Health-related Rehabilitation Research Articles

The societal impact of individual placement and support implementation on employment outcomes for young adults receiving temporary health-related welfare benefits: a difference-in-differences study.

Individual placement and support (IPS) is an evidence-based practice that helps individuals with mental illness gain and retain employment. IPS was implemented for young adults at a municipality level through a cross-sectoral collaboration between specialist mental healthcare, primary mental healthcare, and the government funded employment service (NAV). We investigated whether IPS implementation had a causal effect on employment outcomes for all young adults in receipt of a temporary health-related rehabilitation (work assessment allowance, WAA) welfare benefit, measured at the societal level compared to municipalities that did not implement IPS. We used a difference in differences design to estimate the effects of IPS implementation on the outcome of workdays per year using longitudinal registry data. We estimate the average effect of being exposed to IPS implementation during four-years of implementation compared to ten control municipalities without IPS for all WAA recipients. We found a significant, positive, causal effect on societal level employment outcomes of 5.6 (p = 0.001, 95% CI 2.7-8.4) increased workdays per year per individual, equivalent to 12.7 years of increased work in the municipality where IPS was implemented compared to municipalities without IPS. Three years after initial exposure to IPS implementation individuals worked, on average, 10.5 more days per year equating to 23.8 years of increased work. Implementing IPS as a cross sectoral collaboration at a municipality level has a significant, positive, causal, societal impact on employment outcomes for all young adults in receipt of a temporary health-related rehabilitation welfare benefit.

Changes in health-related rehabilitation trajectories following a major Norwegian welfare reform

BackgroundIn this study we investigated the health-related rehabilitation trajectories of young Norwegian adults between 2004–2019. The study period is interesting because it overlaps with an extensive welfare system reform that occurred in Norway between 2006–2011. In parallel with the reform there was a substantial increase in health-related welfare dependency among young people due to mental health conditions.To better understand this group, we addressed three questions: 1) what were the most typical health-related rehabilitation trajectories for young Norwegians aged 23–27 between 2004–2019, 2) did the trajectories and composition of health-related benefit recipients change overtime and 3) in parallel with the welfare reform, do we see improved labour market outcomes in our study population?MethodsUsing high-quality Norwegian registry data, we established four cohorts of Norwegian health-related rehabilitation benefit recipients aged 23–27 in either 2004 (cohort 1), 2008 (cohort 2), 2011 (cohort 3) or 2014 (cohort 4). The follow-up period for each cohort was six years. We used sequence and cluster analyses to identify typical health-related rehabilitation trajectories. In addition, descriptive statistics and multinomial logistic regression were used to scrutinise the relationship between trajectory types, sociodemographic characteristics and cohort membership.ResultsThe majority follow trajectories consisting of welfare dependency, unemployment and unstable, low-income work. Both the trajectories and composition of the study population changed across cohorts. Over the observation period there was a 1) three-fold increase in the proportion following a trajectory ending in permanent disability benefits, 2) nine-fold increase in the proportion following trajectories characterised by long periods of health-related rehabilitation, 3) five-fold decrease in the share following unemployment occupational handicap trajectories 4) 6.9% increase in the proportion of early school leavers and 5) 8.9% decrease in the share with disabled parents.ConclusionOur study population is a vulnerable group with suboptimal mental health, functioning and employment outcomes. In conjunction with the welfare reform, we witnessed a significant drop in use of work-related benefits, accompanied by a substantial increase in uptake of health-related rehabilitation- and disability benefits. Thus, it appears that rather than improving employment outcomes, welfare policy changes have created a new problem by steering a greater proportion into disability benefits.

Relations between indoor rehabilitation and basic health services in a developing country.

and Introduction: Physical rehabilitation is vital for patients to regain maximum function. Approximately 80% of people with a disability live in developing countries, where they face multiple challenges in rehabilitation. The goal of the study was to conduct an analysis of indoor rehabilitation programs based on the demographics and medical conditions of the admitted patients and to relate to the available basic health and rehabilitation facilities. This was a mixed method study conducted in an inpatient rehabilitation ward of a tertiary level academic university hospital in a developing country. All admitted patients who stayed for a period of minimum two weeks were included in the study. Demographic and clinical data were obtained by means of a retrospective medical record review utilizing a standardized data extraction form. The study was further strengthened by an online literature search for the available documents for analysis, relation, and discussion. Among the 1,309 admitted patients was male- female ratio was 10:7, with the majority (31.4%) cases falling between the ages of 46 and 60yrs. Rehabilitation outpatient department was the principal mode of admission (78%), and musculoskeletal and neurological conditions represented the maximum number (79.8%). Majority of patients (60.8%) were discharged home on completion of the rehabilitation program with a large number of patients who were absconded. Poor health budget allocation and lack of prioritization of the rehabilitation sector face multiple challenges, including the rehabilitation team functioning resources, space crisis for expansion which was further impacted by the COVID-19 pandemic. The country's current health-related rehabilitation process and socio-demographic variables have a negative relationship. There was a large number of missing data in the medical records and many patients were lost prematurely from the indoor rehabilitation program. Musculoskeletal disorders were common, and the majority of patients were discharged home once the program was completed.

Rehabilitation Perspectives of COVID-19 Pandemic in Bangladesh

Introduction: The COVID-19 has overwhelmed health systems across the countries globally. This pandemic has also impacted health related rehabilitation services worldwide which is particularly profound in low and middle-income countries including Bangladesh.
 Methods: Information used in the study gathered from World Health Organization (WHO) Bangladesh Director General of Health Services (DGHS), Institute of Epidemiology Disease Control and Research (IEDCR), online literature search using PubMed and PubMed Central research engines. Information also collected over personal telephone and email correspondence from the selected government, public, corporate, non-government institutes, and rehabilitation personals during the period of March-May 2020. Gathered data were analyzed; a set of challenges identified, and recommendations were made for a safe and standard working rehabilitation environment in the altered COVID-19 situation.
 Results: Rehabilitation doctors and therapists at most of the public and private institutes are dedicated to COVID-19 services as per the local administrative directives keeping routine rehabilitation services apart. Few rehabilitation workforces to continue team works, environmental hygiene maintenance and space crisis at service outlets were the major challenges. Specially arranged virtual OPD and telerehabilitation services opened to minimize the rehabilitation burden and sufferings of the patient during the COVID-19 pandemic lock down restriction period.
 Conclusion: COVID-19 seriously impacted the overall schedule of rehabilitation services. Rehabilitation must be recognized as an un-omissible part of COVID-19 management which requires a planned accommodative working environment in the altered situation within the health care system. Recommendations are provided to keep this pandemic contained while providing adequate and standard rehabilitation services to the disabled in the safe environment in line with WHO rehabilitation 2030.
 J Bangladesh Coll Phys Surg 2020; 38(0): 76-81

Health-Related Rehabilitation after the 2008 Great Wenchuan Earthquake in China:A Ten Year Retrospective Systematic Review.

Being one of the world’s seismically hazard-prone countries, the People’s Republic of China (PRC) witnessed an 8.0-magnitude earthquake on May 12th 2008—which was reported as one of the most destructive disasters since its founding. Following this earthquake, rehabilitation was greatly required for survivors to enable them to achieve and maintain optimal independence; functioning; full physical, mental and social ability; inclusion; and participation in all aspects of life and environments. We conducted a systematic review based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to retrospectively identify, in five English databases/sources, the existing evidence about the Health-Related Rehabilitation (HRR) that was rendered to the survivors of the 2008 Wenchuan earthquake between 2008 and 2018. Only 11 studies out of 828 initial studies retrieved were included in our study and reported the survivors of the 2008 Wenchuan earthquake to have been aged between 10.5 and 55.7, and predominantly diagnosed with posttraumatic stress disorders. Their HRR was mainly premised on physical and physiological therapies, as well as traditional Chinese medicine and digital technologies. Although all HRR interventions used were reported to be effective, none was identified as much more effective than the others in the post-earthquake era —which calls for more robust research to build upon our systematic review.

Contribution of the scientific field of Physical and Rehabilitation Medicine to improvements in health-related rehabilitation at all levels of the healthcare system: A discussion paper.

Rehabilitation is an important health strategy that should be implemented at all levels of the healthcare system and at all levels of care. Scientific evidence is vital to strengthen rehabilitation; therefore, research in the scientific field of Physical and Rehabilitation Medicine (PRM) should be implemented and linked to all levels of the healthcare system. PRM research can be categorized into 5 areas: (i) biosciences in rehabilitation; (ii) biomedical rehabilitation sciences and engineering; (iii) clinical PRM sciences; (iv) integrative rehabilitation sciences; and (v) human functioning sciences. At the level of the healthcare system, rehabilitation can be divided into micro-, meso- and macro-levels. This paper discusses the contribution of the five above research areas to health-related rehabilitation at the different levels of the healthcare system. The contribution of PRM research can have synergistic value and facilitate improvements and implementation of scientific evidence in rehabilitation at all levels of healthcare. From a broader perspective, improved understanding of the contribution of each area of the scientific field of PRM and the priorities for the healthcare system that are set by relevant stakeholders will contribute to the advancement and rapid attainment of overall goals. LAY ABSTRACTRehabilitation leads to better health, participation, and quality of life of persons with chronic disease or impairment. It should be part of health care at all levels. In order to implement rehabilitation services, it is important to create a scientific basis. Science in the field of rehabilitation includes studies on mechanisms of disease and healing process, the effects of the application of treatments on the body, the effectiveness of therapy as well as the implementation of rehabilitation projects, and the theoretical basis. The results of such work are helpful to implement and optimize rehabilitation in clinical work and in health policies. The goal is that every person who needs rehabilitation will have access to quality rehabilitation services.

Description of health-related rehabilitation service provision and delivery in randomized controlled trials: A topic review.

To determine how health-related rehabilitation services have been described in recently pub-lished randomized clinical trials, using the International Classification System for Service Organization in Health-Related Rehabilitation (ICSO-R 2.0) as a framework. Medline was searched for English--language randomized clinical trials (RCTs) published between 1 January 2018 and 31 December 2018. RCTs were eligible if the primary goal was to provide rehabilitation services to targeted patient populations. Two authors independently screened and extracted data, and assessed the methodological quality of eligible trials. Descriptive analysis was used to compare service descriptions between eligible trials and the ICSO-R 2.0 framework (23 categories, 9 categories for provider, 14 categories for delivery). Twenty-nine RCTs, with a wide range of organizational units and target groups, were included. The median number of categories reported in the provider dimension was 4 (range 3-5). The median number of categories reported in the service delivery dimension was 8 (range 6-12). None of the RCTs described all ICSO-R recommended categories. Descriptions of service organization in rehabilitation varied widely among recently published randomized clinical trials. Use of the framework for the classification of service organization and standardization of description of services is recommended in future RCTs, to facilitate better comparisons in service research across studies.

Randomized Controlled Trials of Rehabilitation Services in the Post-acute Phase of Moderate and Severe Traumatic Brain Injury - A Systematic Review.

Background and aims: There is a gap in knowledge regarding effective rehabilitation service delivery in the post-acute phase after traumatic brain injury (TBI). Recently, Gutenbrunner et al. proposed a classification system for health-related rehabilitation services (International Classification System for Service Organization in Health-related Rehabilitation, ICSO-R) that could be useful for contrasting and comparing rehabilitation services. The ICSO-R describes the dimensions of Provision (i.e., context of delivered services), Funding (i.e., sources of income and refunding), and Delivery (i.e., mode, structure and intensity) at the meso-level of services.We aim to:-Provide an overview of randomized, controlled trials (RCTs) with rehabilitation service relevance provided to patients with moderate and severe TBI in the post-acute phase using the ICSO-R as a framework; and-Evaluate the extent to which the provision, funding and delivery dimensions of rehabilitation services were addressed and differed between the intervention arms in these studies.Materials and methods: A systematic literature search was performed in OVID MEDLINE, EMBASE, CINHAL, PsychINFO, and CENTRAL, including multidisciplinary rehabilitation interventions with RCT designs and service relevance targeting moderate and severe TBI in the post-acute phase.Results: 23 studies with 4,644 TBI patients were included. More than two-thirds of the studies were conducted in a hospital-based rehabilitation setting. The contrast in Context between the intervention arms often co-varied with Resources. The funding of the services was explicitly described in only one study. Aspects of the Delivery dimension were described in all of the studies, and the Mode of Production, Intensity, Aspects of Time and Peer Support were contrasted in the intervention arms in several of the studies. A wide variety of outcome measures were applied often covering Body function, as well as the Activities and Participation domains of the International Classification of Functioning, Disability, and Health (ICF).Conclusion: Aspects of service organization and resources as well as delivery may clearly influence outcome of rehabilitation. Presently, lack of uniformity of data and collection methods, the heterogeneity of structures and processes of rehabilitation services, and a lack of common outcome measurements make comparisons between the studies difficult. Standardized descriptions of services by ICSO-R, offer the possibility to improve comparability in the future and thus enhance the relevance of rehabilitation studies.

Fatores associados à depressão em homens e mulheres presos

The prevalence of depression is high in the prison system, and the differences between sex regarding associated risk factors are still not clear. We analyzed the correlated factors of depression among incarcerated men and women in the state of São Paulo, Brazil. A cross-sectional study with stratified and multi-stage probabilistic sample was performed. Composite International Diagnostic Interview (CIDI) was applied for psychiatric diagnostic classification, as well as a questionnaire on criminal history with 1,192 men and 617 women. Lifetime prevalence of mental disorder was calculated, and association analysis performed by multinomial logistic regression stratified by sex. A dependent variable was categorized into depression, any other mental disorder and no mental disorder (reference). The prevalence of depression was of 33.3% -(30.3 - 36.5) in women and 12.9% (11.1 - 15.0) in men. Depression was associated with disciplinary penalty, being in a stable relationship, physical health problems and history of infringement in adolescence in men. Regarding other mental illnesses, the correlated factors were historical transgression during adolescence and re-offense. Among women, depression was associated with physical health problems, drug crimes, violent crimes and being imprisoned. Results confirmed the differences between associated factors with depression regarding sex. Differences in the profile between men and women require effective specialized programs, considering the need for coping strategies for incarcerated men and health-related rehabilitation for women with depression.

Using concept mapping to develop a human rights based indicator framework to assess country efforts to strengthen rehabilitation provision and policy: the Rehabilitation System Diagnosis and Dialogue framework (RESYST)

BackgroundRehabilitation is crucial for the realization of the right to health and a proper concern of global health. Yet, reliable information to guide rehabilitation service planning is unavailable in many countries in part due to the lack of appropriate indicators. To ensure universal health coverage and meet the central imperative of “leaving no one behind” countries must be able to assess key aspects of rehabilitation policy and provision and monitor how they have discharged their human rights responsibilities towards those most disadvantaged, including people with disability. This article describes the process of developing an expert guided indicator framework to assess governments’ efforts and progress in strengthening rehabilitation in line with the Convention on the Rights of Persons with Disabilities.MethodsA systems methodology - concept mapping - was used to capture, aggregate and confirm the knowledge of diverse stakeholders on measures thought to be useful for monitoring the implementation of the Convention with respect to health related rehabilitation. Fifty-six individuals generated a list of 107 indicators through online brainstorming which were subsequently sorted by 37 experts from the original panel into non overlapping categories. Forty-one participants rated the indicators for importance and feasibility. Multivariate statistical techniques where used to explore patterns and themes in the data and create the indicators’ organizing framework which was verified and interpreted by a select number of participants.ResultsA concept map of 11 clusters of indicators emerged from the analysis grouped into three broader themes: Governance and Leadership (3 clusters); Service Delivery, Financing and Oversight (6 clusters); and Human Resources (2 clusters). The indicator framework was comprehensive and well aligned with the Convention. On average, there was a moderately positive correlation between importance and feasibility of the indicators (r = .58) with experts prioritizing the indicators contained in the clusters of the Governance and Leadership domain. Two of the most important indicators arose from the Service Delivery, Financing and Oversight domain and reflect the need to monitor unmet needs and barriers in access to rehabilitation. In total, 59 indicators achieved above average score for importance and comprised the two–tiered priority set of indicators.ConclusionConcept mapping was successful in generating a shared model that enables a system’s view of the most critical legal, policy and programmatic factors that must be addressed when assessing country efforts to reform, upscale and improve rehabilitation services. The Rehabilitation Systems Diagnosis and Dialogue framework provides a data driven basis for the development of standardized data collection tools to facilitate comparative analysis of rehabilitation systems. Despite agreement on the importance and feasibility of 59 indicators, further research is needed to appraise the applicability and utility of the indicators and secure a realistic assessment of rehabilitation systems.

Effective rehabilitation services in the post-acute phase of moderate and severe traumatic brain injury

Background and aims: Rehabilitation services to traumatic brain injury (TBI) have been focused in the acute phase, underpinning the importance of early initiated and well-organized delivery. Less is known about effective rehabilitation service delivery in the post-acute and later phases after TBI. Lack of a framework for depicting differences in service delivery may also contribute to the knowledge gap. Recently, Gutenbrunner et al (J Rehabil Med 2015) proposed a classification for health-related rehabilitation services (International Classification System for Service Organization in Health-related Rehabilitation, ICSO-R) describing provision (i.e., context of delivered services), funding (i.e., sources of income and refunding) and delivery (i.e. mode, structure and intensity) aspects which may be useful for contrasting and comparing rehabilitation services. Aims of this review are: – provide an overview of randomized controlled trials (RCTs) with rehabilitation service relevance provided to moderate and severe TBI in the post-acute phase; – evaluate to which extent providing, funding and delivery dimensions of rehabilitation services are addressed. A systematic literature search was carried out in OVID MEDLINE; EMBASE, CINHAL, PsychINFO and Social SCI, identifying 50 relevant RCTs. The studies emerged from nine different counties across all continents except Africa. Two-third of the studies were conducted in a hospital-based rehabilitation setting. In general, funding of the services was not described. In the delivery dimension, therapeutic strategies targeting body functions (78%) was dominating. Only one study was clearly designed to evaluate service delivery mode aspects, finding no difference between the effects of in-hospital or home-based rehabilitation regarding return to gainful employment. There is a lack of RCTs for evaluation of rehabilitation services in the post-acute phase for moderate and severe TBI. Service aspects may be implicit and possible to evaluate given standardized and better descriptions of the provider, funding and delivery dimensions according to ICSO-R.

Compliance with standards of practice for health-related rehabilitation in low and middle-income settings: development and implementation of a novel scoring method

Purpose: To (A) develop a method for measuring compliance with standards, and (B) implementation of the method in 12 rehabilitation centers in six low and middle-income countries (LMICs).Methods: In part A, existing standards were compiled and operationalized into scores, organized into 5 ‘scorecards’ and 15 ‘sub-scorecards’, then tested and refined in an iterative process. In part B, 12 rehabilitation centers in 6 countries implemented the standards using the new method, revealing relative performance between centers, and across different standards. Internal consistency of scores within domains was computed using Chronbach’s alpha.Results: A standardized method for scoring compliance with standards for rehabilitation was developed. The method evaluated compliance with standards in five domains of practice: user focused approach, service outputs, finances, staff, and general management. Multiple standards within domains were strongly related, with Chronbach’s alpha >0.80 for all but the equipment and supplies domain. Overall, in the 12 rehabilitation centers examined, 36% of standards were met or exceeded. Compliance within each scoring domain was 56% (user-focused approach), 38% (service outputs), 27% (financial management), 30% (staff management), and 33% (general management). Two out of 12 (17%) of centers met more than two-thirds of the standards, 3 (25%) met more than one-third of standards, while the remaining 7 (58%) met less than one-third of standards.Conclusions: A new, standardized method for measuring performance of rehabilitation services in LMICs was developed. The method examines standards in five rehabilitation practice domains, and can be used to understand barriers to quality performance, particularly in resource-constrained settings. Implementation of the method demonstrated that current compliance with standards is modest. Ongoing interest in new standards for rehabilitation practice should be accompanied by measures to ensure they are used to strengthen quality in an emerging rehabilitation sector.Implications for rehabilitationWe developed a method for measuring compliance with standards for rehabilitation, and implemented the method in 12 rehabilitation centers in low and middle income countries.We demonstrate modest compliance with an adapted list of known standards of practice.New standards, scoring methods and evidence of current performance may assist service providers and policy makers to implement standards, and methods to strengthen rehabilitation services.Modest compliance with current standards suggest new emphasis on quality performance of health-related rehabilitation is neededNew emphasis on standards for rehabilitation should be accompanied by consideration of how performance against those standards can be measured and improved.

Principles of Assessment of Rehabilitation Services in Health Systems: Learning from experiences.

Strengthening of health-related rehabilitation services must start from the needs of persons with health conditions experiencing disability and should be implemented within health systems. The implementation of rehabilitation services in health systems should be planned and realized according to the World Health Organization's 6 constituents of health systems (i.e. health service delivery; health workforce; health information systems; essential medicines; financing; and leadership and governance). The development of recommendations based on situation analysis and best-available data is crucial. In order to facilitate such data collection at a national level, a checklist and a related questionnaire (Rehabilitation Service Assessment Tool (RSAT)) were developed and implemented. The following steps were followed to develop a checklist for implementation of rehabilitation services: a literature search, drafting, checking and testing the list, and development of the RSAT. The RSAT comprises 8 sections derived from 5 main domains of the most important areas of information (i.e. country profile; health system; disability and rehabilitation; national policies, laws, and responsibilities; and relevant non-governmental stakeholders). The implementation of RSAT in different missions has shown that the principles are working well and that RSAT is feasible and helpful. Further field testing is important and the development of an internationally agreed tool should be promoted.

Situation analysis of rehabilitation service to support the national disability and rehabilitation plan in the Democratic People´s Republic of Korea.

In 2013, the Democratic People's Republic of Korea (DPRK) signed the United Nations Convention on the Rights of Persons with Disabilities (UN-CRPD). Since the concept of rehabilitation services in the DPRK did not meet international standards, the government, through the Korean Federation for Protection of the Disabled (KFPD) and Munsu Rehabilitation Hospital (MRH), set up a technical consultation with external experts. Two rounds of consultations were performed, in August 2016 and March 2017, with available methodology, as used in previous consultation processes, but excluding site visits. The consultations started by collecting available data and holding workshops with representatives from the KFPD and the MRH. The results are listed as recommendations for the improvement of health-related rehabilitation services in the DPRK. The results were further developed by KFPD into a draft National Strategy and Action Plan on Comprehensive Rehabilitation (NSAPCR) 2017-2020. The draft was discussed with external experts for further improvement prior to discussion with the government. Overall, the consultation processes was successful, despite the limitation of not making site visits. Recent developments in the DPRK include ratification of the UN-CRPD in December 2016. The authors hope that the NSAPCR can be implemented successfully, leading to improved quality of life for people with disabilities in the DPRK.

Responding to the World Health Organization Gobal Disability Action Plan in Ukraine: Developing a National Disability, Health and Rehabilitation Plan.

In order to support the development of a National Disability, Health and Rehabilitation Plan (NDHRP) for Ukraine, a technical consultation was carried out by a Rehabilitation Advisory Team (RAT) of the International Society of Physical and Rehabilitation Medicine (ISPRM) in 2015. The consultation was based on assessment of the situation of persons with disabilities and the rehabilitation system in Ukraine. Recommendations for activities and projects to improve rehabilitation services within the healthcare system were developed and proposed. In order to reach consensus on the recommendations, dialogues were held with different stakeholders, including the Ministry of Public Health. The recommendations included: coordination of disability and rehabilitation policies within the Ministry of Public Health and among other involved ministries; translation and adaptation of international definitions of functioning, disability, and assessment tools into Ukrainian; data collection on the epidemiology of disability and the need for rehabilitation; implementation of health-related rehabilitation services; and implementation of international definitions and curricula of rehabilitation professions. The mission was regarded as successful and one year later a few changes had been adopted by the Ukrainian government. Further action based on this research is necessary. It will be important to track the changes and evaluate the results after an appropriate period of time.

Strengthening health-related rehabilitation services at national levels.

One of the aims of the World Health Organization's Global Disability Action Plan is to strengthen rehabilitation services. Some countries have requested support to develop (scale-up) rehabilitation services. This paper describes the measures required and how (advisory) missions can support this purpose, with the aim of developing National Disability, Health and Rehabilitation Plans. It is important to clarify the involvement of governments in the mission, to define clear terms of reference, and to use a systematic pathway for situation assessment. Information must be collected regarding policies, health, disability, rehabilitation, social security systems, the need for rehabilitation, and the existing rehabilitation services and workforce. Site visits and stakeholder dialogues must be done. In order to develop a Rehabilitation Service Implementation Framework, existing rehabilitation services, workforce, and models for service implementation and development of rehabilitation professions are described. Governance, political will and a common understanding of disability and rehabilitation are crucial for implementation of the process. The recommendations of the World Report on Disability are used for reporting purposes. This concept is feasible, and leads to concrete recommendations and proposals for projects and a high level of consensus stakeholders.

Combined cognitive and vocational interventions after mild to moderate traumatic brain injury: study protocol for a randomized controlled trial

BackgroundA considerable proportion of patients with mild to moderate traumatic brain injury (TBI) experience long-lasting somatic, cognitive, and emotional symptoms that may hamper their capacity to return to work (RTW). Although several studies have described medical, psychological, and work-related factors that predict RTW after TBI, well-controlled intervention studies regarding RTW are scarce. Furthermore, there has traditionally been weak collaboration among health-related rehabilitation services, the labor and welfare sector, and workplaces.Methods/designThis study protocol describes an innovative randomized controlled trial in which we will explore the effect of combining manualized cognitive rehabilitation (Compensatory Cognitive Training [CCT]) and supported employment (SE) on RTW and related outcomes for patients with mild to moderate TBI in real-life competitive work settings. The study will be carried out in the southeastern region of Norway and thereby be performed within the Norwegian welfare system. Patients aged 18–60 years with mild to moderate TBI who are employed in a minimum 50% position at the time of injury and sick-listed 50% or more for postconcussive symptoms 2 months postinjury will be included in the study. A comprehensive assessment of neurocognitive function, self-reported symptoms, emotional distress, coping style, and quality of life will be performed at baseline, immediately after CCT (3 months after inclusion), following the end of SE (6 months after inclusion), and 12 months following study inclusion. The primary outcome measures are the proportion of participants who have returned to work at 12-month follow-up and length of time until RTW, in addition to work stability as well as work productivity over the first year following the intervention. Secondary outcomes include changes in self-reported symptoms, emotional and cognitive function, and quality of life. Additionally, a qualitative RTW process evaluation focused on organizational challenges at the workplace will be performed.DiscussionThe proposed study will combine cognitive and vocational rehabilitation and explore the efficacy of increased cross-sectoral collaboration between specialized health care services and the labor and welfare system. If the intervention proves effective, the project will describe the cost-effectiveness and utility of the program and thereby provide important information for policy makers. In addition, knowledge about the RTW process for persons with TBI and their workplaces will be provided.Trial registrationClinicalTrials.gov, NCT03092713. Registered on 10 March 2017.

Evidence based position paper on Physical and Rehabilitation Medicine (PRM) professional practice for ageing people with disabilities. The European PRM position (UEMS PRM Section).

Ageing people with disabilities (APwDs) are faced with challenges of ageing which is straightforwardly related to disability that adds to the burden related to their early-onset disability. The aim of the paper is to improve Physical and Rehabilitation Medicine (PRM) physicians' professional practice for APwDs (as a distinct group from those who are disabled due to the ageing process) in order to promote their functioning properties and to reduce activity limitations and/or participation restrictions. A systematic review of the literature and a Consensus procedure by means of a Delphi process have been performed involving the delegates of all European countries represented in the UEMS PRM Section. The systematic literature review is reported together with the 30 recommendations resulting from the Delphi procedure. The professional role of PRM physicians in relation to APwDs is extending, expanding and/or improving health-related rehabilitation services worldwide in various settings (getting beyond the rehabilitation facilities) emphasizing the concept of integrated care with collaboration across other sectors to meet the specific needs of APwDs. This evidence based position paper (EBPP) represents the official position of the European Union through the UEMS PRM Section and designates the professional role of PRM physicians in APwDs.

Rehabilitation Services Provision and Payment.

Persons with spinal cord injury (SCI) experience disability and have significant need for rehabilitation. To deliver appropriate rehabilitation, interventions and programs suitable services must exist. A prerequisite for system improvement is a description of rehabilitation services. The aim of this paper was to develop a rehabilitation service framework for SCI. Additionally, principles and models of payment of rehabilitation services will be discussed. Health-related rehabilitation services should be available along the continuum of care and implemented at all levels of health care. The three most important types of services are acute, postacute, and long-term rehabilitation services. Health-related rehabilitation services for patients with SCI must be able to provide high-quality equipment and a well-trained, highly specialized and multiprofessional team of rehabilitation workers. The principles of payment for SCI rehabilitation services vary according to the organization of health care systems, which primarily depends on the sources of money (eg, from national health care systems, other health insurances, or out of pocket). Funding systems and payment criteria may influence service provision and justice in service delivery. It is important to analyze the provision of rehabilitation services and the related funding system using uniform assessment and evaluation tools.

European initiative for the application of the International Classification of Service Organization in Health-related Rehabilitation (ICSO-R).

The International Classification of Functioning, Disability and Health (ICF) should be used as the framework for the development of a clinical assessment schedule for clinical quality management of health-related rehabilitation services. For the description of rehabilitation services a working group of the ISPRM-WHO-Liaison Committee proposed an instrument called "International Classification System for Service Organization in Health-related Rehabilitation" or ICSO-R. To test the applicability and feasibility of ICSO-R to describe rehabilitation services and to propose further improvements. A workshop was held. SPF (Swiss Paraplegic Research) in Nottwil, January 2016. Six working groups, composed of delegates from UEMS PRM (Physical and Rehabilitation Medicine Section and Board of the European Union of Medical Specialists) and experts from other rehabilitation professions. Each working group selected an existing service of a predefined category (one acute, three post-acute and two long-term rehabilitation services). The instructions were: 1) make a narrative description of an exemplary service; 2) describe the exemplary service using the dimensions and categories of ICSO-R; 3) comment on feasibility of the ICSO-R table, on shortcomings, and make suggestions for improvement. The narrative and ICSO-R descriptions were analyzed and compared, and recommendations were made for modification of ICSO-R. The narratives were very heterogeneous and none comparable. ICSO-R use was feasible and significantly increased precision and comparability of the descriptions of existing rehabilitation services. Proposals for improvement were made, for example the addition of lacking categories. Suggestions were made for clarification of a number of characteristics, including a taxonomy with value sets. The UEMS PRM workshop on the description of health-related rehabilitation services for use in a clinical quality management schedule clearly demonstrated feasibility and applicability of ICSO-R, showing more precise and comparable descriptions as compared to the narratives. However, in a next version some modifications should be made to improve clarity. It is recommended to use ICSO-R to describe and compare existing as well as model rehabilitation services for benchmarking and implementation into health systems worldwide. The ISPRM-WHO Liaison committee working group will further modify and improve ICSO-R.