Assessment Of Work Capacity Research Articles

Quality of medical certificates issued in long-term sick leave or disability in relation to patient characteristics and delivery of health care

To assess the quality of medical certificates issued during long-term sick leave or disability. We collected a stratified randomised sample of 250 medical certificates issued for assessment of work capacity: Certificates issued in primary health care (PHC) with a locomotor, psychiatric or other main diagnosis, in psychiatric care, and in other secondary care. Four experts performed a quality assessment per section of the certificate and globally. The certificates varied from short notes to extensive documents. Those issued in PHC included more diagnoses per certificate (p < 0.0001) than in secondary care. PHC physicians had a longer professional relationship to their patients (p = 0.009). Information on work capacity was entirely adequate and relevant in only 10% of the certificates. Disturbed mental function was indicated in 60% of the certificates without psychiatric main diagnosis. Whether indicated medical state influenced functional state was not assessable in 46 (19 %) of the certificates due to lack of information. Similarly, if reduced function influenced working capacity was not assessable in 66 (27 %) of the certificates. The global quality differed (p < 0.0001) between certificates issued in primary care 5.7 (CI 5.5-5.9) and secondary care 6.9 (CI 6.5-7.3). There is a need for improvement of the quality of medical certificates issued in cases of long-term sick leave or disability. The quality of medical certificates was low and lacked necessary information requested by the Social Insurance Agency. The quality was lower in certificates issued in primary care, which might be explained by a different case-mix.

1054 – Assessment of health and working capacity of people with dementia for purposes of the social security system

A new approach to health assessment and the rate of working capacity decline of patients suffering from dementia, is based on the results (as of January 1, 2010) of a project entitled: Advances in medical science reflected in functional health state assessment and working incapacity in relation to International Classification of Diseases and International Classification of Functioning, Disability and Health. The total number of hospitalizations due to dementia (F01, F03, G30) increased by more than one fifth (from 6549 to 7981 hospitalizations) between 2006 and 2010. However, the overall number of disabilities between 2006 and 2009 decreased by one half (from 2998 to 1571), and between 2010 and 2011 dropped to 5% of its original number (190 and 144 cases respectively). Nevertheless, between 2007 and 2011, there was a 50% increase in the number of patients with institutionally confirmed disabilities (from 6270 to 9504). Conclusion The new approach to incapacity assessment is in accordance with medical experts' opinions and advances in medical science, related to function ability, activity and participation. The new way of incapacity assessment could be the reason for the dramatic decrease in the number of institutionally confirmed disabilities in 2010 and 2011, despite the growing number of patients suffering from dementia. Such discrepancy may also be explained by early diagnostics and more effective treatment, which prevent patients with dementia from becoming disabled. Moreover, this hypothesis corresponds to the increasing number of patients with a certain degree of dependence due to dementia.

Development of short form questionnaires for the assessment of work capacity in cardiovascular rehabilitation patients

Prevention of job loss is an essential objective of cardiovascular rehabilitation. However, comprehensive and economic diagnostic instruments on work limitations are missing. The present study describes development of short form questionnaires from 2 domains of the WCIB-Cardio item banks for the assessment of work capacity in cardiovascular rehabilitation patients. 283 cardiovascular rehabilitation patients were recruited from 14 German rehabilitation clinics. Based on the WCIB-Cardio with the domains of cognitive and physical work capacity, we developed a short form for both domains. Item selection criteria were content coverage, content appropriateness, internal consistency reliability (≥ 0.8). We used correlation of person location scores of the short forms with person location scores of the full item banks to examine the extent of measurement precision. For each domain of the WCIB-Cardio a short form was developed (cognitive work capacity - 14 items; physical work capacity 7 - items). In both domains psychometric properties were good (person separation index: cognitive work capacity - 0.80; physical work capacity - 0.80). Correlation meaures of the short form with the full item banks showed a high accordance of person locations for both domains (cognitive work capacity: r = 0.97; physical work capacity: r = 0.95). The calibrated instrument WCIB-Cardio provides the possibility to develop short form questionnaires with high psychometric quality. These short forms make it possible to monitor patient's work capacity in cardiovascular rehabilitation settings in a more economical way.

Aspects of functioning and environmental factors in medical work capacity evaluations of persons with chronic widespread pain and low back pain can be represented by a combination of applicable ICF Core Sets

BackgroundMedical work capacity evaluations play a key role in social security schemes because they usually form the basis for eligibility decisions regarding disability benefits. However, the evaluations are often poorly standardized and lack transparency as decisions on work capacity are based on a claimant’s disease rather than on his or her functional capacity. A comprehensive and consistent illustration of a claimant’s lived experience in relation to functioning, applying the International Classification of Functioning, Disability and Health (ICF) and the ICF Core Sets (ICF-CS), potentially enhances transparency and standardization of work capacity evaluations. In our study we wanted to establish whether and how the relevant content of work capacity evaluations can be captured by ICF-CS, using disability claimants with chronic widespread pain (CWP) and low back pain (LBP) as examples.MethodsMixed methods study, involving a qualitative and quantitative content analysis of medical reports. The ICF was used for data coding. The coded categories were ranked according to the percentage of reports in which they were addressed. Relevance thresholds at 25% and 50% were applied. To determine the extent to which the categories above the thresholds are represented by applicable ICF-CS or combinations thereof, measures of the ICF-CS’ degree of coverage (i.e. content validity) and efficiency (i.e. practicability) were defined.ResultsFocusing on the 25% threshold and combining the Brief ICF-CS for CWP, LBP and depression for CWP reports, the coverage ratio reached 49% and the efficiency ratio 70%. Combining the Brief ICF-CS for LBP, CWP and obesity for LBP reports led to a coverage of 47% and an efficiency of 78%.ConclusionsThe relevant content of work capacity evaluations involving CWP and LBP can be represented by a combination of applicable ICF-CS. A suitable standard for documenting such evaluations could consist of the Brief ICF-CS for CWP, LBP, and depression or obesity, augmented by additional ICF categories relevant for this particular context. In addition, the unique individual experiences of claimants have to be considered in order to assess work capacity comprehensively.

Sickness certification as a complex professional and collaborative activity - a qualitative study

BackgroundPhysicians have an important but problematic task to issue sickness certifications. A manifold of studies have identified a wide spectrum of medical and insurance-related problems in sickness certification. Despite educational efforts aiming to improve physicians’ knowledge of social insurance medicine there are no signs of reduction of these problems. We hypothesised that the quality deficits is not only due to lack of knowledge among issuing physicians. The aim of the study was to explore physicians’ challenges when handling sickness certification in relation to their professional roles as physicians and to their interaction with different stakeholders.MethodsOne hundred seventy-seven physicians in Stockholm County, Sweden, participated in a sick-listing audit program. Participants identified challenges in handling sick-leave issues and formulated action plans for improvement. Challenges and responsible stakeholders were identified in the action plans. To deepen the understanding facilitators of the program were interviewed. A qualitative content analysis was performed exploring challenge categories and categories of stakeholders with responsibility to initiate actions to improve the quality of the sick-listing process. The challenge categories were then related by their content to professional competence roles in accord with the Canadian Medical Education Directions for Specialists (CanMEDS) framework and to the stakeholder categories.ResultsSeven categories of challenges were identified. Practitioner patient interaction, Work capacity assessment, Interaction with the Social Insurance Administration, The patient’s workplace and the labour market, Sick-listing practice, Collaboration and resource allocation within the Health Care System, Leadership and routines at the Health Care Unit. The challenges were related to all seven CanMEDS roles. Five categories of stakeholders were identified and several stakeholders were involved in each challenge category.ConclusionsPhysicians performing sickness certification tasks experience a complex variety of challenges. From physician perspective actions to handle these need to be initiated in interaction with both medical and non-medical stakeholders. The relation between the challenges and a well-established professional competence framework revealed a complex pattern. Thus, from a public health perspective, educational activities aimed to improve the sick-listing process should address all physician competences including identification and interaction with stakeholders, and not just knowledge of social insurance medicine.

Calibration of an item bank for work capacity in cardiological rehabilitation patients

Prevention of work loss is a core objective of cardiovascular rehabilitation. However, comprehensive and economic diagnostic instruments on work limitation are missing. The present study describes the calibration of an item bank for work capacity in cardiovascular rehabilitation patients. This study was based on an item pool (166 items) for assessing work capacity in orthopaedic rehabilitation patients. A total of 349 cardiovascular rehabilitation patients were recruited from 14 German rehabilitation inpatient centres. Exploratory factor analysis was used to determine underlying dimensions of work capacity. Rasch analysis was applied to test for fit of the model, item fit, unidimensionality, particularly local independence and differential item functioning using RUMM2030. Two independent factors (cognitive work capacity/physical work capacity) were found. Fitting of the data to the Rasch model was initially poor (significant item-trait interaction for both factors; p < 0.001). After rescoring disordered categories, excluding misfitting items and items with differential item functioning, 20 and 18 items remained for cognitive work capacity and physical work capacity. Item-trait interaction (cognitive work capacity p = 0.24; physical work capacity p = 0.95) and person separation index (cognitive work capacity = 0.81; physical work capacity = 0.85) were satisfactory. Unidimensionality was given for both factors. The calibrated item bank provides the basis to assess work capacity in cardiovascular rehabilitation patients, fulfilling high psychometric standards. Further, the item bank could be either used to develop a computer adaptive test or an economic short-form questionnaire.

Maximum acceptable weight of lift reflects peak lumbosacral extension moments in a functional capacity evaluation test using free style, stoop and squat lifting

It is unclear whether the maximum acceptable weight of lift (MAWL), a common psychophysical method, reflects joint kinetics when different lifting techniques are employed. In a within-participants study (n = 12), participants performed three lifting techniques – free style, stoop and squat lifting from knee to waist level – using the same dynamic functional capacity evaluation lifting test to assess MAWL and to calculate low back and knee kinetics. We assessed which knee and back kinetic parameters increased with the load mass lifted, and whether the magnitudes of the kinetic parameters were consistent across techniques when lifting MAWL. MAWL was significantly different between techniques (p = 0.03). The peak lumbosacral extension moment met both criteria: it had the highest association with the load masses lifted (r > 0.9) and was most consistent between the three techniques when lifting MAWL (ICC = 0.87). In conclusion, MAWL reflects the lumbosacral extension moment across free style, stoop and squat lifting in healthy young males, but the relation between the load mass lifted and lumbosacral extension moment is different between techniques. Practitioner Summary: Tests of maximum acceptable weight of lift (MAWL) from knee to waist height are used to assess work capacity of individuals with low-back disorders. This article shows that the MAWL reflects the lumbosacral extension moment across free style, stoop and squat lifting in healthy young males, but the relation between the load mass lifted and lumbosacral extension moment is different between techniques. This suggests that standardisation of lifting technique used in tests of the MAWL would be indicated if the aim is to assess the capacity of the low back.

Work capacity assessment of Nigerian bricklayers

Article history: Received March 7, 2011 Received in Revised form August, 25, 2011 Accepted 25 August 2011 Available online 28 August 2011 The main aim of this study is to assess the physical work capacity of bricklayers with focus on the energy expenditure during work. Eighty Nine bricklayers’ working on various sites in Ibadan and Eruwa towns of Oyo State, Nigeria are used for the study. Correlation and regression analysis using SPSS 16.0 Statistical Package was used to determine the relationship between VO2 given the age and weight of the subjects; % RHR(Relative Heart Rate) and working heart rate (HRW) given weight; VO2 and %RHR given Body Mass Index (BMI). The results showed that the mean energy expenditure of bricklaying was 1.5l/min of oxygen (7.23Kcal/min, using a conversion factor of 4.82) which classified bricklaying as “heavy work”. A rest allowance of 64.45% (38.67 minutes rest for 60 minutes work duration) was calculated . It was concluded that there is a need to redesign the work content of the aforementioned occupation in order to reduce excessive strain on the workers, which in turn will increase productivity. © 2012 Growing Science Ltd. All rights reserved.

Frequency and severity of problems that general practitioners experience regarding sickness certification

Objective. Tasks involved in sickness certification constitute potential problems for physicians. The objective in this study was to obtain more detailed knowledge about the problems that general practitioners (GPs) experience in sickness certification cases, specifically regarding reasons for issuing unnecessarily long sick-leave periods. Design. A cross-sectional national questionnaire study. Setting. Primary health care in Sweden. Subjects. The 2516 general practitioners (GPs), below 65 years of age, who had consultations involving sickness certification every week. This makes it the by far largest such study worldwide. The response rate among GPs was 59.9%. Results. Once a week, half of the GPs (54.5%) found it problematic to handle sickness certification, and one-fourth (25.9%) had a patient who wanted to be sickness absent for some reason other than medical work incapacity. Issues rated as problematic by many GPs concerned assessing work capacity, prognosticating the duration of incapacity, handling situations in which the GP and the patient had different opinions on the need for sick leave, and managing the two roles as physician for the patient and medical expert in writing certificates for other authorities. Main reasons for certifying unnecessarily long sick-leave periods were long waiting times in health care and in other organizations, and younger and male GPs more often reported doing this to avoid conflicts with the patient. Conclusion. A majority of the GPs found sickness certification problematic. Most problems were related to professional competence in insurance medicine. Better possibilities to develop, maintain, and practise such professionalism are warranted.

Will musculoskeletal and visual stress change when Visual Display Unit (VDU) operators move from small offices to an ergonomically optimized office landscape?

This study investigated the effect of moving from small offices to a landscape environment for 19 Visual Display Unit (VDU) operators at Alcatel Denmark AS. The operators reported significantly improved lighting condition and glare situation. Further, visual discomfort was also significantly reduced on a Visual Analogue Scale (VAS). There was no significant correlation between lighting condition and visual discomfort neither in the small offices nor in the office landscape. However, visual discomfort correlated significantly with glare in small offices i.e. more glare is related to more visual discomfort. This correlation disappeared after the lighting system in the office landscape had been improved. There was also a significant correlation between glare and itching of the eyes as well as blurred vision in the small offices, i.e. more glare more visual symptoms. Experience of pain was found to reduce the subjective assessment of work capacity during VDU tasks. There was a significant correlation between visual discomfort and reduced work capacity in small offices and in the office landscape. When moving from the small offices to the office landscape, there was a significant reduction in headache as well as back pain. No significant changes in pain intensity in the neck, shoulder, forearm, and wrist/hand were observed. The pain levels in different body areas were significantly correlated with subjective assessment of reduced work capacity in small offices and in the office landscape. By careful design and construction of an office landscape with regard to lighting and visual conditions, transfer from small offices may be acceptable from a visual-ergonomic point of view.

Occupational Rehabilitation in Hong Kong: Current Status and Future Needs

This paper reviews the development of occupational rehabilitation in Hong Kong, both in terms of the science as well as the service for injured workers. Besides, it also reviews the existing Employees' Compensation Ordinance for work injury to illustrate how the policy could influence the success and development of the discipline. Five experienced occupational rehabilitation providers, including 1 occupational medicine specialist, 3 occupational therapists, and 1 physiotherapist critically reviewed the past and current development of occupational rehabilitation in Hong Kong as well as the local contextual factors, which could influence its future development. Since the enactment of the Employees' Compensation Ordinance in the 1950s, there have been progressive improvements in the field of occupational rehabilitation in Hong Kong. Services in the early years were mostly based on the biomedical model, where doctors and patients tended to focus on clinical symptoms and physical pathology when making clinical decisions. Since then, remarkable academic achievements have been made in the field locally, from the validation of clinical instruments for assessment of work capacity, assessment of employment readiness to the evaluation of efficacy of interventional programs for injured workers focusing on work related outcomes. However, there has been a relatively lack of progress in the development of related policies and implementation of related programs for occupational rehabilitation. There is no built in linkage between rehabilitation, compensation and prevention in the current system in Hong Kong, and there is no rehabilitation policy specific to those workers with occupational diseases and injuries. There are still deficiencies in the development and provision of occupational rehabilitation services in Hong Kong. Incorporation of requirements for occupational rehabilitation at the legislation and policy levels should be seriously considered in the future. Besides, the development of the Occupational Medicine subspecialty in the public hospital system in Hong Kong is considered a facilitator to the future development of occupational rehabilitation in Hong Kong.

Work capacity assessment and return to work: A scoping review

This review sought to synthesize existing evidence on work capacity assessments and to identify the knowledge supporting their use in return to work practice and future research. A scoping review was conducted identifying studies examining assessments used in return to work. Studies published before 1986 and studies not written in English were excluded. A five point relevancy criteria was used to establish the fit of articles with the research question. Articles were thematically analyzed into components of the PEO Model, proposed future research, and areas of vested interest. Forty four articles met the criteria for inclusion. For over twenty five years, work capacity assessment literature has remained focused on the individual's physical work performance capacities. Gaps were identified in the lack of qualitative research and incorporation of person, occupation, and environmental dimensions in evaluation of work capacity. Future research recommendations emphasize the need for knowledge generation on work modification and investigation of psychosocial factors that impact work capacity and return to work yet only minimal progression is evident in these areas in the literature reviewed. The limited consideration of the occupation and environmental dimensions in returning to work and the global interest in work capacity assessment highlight the need for the development of contextually based assessment tools. Assessment needs to move toward the incorporation of environmental and occupational aspects in addition to the person dimension in a culturally transcendent manner.

Occupational therapists as expert witnesses on work capacity

The aim of this study was to explore the particular challenges for occupational therapists during their cross-examination as an expert witness on work capacity. Grounded theory methodology was used to collect and analyse data. Interviews were conducted with 31 participants with direct experience of occupational therapy work capacity assessments. Of these, 19 were occupational therapists, six were medical specialists and six were lawyers. All participant groups perceived that maintaining one's credibility in the witness box was of paramount importance. The occupational therapists identified 11 strategies that barristers may use to challenge their credibility as an expert witness. The three professional groups proposed practices that maintain occupational therapists' credibility as expert witnesses on the work capacity of personal injury claimants.

Does variation in general practitioner (GP) practice matter for the length of sick leave? A multilevel analysis based on Norwegian GP-patient data

In Norway, as in many countries, the national insurance system is under economic stress from demographic change impacting on the pensions versus contributions balance, and an increasing number of disability and sickness benefit claimants. The general practitioner (GP) is responsible for assessing work capacity and issuing certificates for sick leave based on an evaluation of the patient. Although many studies have analyzed certified sickness absence and predictive factors, no studies assess its variation between patients, GPs or geographical areas within a multilevel framework. Using a rich Norwegian matched patient-GP data set and employing a multilevel random intercept model, the study attempts to disentangle patient, GP and municipality-level variation in the certified sickness absence length for Norwegian workers in 2003. We find that most observed patient and GP characteristics are significantly associated with the length of sick leave (LSL) and medical diagnosis is an important observed factor explaining certified sickness durations. However, 98% of the unexplained variation in the LSL is attributed to patient factors rather than influenced by variation in GP practice or differences in municipality-level characteristics. Our findings indicate that GPs practice variation does not matter much for the patients' LSL. Our results are compatible with a high degree of patient involvement in current general practice. Based on this understanding one may infer that GPs play an advocate role for their patients in Norway, where the patients' own wishes are important when decisions are made.

What physicians want to learn about sickness certification: analyses of questionnaire data from 4019 physicians.

BackgroundSickness absence is a problem in many Western countries. Physicians have an essential role in sickness certification of patients, which is often recommended in health care but may have side effects. Despite the potentially harming impact of sickness absence, physicians have very limited training in insurance medicine, and there is little research on sickness certification practices. Our aim was to ascertain what knowledge and skills physicians in different clinical settings feel they need in order to improve their competence in sickness certification.MethodsThe data for analysis were collected in 2004 in Stockholm and Östergötland Counties, Sweden, by use of a comprehensive questionnaire about sickness certification issues, which was sent to 7,665 physicians aged ≤ 64 years. The response rate was 71% (n = 5455). Analyses of association and factor analysis were applied to the various aspects of competence to establish a skills index and a knowledge index, which were used to compare the results for physicians in different clinical settings.ResultsMost physicians stated they needed more knowledge and skills in handling sickness certification, e.g. regarding how to assess work capacity (44%) and optimal length and degree of sickness absence (50%), and information about aspects of the social insurance system (43-63%). Few (20%) reported needing to know more about issuing sickness certificates. The index scores varied substantially between different clinical settings, and this disparity remained after adjustment for sex, years in practice, workplace policy, and support from management. Scores on the skills index were significantly higher for physicians in primary care than for those working in other areas.ConclusionsA majority of physicians in most types of clinics/practices, not only primary care, indicated the need for more knowledge and skills in handling sickness certification cases. Increased knowledge and skills are needed in order to protect both the health and equity of patients. However, few physicians stated that they needed more skills in filling out sickness certificates, which contradicts previous findings about such documents being of poor quality and suggests that factors other than mere knowledge and skills are involved.

Return to Work After Burn Injury: Burn-Injured Individualsʼ Perception of Barriers and Facilitators

The aim of this study was to explore burn-injured individuals' perception of factors seen as facilitators or barriers in the process of returning to work after a severe burn injury. Semistructured interviews were prospectively conducted with 39 former burn injury patients, admitted to the Uppsala Burn Center between March 2000 and March 2007. The participants were employed or studying at the time of injury and were interviewed on average 4.6 years after the burn. The interview data were analyzed with qualitative content analysis. Factors acknowledged by the participants as facilitators and barriers to return to work (RTW) were identified and sorted into five categories: the Individual, Social Life, Health Care and Rehabilitation, the Workplace, and Social Welfare Agencies. Facilitators were perceived to a great extent as individual characteristics, such as own ability to take action, setting up goals in rehabilitation, having willpower, being persistent, and learning to live with impairments. The possibility of getting modified work tasks or a change of workplace, when having physical or psychological impairments, was also seen as facilitating factors. Some barriers experienced as delaying RTW were difficulties when ceasing pain medication, limited knowledge of wound care at primary health care facilities, lack of individualized rehabilitation plans, and lack of psychological support during rehabilitation. Former burn injury patients emphasized psychological resources and capabilities as facilitators in the RTW process. The need in rehabilitation for a coordinator and for assessment of work capacity, and not solely a focus on impairments, is discussed.

Junior doctors need training in sickness certification

A recent report highlights the need for clear standards of practice regarding working-age health. Despite this, little is known about training or performance of sickness certification by junior doctors in secondary care. To see what sickness certification training had been received by practising hospital postgraduate trainees and establish how confident and knowledgeable they were in this area. We also evaluated the feasibility and face validity of a paper-based educational module. We surveyed 51 junior doctors in a variety of specialties, at all grades. Questions concerned training and practice of sickness certification and assessing capacity for work. A knowledge test regarding formal guidelines, use of forms and self-certification was undertaken, before participants evaluated a 10 min training module. Seventy-nine per cent of participants lacked knowledge in sickness certification, and 55% were not confident to assess capacity for work; 66% had received no training at all and 71% participants followed no guideline. Many could not identify or explain the use of certificates: MED-3 (50 or 71%, respectively), MED-5 (42 or 38%, respectively), MED-10 (0 or 17%, respectively), RM-7 (2 or 6%, respectively) and DS-1500 (6 or 8%, respectively). Majority of participants thought that an educational module could increase knowledge and skill in sickness certification (96%) and in assessing work capacity (74%). Junior doctors are involved in sickness certification, but there is a lack of training at undergraduate and postgraduate level, and many are unaware of formal guidance. The majority of junior doctors are concerned about lack of knowledge in this area and to a lesser extent in assessing patients' capacity to work. A simple educational module could improve confidence, knowledge and skills in sickness certification.

Cost-effectiveness analysis of rituximab treatment in patients in Germany with rheumatoid arthritis after etanercept-failure

The present health economic analysis investigated the cost-effectiveness-ratios of either (1) rituximab or (2) an alternative TNF-alpha-inhibiting agent as second line biological treatment in patients with active rheumatoid arthritis (RA) and an inadequate response to etanercept therapy. Incremental cost per quality-adjusted life-year (QALY) gained by rituximab treatment of RA is compared to TNF-inhibitor change (standard sequence) in a Markov-model (perspective: health care payer, full life-time approach). Direct cost components taken into account were treatment costs (medication-, administration- and monitoring costs) and resource utilisation (outpatient costs, inpatient costs). Indirect costs were estimated separately by the assessment of impaired work capacity due to RA (2008 Euro currency, discount rate 3.5%). Utility measures for the different treatment options were obtained from the ACR-response rates of published pivotal clinical trials. Direct costs amount to euro 178,373 (standard sequence) and euro 192,295 (rituximab sequence), respectively, rendering incremental direct costs of euro 13,922. Incremental utilities yield 0.57 QALYs and the incremental cost-effectiveness-ratio (ICER) of rituximab compared to the standard sequence amounts to euro 24,517. Inclusion of indirect costs leads to less incremental costs and a lower ICER of euro 15,565/QALY. Thus, ICERs stay beneath the accepted threshold of euro 50,000/QALY. Rituximab appears to be a cost-effective treatment alternative compared to the switch between TNF-inhibitors as second line biological treatment in patients with active RA having failed etanercept.

Medico-Legal Employability Assessment: Myths, Mistakes and Misconceptions

The onset of injury and disability can have a significant negative effect on individuals' social, interpersonal and vocational participation. This in turn impacts on individuals' current and future earning capacity. An objective assessment of post-injury work capacity is often sought through legal processes to determine the extent of this loss. Onset of disability does not necessarily mean lack of ability to work. Changes in employment potential are, however, commonplace post-injury. This paper canvasses a range of issues confronting professionals who assess employment potential following injury, especially in medico-legal settings. What needs to be assessed, what assumptions need to be avoided and what practices undermine reliable and valid vocational assessment are discussed. Recommendations and suggestions about how to perform employability assessment to meet the standards required by the court system of expert witnesses are also outlined.

Diagnostik der koronaren Herzkrankheit – Initiale Abklärung, Ergometrie, Leistungs- und Arbeitsfähigkeit

Coronary artery disease either presents with acute chest pain or with exercise induced chest symptoms or shortness of breath. The differentiation between stable and unstable Angina pectoris is prognostically important, unstable angina is managed as an acute coronary syndrome including hospital admission, patients with stable symptoms can be further evaluated in an outpatient setting. A broad differential diagnosis of other cardiac and non-cardiac causes must be considered. Important initial diagnostic steps are cardiovascular risk stratification and prove of ischemia (or scar, necrosis) either at rest or usually exercise-induced, if necessary by additional imaging. Exercise capacity is assessed by physiological parameters (watt, VO2max., MET and distance) during exercise tests like ergometry, spiroergometry or 6-minute walking test (e.g. heart failure patients). Additional factors must be considered for the assessment of working capacity.