Improved understanding of effective therapeutic interventions (TI) is required to optimise mobility outcomes in people with multiple sclerosis (pwMS) undergoing multidisciplinary neurological rehabilitation (MNR). The primary objective was to explore clinically meaningful effects of active TI on mobility during inpatient MNR. Secondary objectives were to assess mobility-related goal attainment and to develop and evaluate a standardised TI documentation catalogue. A TI catalogue and manual were developed and refined based on moderate interrater reliability from 12 video-recorded therapy sessions rated by eight clinicians. Usability was assessed by 47 physiotherapists using the System Usability Scale (SUS). Mobility outcomes included the 12-item Multiple Sclerosis Walking Scale (MSWS-12), 2-Minute Walk Test (2 MWT), Five Times Sit-to-Stand Test (5-TSTS), and Timed 25-Foot Walk. Effect sizes were calculated for individual and group-based TI. Goal attainment was measured using Goal Attainment Scaling. The TI catalogue showed good usability (mean SUS score 72.3). Significant improvements were observed across all mobility outcomes, with clinically meaningful changes for MSWS-12, 2MWT and 5-TSTS. Gait training variants, robot-assisted gait training, strength, task-oriented, dual-task, endurance, coordination, and balance training showed medium-to-large effect sizes. Goal achievers demonstrated significantly greater improvements in walking perception, speed, and distance than non-achievers, with no difference in sit-to-stand performance. Over 88% of 255 pwMS achieved or exceeded their therapy goals. The TI catalogue is a reliable and practical tool for documenting TI in routine MNR. Several interventions, particularly stair gait training, strength training, and robot-assisted gait training, were associated with clinically meaningful mobility improvements in pwMS. The study was prospectively registered with the German Clinical Trials Register (DRKS00025216 and DRKS00030391).

Sedentary behavior (SB) is highly prevalent during stroke rehabilitation. Evaluating both the duration and pattern of SB may inform tailored interventions. This study aimed to classify patients with stroke undergoing inpatient rehabilitation into distinct subgroups based on multiple SB indicators at admission and examine their longitudinal changes in SB outcomes over a 1-month period. This multicenter prospective longitudinal study was conducted across 14 rehabilitation hospitals in Japan. SB was objectively assessed using triaxial accelerometers at admission and at 1 month. K-means clustering was applied to the following 5 SB-related variables: short (<30 minutes), medium (30-59 minutes), and long (≥60 minutes) sedentary bout ratios; total SB time; and break frequency. Longitudinal changes were examined using generalized linear mixed models. A total of 420 participants (median age 71.0 years; 57.9% male) were enrolled. Clustering analysis identified 3 subgroups: low SB (n = 109), moderate SB (n = 196), and high SB (n = 115). Generalized linear mixed models showed significant main effects of time for most SB indicators, except the long SB bout ratio. Significant group × time interactions were observed for the short and medium SB bout ratios and break frequency in the low SB group and for the medium and long SB bout ratios in the high SB group (P < 0.05). Three distinct SB phenotypes were identified among patients with stroke during inpatient rehabilitation. Early behavioral profiling using SB indicators may support the development of individualized strategies to reduce sedentary time.

Through a partnership and collaborative design process involving technologists and healthcare professionals, a web platform featuring a digital rehabilitation plan was developed. This process tackles recognised challenges in information and communication technology for rehabilitation, such as fragmented data flows and low-quality user interfaces. The digital rehabilitation plan facilitates shared decision-making by allowing patients to customise their plan while providing healthcare professionals with the necessary access to support the patient's journey. This study assessed the experiences of end-user healthcare professionals and patients regarding the plan's usability, its potential for shared decision-making, and identified potential areas for improvement. This qualitative exploratory study employed semi-structured focus group discussions involving three distinct participant groups: (i) patients, (ii) healthcare professionals, and (iii) a combined group of patients and healthcare professionals. The discussions focused on various stages of the rehabilitation process, including the pre-admission phase, inpatient care, rehabilitation plans, evaluations during inpatient stays, and outpatient follow-ups. The recorded discussions were transcribed and analysed using reflexive thematic analysis to uncover patterns, contradictions, and dilemmas in the participants' experiences and perspectives. Patients and healthcare professionals appreciated the digital rehabilitation plan and acknowledged its contribution to shared decision-making. However, patients requested a wider range of digital support and communication tools for inpatient rehabilitation and follow-up, e.g., a "my page" with access to relevant information, chat support, educational tools, and videos. Professionals were reluctant to expand the use of the web platform due to past negative experiences with information and communication technology, and had less motivation to change work processes further. When patients and professionals were brought together, the discussion led to a shift in the professionals' opinions, revealing a potential for improved collaboration, communication, and shared decision-making. This study underscores the necessity of involving all stakeholders in the design of a digital tool to ensure that all end-users ' needs and wants are accounted for. Involving patients in both design and implementation can uncover biases, identify barriers, and enhance usability, thereby promoting digital communication and shared decision-making in rehabilitation. Bringing stakeholders together revealed that while healthcare professionals encounter barriers due to established procedures, patients' familiarity with everyday technology and enthusiasm for digital tools shifted professionals' perspectives. Lessons learned from this research project were fed back to the developer of the web platform, and taken into account to strengthen the web platform's potential for communication and shared decision-making in rehabilitation planning. This study was approved by the Norwegian Agency for Shared Services in Education and Research, Data Protection Services for Research, reference number 116434.

Spinal cord injury (SCI) at or above the thoracic sixth spinal cord level disrupts descending sympathetic and parasympathetic control, leading to severe autonomic dysfunctions including cardiovascular and pelvic organ function. These complications adversely affect the quality of life and are associated with increased morbidity and mortality after SCI. Transcutaneous spinal cord stimulation (tSCS) may offer therapeutic benefits for these functions. The safety of tSCS in subacute SCI, however, remains unknown. Therefore, this study aims to evaluate the feasibility of tSCS for autonomic recovery in individuals with subacute SCI within six months since injury. We designed a two-phase clinical protocol consisting of a pilot randomized controlled trial conducted during inpatient rehabilitation (Project A), followed by a post-discharge outpatient phase with a single-arm quasi-experimental design (Project B). In Project A, 26 adults with cervical or upper thoracic (≥T6) American Spinal Injury Association Impairment Scale (AIS) A-C SCI are planned to be enrolled and randomly assigned to receive tSCS or sham stimulation for five sessions (up to 90 minutes each) in parallel with standard care. Following discharge from inpatient rehabilitation, eligible participants will be offered continuation in Project B. New eligible participants who have not participated in Project A will also be recruited into Project B. They will receive 18 tSCS sessions over six weeks in the laboratory setting. Primary outcomes focus on feasibility, including recruitment, retention, and stimulation-related adverse events. Clinical outcomes will be collected at baseline, after each intervention, and at six months and one-year post-injury. Feasibility results will be summarized descriptively, and exploratory analyses of autonomic outcomes, including cardiovascular and pelvic organ function, will provide preliminary estimates of autonomic responses. The study has been approved by the University of Washington Institutional Review Board. Written informed consent will be obtained from all participants. Results will be submitted to peer-reviewed journals and shared with the scientific/clinical communities and individuals with lived experience of SCI. ClinicalTrials.gov NCT06540859.

Introduction . Ischemic stroke, characterized by combined motor and cognitive impairments and accompanied by an increase in the global burden and needs for rehabilitation, requires early, structured and dosed kinesiotherapy at the inpatient stage, with an assessment of its effectiveness using validated functional, cognitive and patient-oriented scales. Aim . To assess the dynamics of functional independence, cognitive status, and stroke-specific quality of life in patients of both sexes undergoing early kinesiotherapy in an inpatient setting. Materials and methods . A total of 60 patients (29 women, 31 men) were examined at the Kyrgyz Research Institute of Balneology and Rehabilitation Treatment, average age 65.68 ± 10.34 years. Rehabilitation was initiated at an early stage and included verticalization, passive and active exercises, as well as therapy based on the Bobath concept. The Barthel Index, the Mini-Mental State Examination (MMSE), and the Stroke-Specific Quality of Life (SS-QOL) questionnaire were assessed at admission and at discharge after 20 days. Results . During the inpatient rehabilitation stage, patients with ischemic stroke demonstrated statistically significant improvements in functional and cognitive status, as well as in several quality-of-life indicators. According to the Barthel Index, the level of functional independence increased significantly from 54.83 ± 22.62 to 99.25 ± 20.95 points (p &lt; 0.05); similar dynamics were observed in women (from 53.45 ± 23.05 to 98.27 ± 22.64) and men (from 56.12 ± 22.13 to 100.16 ± 19.19; p &lt; 0.05). Cognitive status assessed by the MMSE also improved significantly: the mean score increased from 26.55 ± 3.47 to 29.38 ± 1.42 points (p &lt; 0.05), with comparable changes in women (26.93 ± 3.14 to 29.38 ± 1.45) and men (26.19 ± 3.72 to 29.39 ± 1.38; p &lt; 0.05). According to the SS-QOL questionnaire, statistically significant improvements were observed in the domains of “family role,” “mobility,” “mood,” “self-care,” “social role,” and “upper limb function” (p &lt; 0.05). Several domains (energy, speech, thinking, vision, personality traits, and productivity) demonstrated positive trends without reaching statistical significance (p &gt; 0.05). Overall, the findings indicate substantial recovery of functional independence, cognitive function, and key components of quality of life during the early rehabilitation period, with no clinically significant gender differences. Conclusion . Early kinesiotherapy initiated in the acute phase of ischemic stroke and implemented through a stepwise program of mobilization and function-oriented exercises is associated with clinically significant improvements in functional independence and cognitive status. It also provides a statistically significant increase in stroke-specific quality of life, predominantly in domains related to mobility, self-care, upper limb function, emotional well-being, and social participation.

Clinical Factors Associated With Functional Recovery in Pediatric Traumatic Brain Injury.

Geriatric rehabilitation reduces mortality and long-term care home (LTCH) admission. However, cognitive impairment is often perceived to be a barrier for successful rehabilitation. Our objective was to determine the impact of cognitive impairment on rehabilitation outcomes using a systematic review of inpatient geriatric rehabilitation. We conducted a secondary analysis of a recent systematic review and meta-analysis of geriatric rehabilitation in the inpatient settings. We screened 29 randomized controlled trials (RCTs) included in the original systematic review for those that reported rehabilitation outcomes (e.g. mortality, LTCH admission) by cognitive status (high vs. low cognition as defined by score cutoff or dementia diagnosis). Results were analyzed by (i) a meta-analysis of outcomes in those with cognitive impairment and (ii) pooling the within study interaction by cognitive status. Of 29 RCTs, 8 RCTs (1134 patients) reported outcomes by cognitive status. For the subgroup of patients with cognitive impairment, the risk ratio (RR) of mortality at the longest follow up was 0.75 (95% confidence interval [CI] 0.39 to 1.45, I2 = 61.0%) and the RR of LTCH admission was 0.89 (95% CI 0.62 to 1.28, I2 = 0). There was no interaction between baseline cognitive status and mortality (pooled interaction of difference in logRR - 0.12, 95% CI -0.72 to 0.48) or LTCH admission (pooled interaction 0.17, 95% CI -0.34 to 0.68). There is no interaction between baseline cognitive status and the outcomes in this systematic review, suggesting that baseline cognitive impairment does not alter the mortality and institutionalization benefits of geriatric rehabilitation. PROSPERO: CRD42022345078.

Efficacy of inpatient pulmonary rehabilitation in elderly patients with acute exacerbation of COPD: randomised controlled trial study.

Traumatic brain injury (TBI) mechanisms are often grouped together in research. Differences in acute and long-term outcomes across mechanisms of injury (MOIs) remain unclear, partly because of confounding by age. Modeling MOI-specific effects can inform clinical triage and prognostication. We examined the relationship between motor vehicle accidents (MVAs) vs falls, the 2 most common MOIs, and acute and 1-year post-injury outcomes, after rigorous control of demographic and preinjury personal factors. Data were analyzed from individuals with moderate-to-severe TBI requiring inpatient rehabilitation from the TBI Model Systems National Database, a multicenter prospective longitudinal cohort study. The analytic sample was restricted to individuals aged 16-79 years with an MOI due to MVA or fall occurring between April 2010 and January 2023. We used inverse probability of treatment weighting, based on propensity scores, to adjust for 14 demographic and preinjury personal characteristics and estimate the causal effect of MOI on acute and 1-year outcomes after TBI. Acute hospital and rehabilitation outcomes included the following: Glasgow Coma Scale (GCS), sedation, intubation, post-traumatic amnesia duration, time to follow commands (TFC), length of hospital stay (LOS), and Functional Independence Measure (FIM) cognitive and motor scores. One-year outcomes included the following: Disability Rating Scale and Participation Assessment with Recombined Tools Objective. Among 5,181 participants (mean age 45.1 ± 19.5, 70% male), 48.4% sustained their injury from MVAs and 51.6% from falls. After weighting and multiple comparisons adjustment, the MVA group had lower GCS total scores by 1.27 points (95% CI -1.92 to -0.61; adjusted p = 0.001), greater odds of receiving sedation (odds ratio 1.43, 95% CI 1.11-1.85; adjusted p = 0.014), longer TFC by 1.64 days (95% CI 0.39-2.89; adjusted p = 0.017), and lower discharge FIM motor scores by 4.28 points (95% CI -7.50 to -1.26; adjusted p = 0.014). At 1 year after injury, disability levels and community participation did not differ. MVA-related TBI was associated with worse acute outcomes. However, by 1 year after injury, disability level and community participation do not differ. This work highlights novel findings in short-term and long-term outcomes after falls and MVAs, the leading TBI causes, which are not explained by confounders such as age. Findings may not generalize beyond patients receiving inpatient rehabilitation for TBI.

Australian inpatient rehabilitation facilities are increasingly integrating rehabilitation technologies to support patient recovery. However, little is known about patient perceptions of rehabilitation technologies and the intensity of therapy able to be facilitated. This study aimed to quantify the amount of practice being achieved by patients in an Australian inpatient rehabilitation setting and explore their perceptions of upper limb rehabilitation technologies. A multimethod study design was used to investigate the perceptions and use of rehabilitation technologies (i.e. InMotion, Fourier ArmMotus, SaeboReJoyce and Touch Accessible Platform for Interactive Technology) by adult inpatients. Semi-structured interviews and the System Usability Scale were completed. Observations of routine therapy sessions were undertaken to quantify the amount and intensity of technology-based practice. Ten participants were recruited (50% male, mean age 62years). A total of 15 sessions were observed across all participants using robot-assisted therapy and Touch Accessible Platform for Interactive Technology at an average duration of 35min/session; of which 29min was active therapy. Most participants described their experiences with rehabilitation technologies positively, highlighting benefits for recovery, enjoyability and easy usability. Participants rated the technologies highly on the System Usability Scale, with total scores ranging between 65 and 100 for usability, and a minimum rating of 'good' for user-friendliness. Rehabilitation technologies were well received by adults undergoing inpatient rehabilitation and with application for a range of impairments. The technologies facilitated enjoyment of daily therapy, and participants were comfortable with limited therapist input when using the devices. Additionally, participants were able to engage in highly intensive practice using the technologies.

Background Digital health–driven rehabilitation systems incorporating Internet of Things (IoT) technologies have attracted increasing attention as a means to support upper limb motor recovery after stroke. However, detailed clinical descriptions of their implementation in routine inpatient rehabilitation remain limited. Case presentation We report the case of a right-handed man in his forties with right-sided upper limb motor impairment following putaminal hemorrhage. The patient underwent rehabilitation using a digital health–driven IoT-based upper limb rehabilitation system starting approximately one month after stroke onset during the convalescent rehabilitation phase. Intervention The intervention was conducted over a two-week period, consisting of 10 sessions (approximately 40 min per session) as part of routine inpatient rehabilitation. The system integrated a portable smart projector, a three-dimensional motion capture sensor, and a communication robot to deliver interactive, task-oriented training. Five activities of daily living–oriented tasks (wiping, unlocking, squeezing, cup transfer, and typing) were implemented, with task difficulty adjusted by the treating occupational therapist according to the patient's performance. Outcomes Upper limb motor function assessed by the Fugl–Meyer Assessment for the Upper Extremity improved from 63 to 66. Real-world arm use assessed by the Motor Activity Log showed an Amount of Use score of 5 both before and after the intervention, suggesting a ceiling effect, while the Quality of Movement score improved slightly from 4.8 to 5. The patient demonstrated high engagement and adherence throughout the intervention, and no adverse events were observed. Conclusion This case report demonstrates the clinical feasibility of integrating a digital health–driven IoT rehabilitation system into routine inpatient stroke rehabilitation. Although generalization is limited by the single-case design, the present case highlights the potential of IoT-based digital health technologies to support task-oriented training and patient engagement in upper limb rehabilitation.

Purpose Using digital devices to enhance the dose and type of physiotherapy exercises improved mobility and physical activity among adults undertaking rehabilitation in a previous randomised trial. The objective of this study was to determine the feasibility of implementing this intervention in routine practice in a public hospital to inform the conduct of a large-scale implementation trial. Materials and methods Feasibility hybrid type II implementation-effectiveness trial. Patients from an inpatient rehabilitation ward were randomised into control or intervention groups. Both groups received usual care. The intervention group received additional exercises using digital devices provided by trained physiotherapists. Primary feasibility outcomes were: exercise dose documented, rate of recruitment, and provision of ≥30 min daily exercise using digital devices. Results Twenty-two patients were randomised; 11 in each group. Exercise dosage was documented 100% of the time, one participant was recruited every 5 weeks, and 36% of intervention participants received ≥30 min of daily exercise using digital devices over 14 days. Conclusions Exercises using digital devices can be delivered within usual rehabilitation staffing levels, with intended dosage achieved for one third of participants. A large-scale implementation trial is feasible if trial processes and intervention challenges are addressed, and more study sites are included. Trial registration Australian and New Zealand Clinical Trial Registry; ACTRN12621000938808.

The characterization of dysphagia in COVID-19 rehabilitation patients: An inpatient rehabilitation cohort study.

ABSTRACT Introduction The length of stay (LOS) for inpatient SCI rehabilitation varies widely worldwide, including high-income countries. Understanding the individual factors that influence LOS at the country level provides valuable insights for optimizing rehabilitation services and resource allocation. Currently, representative data on LOS in rehabilitation following SCI in Switzerland are lacking. Objective To provide a population-based description of rehabilitation LOS and its determinants after SCI in Switzerland. Methods This study utilized data from the Swiss Spinal Cord Injury inception cohort, comprising individuals admitted to specialized rehabilitation between 2020 and 2023. Missingness was addressed using multiple imputation. Flexible parametric survival models were employed to identify significant relationships between rehabilitation LOS and the following determinants: patient and lesion characteristics, comorbidity status, functional independence at admission, common secondary health conditions (urinary tract infection, decubitus ulcers, and pneumonia), LOS in acute care, and rehospitalization. Results The main analysis included 831 individuals with SCI, revealing a median LOS of 139 days (IQR 79.0-189.0). Independent associations with rehabilitation LOS identified in the fully adjusted model included age at SCI, level and lesion severity, urinary tract infections, decubitus ulcers, and functional independence at admission. Additionally, pneumonia and rehospitalization were significantly associated with LOS in supplementary expanded analyses based on a larger sample size with increased power. Conclusion This study described the LOS for SCI rehabilitation in Switzerland and identified critical patient- and lesion-related determinants. The insights gained are instrumental for healthcare providers and policymakers in enhancing the efficiency and quality of SCI rehabilitation services.

To present sex-specific reference data for peak oxygen uptake (V̇O2peak) in Norwegian patients with coronary artery disease (CAD) undergoing cardiac rehabilitation and examine its association with major adverse cardiovascular events (MACE). We retrospectively analysed treadmill cardiopulmonary exercise test (CPET) data from 1,651 CAD patients (21% women; mean (SD) age 61 (9) years) attending inpatient cardiac rehabilitation (2004-2022). Patients were categorized by index event: myocardial infarction (MI), coronary artery bypass grafting, or percutaneous coronary intervention/pharmacologically treated CAD. Age-, sex-, and diagnosis-specific V̇O2peak reference data were generated. Associations between V̇O2peak and a combined MACE endpoint (all-cause mortality, acute coronary syndrome, stroke, or heart failure) were assessed using Cox proportional hazards models including natural cubic splines for assessing non-linear patterns. Men had higher V̇O2peak than women (mean (SD) 26.9 (6.7) vs. 23.2 (5.3) mL·kg-1·min-1; p < 0.001). V̇O2peak was on average 2.5 and 1.7 mL·kg-1·min-1 lower per decade of age in men and women, respectively. Patients with a previous MI had the highest V̇O2peak, followed by CABG and PCI/CAD (p <0.001). During 7,880 person-years, 510 patients (36%) experienced MACE. Each 1 mL·kg-1·min-1 higher V̇O2peak was associated with a 7% lower MACE risk (HR [95 % CI]; 0.93 [0.92-0.95]) in men and 5% (HR [95 % CI]; 0.95 [0.91-0.99]) in women. Patients in the highest cardiorespiratory fitness quartile had a 55% lower risk compared to the lowest quartile. Associations were consistent across CAD subcategories. Sex-specific natural cubic spline models revealed inverse, non-linear associations. This study provides novel sex- and diagnosis-specific V̇O2peak reference values for Norwegian CAD patients and confirms V̇O2peak as a strong prognostic marker, supporting its integration into routine secondary prevention and individualized care.

Acute Left-Sided Weakness in Inpatient Rehabilitation: A Clinical Vignette.

Enrollees in Medicare Advantage (MA) receive less intensive post-acute care (PAC) than those in traditional Medicare, but the implications of this lower intensity, particularly for patients with complex needs, remain poorly understood. To estimate the association of MA enrollment with PAC use and patient outcomes for hospitalized beneficiaries with hip fracture or stroke. A quasi-experimental difference-in-differences analysis leveraging the geographic expansion of MA from 2012 to 2017. The study included 148,396 stroke and 126,046 hip fracture hospitalizations, representing quasi-exogenous hospitalization events in high MA-growth counties. Initial PAC setting, 30-day all-cause hospital readmission, and 30- and 90-day all-cause mortality. MA enrollment was associated with fewer discharges to inpatient rehabilitation facilities (stroke: -8.9 pp; 95% CI, -9.88 to -7.92; hip fracture: -14.4 pp; 95% CI: -15.38 to -13.42). While 30-day readmissions were modestly lower for MA enrollees in both cohorts, MA enrollees experienced a 7.1% relative increase in 30-day mortality for stroke (0.6 pp; 95% CI: 0.01 to 1.19) and an 11.9% relative increase in 90-day mortality for hip fracture (1.3 pp; 95% CI: 0.52 to 2.08). This adverse mortality effect was concentrated in markets with high baseline IRF use (> = 33.3% of discharges, top tercile), where MA enrollment was associated with an 18.0% relative increase in 90-day mortality for stroke (2.0 pp; 95% CI: 0.82 to 3.18) and a 22.3% relative increase in 90-day mortality for hip fracture (2.3 pp; 95% CI: 0.93 to 3.67). MA enrollment was associated with lower IRF use, modestly lower readmissions, and a higher mortality risk for hip fracture and stroke. These findings suggest that MA's strategy of shifting patients to lower-cost settings may carry unintended adverse consequences for clinically complex patients.

Purpose Digital devices can be used to deliver mobility exercises in rehabilitation. However, the best way to implement this intervention into practice is unclear. This paper describes the feasibility of delivering strategies to implement digital devices as part of a feasibility hybrid type II implementation-effectiveness trial. Materials and methods Physiotherapists were recruited from a public hospital rehabilitation ward. Training a clinical champion, loaning equipment and changing the gym environment, education and training, facilitation, and audit and feedback strategies were to support implementation. Feasibility outcomes were fidelity and dose of implementation strategies delivered and use of digital devices after receiving implementation strategies, collected from an implementation diary and surveys. Results Twenty-seven physiotherapists were recruited and received implementation strategies, mostly delivered by the clinical champion. Strategies were delivered as intended (fidelity) but at a higher dosage than anticipated, including 122 h of training (dose). All physiotherapists reported using digital devices with their patients after receiving the implementation strategies. Conclusions A multi-faceted implementation strategy was feasible to support physiotherapists to use digital devices to train mobility in rehabilitation. The clinical champion played a central role in embedding digital devices into the clinical setting. Trial registration Australian and New Zealand Clinical Trial Registry; ACTRN12621000938808.

Purpose Anxiety and depression are the most prevalent mental disorders in rehabilitation populations and negatively impact rehabilitation outcomes. The Patient Health Questionnaire for Depression and Anxiety (PHQ-4) is an ultra-brief screening instrument validated for general and primary care populations. We validated the PHQ-4 for the first time for the rehabilitation setting. Materials and Methods The study sample consisted of 66,412 patients attending multimodal inpatient rehabilitation, covering various medical indications. To validate the PHQ-4's factorial validity, we conducted confirmatory factor analyses (CFA). Multi-group CFAs assessed measurement invariance. Convergent validity was tested using ordinal logistic regression to model the PHQ-4's association with measures of quality of life, vocational impairment, and work ability. Results The results demonstrated excellent fit for a two-factor solution. Reliability indices were adequate for a screening instrument (McDonald's ω .775–.852). Measurement invariance was demonstrated across age, gender, and all but one medical indication. Convergent validity was supported, showing associations with age and common patient reported outcomes. Conclusions This study demonstrates that the PHQ-4 is a valid and reliable tool for screening for anxiety and depression in rehabilitation settings. Based on a substantial sample and preregistered analysis strategy, the findings will likely generalize to rehabilitation populations in other countries.

Psychological comorbidities in cancer patients are common and associated with additional limitations in work participation. This longitudinal analysis examines the impact of psychological comorbidity in women with breast cancer on work participation after cancer rehabilitation.We used the scientific use file "SUFRSDLV20B" of the German Pension Insurance. Women with breast cancer who had completed inpatient post-acute rehabilitation in 2017 were included. Characteristics of patients with and without psychological comorbidity at the time of rehabilitation and their employment histories up to two years later were analyzed descriptively. Multiple logistic regressions tested the association between psychological comorbidity and stable employment as well as receiving a disability pension.Data from 2,310 women were analyzed, of whom 478 (21%) had a psychological comorbidity. Women with psychological comorbidity were more often unemployed before rehabilitation (11 vs. 8%) and also more frequently received sickness and unemployment benefits after rehabilitation. Psychological comorbidity was significantly associated with a lower chance of stable employment (OR=0.7; 95% CI 0.5 to 0.9; p=0.010) and a higher chance of receiving a disability pension (OR=1.9; 95% CI 1.2 to 3.1; p=0.008) two years after rehabilitation. The strongest association was observed for depression.In women with breast cancer, a psychological comorbidity was associated with restricted work participation two years after rehabilitation. These results indicate the need for early detection of psychological comorbidities and psycho-oncological as well as work-related interventions.