Monitoring the quality in rehabilitation practice among patients with hand injuries: An ICF-based model of patient oriented rehabilitation

Status:

completed 10/2009

Aims:

Based on the previous DASH project, the primary goal of this study was to provide a universally applicable patient-oriented programme in hand rehabilitation by means of the development of practice guidelines.
"International Classification of Functioning, Disability and Health" (ICF) served as the conceptual framework of this comprehensive prognostic model ("Ludwigshafen Model of Hand Rehabilitation"). Using the model, practical difficulties as well as factors leading to successful or unsuccessful rehabilitation could be identified.

Activities/Methods:

1. Using a computer-based procedure, patients were classified into various subgroups based on the analyses of the objective and subjective data
2. Patients within a subgroup demonstrated maximum similarity with regard to the variables measured
3. Between the subgroups, patients demonstrated maximum dissimilarity with regard to the variables measured
4. Using comparative analyses, it was possible to identify which variables and by which patient group were relevant to a positive rehabilitation outcome

Results:

93 patients (76 men, 17 women) participated in the study. Average age was 44 yrs. 64 patients were primarily treated elsewhere before taking part in the hand rehabilitation programme of the BGU Lu (time from accident until the start and end of rehabilitation was MV 384 and 461 days). For patients treated primarily in domo the time period was approximately half (MV 159 and 223 days). During rehabilitation, clinical variables and DASH scores improved significantly. These improvements were sustained at four-month follow-up, thereby demonstrating the effectiveness of the physio- and occupational therapy programmes. Patients´ own goals dictated and validated the therapeutic interventions and, based on ICF domains, vocational "core sets" were developed. At the beginning of treatment 47% of the sample rated BG support as good or very good, 17% as moderate and 36% as weak or non-existent.
Three distinct sub-groups were identified with regard to pain. Irrespective of the type of injury, the group with continuous, severe pain demonstrated the worst outcome.
Within the total sample scores of depression and general psychological distress improved significantly between the beginning and end of treatment. High levels of emotional distress were present in approximately 25% of patients and required psychological treatment during their rehabilitation. At all three data collection times emotionally distressed patients reported higher pain levels and poorer functioning than other groups. Severe pain coupled with emotional distress represents a "fatal combination" for rehabilitation outcome.
Satisfaction with treatment received was very high (29.6 from 32 points). 89% of patients were in favour of the patient-oriented concept.
Four months after discharge, 51% had returned to work, 14% were retraining or in an ABE and 35% were still unable to work.

Conclusion and Relevance of Findings for the German Social Accident Insurance
1. The ICF is suitable both as a conceptual framework and a practical model relevant to all aspects of rehabilitation. Validation of therapeutic interventions is through the patients´own ICF-based aims of treatment. Of interest to the DGUV is whether other hand-injured groups identify similar vocational aims, thus providing general guidelines for interventions.
2. The effectiveness and sustainability of the patient-oriented concept are confirmed and justify its routine application in daily clinical practice. Our study offers, for the first time, a practical procedure whereby the whole rehabilitation team can actively support the patients´ involvement in their treatment.
3. At the start of treatment 36% of patients reported little or no contact with and support from their BGs. This finding indicates considerable room for improvement within the BGs themselves.
4. A significant proportion of the sample (25%) was found to suffer from high levels of psychological distress and required psychological treatment. Due to lack of staff in the department of psychology, these needs will not be met when the project finishes.
5. A similar situation exists with regard to pain therapy. Due to lack of staff consultations with the pain therapist are delayed, which in turn hinders progress in the areas of physio- and occupational therapy.
6. Patients with continuous pain and high levels of psychological distress were found in all categories of injuries. This result confirms outcome cannot be predicted solely on the basis of the type or extent of the injury - this requires a biopsychosocial approach.

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