.

OBJECTIVE: The aim was to describe the differences in symptoms, functioning and quality of life between women on long-term sick-leave due to protracted musculoskeletal pain with and without concomitant depression. DESIGN: Descriptive and comparisons with/without comorbid depression. METHODS: 332 female patients were examined by three specialist physicians in psychiatry, orthopedic surgery, and rehabilitation medicine and assigned to four groups according to the ICD-10 diagnoses: low back/joint disorders (LBJ, n = 150), myalgia (M, n = 43), fibromyalgia (FM, n = 87), or depression without somatic pain diagnosis (DE, n = 52). RESULTS: Patients with somatic pain conditions LBJ, M, or FM showed more activity-related difficulties if concomitant depression was present during the activities 'focusing attention', 'making decisions', and 'undertaking a single task'; and in the domains 'energy level', 'memory functions', 'emotional functions', and 'optimism/pessimism'. Patients with FM and concomitant depression perceived higher pain intensity than patients in group DE. No statistically significant differences in physically related activities were noted between each of the somatic pain conditions with and without coexisting depression. FM patients with coexisting depression reported fewer painful sites on their pain drawings compared with FM-patients without depression. Patients with LBJ or FM and concomitant depression reported lower quality of life in the dimensions vitality, social functioning, emotional role, and mental health. Comorbid depression affected disability and restricted working capacity by reducing mental activity and functioning but not by affecting physical activity problems. CONCLUSION: Women on long-term sick-leave, who have concomitant depression with LBJ or FM, also have more difficulties in focusing attention, making decisions, and carrying out tasks, and with memory functions and optimism/pessimism, as well as reduced quality of life in the dimensions of vitality, social functioning, emotional role, and mental health, than female patients without comorbid depression. As a consequence we suggest further efforts to integrate somatic and psychiatric interventions in the same rehabilitation program.

A conceptual definition of vocational rehabilitation based on the ICF: building a shared global model.

BACKGROUND: The International Classification of Functioning, Disability and Health (ICF) is a conceptual framework and classification system by the World Health Organization (WHO) to understand functioning. The objective of this discussion paper is to offer a conceptual definition for vocational rehabilitation (VR) based on the ICF. METHOD: We presented the ICF as a model for application in VR and the rationale for the integration of the ICF. We also briefly reviewed other work disability models. RESULTS: Five essential elements of foci were found towards a conceptual definition of VR: an engagement or re-engagement to work, along a work continuum, involved health conditions or events leading to work disability, patient-centered and evidence-based, and is multi-professional or multidisciplinary. CONCLUSIONS: VR refers to a multi-professional approach that is provided to individuals of working age with health-related impairments, limitations, or restrictions with work functioning and whose primary aim is to optimize work participation. We propose that the ICF and VR interface be explored further using empirical and qualitative works and encouraging stakeholders' participation.

The ICF and postsurgery occupational therapy after traumatic hand injury.

Recent studies have examined the effectiveness of hand rehabilitation programmes and have linked the outcomes to the concept of ICF but not to specific ICF category codes. The objective of this study was to gain experience using ICF concepts to describe occupational therapy interventions during postsurgery hand rehabilitation, and to describe improvement in functioning using ICF categories. In addition, investigated was the agreement between the ICF categories for occupational therapy interventions and the outcome measures used. Fifteen patients with traumatic hand injuries agreed to participate. Outcome measures were used to assess the following variables: range of motion, grip strength, pain intensity, upper-extremity functioning and health-related quality of life. Analysis of variance for repeated measures was used between the measures at baseline and at 3-month and 12-month follow-ups. The results showed that a pattern of occupational therapy interventions concerning body functions and body structures, activities and environmental factors could be identified during the early postsurgery phase and for interventions at participation level during the later phase. Agreement between occupational therapy interventions and outcome measures was found for 11 pairs. Three of the pairs concerned body function and eight were at the activity and participation level. During the rehabilitation process, the majority of improvements took place between baseline and the 3-month follow-up. We concluded that ICF categories can be used to describe occupational therapy interventions in postsurgery hand rehabilitation after trauma; that the use of ICF as a reference framework provides a clear picture of which health domains are addressed; and that a consistent use of ICF categories facilitates linking between rehabilitation interventions and outcome assessments, thereby increasing the possibility of showing the effects of these interventions.

Developing a Core Set to describe functioning in vocational rehabilitation using the international classification of functioning, disability, and health (ICF).

INTRODUCTION: The consequences of accidents, injuries, and health conditions that prevent workers from engaging in employment are prevailing issues in the area of work disability. Vocational rehabilitation (VR) programs aim to facilitate return-to-work process but there is no universal description of functioning for patients who participate in VR. Our objective is to develop a Core Set for VR based on the international classification of functioning, disability, and health (ICF). An ICF Core Set is a short list of ICF categories with alphanumeric codes relevant to a health condition or a health-related event. METHODS: Development process consists of three phases. First is the preparatory phase which consists of four parallel studies: (1) systematic review of the literature, (2) worldwide survey of experts, (3) cross-sectional study, and (4) focus group interview. Patients with various health conditions are to be recruited from five VR centers located in Switzerland and Germany. The second phase is a consensus conference where findings from the preparatory phase will be presented followed by a multi-stage consensus process to determine the ICF categories that will comprise the Core Set for VR. The final phase consists of validation studies in several health conditions and settings. CONCLUSIONS: We expect the first version of the ICF Core Set for VR to be completed in 2010. The Core Set can serve as a guide in the evaluation of patients and in planning appropriate intervention within VR programs. This Core Set could also provide a standard and common language among clinicians, researchers, insurers, and policymakers in the implementation of successful VR.

Improved employment rates after multiprofessional cross-sector cooperation in vocational rehabilitation: a 6-year follow-up with comparison groups.

The objective of this study was to better understand the long-term effects of an improved model for cooperation on employment between rehabilitation professionals in vocational rehabilitation (VR). To compare these effects with those associated with the traditional model of cooperation. The study featured a group of patients who participated in a developmental project. All of the patients had some degree of restricted work capacity, which was evidenced somatically as well as mentally/socially. They had all experienced long periods of unemployment during the 2-year period before the intervention. A 'natural experiment study design' that relied on database records was used. Using matching criteria, we identified 'social twins' from a government register to create comparison groups at the local, county and national levels (n = 4 x 51 patients). Repeated-measures analysis of variance and logistic regression were used to analyse the data. The majority (59%) of the study group was employed 3 years after the intervention compared with 39 and 41% in the two matched control groups, respectively. The corresponding figures after 6 years were 51 versus 39 and 37%. An individual with a somatically restricted work capacity was about twice as likely to secure gainful employment following VR as compared with an individual with a mentally/socially restricted work capacity. In conclusion, the study focused on an improved method of cooperation between rehabilitation actors in the context of VR programmes. A model that included systematic multiprofessional cross-sector group meetings was explored, and we concluded that a substantial percentage of the enrolled patients successfully secured employment over a 6-year period. This percentage exceeded that of matched pairs in a county and national group; we presume that these groups represented 'the usual form of cooperation'.

Vocational rehabilitation: an educational review.

The aim of this review is to describe aspects of vocational rehabilitation relevant for a physician aiming to become a specialist in physical and rehabilitation medicine (PRM). The review discusses the epidemiology of incapacity for work, the major patient groups in vocational rehabilitation (musculoskeletal and psychiatric diagnoses comprise approximately 50-70% of the patients), the influence of different kinds of environmental and individual risk factors on work resumption (such as the legal framework, application of the law, resources for rehabilitation and its effectiveness, the degree of co-operation between vocational rehabilitation agencies, economic factors/labour market situation, medical and personal factors). The review describes different models of vocational rehabilitation, the effectiveness of various vocational rehabilitation programmes on work resumption or sick leave (where strong evidence is reported for multi-modal rehabilitation programmes for patients with long-lasting musculoskeletal pain). Finally, there are sections about the PRM physician's history-taking in vocational rehabilitation (using the International Classification of Functioning, Disability and Health (ICF)), and report writing with a structure where ICF body functions and activity limitations are reported separately.

Long-term sick leavers with difficulty in resuming work: comparisons between psychiatric-somatic comorbidity and monodiagnosis.

The number of patients with difficulty in resuming work after long-term sick leave has increased in several European countries including Sweden. The general aim of this study was a comprehensive description--based on multidisciplinary diagnostics and assessments--of patients with the common feature of marked difficulty in resuming working life after a long absence. A particular aim was to elucidate the possible effect of comorbidity on pain descriptors, disability, quality of life, assessed working ability and rehabilitation needs. Six hundred and thirty-five long-term sick leavers were referred from National Insurance Offices and consecutively accepted for investigation. Several self-report questionnaires were used. All patients were examined by three board-certified specialist physicians in psychiatry, orthopaedic surgery and rehabilitation medicine, respectively. Fifty-five percent of the patients had psychiatric-somatic comorbidity. The three most frequent combinations of diagnoses in the comorbidity group were fibromyalgia/myalgia and depressive episode, fibromyalgia/myalgia and recurrent depression, spinal pain and depressive episode, whereas the three most frequent in those with psychiatric diagnosis only were depressive episode, recurrent depression, phobias/anxiety. Differences in pain descriptors and in difficulties with activities were found among the three groups. All had lower health-related quality of life than references. Only one-sixth had no assessed working capacity and only 3% were assessed as able to resume work without rehabilitation; 80% were multidisciplinarily assessed as needing rehabilitation. Patients with psychiatric diagnoses, with or without concomitant somatic diagnoses, need medical rehabilitation or medical/vocational rehabilitation in combination to a greater extent than patients with somatic diagnoses only. This implies that medical rehabilitation programmes ought to adapt increasingly to the needs of patients with psychiatric-somatic comorbidity.

Long-term sick-leavers with fibromyalgia: Comparing their multidisciplinarily assessed characteristics with those of others with chronic pain conditions and depression.

OBJECTIVE: The aim was to gain knowledge of fibromyalgia (FM) patients on long-term sick leave and with particular difficulties in resuming work, and to compare them with patients with myalgia, back or joint diagnoses, and depression. METHODS: Patients were identified by and referred from social insurance offices and were multidisciplinarily examined by three board-certified specialists in psychiatry, orthopedic surgery and rehabilitation medicine. Ninety-two women were diagnosed with FM only. Three female comparison groups were chosen: depression, back/joint diagnoses, and myalgia. RESULTS AND CONCLUSIONS: Ceaseless pain was reported by 73% of FM patients, 54% of back/joint diagnoses patients, 43% of myalgia patients, and 35% of depression patients. The distribution of pain (>50%) in FM patients was to almost all regions of the body, and in depression patients to the lower dorsal neck, upper shoulders and lumbosacral back but not in the anterior body. Reduced sleep was more evident in FM patients. FM patients did not meet more criteria for personality disorder than patients with the other somatic pain conditions. The most common dimension of "personality traits" of somatic pain conditions was the "obsessive compulsive" but at a level clearly below that indicating a personality disorder. More FM patients experienced disabilities, the most common being in the mobility and domestic-life areas.

Systematic co-operation between employer, occupational health service and social insurance office: a 6-year follow-up of vocational rehabilitation for people on sick-leave, including economic benefits.

OBJECTIVE: To evaluate the effects of systematic co-operation among municipal employees on the number of sick-leave days per month and the type of benefit granted by the Social Insurance Office. A further aim was to evaluate the economic consequences for society. DESIGN: A 6-year follow-up study with a matched-pairs design. METHODS: Days on sick-leave were calculated for each subject one year before the intervention started and yearly for the following 6-year period. Statistical mixed-model analysis was used. The economic benefit of the intervention was estimated as the increased production stemming from fewer days on sick-leave. SUBJECTS: Sixty-four employees on long-term sick-leave were individually matched with controls from another Social Insurance Office in a county with a socioeconomic structure similar to that of the study group. RESULTS: The study group had 5.7 fewer days on sick-leave per month and person over the 6-year period (p=0.003). The estimated average economic benefit of the intervention was euro36,600 per person over the 6-year period. In conclusion, those who received systematic co-operation in vocational rehabilitation had fewer days on sick-leave than their "treatment-as-usual" peers. This effect persisted over 6 years, generating substantial net economic gains for society.

Does rehabilitation decrease shoulder muscle activity in fibromyalgia in work or housework tasks? An electromyographical study.

PURPOSE: This study sought to investigate whether patients with fibromyalgia (FM) are able to perform a work task and home care tasks with less muscle activity, recorded as surface EMG, after a rehabilitation programme as compared to before rehabilitation. METHOD: Muscle activity in shoulder and arm muscles was measured with surface EMG during a job task and three housework tasks before and after an individually adjusted rehabilitation programme for 16 female patients with FM. Ten healthy women were measured in the same way. Pain intensity and perception of exertion were assessed with Borg's CR100 scale after every activity. RESULTS: The patients decreased their muscle activity more than the healthy subjects did in the trapezius pars descendens of the non-dominant side during computer typing and ironing. A decrease in pain intensity and perceived exertion after the computer typing and ironing coincided with the decreased muscle activity. CONCLUSION: Patients with FM are able to learn to perform a work task and a home-care task with less muscle activity in trapezius pars descendens after a rehabilitation programme. Decreased pain intensity and perception of exertion may indicate that these two experiences accompany the decrease in muscle activity.

Multi-professional vocational rehabilitation group meetings with female clients: a qualitative study.

Many women require vocational rehabilitation before they can return to work. The objective with the present study was to describe female clients' situation during the rehabilitation process, as it became apparent during the rehabilitation meetings with the various actors involved. The clients' diagnoses varied, but the majority was affected with musculoskeletal disorders. The meetings were audio-taped and transcribed verbatim, after which they were analysed by qualitative content analysis. The following themes emerged: Adaptation to the rehabilitation group; client's health status; the workplace's significance for rehabilitation; and the client's decision-point. Conflict between health and work was immensely important for rehabilitation. Differences in attitude were apparent during the rehabilitation meetings, as some clients were passive and exercised less influence on the planning, than the other more active clients did.