Health-related quality of life, needs, and concerns among cancer survivors referred to rehabilitation in primary healthcare setting.

BACKGROUND AND PURPOSE: There is a growing need for rehabilitation services beyond hospitals. This study aims to describe challenges faced by cancer survivors (CSs) referred for rehabilitation in primary healthcare, employing standardized scales measuring health-related quality of life (HRQOL) and open-ended questions. Furthermore, the study explores the applicability of patient-reported outcomes (PROs) in comprehensively understanding challenges encountered by CSs. MATERIAL AND METHODS: This cross-sectional study involves CSs referred for cancer rehabilitation in a primary healthcare setting, including those participating in PROs as a part of routine practice. HRQOL was assessed using the Functional Assessment of Cancer Therapy-General (FACT-G). The International Classification of Functioning, Disability and Health (ICF) framed the analysis of responses to open-ended questions 'what concerns you the most?' and 'what matters to you?'  Results: FACT-G showed the lowest scores for functional well-being (14.4) and emotional well-being (16.6), with higher scores for physical well-being (18.9) and social/family well-being (21.1). Responses to open-ended questions unveiled worries about everyday life and how cancer will impact family well-being presently and in the future. Furthermore, CSs reported a need to maintain normality and proactively address the challenges posed by the disease. INTERPRETATION: CSs referred for rehabilitation in primary healthcare experience comprehensive challenges necessitating a holistic rehabilitation approach. This includes interventions supporting CSs in dealing with uncertainty, regaining a sense of control, and addressing family well-being concerns. When using PROs for need assessment, the combination of validated HRQOL scales and open-ended questions is crucial for an in-depth understanding of CSs' challenges.

Navigating (un)certainty in 'downhill' trajectories: An ethnographic study about rehabilitees' and professionals' experiences of goal-setting in Parkinson's disease rehabilitation.

OBJECTIVE: To explore rehabilitees' and professionals' experiences of goal-setting in a context of (un)certainty with a progressive neurodegenerative disease and how they navigate this (un)certainty in Parkinson's disease rehabilitation. DESIGN: A long-term multi-sited ethnographic fieldwork (2019-2020) following 20 rehabilitees and their goals over time and settings. Observation at 30 goal-setting meetings. PARTICIPANTS: Rehabilitees and professionals in Danish Parkinson's disease rehabilitation. Two randomly chosen groups of rehabilitees attending a Parkinson's disease course at a rehabilitation centre participated. METHODS: Semi-structured interviews and participant observation. RESULTS: Living with Parkinson's disease holds a certainty that the condition will progress yet an uncertainty regarding the pace and severity, as indicated by the notion (un)certainty. The (un)certainty challenges goal-setting. Reflecting on goal-setting, rehabilitees brought forth existential, economical, and societal considerations. Some expressed an ambivalent view, questioning the value of goal-setting with a progressive condition, yet finding own rehabilitation goals relevant. Others expressed a pragmatic view, attuning goals to fit the situation. Professionals found that the visible and invisible symptoms and the uncertain pace of Parkinson's made goal-setting challenging. They had to strike a balance between mentioning symptoms to come, yet not rendering the future too bleak. CONCLUSIONS: Rehabilitees and professionals found that setting goals in a condition that progresses is no easy task. They made use of strategies such as observation, repetition, future-proofing strategies, and attuning goals to navigate the (un)certainty. In goal-setting, to maintain functioning with progressive Parkinson's disease was a viable goal. Participants found they just do the best they can to navigate (un)certainty.

Two-Year Follow-Up on Return to Work in a Randomised Controlled Trial Comparing Brief and Multidisciplinary Intervention in Employees on Sick Leave Due to Low Back Pain.

PURPOSE: To study return to work (RTW) at 2-year follow-up in a randomised controlled trial comparing brief intervention (BI) and multidisciplinary intervention (MDI) in employees on sick leave due to low back pain (LBP) stratified for job relations. METHODS: In total 476 employees on sick leave for 4-12 weeks due to LBP were divided into strata with weak or strong job relations, based on perceived risk of losing job and influence on job planning. In each stratum participants were allocated to BI or MDI. All participants received BI, i.e. a clinical examination by a rheumatologist and physiotherapist. In addition, MDI involved a case manager who made a rehabilitation plan in collaboration with the participant. The primary outcome was time to RTW. Secondary outcomes were median weeks in different employment status and selfreported pain, disability and psychological health. Sustained RTW was estimated by work status the last 4 weeks before the 2-year date. RESULTS: Participants with strong job relations who received BI had a higher RTW rate (hazard ratio = 0.74 (95% CI 0.57; 0.96)) and spent more weeks working than participants who received MDI. In the stratum of weak job relations, no difference was seen regarding RTW and weeks working. For health-related outcomes and sustained RTW no significant results were found in neither stratum. CONCLUSIONS: Employees with strong job relations achieved higher RTW rates when receiving BI compared to MDI, while no difference was found between intervention groups for employees with weak job relations. TRIAL REGISTRATION: Current Controlled Trials ISRCTN14136384. Registered 4 August.

Labor Market Attachment 2 Years After Colorectal Cancer Surgery: A Population-based Study.

Objectives: To investigate the association between clinical/sociodemographic factors and labor market attachment, and to estimate employment probability 2 years after colorectal cancer (CRC) surgery. Background: A rising prevalence of younger CRC survivors commands a stronger focus on labor market attachment. The association between clinical factors like type of surgery and CRC survivors' labor market attachment remains poorly investigated. Methods: National registries provided information on employment status and clinical/sociodemographic variables for all 20- to 60-year-old CRC patients without previous cancer diagnosed in Denmark from 2001 to 2014, undergoing surgery and being attached to the labor market. Associations between clinical/sociodemographic factors and labor market attachment were investigated in multiple logistic regression analyses. Results: A total of 5755 CRC patients were included. Two years after surgery, 59.7% were working. Factors significantly associated with a higher probability of working were being in the 46 to 50 years age group, male gender, higher educational level, no comorbidity, working at the time of diagnosis, lower Union for International Cancer Control stage, and undergoing surgery in the most recent of four time-periods. Two years after undergoing surgery, the probability of working was significantly higher for left-sided than for right-sided colon resections, higher for low anterior resection (LAR)/high tumor than for LAR/low tumor, and higher for abdominoperineal resection than for Hartmann's procedure. Of the 4798 (86.8%) patients alive 2 years after surgery, 68.8% were working, 7.8% had retired, whereas 23.4% were on temporary benefits, sick leave, or disability pension. Conclusions: Clinical/sociodemographic factors were associated with the probability of working 2 years after surgery. This knowledge can be used to inform patients and target interventions towards patients with low post-CRC probability of working.

'Work is a motivator in life' Strategies in managing work participation among highly educated employees with depression.

BACKGROUND: Work participation among employees with depression is hampered due to cognitive impairments. Although studies show higher levels of work disability among people with a lower education, highly educated employees may encounter specific challenges in fulfilling their work role due to the cognitive impairments of depression, as they often perform cognitively demanding jobs. There is little knowledge about their challenges and opportunities with regard to work participation. OBJECTIVE: To investigate how highly educated employees with depression manage work participation by focusing on their views on opportunities and challenges in fulfilling their work role. METHODS: Eight individual interviews with highly educated employees with depression were conducted. Transcripts were analysed using qualitative content analysis. RESULTS: The analysis revealed four categories: struggling with acknowledging depression and disclosure; fear of being stigmatised at work; work is a motivator in life; and striving to fulfil the work role at the expense of private life activities. CONCLUSIONS: Highly educated employees with depression need guidance regarding the disclosure of information about health issues and work ability. To successfully manage their work role, they need a clear plan with outlined tasks, demands and goals. Healthcare professionals and workplaces should support them in setting limits with regard to work tasks and working hours.

Needs for occupational assistance among young adults with ADHD to deal with executive impairments and promote occupational participation - a qualitative study.

PURPOSE: To examine perceived aspects of importance among young adults with ADHD to participate and engage in occupational activities, and to explain how support from occupational specialists can assist them to deal with executive impairments. MATERIALS AND METHODS: Individual interviews with eight young adults with attention-deficit/hyperactivity disorder. The interview guide was based on assumptions derived from the literature regarding executive functioning and issues related to participation in occupational activities, alongside the needs for social support. Interview transcripts were analysed using qualitative content analysis. RESULTS: Four categories emerged from the analysed interviews: (1) Being involved in an occupational environment fulfils a need for social contact, (2) Occupational activities must be clear and within interest (3) Self-confidence and daily routines are prerequisites for occupational participation (4) Having a lifeline providing continuous support is important. CONCLUSIONS: Routines, interest and structure in everyday life are important to engage in occupational activities. There is a need for continuous support from a trusted person to establish and maintain healthy daily routines. Occupational specialists can be a vital resource, as they possess specific knowledge on the possibilities for occupation, and additionally, they can fulfil the young adults' needs for continuous support. There is a need for studies questioning how some young adults with ADHD fulfil their work role despite executive impairments. Focusing on executive functioning can be a valuable supplement to the focus on specific diagnoses in research and practice.

Associations between work environment, health status and sick leave among pregnant employees.

Aims: To study the associations between and timing of psychosocial and physical work factors and health status on sick leave among Danish pregnant employees. Methods: A total of 910 pregnant women completed a questionnaire in gestational weeks 12 (baseline) and 27 (follow-up). Information about psychosocial and physical work factors and health status was obtained at baseline. Associations with sick leave ⩾14 days were estimated using logistic regression. Further, the impact of timing and duration of exposure on sick leave were examined. Results: A total of 133 women (14.6%) reported ⩾14 days of sick leave at follow-up (27 weeks of gestation). Work-related risk factors for sick leave were high work pace, low influence, low recognition, low job satisfaction, conflict in work-family balance, standing/walking, heavy lifting, and shift work/night shift. Health-related risk factors were burnout, stress, possibility of depression, low work ability, previous sick leave, and poor self-rated health. Being exposed to work-related risk factors during the first 27 weeks of pregnancy or at follow-up increased the risk of sick leave compared with those not exposed at any time or only exposed at baseline. Poor health status increased the risk if women were exposed in the first 27 weeks of pregnancy; however, high possibility of depression was also a risk factor when experienced in early pregnancy. Conclusions: Psychosocial and physical work-related risk factors and poor health status were associated with more sick leave in pregnant employees. Early adjustment of work-related risk factors at the workplace is needed to reduce sick leave.

Navigating a Middle Ground - Exploring Health Professionals' Experiences and Perceptions of Providing Rehabilitation in Outdoor Community Settings.

Contemporary practice has started to rethink use of outdoor and community environments for advancing comprehensive rehabilitation outcomes. The aim is to examine health professionals' experiences and perceptions of providing rehabilitation in outdoor community settings. The purpose is to use these experiences to generate practice-based knowledge in using the outdoors as a means to guide community-based rehabilitation. The Interpretive Description methodology was accompanied by social practice theory. Fieldwork was conducted utilizing participant observation, photovoice, and focus-group interviews. Included were 27 health professionals. The analysis revealed how "naturalistic learning opportunities" offered health professionals strategies to empower activity and participation levels and yet invoked "rehabilitation setting tensions." A continuum was engaged in the theme "navigating a middle ground," representing an integrated environment approach; rehabilitation in conventional indoor and outdoor community settings. Development of a sustainable concept for outdoor community-based rehabilitation involves strengthening health professionals' competencies and skills for providing outdoor and community work.

Understanding depression as a workplace issue: Clarifying employers' attitudes to manage employees with depression.

BACKGROUND: Sickness absence due to depression has indirect and direct costs for employers. Whilst employers play a key role in establishing supportive work environments and providing work adjustments, there is a lack of knowledge on employers' attitudes to support employees with depression. OBJECTIVE: To investigate employers' attitudes to manage employees' depression, focusing on the employers' opportunities and challenges to support employees with depression. METHODS: Individual interviews were conducted with five employers. Interview transcripts were analysed using qualitative content analysis. RESULTS: Four categories emerged from the interviews: Attitude to and understanding of depression affect supportive practices; Dilemma between supporting employees with depression and accommodating workplace needs; The employer-employee relationship influences supportive practices; and Work accommodations target the employee's ability to work. CONCLUSION: Employers may need a wider understanding of depression and the importance of the work environment influencing work disability due to depression. Studies should investigate how knowledge of work disability due to depression can be transferred to workplaces.Conflicting agendas of the vocational rehabilitation stakeholders poison opportunities to support, and initiatives may aim to promote employers' understanding of the benefits of collaborating with other stakeholders. The involvement of decision-makers to provide initiatives that support employers in managing employees with depression to promote their work participation is recommended.

Educational attainment and work disability in cancer survivors: Do diagnosis and comorbidity affect this association?

OBJECTIVES: To study whether educational attainment had less impact on work disability in cancer survivors than in individuals without cancer. To study whether comorbidity had a higher impact on work disability in low-educated cancer survivors than in high-educated and whether this impact differed when compared with individuals without cancer. METHODS: Linkage of population-based public health survey data and the Danish Cancer Registry formed two groups: cancer survivors (n = 3,514) and cancer-free individuals (n = 171,262). In logistic regression models, the risk of experiencing an 8-week sick leave spell and the granting of disability pension within a 3-year follow-up period was studied in three educational levels and whether these associations were modified by history of cancer and comorbidity. Odds ratios (OR) with 95% confidence intervals (CI) are reported. RESULTS: Non-stratified adjusted risk of experiencing an 8-week sick leave spell (OR: 1.41, 95% CI (1.33-1.49)) or being granted a disability pension (OR: 1.61, 95% CI (1.31-1.97)) was significantly higher in low-educated than in high-educated respondents. Cancer or comorbidity did not significantly interact with education on the risk of work disability. CONCLUSIONS: A moderate impact of low education on future work disability was found for all respondents, neither history of cancer nor comorbidity modified this association.

Experiences of Older Adults After Hip Fracture: An Integrative Review.

PURPOSE: The aim of the study was to identify and synthesize scientific evidence on older adults' experience after hip fracture in relation to their physical and mental health, functional performance, and participation and to determine which personal or social factors influence functional capacity after hip fracture. DESIGN: Integrative review. METHODS: Eleven qualitative or quantitative papers published between 2001 and 2015 were analyzed using integrative review methodology as described by Whittemore and Knafl. RESULTS: Older adults experienced pain and decline in personal and instrumental activities of daily living and used adaptation strategies to cope with the hip fracture. CONCLUSION: Hip fracture affected the older adults' mobility, body image, mental health, and capacity for participation. CLINICAL RELEVANCE: Pain measurement tools focusing on various perspectives of health as well as rehabilitation programs focusing on changes in body function and body image and increased awareness of vulnerability in older adults may promote functional capacity after hip fracture.

Anxiety and depression in spine surgery-a systematic integrative review.

BACKGROUND: Symptoms of preoperative anxiety and depression occur in approximately one-third of patients with chronic back pain undergoing surgery. In the last 2 decades, several studies have established that preoperative anxiety and depression are important outcome predictors of greater pain and physical impairments, and lower health-related quality of life in patients undergoing spine surgery. To accommodate symptoms of anxiety and depression and thereby better surgical outcomes, we need to identify factors associated with these symptoms. PURPOSE: We aimed to identify factors associated with symptoms of anxiety and depression in adults both before and after undergoing spinal surgery. STUDY DESIGN: An integrative literature review was carried out. METHODS: The independent charity Helsefonden supported this literature review by contributing $45,000 to remunerate a dedicated investigator. A systematic literature search was conducted in PubMed, CINAHL, PsycINFO, Embase, Scopus, Cochrane, and Web of Science. A three-step selection and assessment process was conducted; titles and abstracts of 1,124 articles were skimmed for relevance and of these, 53 articles were found to be of relevance and were read in full. Articles not meeting the inclusion criteria (n=26) were excluded. The 31 articles were critically appraised for methodological validity; 14 of these were synthesized and analyzed using a convergent qualitative design to transform both qualitative and quantitative articles into qualitative findings. RESULTS: Fourteen studies were included, reporting results based on 4,833 participants, 3,017 men and 1,816 women, whose mean age was approximately 49 years. From these results, we extracted 75 individual findings, which we then divided into five categories of factors associated with anxiety and depression both before and after undergoing spine surgery: pain, information, disability, employment, and mental health. CONCLUSIONS: Five categories of interacting factors that influenced symptoms of anxiety and depression both before and after surgery were identified: pain, lack of information, disability, return to work, and mental health. Information appears to have a regulating effect on anxiety and depression.

Systematic Literature Review on ICF From 2001 to 2013 in the Nordic Countries Focusing on Clinical and Rehabilitation Context.

We present a systematic review on International Classification of Functioning, Disability and Health (ICF) used in the Nordic countries from 2001 through 2013, describing and quantifying the development in utilization of ICF, and describe the extent to which the different components of the ICF have been used. A search was conducted in EMBASE, MEDLINE and PsycInfo. Papers from Nordic countries were included if ICF was mentioned in title or abstract. Papers were assigned to one of eight categories covering the wide rehabilitation area; furthermore, area of focus was assigned. Use of ICF components and intervention were coded in papers categorized as "clinical and/or rehabilitation contexts" or "non-clinical contexts". One hundred seventy papers were included, of these 99 papers were from the categories "clinical and/or rehabilitation contexts" or "non-clinical contexts". Forty-two percent of the 170 included papers were published in the period 2011 - 2013. There was an increase in ICF-relevant papers from 2001 to 2013, especially in the categories "clinical and/or rehabilitation contexts" and "non-clinical contexts". The most represented focus areas were neurology, musculoskeletal, and work-related areas. All five or at least four ICF components were mentioned in the results or discussions in most papers, and activity was most frequently mentioned.

Wage-subsidised employment as a result of permanently reduced work capacity in a nationwide cohort of patients diagnosed with haematological malignancies.

BACKGROUND: Patients with haematological malignancies have a poorer labour market prognosis than the general population. We have previously found that they have low rates of return to work, and a higher risk of being granted disability pension, than individuals without a history of these diseases. The aim of this study was to further investigate the labour market prognosis for these patients, by comparing the risk of being granted wage-subsidised (WS) employment as a result of permanently reduced work capacity among patients diagnosed with haematological malignancies to a reference cohort, and to determine if relative risks differ between subtypes of haematological malignancies. MATERIAL AND METHODS: We combined data from national registers on Danish patients diagnosed with haematological malignancies between 2000 and 2007 and a reference cohort without a history of these diseases. A total of 3194 patients and 28 627 reference individuals were followed until they were granted WS employment, disability pension, anticipatory pension, old age pension, emigration, death or until 26 February 2012, whichever came first. RESULTS: A total of 310 (10%) patients and 795 (3%) reference individuals had their work capacity permanently reduced to an extent that they were granted WS employment during the follow-up period. Age- and gender-adjusted relative risks differed significantly between the subgroups of haematological malignancies, and four years after diagnosis they ranged from 2.47 (95% CI 1.46-4.16) for patients with Hodgkin lymphoma to 10.83 (95% CI 7.15-16.40) for patients with chronic myeloid leukaemia. CONCLUSION: All eight subtypes of haematological malignancies were associated with an increased risk of being granted WS employment due to permanently reduced work capacity compared to the reference cohort. The relative risks differed according to haematological malignancy subtype, and the highest was found for patients with chronic myeloid leukaemia.

Cross-national validation of prognostic models predicting sickness absence and the added value of work environment variables.

PURPOSE: To validate Dutch prognostic models including age, self-rated health and prior sickness absence (SA) for ability to predict high SA in Danish eldercare. The added value of work environment variables to the models' risk discrimination was also investigated. METHODS: 2,562 municipal eldercare workers (95% women) participated in the Working in Eldercare Survey. Predictor variables were measured by questionnaire at baseline in 2005. Prognostic models were validated for predictions of high (≥30) SA days and high (≥3) SA episodes retrieved from employer records during 1-year follow-up. The accuracy of predictions was assessed by calibration graphs and the ability of the models to discriminate between high- and low-risk workers was investigated by ROC-analysis. The added value of work environment variables was measured with Integrated Discrimination Improvement (IDI). RESULTS: 1,930 workers had complete data for analysis. The models underestimated the risk of high SA in eldercare workers and the SA episodes model had to be re-calibrated to the Danish data. Discrimination was practically useful for the re-calibrated SA episodes model, but not the SA days model. Physical workload improved the SA days model (IDI = 0.40; 95% CI 0.19-0.60) and psychosocial work factors, particularly the quality of leadership (IDI = 0.70; 95% CI 053-0.86) improved the SA episodes model. CONCLUSIONS: The prognostic model predicting high SA days showed poor performance even after physical workload was added. The prognostic model predicting high SA episodes could be used to identify high-risk workers, especially when psychosocial work factors are added as predictor variables.

Are fatigue, depression and anxiety associated with labour market participation among patients diagnosed with haematological malignancies? A prospective study.

OBJECTIVES: The objectives of this study are to examine levels of fatigue, depression and anxiety following diagnosis of a haematological malignancy, to determine the incidence of return to work (RTW) and long-term sickness absence (LTSA) during 1-year follow-up and to examine whether fatigue, depression and anxiety are associated with RTW and LTSA in this group of cancer patients. METHODS: Questionnaire-based data on fatigue, depression and anxiety were obtained at baseline. In all, 196 patients returned the questionnaire. Of these, 106 patients were on sick leave and 90 patients were working. They were all followed prospectively for 1 year using register-based data on labour market participation. RESULTS: At baseline, high levels of fatigue, depression and anxiety were more prevalent among sickness absent patients than in those working. Half of the sickness absent patients returned to work during follow-up, and only 10 (11%) working patients experienced LTSA. Sickness absent patients with highest scores of physical fatigue were less likely to RTW than those with lowest scores (RRadj 0.43, 95% CI 0.23-0.78). Similar, we found an association between symptoms of anxiety and RTW (p = 0.048). This association was though non-significant in multivariable analyses (p = 0.068). No significant association was found between depression and RTW. CONCLUSION: Half of sickness absent patients returned to work, and only a few of working patients experienced LTSA during follow-up. Patients reporting high levels of physical fatigue were less likely to RTW. There was a similar tendency for anxiety, whereas we found no association between depression and RTW. Larger prospective studies are needed.

Risk of disability pension for patients diagnosed with haematological malignancies: a register-based cohort study.

UNLABELLED: Patients with haematological malignancies are at increased risk of experiencing work-related problems. The aims of this study were to compare the risk of disability pension (DP) among patients diagnosed with eight subtypes of haematological malignancies to a reference cohort, and to determine if relative risks differ between these subtypes; to evaluate the influence of socioeconomic factors, demographic factors, and clinical factors on the risk of DP; and to investigate if these associations differ between the reference cohort and the patient cohort. MATERIAL AND METHODS: We combined data from national registers on Danish patients diagnosed with haematological malignancies between 2000 and 2007 and a reference cohort without a history of these diseases. A total of 3194 patients and 28 627 reference individuals were followed until DP, emigration, old age pension or anticipatory pension, death or 26 February 2012, whichever came first. RESULTS: A total of 550 (17%) patients and 1511 (5%) reference individuals were granted DP. Age- and gender-adjusted relative risks differed significantly between the subgroups of haematological malignancies and ranged from 2.64 (95% CI 1.84-3.78) for patients with Hodgkin lymphoma to 12.53 (95% CI 10.57-14.85) for patients with multiple myeloma. In the patient cohort we found that gender, age, comorbidity, ethnicity, educational level, household income, history of long-term sick leave, and need of treatment with anxiolytics or antidepressants after diagnosis were associated with receiving DP. However, most of these associations were stronger in the reference cohort. CONCLUSION: All eight subtypes of haematological malignancies were associated with an increased risk of DP compared to the reference cohort. The relative risks differed according to subtype, and patients with multiple myeloma had the highest risk of DP. Furthermore, most socioeconomic, demographic and clinical factors had a stronger impact on the risk of DP in the reference cohort than in the patient cohort.

Early versus late initiation of rehabilitation after lumbar spinal fusion: economic evaluation alongside a randomized controlled trial.

STUDY DESIGN: Economic evaluation conducted alongside a randomized controlled trial with 1-year follow-up. OBJECTIVE: To examine the cost-effectiveness of initiating rehabilitation 6 weeks after surgery as opposed to 12 weeks after surgery. SUMMARY OF BACKGROUND DATA: In a previously reported randomized controlled trial, we assessed the impact of timing of rehabilitation after a lumbar spinal fusion and found that a fast-track strategy led to poorer functional ability. Before making recommendations, it seems relevant to address the societal perspective including return to work, quality of life, and costs. METHODS: A cost-effectiveness analysis and a cost-utility analysis were conducted. Eighty-two patients undergoing instrumented lumbar spinal fusion due to degenerative disc disease or spondylolisthesis (grade I or II) were randomized to an identical protocol of 4 sessions of group-based rehabilitation and were instructed in home exercises focusing on active stability training. Outcome parameters included functional disability (Oswestry Disability Index) and quality-adjusted life years. Health care and productivity costs were estimated from national registries and reported in euros. Costs and effects were transformed into net benefit. Bootstrapping was used to estimate 95% confidence intervals (95% CI). RESULTS: The fast-track strategy tended to be costlier by €6869 (95% CI, -4640 to 18,378) while at the same time leading to significantly poorer outcomes of functional disability by -9 points (95% CI, -18 to -3) and a tendency for a reduced gain in quality-adjusted life years by -0.04 (95% CI, -0.13 to 0.01). The overall probability for the fast-track strategy being cost-effective does not reach 10% at conventional thresholds for cost-effectiveness. CONCLUSION: Initiating rehabilitation at 6 weeks as opposed to 12 weeks after surgery is on average more costly and less effective. The uncertainty of this result did not seem to be sensitive to methodological issues, and clinical managements who have already adapted fast-track rehabilitation strategies have reason to reconsider their choice. .

The effect of timing of rehabilitation on physical performance after lumbar spinal fusion: a randomized clinical study.

BACKGROUND: The number of patients undergoing lumbar spinal fusion procedures (LSF) has risen in recent years, but only few studies have examined different rehabilitation strategies for this patient group. PURPOSE: To evaluate the impact of initiating rehabilitation either 6 or 12 weeks after a LSF based on the patients' physical performance using the 6-min walking test (6MWT) and the Åstrand Fitness test (AF-test) as measurement. METHODS: A multicentre RCT including 82 patients with degenerative disc diseases undergoing LSF randomly assigned to initiate rehabilitation either 6 or 12 weeks after surgery. Both groups received the same group-based rehabilitation. The main outcome measures were the 6MWT and the AF-test, secondarily questionnaire-based measures. Follow-up at baseline as well as at 3, 6 and 12 months after surgery. RESULTS: Comparing the two groups no statistically significant difference was found in walking distance or fitness over time. In both groups, the patients achieved an overall increase in walking distance (p < 0.01), but no improvement in fitness. The 6MWT showed significant correlation (-0.37 to -0.59) with the questionnaire-based outcome measures (p < 0.01). The AF-test did not correlate to either the 6MWT or any of the questionnaire-based outcome measures. CONCLUSION: No difference was found in the effect of initiating rehabilitation either 6 or 12 weeks after LSF on the patients' physical performance in terms of fitness and walking distance. The 6MWT showed fair to moderate correlation to the questionnaire-based outcome measures. The AF-test showed no significant independent value, and we question its use in LSF patients.