What is the value of occupational therapy in return to work for breast cancer patients? A qualitative inquiry among experts.

An increasing number of patients are confronted with breast cancer (BC) and functional limitations after treatment. Occupational therapy (OT) is successful in return to work (RTW), but not yet available for BC patients. This paper explores experts' opinions on OT interventions for RTW in BC patients in the Belgian context. Primary data were topic-interviews with all heads of OT departments in Flemish University Hospitals (n = 5). Secondary data were four focus group interviews with care professionals in oncological rehabilitation (n = 41). All data were transcribed and thematic analysis was used. Integrated in multidisciplinary teamwork, OT interventions should have a holistic and client-centred approach, start early in the rehabilitation process, include workplace visits and contacts with relevant stakeholders, and use goal setting to start up tailor made rehabilitation, linking assessment of abilities and work. Occupational therapists are regarded as professionals who can effectively answer BC patients unmet needs regarding RTW due to their skill to bridge between care and workplace. According to the experts, OT interventions supporting RTW in BC patients are useful when integrated in regular healthcare. They agree on the components but organisational barriers should be removed, for example not providing reimbursement for including this type of support trough healthcare insurance.

Validation of the EUMASS Core Set for medical evaluation of work disability.

OBJECTIVE: To perform a content validation of the EUMASS Core Set across six European social insurance systems. The EUMASS Core Set contains 20 categories to describe the functional (in-) capacity of claimants for disability benefits. METHODS: We performed an exploratory, cross-sectional study. We used the EUMASS Core Set, added scales to rate the relevance of the 20 categories and added additional questions concerning comprehensiveness, usefulness and sufficiency of the instrument. Medical examiners from European countries filled in this instrument in 10 consecutive claim assessments. RESULTS: Forty-eight medical examiners in six different countries evaluated 446 claimants. The medical examiners used all categories to describe the claimants' functional (in-) capacity. Medical examiners missed 41 different categories, often mental functions (n = 17). They rated the instrument as useful in 68.4% and as sufficient in 63.2% of the claims. Perceived usefulness varied among countries, but not among disease groups. Perceived sufficiency varied among countries and disease groups. CONCLUSION: The EUMASS Core Set is promising for reporting about functional (in-) capacities. It contains relevant categories for disability evaluation among countries and disease groups. Adding more mental functions might make it more applicable. Medical examiners found it useful and sufficient to evaluate functional (in-) capacity. Implications for Rehabilitation In medical reports of evaluation of work disability, reporting about functional capacity is often unstructured in free text, making the reports difficult to understand. The EUMASS Core Set contains common definitions for expressing functional capacity and is expected to support taking decisions, to improve the quality of decisions and to allow national and international comparisons. Our study suggests the EUMASS core set to be comprehensive, useful and sufficient to express functional capacity in disability evaluation.

Lifestyle after bariatric surgery: a multicenter, prospective cohort study in pregnant women.

BACKGROUND: To ensure a good pregnancy outcome after bariatric surgery, a healthy life-style and a multidisciplinary prenatal follow-up is recommended. The aim of this prospective multicenter trial was to compare diet quality and physical activity (PA) of pregnant women with bariatric surgery with current lifestyle recommendations. METHODS: Pregnant women (>18 years, prepregnancy BMI 28 ± 6 kg/m², 39 % nulliparae, 25 % smokers) with a history of bariatric surgery were recruited and allocated to two groups according to surgery type: restrictive (N = 18) and bypass group (N = 31). One 7-day dietary record and one Kaiser questionnaire on PA were collected during the first and second trimester. Dietary quality was assessed using the Healthy Eating Index. RESULTS: The diet quality did not change during pregnancy (restrictive group p = 0.050; bypass group p = 0.975) and was comparable between groups (first trimester p = 0.426; second trimester p = 0.937). During the first trimester, 15 % of the pregnant women had a healthy diet quality, 82 % had a diet that needed improvement, and 3 % had a poor diet quality. This was independent of surgery type and was comparable in the second trimester (p = 0.525). No difference between groups was observed for the PA level, but the PA level in the bypass group significantly decreased from the first to the second trimester (p = 0.033). CONCLUSIONS: Nutritional advice and lifestyle coaching in this high-risk population seems recommendable since only 15 % of the pregnant women had a healthy diet quality, 25 % was smoking at the beginning of pregnancy, and the reported PA levels were low.

Rigour of development does not AGREE with recommendations in practice guidelines on the use of ice for acute ankle sprains.

OBJECTIVE This study evaluated whether the Appraisal of Guidelines Research and Evaluation (AGREE) rigour of development score of practice guidelines on ice for acute ankle sprains is related to the convergence between recommendations. DESIGN The authors systematically reviewed guidelines on ice for acute ankle sprains. Four appraisers independently used the AGREE instrument to evaluate the rigour of development of selected guidelines. For each guideline, one reviewer listed the cited evidence on ice and calculated a cited evidence score. The authors plotted the recommended durations and numbers of ice applications over the standardised rigour of development score to explore the relationships. DATA SOURCES Three reviewers searched for guidelines in Medline, Embase, Sportdiscus, PEDro, G-I-N Guideline Library, Trip Database, SumSearch, National Guideline Clearinghouse and the Health Technology Assessment database, and conducted a web-based search for guideline development organisations. ELIGIBILITY CRITERIA Eligible guidelines had a development methodology that included a process to search or use results from scientific studies and the participation of an expert group to formulate recommendations. RESULTS The authors identified 21 guidelines, containing clinically significant variations in recommended durations and numbers of ice applications. The median standardised rigour of development score was 57% (IQR 18 to 77). Variations occurred evenly among guidelines with low moderate or high rigour scores. The median evidence citation score in the guidelines was 7% (IQR 0 to 61). CONCLUSIONS There is no relationship between the rigour of development score and the recommendations in guidelines on ice for acute ankle sprains. The guidelines suffered from methodological problems which were not captured by the AGREE instrument.

Guidelines for assessment of work disability: an international survey.

BACKGROUND: Assessments of long-term work disability are carried out by social insurance physicians (SIPs) and are little supported with evidence or instruments. Guidelines are hardly ever used in social insurance medicine. Developments in social insurance medicine might be slow as insurance is different from clinical medicine. AIMS: We explored the comparability of assessments in social insurance medicine in different countries and asked what guidelines were in official use. METHODS: Eighteen European countries were invited. A questionnaire on assessments practices was sent to national experts. A comparative table was presented to all contributors. Countries with guidelines were visited. Guidelines were categorised according to their purpose and their contents were compared. The results were presented to experts of the participating countries for validation. RESULTS: Fourteen countries participated. Functional capacity assessment was common. Guidelines for SIPs were reported to be officially in use in Germany, Ireland, the Netherlands and Switzerland. Twenty-two guidelines were medical and eleven were procedural. Medical guidelines mainly treated the same topics. Procedural guidelines were more variable. CONCLUSION: Assessment of work disability is comparable between countries. Medical and procedural guidelines should be further developed and tested on their value in practice. The procedural guidelines need to be published in a clear and comparable manner. The legal security of claimants would be endorsed by this. Germany and the Netherlands are most experienced and could take the lead in international development.

Patients at risk for long-term sick leave because of low back pain.

BACKGROUND CONTEXT: Ten percent of patients with low back pain (LBP) are not able to resume work within 3 months of sick leave, accounting for 90% of all medical and indemnity costs. PURPOSE: To quantify the relative contribution of sociodemographic, clinical, occupational, and psychological risk factors in determining the non-return to work after 3 months of compensated LBP and to develop a screening tool to identify patients who require further guidance and rehabilitation. STUDY DESIGN/SETTING: A 6-month prospective cohort study of disabled workers applying for compensation benefit because of LBP during a 6-month period in the Belgian compulsory health insurance system. PATIENT SAMPLE: Three hundred and forty-six patients. OUTCOME MEASURES: Patients unable to resume work within 3 months of sick leave were classified as bad outcomes. METHODS: Consecutively, injured workers applying for income replacement benefits between October 2003 and March 2004 because of LBP were followed 6 months after the start of the sick leave period. All subjects underwent a standardized physical examination and completed a battery of 12 self-report questionnaires. RESULTS: Forty-seven percent of the population had not resumed work 3 months after the start of the sick leave period. The risk factors for sickness absence more than 3 months were Oswestry disability index (odds ratio for each point increase: 1.04; 95% confidence interval: 1.02-1.06), fear of avoidance severity score (odds ratio for each point increase: 1.05; confidence interval: 1.02-1.09), blue collar worker (odds ratio: 2.18; confidence interval: 1.21-3.92), LBP for less than 12 weeks before sick leave (odds ratio: 0.32; confidence interval: 0.17-0.64), and pain behavior (odds ratio for each point increase: 1.72; confidence interval: 1.25-2.39). A multivariate screening test based on five questions identified 80% of the patients unable to resume work after 3 months of sick leave (specificity: 56.6; cut off: 0.4). CONCLUSIONS: A questionnaire comprising a limited set of items allows a practical screening of LBP patients unlikely to resume work.

Medico-legal reasoning in disability assessment: a focus group and validation study.

BACKGROUND: Decisions on disability pensions are based, among others, on medical reports. The way these medical assessments are performed is largely unclear. The aim of the study was to determine which grounds are used by social insurance physicians (SIPs) in these assessments and to determine if the identification of these grounds can help improve the quality of assessments in social insurance practice. The article describes a focus group study and a questionnaire study with SIPs in four different countries. METHOD: Using focus group discussions of SIPs discussing the same case in Belgium, the Netherlands, Norway and Slovenia (N = 29) we determined the arguments and underlying grounds as used by the SIP's. We used a questionnaire study among other SIPs (N = 60) in the same countries to establish a first validation of these grounds. RESULTS: Grounds in the focus groups were comparable between the countries studied. The grounds were also recognized by SIPs who had not participated in the focus groups. SIPs agreed most on grounds with regard to the claimant's health condition, and about the claimant's duty to explore rehabilitation and work resumption, but less on accepting permanent incapacity when all options for treatment were exhausted. CONCLUSION: Grounds that SIPs use refer to a limited group of key elements of disability evaluation. SIPs interpret disability in social insurance according to the handicapped role and strive at making their evaluation fair trials. ICF is relevant with regard to the health condition and to the process of evaluation. Identification of grounds is a valuable instrument for controlling the quality of disability evaluation. The grounds also appear to be internationally comparable which may enhance scientific study in this area.

Factors influencing return to work after surgical treatment for carpal tunnel syndrome.

BACKGROUND: Controversy exists regarding the factors influencing the duration of work incapacity after surgically treated carpal tunnel syndrome (CTS). AIM: To determine relevant factors related to return to work. METHODS: Surgical technique, clinical factors, demographic factors, other medical problems, psychosocial factors, work-related and economical factors were reviewed in patients operated on for CTS. Statistical multivariate analyses were performed to identify the baseline factors influencing the work incapacity period. RESULTS: A total of 107 cases were reviewed. Professional exposure to repetitive movements and heavy manual handling activity were associated with a longer return-to-work interval. The duration of work incapacity period was not significantly related to the socioprofessional category of the patient (self-employed or employee) or to the type of the procedure (open versus endoscopic surgery). CONCLUSION: Work-related features have a more important influence on return to work than personal, pathological or surgical features.

Quality of life and disability after ilio-inguinal lymphadenectomy.

AIM: To examine and report the quality of life together with the level of disability of cancer patients who underwent therapeutic ilio-inguinal lymphadenectomy. MATERIALS AND METHODS: The complete files of 62 patients who underwent 66 procedures between January 1990 and November 2006 were obtained and analysed retrospectively. Data concerning postoperative complications, presence and extent of lymphoedema, physical symptoms, duration of disability, daily life and social activities were collected through a specific questionnaire and reviewed. RESULTS: Early postoperative complications occurred in 36% of cases. Sixty-five percent of patients developed some degree of postoperative lymphoedema. Twenty patients suffered at least one episode of erysipelas. Median postoperative disability was 4 months (range 1.5 to 24 months). Among the active population, 8 patients (18%) never returned to work. Postoperative quality of life was good or very good for most patients, with acceptable limitation in daily activities. CONCLUSION: Ilio-inguinal lymphadenectomy is the only radical procedure able to provide long-term tumour control and maintain a good to very good quality of life, thus providing a real possibility of returning to work.

Does enhanced information exchange between social insurance physicians and occupational physicians improve patient work resumption? A controlled intervention study.

BACKGROUND: Patient work resumption after sickness absence varies even among patients with similar pathologies and characteristics. Explanations remain uncertain. One newly investigated field is "information asymmetry", a situation in which critical information is not appropriately exchanged between stakeholders in disability management. It is hypothesised that information asymmetry between social insurance physicians and occupational physicians prolongs sickness absence. OBJECTIVES: To assess the influence of enhanced information exchange between these physicians on patient outcome. METHODS: Non-randomised controlled intervention study. The setting was the work inability assessment consultation of social insurance physicians in Belgium. Inclusion criteria were: employee, age 18-50, and subacute (more than one month) sickness absence. The intervention was a structured information exchange (through the use of a communication form) between the patient's social insurance physician and occupational physician. The intervention started when the patient's sickness absence reached the subacute stage, and ended when the sickness absence benefit was ceased or the duration exceeded one year. The primary outcome measure was the sickness absence benefit status of the patient assessed one year after benefit onset. RESULTS: Of the 1883 patients asked to enroll in the study, 1564 (84%) participated; 505 (32%) of 1564 patients were assigned to the intervention group and 1059 (68%) to the control group; 1553 (99%) of 1564 patients completed the study. In the intervention group, 86% received no sickness absence benefit at the end of the study, versus 84% in the control group (95% CI 0.91-1.15). No significant differences in other outcome parameters were obtained. CONCLUSIONS: Information exchange between physicians may not be enough to influence work resumption among patients on sickness absence. Further research on stakeholders' information asymmetry and its effect on the outcome of patients are necessary. The complexity of information asymmetry in disability management cannot be underestimated.

Impairment and return to work after intra-articular fractures of the calcaneus.

Intra-articular fractures of the calcaneus typically occur in individuals working on ladders, scaffolding or roofs. Male individuals in their productive age are most at risk. The functional problems that frequently persist are a well-known risk since they may obstruct a safe resumption of the former job. According to the data of the National Institute for Sickness and Invalidity Insurance the number of calcaneal fractures in Belgium have stabilised over the last ten years. These figures indicate the necessity for a better prevention policy. Scientific literature about the problem of impairment and disability in these cases is rare and lacks uniformity. A retrospective study was therefore performed on 65 private insurance compensation patients who were treated for intra-articular calcaneal fractures. The mean period of work incapacity was 260.5 days and the mean percentage of impairment was 12.3%. A large group (86.2%) were able to resume their former activities including the height workers. More than half of the patients (57%) needed a supportive device. Working at heights and falls from a height were a significant risk factor for long-term work incapacity. The figures are compared with the limited literature and further discussed.

Predictors for work incapacity continuing after disc surgery.

OBJECTIVES: This study was carried out to provide information on and identify factors about the fitness for work 12 months after disc herniation surgery. In addition a predictive tool for this outcome was developed. METHODS: A selected patient population (N = 177) operated on for lumbar disc herniation from September 1995 until May 1996 was evaluated by medical advisers of a sickness fund. The patients were submitted to a standardized interview about their personal, social, medical, professional, and psychological status. To assess the functional status of the lumbar spine, a standardized clinical examination was used. RESULTS: Eighty-five percent of the patients were employed 1 year after surgery. The most important predictors at 6 weeks after intervention were the estimation of pain according to a visual analogue scale, the patient's prediction of his possibilities to resume work, the Oswestry disability index score, and the Zung depression score. Of the clinical factors, nonorganic signs and sensory disturbances after surgery were negative prognosticators for long-lasting disability. Using the Oswestry score, the Zung score, the patient's own prediction, the score on the Social Readjustment Rating Scale, and the score on the Modified Somatic Perception Questionnaire, 86% of the poor outcomes could be correctly classified. CONCLUSIONS: The Oswestry disability scale and the Zung depression scale should be included in the routine postoperative assessment after disc surgery and the patient's own prediction of his possibility for fitness for work should be taken seriously. If a poor outcome is predicted, the patient is in need of rehabilitation and should be guided more intensely.

Return to work after surgery for lumbar disc herniation. A rehabilitation-oriented approach in insurance medicine.

STUDY DESIGN: An intervention study by the medical advisers of a social security sickness fund on a mandatorily insured patient population after open discectomy for herniated lumbar intervertebral disc. The medical advisers were randomized into two groups: a control group (n = 30) and an intervention group (n = 30). OBJECTIVES: To compare a rehabilitation-oriented approach in insurance medicine focused primarily on early mobilization and early resumption of professional activities with the usual claim-based practice. SUMMARY OF BACKGROUND DATA: This study included 710 patients, with a mean age of 39.2 years, who underwent surgery for herniated lumbar disc. METHODS: Medical advisers in the rehabilitation-oriented group examined the patients monthly, starting at 6 weeks after the surgical intervention. They used a newly developed protocol to motivate the patients and treating physicians toward social and professional reintegration. RESULTS: At 52 weeks, 10.1% of the patients guided by medical advisers from the rehabilitation-oriented group had not resumed work in contrast to 18.1% of the patients in the control group. It was statistically proven that this effect also holds during the follow-up period. CONCLUSIONS: A rehabilitation-oriented approach by the medical advisers of social security can increase the probability of a return to work for patients after lumbar disc herniation surgery.

Social insurance cost of standard discectomy and percutaneous nucleotomy. A retrospective study of 87 social insurance claim files of male blue collar workers.

A retrospective review of social insurance claim files of male blue collar workers was conducted to compare the social insurance costs of percutaneous lumbar nucleotomy with standard lumbar discectomy ; 29 percutaneous nucleotomy procedures were matched with 58 standard discectomies all carried out between January 1992 and December 1994. It was concluded that a standard discectomy procedure results in significantly higher costs during hospitalisation with respect to surgery, anaesthesia and hospital stay. A percutaneous nucleotomy leads to a significantly higher outpatient expenditure especially in radiology and medical devices. The relative proportion of outpatient practitioner's visits and hospital stay costs was significantly higher for the standard discectomy whereas medical devices had a relatively higher share in outpatient expenditure for the percutaneous nucleotomy. In this population of 87 compensation claimants, the average social insurance costs did not significantly differ between the percutaneous nucleotomy and the standard discectomy.

Fitness for work after surgery for lumbar disc herniation: a retrospective study.

This report retrospectively evaluates fitness for work in 3956 cases of surgery for lumbar disc herniation between 1992 and 1994. Patient records were derived from a database including all interventions of the insured population of the largest Belgian sickness fund. The datafile consisted of 126 cases of percutaneous nucleotomy (nucleotomy group), 286 cases of lumbar disc surgery with fusion (fusion group) and 3544 cases of standard lumbar disc surgery (standard group). Fitness to resume work within 12 months after intervention was obtained in about 70% of the patients in the standard and nucleotomy groups but in only 45% of the patients in the fusion group. Ten medicosocial factors were related to fitness for work as outcome measure. Incapacity for work more than 12 months after intervention was defined as a bad outcome. Logistic regression was used to test the combined relative significance of the different variables. For the standard group a long duration of work incapacity before intervention, older age, lower benefit, employment as a blue-collar worker, a long duration of hospital stay and unemployment were significantly associated with a poor outcome. Related factors for the fusion group were a long duration of work incapacity before operation, a long duration of hospital stay and unemployment. For the nucleotomy group, no factor was significantly associated with a poor outcome. For the total group, discectomy combined with fusion was significantly related to a poor outcome whereas a standard discectomy and a percutaneous nucleotomy did not differ in their impact on fitness for work.

Fitness for work after laparoscopic and open cholecystectomy.

To determine the impact of the type of surgical intervention and medicosocial factors in the fitness for work after cholecystectomy, 2094 records of patients were reviewed. Subjects were Christian sickness fund recipients who underwent surgery from 1992 until 1994 with a follow-up period between 1 to 3 years. A work incapacity longer than 6 weeks was defined as a bad outcome. Data were analyzed using univariate statistics (chi2-test) and logistic regression. A laparoscopic cholecystectomy was significantly associated with an earlier fitness for work and a shorter period of hospital stay. In general, a bad outcome was also related to a longer period of work incapacity before the intervention, older age, longer hospital stay, employment as a blue collar worker and operation in a non-university medical center. These factors should be taken into account in the selection of patients for cholecystectomy, and in policies to improve patients recovery and fitness for work. Clear information about the duration of the postoperative recovery period and the incapacity for work should be given to the patients before the intervention. An unnecessary long time of sick leave without medical motive should be avoided.