Multidisciplinary Rehabilitation For Patients Research Articles

Which patients with chronic low back pain respond favorably to multidisciplinary rehabilitation? A secondary analysis of a randomized controlled trial.

The aim of this study was to identify prognostic variables at baseline associated with being responding favorably to multidisciplinary rehabilitation in patients with chronic low back pain (CLBP). A responder analysis was conducted based on data from a randomized controlled trial with 26-week follow-up including 165 patients with CLBP treated at a Danish multidisciplinary rehabilitation center. Patients were dichotomized into responders and non-responders based on the outcome of a minimal clinically important difference of six points on the Oswestry Disability Index. The associations between prognostic variables and responders were analyzed using logistic regression. A total of 139 patients completed the study, of which 42% were classified as responders. Sex and employment status were statistically significant, with a decreased odds ratio (OR) of being a responder found for males compared to females (OR = 0.09, 95% CI = 0.02-0.48) and for being on temporary or permanent social benefits (OR = 0.28, 95% CI = 0.10-0.75) compared to being self-supporting or receiving retirement benefits. Statistically significant interaction (OR = 8.84, 95% CI = 1.11-70.12) was found between males and being on temporary or permanent social benefits. In patients with CLBP, female patients as well as patients who were self-supporting or receiving retirement benefits were significantly more likely than male patients or patients on temporary or permanent social benefits to be a responder to multidisciplinary rehabilitation.

Multidisciplinary rehabilitation of patients with persistent physical symptoms

Multidisciplinary rehabilitation of patients with persistent physical symptoms

Prognostic factors for the improvement of pain and disability following multidisciplinary rehabilitation in patients with chronic neck pain

BackgroundRecent clinical studies have demonstrated the effectiveness of specific, multidisciplinary, bio-psychosocial, rehabilitation programmes for chronic neck pain. However, prognostic factors for the improvement of pain and disability are mostly unknown. Therefore, the aim of this study was to explore prognostic factors associated with improvements in chronic neck pain following participation in a three-week, multidisciplinary, bio-psychosocial, rehabilitation programme.MethodsIn this observational, prospective cohort study, a total of 112 patients were assessed at the beginning, end, and 6 months following the completion of a multidisciplinary, bio-psychosocial, rehabilitation programme. Inclusion for participation in the rehabilitation programme depended upon an interdisciplinary pain assessment. The primary outcome was neck pain and disability, which was measured using the Northern American Spine Society questionnaire for pain+disability and was quantified with effect sizes (ES). Multivariable linear regression analyses were used to explore potential prognostic factors associated with improvements in pain and disability scores at discharge and at the 6-month follow-up period.ResultsThe mean age of the patients was 59.7 years (standard deviation = 10.8), and 70.5% were female. Patients showed improvement in pain+disability at discharge (ES = 0.56; p < 0.001), which was sustained at the 6-month follow-up (ES = 0.56; p < 0.001). Prognostic factors associated with improvement in pain+disability scores at discharge included poor pain+disability baseline scores (partial, adjusted correlation r = 0.414, p < 0.001), older age (r = 0.223, p = 0.024), a good baseline cervical active range-of-motion (ROM) (r = 0.210, p < 0.033), and improvements in the Short-form 36 mental health scale (r = 0.197; p = 0.047) and cervical ROMs (r = 0.195, p = 0.048) from baseline values. Prognostic factors associated with improvements in pain+disability at the 6-month follow-up were similar and included poor pain+disability baseline scores (partial, adjusted correlation r = 0.364, p < 0.001), improvements in the Short-form 36 mental health scale (r = 0.232; p = 0.002), cervical ROMs (r = 0.247, p = 0.011), and better cervical ROM baseline scores. However, older age was not a factor (r = 0.134, p = 0.172).ConclusionsFuture prognostic models for treatment outcomes in chronic neck pain patients should consider cervical ROM and mental health status. Knowledge of prognostic factors may help in the adoption of individualized treatment for patients who are less likely to respond to multidisciplinary rehabilitation.

Serious Gaming During Multidisciplinary Rehabilitation for Patients With Chronic Pain or Fatigue Symptoms: Mixed Methods Design of a Realist Process Evaluation.

BackgroundSerious gaming could support patients in learning to cope with chronic pain or functional somatic syndromes and reduce symptom burdens.ObjectiveTo realize this potential, insight is needed into how, why, for whom, and when it works in actual treatment circumstances.MethodsFollowing a realist approach, process evaluations were performed before, during, and after a two-armed, natural quasi-experiment (n=275). A group of patients with interfering chronic pain or fatigue symptoms received a short additional blended mindfulness-based serious gaming intervention during a multidisciplinary rehabilitation program. A control group only received the regular rehabilitation program. During two sessions before and one session after the experiment, expectations about serious gaming processes were discussed in focus groups with local care providers, implementers, and experts. Patients participated in a survey (n=114) and in semistructured interviews (n=10). The qualitative data were used to develop tentative expectations about aspects of serious gaming that, in certain patients and circumstances, trigger mechanisms of learning and health outcome change. Hypotheses about indicative quantitative data patterns for tentative expectations were formulated before inspecting, describing, and analyzing—with regression models—routinely collected clinical outcome data. An updated program theory was formulated after mixing the qualitative and quantitative results.ResultsQualitative data showed that a subset of patients perceived improvement of their self-awareness in moments of daily social interactions. These results were explained by patients, who played the serious game LAKA, as a “confrontation with yourself,” which reflected self-discrepancies. Important characteristics of serious gaming in the study’s context included innovation factors of relative advantage with experiential learning opportunity, compatibility with the treatment approach, and the limited flexibility in regard to patient preferences. Perceived patient factors included age and style of coping with stress or pain. Learning perceptions could also depend on care provider role-taking and the planning and facilitating (ie, local organization) of serious gaming introduction and feedback sessions in small groups of patients. Quantitative data showed very small average differences between the study groups in self-reported depression, pain, and fatigue changes (-.07<beta<-.17, all 95% CI upper bounds <0), which were mediated by small group differences in mindfulness (beta=.26, 95% CI .02-.51). Mindfulness changes were positively associated with patient involvement in serious gaming (n=114, beta=.36, P=.001). Acceptance of serious gaming was lower in older patients. Average health outcome changes went up to a medium size in patients that reported lower active coping with stress and lower pain coping before serious gaming. Mindfulness changes and gaming acceptance perceptions covaried with group structure and immediate feedback sessions after serious gaming.ConclusionsThis study developed transferable insight into how and why serious gaming can facilitate additional learning about coping in order to reduce burdens of chronic pain or fatigue symptoms in certain patients and in actual treatment circumstances. Future studies are needed to continue the development of this fallible theory. Such research will further support decisions about using, designing, allocating, and tailoring serious gaming to optimize important patient health benefits.Trial RegistrationNetherlands Trial Register NTR6020; https://www.trialregister.nl/trial/5754

Elaborating on the assessment of the risk of bias in prognostic studies in pain rehabilitation using QUIPS\u2014aspects of interrater agreement

BackgroundMany studies have been performed to identify important prognostic factors for outcomes after rehabilitation of patients with chronic pain, and there is a need to synthesize them through systematic review. In this process, it is important to assess the study quality and risk of bias. The “Quality In Prognosis Studies” (QUIPS) tool has been developed for this purpose and consists of several prompting items categorized into six domains, and each domain is judged on a three-grade scale (low, moderate or high risk of bias). The aim of the present study was to determine the interrater agreement of the risk of bias assessment in prognostic studies of patients with chronic pain using QUIPS and to elaborate on the use of this instrument.MethodsWe performed a systematic review and a meta-analysis of prognostic factors for long-term outcomes after multidisciplinary rehabilitation in patients with chronic pain. Two researchers rated the risk of bias in 43 published papers in two rounds (15 and 28 papers, respectively). The interrater agreement and Cohen’s quadratic weighted kappa coefficient (κ) and 95% confidence interval (95%CI) were calculated in all domains and separately for the first and second rounds.ResultsThe raters agreed in 61% of the domains (157 out of 258), with similar interrater agreement in the first (59%, 53/90) and second rounds (62%, 104/168). The overall weighted kappa coefficient (kappa for all domains and all papers) was weak: κ = 0.475 (95%CI = 0.358–0.601). A “minimal agreement” between the raters was found in the first round, κ = 0.323 (95%CI = 0.129–0.517), but increased to “weak agreement” in the second round, κ = 0.536 (95%CI = 0.390–0.682).ConclusionDespite a relatively low interrater agreement, QUIPS proved to be a useful tool in assessing the risk of bias when performing a meta-analysis of prognostic studies in pain rehabilitation, since it demands of raters to discuss and investigate important aspects of study quality. Some items were particularly hard to differentiate in-between, and a learning phase was required to increase the interrater agreement. This paper highlights several aspects of the tool that should be kept in mind when rating the risk of bias in prognostic studies, and provides some suggestions on common pitfalls to avoid during this process.Trial registrationPROSPERO CRD42016025339; registered 05 February 2016.

Prognostic Factors for Physical Functioning After Multidisciplinary Rehabilitation in Patients With Chronic Musculoskeletal Pain: A Systematic Review and Meta-Analysis.

This systematic review aimed to identify and evaluate prognostic factors for long-term (≥6 mo) physical functioning in patients with chronic musculoskeletal pain following multidisciplinary rehabilitation (MDR). Electronic searches conducted in MEDLINE, PsycINFO, EMBASE, CINAHL, Web of Science, and Cochrane CENTRAL revealed 25 original research reports, published 1983-2016, (n=9436). Potential prognostic factors relating to initial pain and physical and psychological functioning were synthesized qualitatively and quantitatively in random effects meta-analyses. The level of evidence (LoE) was evaluated with Grading of Recommendations Assessment, Development and Evaluation (GRADE). Pain-related factors (intensity and chronicity) were not associated with function/disability at long-term follow-up, odds ratio (OR)=0.84; 95% confidence interval (CI), 0.65-1.07 and OR=0.97; 95% CI, 0.93-1.00, respectively (moderate LoE). A better function at follow-up was predicted by Physical factors; higher levels of initial self-reported functioning, OR=1.07; 95% CI, 1.02-1.13 (low LoE), and Psychological factors; low initial levels of emotional distress, OR=0.77; 95% CI, 0.65-0.92, low levels of cognitive and behavioral risk factors, OR=0.85; 95% CI, 0.77-0.93 and high levels of protective cognitive and behavioral factors, OR=1.49; 95% CI, 1.17-1.90 (moderate LoE). While pain intensity and long-term chronicity did not predict physical functioning in chronic pain patients after MDR, poor pretreatment physical and psychological functioning influenced the prognosis negatively. Thus, treatment should further target and optimize these modifiable factors and an increased focus on positive, psychological protective factors may perhaps provide an opening for yet untapped clinical gains.

Effectiveness of Serious Gaming During the Multidisciplinary Rehabilitation of Patients With Complex Chronic Pain or Fatigue: Natural Quasi-Experiment.

BackgroundCurrent evidence for the effectiveness of specialist multidisciplinary programs for burdensome chronic pain and functional somatic syndromes drives the effort to improve approaches, strategies, and delivery modes. It remains unknown to what extent and in what respect serious gaming during the regular outpatient rehabilitation can contribute to health outcomes.ObjectiveThe objectives of our study were to determine the effect of additional serious gaming on (1) physical and emotional functioning in general; (2) particular outcome domains; and (3) patient global impressions of change, general health, and functioning and to determine (4) the dependency of serious gaming effects on adherence.MethodsWe conducted a naturalistic quasi-experiment using embedded qualitative methods. The intervention group patients received an additional guided (mindfulness-based) serious gaming intervention during weeks 9-12 of a 16-week rehabilitation program at 2 sites of a Dutch rehabilitation clinic. Simultaneously, 119 control group patients followed the same program without serious gaming at 2 similar sites of the same clinic. Data consisted of 10 semistructured patient interviews and routinely collected patient self-reported outcomes. First, multivariate linear mixed modeling was used to simultaneously estimate a group effect on the outcome change between weeks 8 and 16 in 4 primary outcomes: current pain intensity, fatigue, pain catastrophizing, and psychological distress. Second, similar univariate linear mixed models were used to estimate effects on particular (unstandardized) outcomes. Third, secondary outcomes (ie, global impression of change, general health, functioning, and treatment satisfaction) were compared between the groups using independent t tests. Finally, subgroups were established according to the levels of adherence using log data. Influences of observed confounding factors were considered throughout analyses.ResultsOf 329 eligible patients, 156 intervention group and 119 control group patients (N=275) with mostly chronic back pain and concomitant psychosocial problems participated in this study. Of all, 119 patients played ≥75% of the game. First, the standardized means across the 4 primary outcomes showed a significantly more favorable degree of change during the second part of the treatment for the intervention group than for the control group (beta=−0.119, SE=0.046, P=.009). Second, the intervention group showed a greater outcome change in depressive mood (b=−2.748, SE=1.072, P=.011) but not in “insufficiency” or concentration problems. Third, no significant group effects on secondary outcomes were found. Fourth, adherence was generally high and invariant.ConclusionsThe findings of this study suggest a very small favorable average effect on relevant health outcomes of additional serious gaming during multidisciplinary rehabilitation. The indication that serious gaming could be a relatively time-efficient component warrants further research into if, when, how, and for which patients serious gaming could be cost-effective in treatment and why.Trial RegistrationNetherlands Trial Registry NTR6020; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=6020 (Archived by WebCite at http://www.webcitation.org/71IIoTXkj)

Total disc replacement versus multidisciplinary rehabilitation in patients with chronic low back pain and degenerative discs: 8-year follow-up of a randomized controlled multicenter trial

Background ContextLumbar total disc replacement (TDR) is a treatment option for selected patients with chronic low back pain (LBP) that is non-responsive to conservative treatment. The long-term results of disc replacement compared with multidisciplinary rehabilitation (MDR) have not been reported previously. PurposeWe aimed to assess the long-term relative efficacy of lumbar TDR compared with MDR. DesignWe undertook a multicenter randomized controlled trial at five university hospitals in Norway. Patient SampleThe sample consisted of 173 patients aged 25–55 years with chronic LBP and localized degenerative changes in the lumbar intervertebral discs. Outcome MeasuresThe primary outcome was self-reported physical function (Oswestry Disability Index [ODI]) at 8-year follow-up in the intention-to-treat population. Secondary outcomes included self-reported LBP (visual analogue scale [VAS]), quality of life (EuroQol [EQ-5D]), emotional distress (Hopkins Symptom Checklist [HSCL-25]), occupational status, patient satisfaction, drug use, complications, and additional back surgery. MethodsPatients were randomly assigned to lumbar TDR or MDR. Self-reported outcome measures were collected 8 years after treatment. The study was powered to detect a difference of 10 ODI points between the groups. The study has not been funded by the industry. ResultsA total of 605 patients were screened for eligibility, of whom 173 were randomly assigned treatment. Seventy-seven patients (90%) randomized to surgery and 74 patients (85%) randomized to rehabilitation responded at 8-year follow-up. Mean improvement in the ODI was 20.0 points (95% confidence interval [CI] 16.4–23.6, p≤.0001) in the surgery group and 14.4 points (95% CI 10.7–18.1, p≤.0001) in the rehabilitation group. Mean difference between the groups at 8-year follow-up was 6.1 points (95% CI 1.2–11.0, p=.02). Mean difference in favor of surgery on secondary outcomes were 9.9 points on VAS (95% CI 0.6–19.2, p=.04) and 0.16 points on HSCL-25 (95% CI 0.01–0.32, p=.04). There were 18 patients (24%) in the surgery group and 4 patients (6%) in the rehabilitation group who reported full recovery (p=.002). There were no significant differences between the groups in EQ-5D, occupational status, satisfaction with care, or drug use. In the per protocol analysis, the mean difference between groups was 8.1 ODI points (95% CI 2.3–13.9, p=.01) in favor of surgery. Forty-three of 61 patients (70%) in the surgery group and 26 of 52 patients (50%) in the rehabilitation group had a clinically important improvement (15 ODI points or more) from baseline (p=.03). The proportion of patients with a clinically important deterioration (six ODI points or more) was not significantly different between the groups. Twenty-one patients (24%) randomized to rehabilitation had crossed over and had undergone back surgery since inclusion, whereas 12 patients (14%) randomized to surgery had undergone additional back surgery. One serious adverse event after disc replacement is registered (<1%). ConclusionsSubstantial long-term improvement can be expected after both disc replacement and MDR. The difference between groups is statistically significant in favor of surgery, but smaller than the prespecified clinically important difference of 10 ODI points that the study was designed to detect. Future research should aim to improve selection criteria for disc replacement and MDR.

Serious gaming during multidisciplinary rehabilitation for patients with complex chronic pain or fatigue complaints: study protocol for a controlled trial and process evaluation

IntroductionMany individuals suffer from chronic pain or functional somatic syndromes and face boundaries for diminishing functional limitations by means of biopsychosocial interventions. Serious gaming could complement multidisciplinary interventions through enjoyment...

Fat in the lumbar multifidus muscles - predictive value and change following disc prosthesis surgery and multidisciplinary rehabilitation in patients with chronic low back pain and degenerative disc: 2-year follow-up of a randomized trial

BackgroundEvidence is lacking on whether fat infiltration in the multifidus muscles affects outcomes after total disc replacement (TDR) surgery and if it develops after surgery. The aims of this study were 1) to investigate whether pre-treatment multifidus muscle fat infiltration predicts outcome 2 years after treatment with TDR surgery or multidisciplinary rehabilitation, and 2) to compare changes in multifidus muscle fat infiltration from pre-treatment to 2-year follow-up between the two treatment groups.MethodsThe study is secondary analysis of data from a trial with 2-year follow-up of patients with chronic low back pain (LBP) and degenerative disc randomized to TDR surgery or multidisciplinary rehabilitation. We analyzed (aim 1) patients with both magnetic resonance imaging (MRI) at pre-treatment and valid data on outcome measures at 2-year follow-up (predictor analysis), and (aim 2) patients with MRI at both pre-treatment and 2-year follow-up. Outcome measures were visual analogue scale (VAS) for LBP, Oswestry Disability Index (ODI), work status and muscle fat infiltration on MRI. Patients with pre-treatment MRI and 2-year outcome data on VAS for LBP (n = 144), ODI (n = 147), and work status (n = 137) were analyzed for prediction purposes. At 2-year follow-up, 126 patients had another MRI scan, and change in muscle fat infiltration was compared between the two treatment groups. Three radiologists visually quantified multifidus muscle fat in the three lower lumbar levels on MRI as <20% (grade 0), 20–50% (grade 1), or >50% (grade 2) of the muscle cross-section containing fat. Regression analysis and a mid-P exact test were carried out.ResultsGrade 0 pre-treatment multifidus muscle fat predicted better clinical results at 2-year follow-up after TDR surgery (all outcomes) but not after rehabilitation. At 2-year follow-up, increased fat infiltration was more common in the surgery group (intention-to-treat p = 0.03, per protocol p = 0.08) where it was related to worse pain and ODI.ConclusionsPatients with less fat infiltration of multifidus muscles before TDR surgery had better outcomes at 2-year follow-up, but findings also indicated a negative influence of TDR surgery on back muscle morphology in some patients. The rehabilitation group maintained their muscular morphology and were unaffected by pre-treatment multifidus muscle fat.Trial registrationNCT 00394732 (retrospectively registered October 31, 2006).

Are the changes in observed functioning after multi-disciplinary rehabilitation of patients with fibromyalgia associated with changes in pain self-efficacy?

Objective: To examine the hypothesis that change in pain self-efficacy is associated with observed and self-reported activity, pain intensity, catastrophizing, and quality of life after multi-disciplinary rehabilitation of fibromyalgia patients.Design: In-depth analyses of secondary outcomes of a randomized-controlled trial.Subjects: Women (N = 187) with fibromyalgia.Methods: Outcomes were Pain Self-Efficacy, Assessment of Motor and Process Skills (AMPS), SF-36 Physical Function (SF-36-PF), pain intensity, and SF-36 Mental Composite Score (SF-36-MCS) to assess quality of life and pain catastrophizing. Individual and group associations between outcomes were examined.Results: Individual changes in pain self-efficacy were not associated with changes in observed activity: AMPS motor (rs = 0.08, p = 0.27) and process (rs = 0.12, p = 0.11), not even in those patients with a clinically relevant improvement in observed functioning (38.5%), and only weakly or moderatly with changes in SF-36-PF; (rs = 0.31, p < 0.0001), SF-36-MSC; (rs = 0.41, p < 0.0001), and pain catastrophizing (rs = −0.31, p < 0.0001). No differences in pain self-efficacy were observed between the rehabilitated group and controls (difference: 1.61; 95% CI: −0.84 to 4.06; p = 0.24). However, a subgroup (34%) had a clinically relevant improvement in pain self-efficacy. This group was younger (mean age 41.4 vs. 45.8, p = 0.01), more recently diagnosed (1.8 vs. 2.8 years, p = 0.003), but had an unresolved welfare situation (59% vs. 40%, p = 0.02).Conclusion: The main hypothesis was falsified, as there was no association between pain self-efficacy and actual performance of activity. The relation to functioning may be limited to perceived, cognitive-emotional aspects, as indicated by the weak to moderate correlations to the self-reported measures.Implications for RehabilitationImprovement in observed activity post multi-disciplinary rehabilitation was not associated with change in pain self-efficacy.Patients performed better after rehabilitation, but did not perceive to have improved their capacity.The relationship between pain self-efficacy and functioning may be limited to cognitive-emotional aspects rather than actual activity.Both observational and self-reported measures should be included in evaluating outcomes of rehabilitation for patients with fibromyalgia.

Barriers to change in depressive symptoms after multidisciplinary rehabilitation for whiplash: the role of perceived injustice.

Depressive symptoms complicate patients' recovery after musculoskeletal injury. There is strong evidence to support the utility of multidisciplinary approaches for treating comorbid pain and depressive symptoms. Despite this, a significant proportion of patients may not experience meaningful reductions in depressive symptoms following intervention. The purpose of this study was to identify barriers to change in depressive symptom during multidisciplinary rehabilitation for patients with whiplash injuries. A total of 53 patients with clinically meaningful levels of depressive symptoms before participating in a standardized multidisciplinary rehabilitation program participated in this study. Patients completed self-report measures of depressive symptoms, demographic factors, pain intensity, disability, posttraumatic stress symptoms, pain catastrophizing, perceived injustice, and self-efficacy upon commencement and completion of the rehabilitation program. Analyses examined whether pretreatment variables predicted change in depressive symptoms over treatment and the maintenance of clinically meaningful levels of depressive symptoms at posttreatment. Duration of work absence and perceived injustice were significant unique predictors of percent change in depressive symptoms in a linear regression analysis. Perceived injustice was the only significant unique predictor of the presence of clinically meaningful levels of depressive symptoms at posttreatment in a logistic regression analysis. The results suggest that the identification of patients with high levels of perceived injustice and implementation of targeted interventions for these patients might contribute to greater improvements in their depressive symptomatology.

Differences between patients with chronic musculoskeletal pain treated in an inpatient or an outpatient multidisciplinary rehabilitation program.

Multidisciplinary rehabilitation for patients with chronic musculoskeletal pain can be provided on an inpatient or on an outpatient basis, but the rationale for choosing between the two programs is unknown. The aim of the study was to identify differences between patients provided inpatient or outpatient rehabilitation. It was a cross-sectional study within usual care. The study included 415 adult rehabilitation patients with chronic musculoskeletal pain with complex psychosocial problems. The measurements used were demographics, Short Form 36 Health Survey, Dutch Personality Questionnaire, Coping with Pain Questionnaire, Tampa Scale of Kinesiophobia, Symptom Checklist 90-Revised. In the multiple logistic analysis, five variables remained significantly different between inpatients and outpatients: inpatients were less likely to have a child aged less than 12 years and to have neck pain; their physical and social functioning were poorer; and their current pain period had lasted longer. The total explained variance was 26%. Five variables were identified as influencing the decision on inpatient or outpatient rehabilitation, but the explained variance was low.

Efficacy of multidisciplinary rehabilitation of patients with chronic headache

Chronic headache is a challenge for general physicians and neurologist, too. In a distinctive number of patients exclusive medical drug therapy is not sufficient. Therefore multidisciplinary headache treatment concepts are an option to optimize treatment and to merge medical and non-medical treatments in a comprehensive therapeutic concept. Recently data on efficacy of multidisciplinary treatment programs are published. The combination of drug therapies including substances like topiramat, amitriptyline and Onabotulinumtoxin A which shown some efficacy in chronic migraine with behavioral psychology, psychiatry, psychosomatic medicine, physical therapy, and sport therapy may outperform a single therapy. Such a therapy can be offer in an outpatient department or as inpatient treatment. Interdisciplinary concepts are needed, which integrate these disciplines in congruent program including patient education and therapy. Multidisciplinary rehabilitation for headache patients should include a follow-up care after treatment in a headache center therefore innovative technologies and collaboration between disciplines, and between hospitals and neurologists or therapist in private practice are necessary.

The effects of multidisciplinary rehabilitation in patients with early‐to‐middle‐stage Huntington's disease: a pilot study

Despite advances in the understanding of Huntington's disease (HD), treatment remains symptomatic. Multidisciplinary rehabilitation, however, appears to impact disease progression. Here we show the feasibility, safety and efficacy of a 9-month multidisciplinary rehabilitation programme in a small cohort of patients with early-to-middle-stage HD. Twenty patients with HD were assigned to two groups, equally matched for cognitive and motor scores. One group received the intervention, whilst the other served as control. The Unified-Huntington's-Disease-Rating-Scale-Total-Motor-Score was the primary outcome measure. Neurocognitive/psychological tests, body composition, postural stability, strength and quality of life assessments were secondary outcome measures. The intervention reduced motor and postural stability deterioration, with minor improvements in depression, cognition and quality of life. Significant gains were observed for fat-free mass and strength. This pilot study suggests that a prolonged multidisciplinary rehabilitation programme in early-to-middle-stage HD is feasible, well-tolerated and associated with therapeutic benefit. Further explorative, larger studies are warranted.

Back to work: evaluation of a multidisciplinary rehabilitation program with emphasis on mental symptoms; A two-year follow up

BackgroundThe aim of this investigation was to analyze temporal changes in anxiety, depression, and stress in patients with musculoskeletal pain for a period of up to 2 years after a multidisciplinary rehabilitation program, in relation to sick-listing (registered with The Swedish Social Insurance Agency [Forsakringskassan] for sickness benefit).MethodsTen persons with full-time sick leave (absence from work for medical reasons) (group 1) and 49 with part-time or no sick leave (group 2) at the end of the 2-year study period participated. It was shown in a previous study that group 1 had higher pain rating and higher subjective physical disability than group 2, with little or no improvement during and after rehabilitation. In the present study, all participants were evaluated with the Hospital Anxiety and Depression scale and a self-rated stress test.ResultsParticipants with full-time sick leave during the study period (group 1) showed improved stress levels but no change in anxiety and depression levels. Anxiety, depression, and stress changed more favorably in participants with part-time or no sick leave than in those with full-time sick leave.ConclusionThe results of this study indicate that investigation and appropriate treatment of psychological symptoms, including anxiety and depression, are important in multidisciplinary rehabilitation of patients with musculoskeletal disorders.

Change in kinesiophobia and its relation to activity limitation after multidisciplinary rehabilitation in patients with chronic back pain

Purpose: To explore the change in kinesiophobia in relation to activity limitation after a multidisciplinary rehabilitation programme in patients with chronic back pain. Method: A prospective cohort study was made including 265 patients. Data were collected at baseline, after rehabilitation, and at 6-months follow-up. Outcome measures were the Tampa Scale for kinesiophobia (TSK) and the disability rating index (DRI). The smallest detectable change (SDC) in TSK was set to 8 scores. Relationships between kinesiophobia and activity limitation/physical ability were explored with regard to subgroups with high, medium and low baseline TSK scores, and for those patients who did or did not reach the SDC in TSK. Results: Improvements in TSK showed high effect sizes in the groups with high and medium baseline TSK scores. Improvements in DRI showed medium effect sizes in all three TSK subgroups. One third of the patients reached the SDC in TSK, and this group also improved significantly more in DRI. The correlation between change in TSK and change in DRI was low. Half of the patients with high TSK score at baseline remained having high DRI at follow-up. Conclusions: Improvement in physical ability was not related to the initial degree of kinesiophobia but to the SDC in TSK. To prevent patients with high kinesiophobia from preserving high activity limitations, it might be useful to include targeted treatment of kinesiophobia.Implications for RehabilitationIntensive multidisciplinary rehabilitation decreases kinesiophobia and activity limitation in patients with chronic back pain.Patients improving >8 scores on the Tampa Scale for kinesiophobia are likely to increase their physical ability.Patients with an initially high degree of kinesiophobia as well as a high level of activity limitation need targeted treatment of kinesiophobia to increase their physical ability.

Systematic review of multidisciplinary rehabilitation in patients with multiple trauma

Multiple trauma is a cause of significant disability in adults of working age. Despite the implementation of trauma systems for improved coordination and organization of care, rehabilitation services are not yet routinely considered integral to trauma care processes. MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, Allied and Complementary Medicine, Physiotherapy Evidence Database, Latin American and Caribbean Literature on Health Sciences and Cochrane Library databases were searched up to May 2011 for randomized clinical trials, as well as observational studies, reporting outcomes of injured patients following multidisciplinary rehabilitation that addressed functional restoration and societal reintegration based on the International Classification of Functioning, Disability and Health. No randomized and/or controlled clinical trials were identified. Fifteen observational studies involving 2386 participants with injuries were included. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach assessed methodological quality as 'poor' in all studies, with selection and observer bias. Although patients with low functional scores showed improvement after rehabilitation, they were unable to resume their pretrauma level of activity. Their functional ability was significantly associated with motor independence on admission and early acute rehabilitation, which contributed to a shorter hospital stay. Injury location, age, co-morbidity and education predicted long-term functional consequences. Trauma care systems were associated with reduced mortality. The gaps in evidence include: rehabilitation settings, components, intensity, duration and types of therapy, and long-term outcomes for survivors of multiple trauma. Rehabilitation is an expensive resource and the evidence to support its justification is needed urgently. The issues in study design and research methodology in rehabilitation are challenging. Opportunities to prioritize trauma rehabilitation, disability management and social reintegration of multiple injury survivors are discussed.

“It is about taking grips and not let myself be ravaged by my body”: A qualitative study of outcomes from in-patient multidisciplinary rehabilitation for patients with chronic rheumatic diseases

Purpose: To explore how patients experience the process and personal impact of deriving outcomes from a rheumatological rehabilitation program. Methods: Semi-structured interviews were conducted with 23 patients with inflammatory rheumatic diseases approximately 2 months after a 4-week hospital based multidisciplinary rehabilitation program. A thematic analysis was applied. Results: Overarching themes were increased dignity and self-respect. Initial uncertainty regarding illness management was exchanged with confident coping and of becoming an active agent in ones own life. Strategies and coping tools tried out during the rehabilitation stay, do by their experienced effect become primary sources of gained insight into illness and symptom manifestation. Both elements give a sense of control and influence self-confidence and motivation to engage in self-management. The process from gained insight and experienced effect of coping tools, to active self management, is however, not automatic. Psychological factors play a key role, and there is a need to take individual psychological themes into account and tailor interventions accordingly. Conclusions: Specialized multidisciplinary rehabilitation is an ongoing active process, in which psychological factors play a key role and must be accounted for. Well targeted rehabilitation has the potential to create outcomes of major personal impact.Implications for RehabilitationWell targeted multidisciplinary rehabilitation has the potential to create outcomes of major personal impactRehabilitation interventions should be tailored according to the patient’s subjective perception of challenges.A secure and supportive environment where patients are met with respect and interest represents a crucial element in rehabilitation.

Cost-utility analysis of a three-month exercise programme vs. routine usual care following multidisciplinary rehabilitation for chronic low back pain

To assess the cost-utility of an exercise programme vs usual care after functional multidisciplinary rehabilitation in patients with chronic low back pain. Cost-utility analysis alongside a randomized controlled trial. A total of 105 patients with chronic low back pain. Chronic low back pain patients completing a 3-week functional multidisciplinary rehabilitation were randomized to either a 3-month exercise programme (n = 56) or usual care (n = 49). The exercise programme consisted of 24 training sessions during 12 weeks. At the end of functional multidisciplinary rehabilitation and at 1-year follow-up quality of life was measured with the SF-36 questionnaire, converted into utilities and transformed into quality--adjusted life years. Direct and indirect monthly costs were measured using cost diaries. The incremental cost-effectiveness ratio was calculated as the incremental cost of the exercise programme divided by the difference in quality-adjusted life years between both groups. Quality of life improved significantly at 1-year follow-up in both groups. Similarly, both groups significantly reduced total monthly costs over time. No significant difference was observed between groups. The incremental cost-effectiveness ratio was 79,270 euros. Adding an exercise programme after functional multidisciplinary rehabilitation compared with usual care does not offer significant long-term benefits in quality of life and direct and indirect costs.