Is global outcome predictable in the rehabilitation of patients with musculoskeletal disorders? A pilot study.

Abstract

Definition of prognostic factors for outcome quality is of increasing interest in rehabilitation medicine. The main question of this pilot study in 552 patients was whether global outcome could be predicted by a team-based chief physician specialized in physical medicine and rehabilitation (PMR), and whether other predictive factors would exist (ICIDH-2 levels, pain, working incapacity). Little data is available about the possibility of global prediction of prognosis in the rehabilitation of patients with musculoskeletal disorders. All 552 patients met each member of the rehabilitation team and key data from each patient was discussed at the rehabilitation conference within the first 2 days. On entry to the study, a chief physician specialized in PMR assessed the patient's key data, which was structured according to ICIDH-2 (ICF) and assessed quantitatively on a scale from zero to ten. Second, the PMR physician rated the expected global prognosis on the basis of ICIDH-2 and other key data, and in respect to the defined rehabilitation goals (see Table 2). At the same time, the patient and an assistant doctor (AD) assessed pain scores (VAS 0-10) and the actual working incapacity (%). These assessments were completed within the first 3 days and were repeated before discharge. Assessment of outcome was rated by both, separately, according to the above-mentioned scale. Different regression models were calculated, searching for significant differences between the numerous variables. In the regression models, the best predictor for outcome was the PMR physician assessment. Complete and good correspondence between prediction and outcome was obtained in 71.4% (42.1% and 29.3%, respectively) in the descriptive model. Quantitatively assessed ICIDH-2 levels, pain at entrance and working incapacity at entrance were not predictive factors for global outcome. The global outcome was rated as very good/good in 79.0% of cases by patient and in 75.1% cases by the AD, as moderate in 13.9% of cases by the patient and 18.4% of cases by the AD, and as poor/worsening in 7.1% of cases by the patient and in 6.5% of cases by the AD. Rating of outcome by the patient and the AD gave complete and good correspondence in 87.6% and no correspondence in only 2.6% of cases. Pain could be reduced highly significantly (P<0.001). There was a highly significant degree of correlation between quality of outcome and pain relief (outcome 'very good' and 'good', P<0.001; 'moderate', P=0.003; 'poor/worsening', not significant). Partial or complete reduction of working incapacity could be reached in 30% of the patients. This had no statistical influence on global outcome; neither did persistent working incapacity. Prediction of global outcome by a team-based PMR assessment seems to be a useful semiquantitative method with high predictive value. The method, including the critical point of validation, is currently being extensively discussed. Prediction is an integral process based on the high information grade of a multiprofessional rehabilitation team, the ICIDH-2 structures, the definition of rehabilitation goals, the knowledge and experience in bio-psycho-social medicine and the application of common sense. Rating of global outcome by the patient/AD is an integrative process as well. Pain relief is an important and very strong factor, with a high degree of influence on global outcome in musculoskeletal rehabilitation, probably by improving quality of life. Working incapacity is no reason for refusing patients rehabilitation and both improvement of working capacity and persistence of working incapacity, has no statistical influence on global outcome. Finally, the extent of the four ICIDH-2 levels, especially negative contextual factors, were not predictive, that is, they had no significant influence on global outcome in this study. In conclusion, prediction of global outcome by a team-based chief physician specialized in PMR is of high predictive value, practicable and useful for rehabilitation processes, quality assurance, insurance companies and health policies. To our knowledge, this is the first published study on this topic.