Rehabilitation status in multiple handicap.

The Edinburgh Rehabilitation Status Scale (ERSS) was applied to 129 attenders at a day center for physical disability. All of the attenders had significant neurological impairment dating from birth or from infancy. Fifty-nine of the subjects (46%) had been diagnosed on conventional grounds as having mental handicap as well as physical disability. ERSS scores were compared with Barthel Index scores in all subjects and with PULSES profile in 50 subjects (27 physical disability alone, 23 combined with mental handicap). The ERSS scores clearly demonstrated significant differences in the level of disablement between the two groups in all four subscales as well as in total scores; the Barthel scores showed differences in self-care and total scores, and, to a lesser extent, in mobility. PULSES failed to differentiate the groups except in one of its subscales. The ERSS is a sensitive index of overall function and is useful in highlighting the additive effect of mental handicap and physical disability, a difference which may not be apparent when other assessment scales are used.

Medical reports on persons claiming compensation for personal injury.

An audit of one insurance company's files on all employer's liability and third party motor claims settled over two years for 5000 pounds or more presented an opportunity to review the medical reports on the patients involved. A stratified random sample of files on 203 patients contained 602 reports prepared by 400 consultants. Content analysis was undertaken to evaluate compliance with published guidance on reports prepared for medico-legal purposes and to ascertain how well reports met recipients' requirements. While clinical topics were well covered, generally to a high standard, other functional, psychosocial and occupational topics, reflecting the wider clinical and non-clinical frame of reference within which lawyers and insurers normally seek information and advice, were covered less frequently, extensively and comprehensively--leaving considerable scope to improve these aspects of assessment and reporting. Further review of this aspect of professional practice should include attention to the appropriateness of existing guidance, postgraduate training requirements and the involvement of other agencies or professions in some aspects of assessment for medico-legal purposes.

Rehabilitation status--the relationship between the Edinburgh Rehabilitation Status Scale (ERSS), Barthel Index, and PULSES profile.

A total of 364 patients attending day centres for the physically disabled had ERSS and Barthel scores recorded during the course of assessment. In addition, 100 of the patients had PULSES profile scores recorded. Correlation of total scores for all three scales confirmed that all three succeeded in measuring disability and all three were significantly related. There were, however, weak correlations between some of the individual subscales of each score, indicating that each of the assessment tools was measuring some dimensions of disability not adequately considered by the other scales. The results suggest that while progress is being made towards better measurement of disability and handicap, further refinement of these particular measurement tools is required.

To work or not to work: that is the question.

Medical publications contain numerous references to obstacles or disincentives confronting patients who wish to return to work after illness or injury. Current developments of importance to this aspect of medical practice and four recent studies, conducted in Edinburgh, that may contribute to the continuing debate about how best to deal with such problems are reviewed. The studies concern measurement of rehabilitation status, identification of potential to benefit from rehabilitation, medical contributions to occupational assessment of accident victims, and patients' patterns of involvement with medical and vocational rehabilitation services. It is concluded that coordination between services is still a major problem and is likely to remain so if more effective bridging between medical and vocational aspects of rehabilitation is not achieved.

Rehabilitation status: a measure of medicosocial dysfunction.

The Edinburgh Rehabilitation Status Scale (ERSS) measures four dimensions in which changes may occur in the course of a disabling illness or during rehabilitation: independence; activity; social integration; and effects of symptoms on lifestyle. It provides a profile of measures, the scores of which can be summated to indicate the overall level of performance of individuals or groups. Studies of its inter-observer reliability and of its application in various disability groups indicate that the ERSS reliably defines the characteristics of individual patients and of groups. The scale can be used conveniently by professional staff working independently or by a multiprofessional rehabilitation team to assess status and changes in patients. It can also be used for measurement of the effectiveness of services and for purposes of research, teaching, and administration.

Rehabilitation and return to work of employers' liability claimants.

Examination of employers' liability (workers' compensation) claims files confirms that accidents at work, resulting in major injury, continue to present a significant challenge to rehabilitation. This review of 209 patients who have pursued such claims describes them from relevant socio-economic, clinical and occupational perspectives; records their return to work; examines medical opinion on their residual disabilities and potential occupational handicap and traces their involvement with rehabilitation and resettlement services. A major finding is an interval of almost two years, on average, between patients' discharge from medical treatment and settlement of their claims. Given the severity of injuries, length of absences from work and the relatively high proportions who either lost their jobs or who were advised to seek less physically demanding alternative occupations, the rate of referral to specialist vocational rehabilitation services during this period was very low. Timely and effective delivery of relevant rehabilitation and resettlement services to such patients should be made a priority for future policy and practice. One half of the sample returned to work before settlement, with more who were unsuccessful in their attempts to do so. The adversarial climate of personal injury claims negotiation in Great Britain therefore may be a less formidable barrier to return to work than is sometimes supposed. Nevertheless, conventional practices and procedures in medicine, law and insurance may still delay or prevent resettlement in some cases. Any attempt to enhance the effectiveness of the present medicolegal system should pay at least as much attention to these iatrogenic factors as to the psychological explanations that have dominated previous thinking on this subject.

A comparison of the predictions made by orthopaedic surgeons, nurses and physiotherapists about the rehabilitation problems of fracture patients.

Health service staff sometimes are not aware of the psychological and social aspects of patients' rehabilitation problems. This paper compares the accuracy of predictions made by orthopaedic surgeons, nurses and physiotherapists about the rehabilitation problems of a series of fracture patients. Predictions were obtained in the acute orthopaedic trauma wards of one hospital, from members of all three professions, about 26 patients selected as likely to have rehabilitation problems. Follow-up data were obtained from interviews with the patients during the six months after their injury and from the orthopaedic case notes. The orthopaedic surgeons accurately predicted 48 per cent of the problems that occurred, the nurses 26 per cent and the physiotherapists 20 per cent. In their predictions the surgeons discriminated more accurately than the nurses or physiotherapists between the occasions on which problems did and did not occur in the follow-up period. The surgeons were better predictors than the other professions about medical and orthopaedic, work and personal and social problems. Fifty-five per cent of the problems that occurred were predicted by members of one or more professions. If it is desired to base early decisions about treatment or referral in rehabilitation on predictions about patients' likely problems, there is a need to increase the proportion of problems that are accurately predicted, and to increase the ability of predictors to discriminate between the occasions on which problems are and are not likely to occur.

Identification of features associated with flying phobia in aircrew.

The psychological and physiological features of 20 aircrew consecutively referred for treatment of anxiety symptoms when flying were compared with a matched control group of uncomplaining aircrew. There were no significant differences between the two groups on psychometric tests of personality, though there were differences in skin conductance; the phobics had a higher rate of spontaneous fluctuation, and habituated less to a repeated auditory tone. More of the phobic group worried about their wives and acknowledged childhood and other adulthood phobias; more had a family history of an episode perhaps best described as flying trauma. Many were on an overseas posting when symptoms presented. These few features could correctly classify 85 per cent of the subjects into the phobic or control group. This type of phobic aircrew index' now requires to be validated prospectively for its predictive value.

Methodology of research in psychosomatic medicine.

This paper reviews some problems in the methodology of clinical psychosomatic research. Its emphasis is on elucidation of symptoms rather than on aetiology of disease and on diagnosis and treatment of known psychopathology, particularly mood disturbance, rather than on underlying speculative mechanisms. Reliability, sensitivity, and validity of measurements are considered to be the keys to advance of knowledge in this field. Samples of patients studied must be representative of a disease, and not of other factors which contribute bias to the observations. Account must be taken of the wide variability found in most measures required in psychosomatic patients, and hence of their lack of specificity to an individual patient.