Birgitta Grahn

Effects of a multidisciplinary rehabilitation programme on health-related quality of life in patients with prolonged musculoskeletal disorders: a 6-month follow-up of a prospective controlled study.

PURPOSE The aim of this prospective, controlled, follow-up study (6 months) was to examine the effects of a multidisciplinary rehabilitation programme on perceived health-related quality of life (HRQL) in patients with prolonged musculoskeletal disorders (PMSD). The programme focused on body awareness therapy and cognitive and relaxation treatment. METHOD The rehabilitation group comprised 122 patients, and there were 114 patients in the matched control group (CG). Both groups of patients had access to primary health care. Baseline data were compared with 6-month follow-up data within and between the groups. The following measurements were employed: HRQL (Nottingham Health Profile), body awareness, postural control, pain (VAS), pain-related medicine consumption, isometric arm muscle endurance, aerobic capacity, psychosomatic symptoms, physical and psychosocial working environment and sick leave. RESULTS Variables that improved significantly as compared with the CG were: HRQL, anxiety, pain related to movements, psychosomatic symptoms and need for pain-related medicines. CONCLUSIONS The multidisciplinary rehabilitation programme used here improved HRQL in patients with PMSD to a greater extent than the standard treatment provided within primary heath care (p = 0.01) at least in the short term.

Work ability – experiences and perceptions among physicians

Purpose. To describe experiences and perceptions of work ability and how it can be assessed among Swedish physicians. Method. We interviewed eight men and six women in the fields of general practice, occupational health, rehabilitation and orthopaedic surgery. Qualitative content analysis was applied to the data. Results. The approach striving to support the patient in mutual confidence was what primarily affected how work ability was understood and how it could be assessed. Two main categories, with sub categories were settled: familiar but vague, with subcategories conflicting expectations and relations and consensus within speciality and the second main category relying on intuition and examinations, with sub categories life as a whole, reasonableness, progression plan, external obstacles and need for knowledge and collaboration. Conclusions. We found that physicians mainly rely on what patients were telling about their work situation when assessing work ability. But it was not clear if they should consider the patients whole life situation, motivation and wishes. Protecting the physician–patient relationship was seen as important as well as the need for teamwork assessments and increased work place knowledge.

Reincentivizing – a new theory of work and work absence

BackgroundWork capacity correlates weakly to disease concepts, which in turn are insufficient to explain sick leave behavior. With data mainly from Sweden, a welfare state with high sickness absence rates, our aim was to develop an explanatory theory of how to understand and deal with work absence and sick leave.MethodsWe used classic grounded theory for analyzing data from >130 interviews with people working or on sick leave, physicians, social security officers, and literature. Several hundreds of typed and handwritten memos were the basis for writing up the theory.ResultsIn this paper we present a theory of work incentives and how to deal with work absence. We suggest that work disability can be seen as hurt work drivers or people caught in mode traps. Work drivers are specified as work capacities + work incentives, monetary and non-monetary. Also, people can get trapped in certain modes of behavior through changed capacities or incentives, or by inertia. Different modes have different drivers and these can trap the individual from reincentivizing, ie from going back to work or go on working. Hurt drivers and mode traps are recognized by driver assessments done on several different levels. Mode driver calculations are done by the worker. Then follows employer, physician, and social insurance officer assessments. Also, driver assessments are done on the macro level by legislators and other stakeholders. Reincentivizing is done by different repair strategies for hurt work drivers such as body repair, self repair, work-place repair, rehumanizing, controlling sick leave insurance, and strengthening monetary work incentives. Combinations of these driver repair strategies also do release people from mode traps.ConclusionReincentivizing is about recognizing hurt work drivers and mode traps followed by repairing and releasing the same drivers and traps. Reincentivizing aims at explaining what is going on when work absence is dealt with and the theory may add to social psychological research on work and work absence, and possibly inform sick leave policies.

Thoughts and feelings of future working life as a predictor of return to work: a combined qualitative and quantitative study of sick-listed persons with musculoskeletal disorders

Purpose. The main aim of this study was to describe the thoughts and feelings of future working life related to return to work (RTW) in sick-listed persons due to musculoskeletal disorders (MSD). Further aim was to compare these descriptions with the persons actual working situation 1, 5 and 10 years after a rehabilitation period. Methods. This study consisted of two parts. The first part had an explorative design, and qualitative content analysis was chosen in order to analyse the response to an open question regarding future working life answered before, persons sick-listed due to MSD (n  ==  320), took part in a rehabilitation programme 10 years ago. The second part had a prospective design and quantitative analysis was used to compare the results of the qualitative analysis with RTW and the working situation 1, 5 and 10 years after baseline. Results. Three categories emerged from the data with a total of nine subcategories. In the categories Motivation and optimism and Limitations to overcome, there were significantly more persons who had RTW 1 year after baseline when compared with the category Hindrance and hesitation. There were also some significant differences between the subcategories. Conclusions. The question, regarding thoughts and feelings of future working life, may be a simple screening method to predict RTW in persons sick-listed with MSD. This will guide the rehabilitation team to adjust the rehabilitation to each persons needs and facilitating RTW.

Promoting work ability in a structured national rehabilitation program in patients with musculoskeletal disorders: outcomes and predictors in a prospective cohort study

BackgroundMusculoskeletal disorders (MSDs) are a major reason for impaired work productivity and sick leave. In 2009, a national rehabilitation program was introduced in Sweden to promote work ability, and patients with MSDs were offered multimodal rehabilitation. The aim of this study was to analyse the effect of this program on health related quality of life, function, sick leave and work ability.MethodsWe conducted a prospective, observational cohort study including 406 patients with MSDs attending multimodal rehabilitation. Changes over time and differences between groups were analysed concerning function, health related quality of life, work ability and sick leave. Regression analyses were used to study the outcome variables health related quality of life (measured with EQ-5D), and sick leave.ResultsFunctional ability and health related quality of life improved after rehabilitation. Patients with no sick leave/disability pension the year before rehabilitation, improved health related quality of life more than patients with sick leave/disability pension the year before rehabilitation (p = 0.044). During a period of −/+ four months from rehabilitation start, patients with EQ-5D ≥ 0.5 at rehabilitation start, reduced their net sick leave days with 0.5 days and patients with EQ-5D <0.5 at rehabilitation start, increased net sick leave days with 1.5 days (p = 0.019). Factors negatively associated with sick leave at follow-up were earlier episodes of sick leave/disability pension, problems with exercise tolerance functions and mobility after rehabilitation. Higher age was associated with not being on sick leave at follow-up and reaching an EQ-5D ≥ 0.5 at follow-up. Severe pain after rehabilitation, problems with exercise tolerance functions, born outside of Sweden and full-time sick leave/disability pension the year before rehabilitation were all associated with an EQ-5D level < 0.5 at follow-up.ConclusionsPatients with MSDs participating in a national work promoting rehabilitation program significantly improved their health related quality of life and functional ability, especially those with no sick leave. This shows that vocational rehabilitation programs in a primary health care setting are effective. The findings of this study can also be valuable for more appropriate patient selection for rehabilitation programs for MSDs.

Validation of the General Motor Function Assessment Scale–An instrument for the elderly

Purpose. The purpose of this study was to test the General Motor Function Assessment Scale (GMF) for content and criterion validity in geriatric home-rehabilitation. Furthermore, the GMF was analysed with respect to sensitivity, distribution, and for floor and ceiling effects. Method. Content validity was explored by questionnaires circulated to ten experts in the field of geriatrics. Three assessment instruments were used to test 66 patients in home rehabilitation. In order to evaluate criterion validity GMF results were compared to results from the ADL-taxonomy test, and the Timed ‘Up and Go’ (TUG) test. GMF scores were analysed regarding, sensitivity, distribution and to check for floor or ceiling effects. Comparisons between pre-intervention assessments and post-intervention assessments were also made. Non-parametric statistics were used. Results. GMF covered and measured areas of relevance according to content validity. No floor effects in any of the subscales of GMF were seen. Comparison of pre-intervention and post-intervention assessments showed significant ceiling effects for all three subscales. As for criterion validity all subscales of GMF in terms of dependence, pain and insecurity correlated significantly with the activity parameter mobility of the ADL-taxonomy and TUG. GMF was sensitive enough to demonstrate changes between pre-intervention and post-intervention status. Conclusions. GMF is a relevant instrument of assessment suitable for physiotherapists rehabilitating elderly in the home environment. For elderly with minor functional limitations the GMF shows ceiling effects.

Work ability: Concept and assessment from a physiotherapeutic perspective. An interview study

The aim of this study was to ascertain experiences and perceptions among physiotherapists (PTs) in Sweden regarding the concept of work ability as well as their perspectives of their professional role in work ability assessments. We conducted an in-depth interview study with four male and twelve female physiotherapists working in the field of occupational health care, orthopaedics, primary health care or rehabilitation. Qualitative content analysis was applied to the data. Work ability was perceived as the ability to perform work tasks as requested. Having the potential to adjust at work and to allocate resources, having an attachment to the workplace and time factors were vital. The physiotherapists were striving for a well-defined role within a multiprofessional team, where work ability assessments were performed in a real work environment. The PTs experienced contradictory roles in relation to the patient but believed they could contribute with valuable material for assessments; this professional help was not always requested. It was noted that there was a need for experience and further education to enable PTs to further engage in work ability assessments. It is important to improve collaboration and to further discuss the work ability concept from the viewpoints of different professionals.

Education and Benchmarking Among Physicians May Facilitate Sick-Listing Practice

Introduction Assessing work ability and sickness certification are considered problematic by many physicians and education and implementation of guidelines to improve knowledge and skills has been requested. Our aim was to study the association between such interventions and physicians’ sick-listing practices. Methods A web-based questionnaire was sent to all physicians working in primary care, psychiatry, orthopedics/rheumatology in the southern region of Sweden before (in 2007 to 1,063 physicians) and after (in 2009 to 1,164 physicians) educational interventions in insurance medicine were offered. Results With a response rate of 58%, half of the physicians (51%) reported to work at a clinic with a sick-listing policy in 2009 compared with 31% in 2007. Primary care physicians (OR 12.4) and physicians who had participated in educational interventions in insurance medicine (OR 2.4) more often had a sick-listing policy at the clinic. Physicians with a longer medical experience (OR 0.7) and those with support at the clinic (OR 0.3) and the possibility to extend time if needed (OR 0.4) were less likely to report of problematic cases while primary care physicians were (OR 2.9). On the contrary, physicians who reported to rarely have the possibility to extend time when handling problematic cases were more likely to issue a higher number of sickness certificates. Conclusions The sick-listing process is often viewed as problematic and more often by primary care physicians. Benchmarking and education in insurance medicine together with the possibility to allocate extra time if encountering problematic cases may facilitate sick-listing practice.

Content and concurrent validity of the motivation for change questionnaire

Introduction Musculoskeletal disorders (MSD) are nowadays seen within a biopsychosocial framework, including salutogenic factors, motivation factors, and coping ability. Such a framework recognizes the importance of motivational factors in health promotion and in rehabilitation. The Motivation for Change Questionnaire (MCQ) has been developed to measure the strength of individuals’ motivation for change in life, MCQ part 1, and work situation, MCQ part 2. The purpose of the study was to test the content and concurrent validity of the MCQ on patients with prolonged musculoskeletal disorders referred to interdisciplinary rehabilitation as a basis for use in medical and occupational rehabilitation. Methods Content validity was studied among an expert group of 20 rehabilitation professionals at a rehabilitation centre, and with 10 individuals suffering from prolonged MSD in the south of Sweden. The experts evaluated the clinical relevance of each question in MCQ. Concurrent validity was studied on 58 patients with prolonged MSD at an interdisciplinary rehabilitation centre in the south of Sweden. They answered MCQ, QPS Nordic questionnaire, KASAM and the Action theory questionnaire. Spearman’s rank correlation coefficient was used in the analyses. Results The MCQ covered and measured areas of relevance according to content validity. No floor effects in any of the subscales of MCQ part 1 were seen. In MCQ part 2, floor effects were seen in two sub indexes. As for concurrent validity subscales of MCQ correlated significantly with QPS Nordic questionnaire and KASAM. Conclusions Findings so far indicate the instrument to be valid for use within the present patient group. The questionnaire can be used to identify patient’s motivating factors for change in life and work, as a basis for motivational work within rehabilitation.

Early workplace dialogue in physiotherapy practice improved work ability at 1-year follow-up—WorkUp, a randomised controlled trial in primary care

Abstract Workplace involvement in rehabilitation for patients with musculoskeletal pain may improve work ability. Convergence Dialogue Meeting (CDM) is a model aimed at helping the patient, the care giver, and the employer to support work ability and return-to-work. Our aim was to study the effect on work ability when adding a workplace dialogue according to CDM in physiotherapy practice for patients with pain in ordinary primary care. We conducted a prospective pairwise cluster randomised controlled trial (ClinicalTrials.gov ID: NCT02609750) in primary care involving 20 primary care rehabilitation units with 1-year follow-up. Adult patients with acute/subacute neck and back pain, worked ≥4 weeks past year and not currently on sick leave or no more than 60 days of sick leave and considered at-risk of sick leave were included (n = 352). All patients received structured physiotherapy and the intervention was the addition of CDM, delivered by the treating physiotherapist. The main confirmatory outcome, work ability (defined as working at least 4 consecutive weeks at follow-up), was assessed by a weekly short text message question on number of sick leave days past week. Work ability was reached by significantly more patients in the intervention group (108/127, 85%) compared with the reference group (127/171, 74%) (P = 0.02). The intervention increased the odds of having work ability at 1-year follow-up, also after adjustment for baseline health-related quality of life (odds ratio 1.85, confidence interval 1.01-3.38). We conclude that an early workplace dialogue in addition to structured physiotherapy improved work ability significantly.