Associations between rehabilitants’ functional limitations and conclusions made by a multidisciplinary team during vocational rehabilitation evaluation: Turku ICF Study

doi:10.4236/ojtr.2013.12007

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Vol.1, No.2, 36-39 (2013) Open Journal of Therapy and Rehabilitation

http://dx.doi.org/10.4236/ojtr.2013.12007

Associations between rehabilitants’ functional

limitations and conclusions made by a

multidisciplinary team during vocational

rehabilitation evaluation: Turku ICF Study

Mikhail Saltychev1*, Aila Kinnunen2, Katri Laimi1

1Department of Physical and Rehabilitation Medicine, Turku University Hospital and University of Turku, Turku, Finland;

*Corresponding Author: [email protected]

2Department of Brain Trauma and Rehabilitation, Turku University Hospital and University of Turku, Turku, Finland

Received 15 August 2013; revised 20 September 2013; accepted 30 September 2013

cense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Purpose: To investigate associations between

functional limitations experienced by rehabili-

tants and multidisciplinary team’s recommenda-

tions during vocational rehabilitation evaluation.

Methods: The descriptions of functional limita-

tions were retrospectively identified for 32 pa-

tients with chronic musculoskeletal disorders.

Vocational rehabilitation evaluation was con-

ducted by a multidisciplinary team in an out-

patient clinic of a university hospital. The de-

scriptions were converted to ICF second-level

categories. Square contingency coefficient Phi

(φ) was calculated to describe the associations

between ICF-categories appearing ≥10 times in

the study sample and the recommendations

given by a professional team. Results: In the

study sample, 84 different ICF second-level cate-

gories were identified (average 18 codes/subject,

range 9 - 25). Of them, 18 categories were ob-

served for at least in 10 rehabilitants. Three sta-

tistically significant correlations were observed

between these 18 categories and recommenda-

tions given by a rehabilitation team. Of them,

positive association of moderate strength was

found between joint mobility and muscle power

functions and recommendation for retirement.

Difficulties in walking showed weak negative

correlation with recommendation for vocational

rehabilitation. Conclusions: During vocational

rehabilitation evaluation, the final recommenda-

tions given by rehabilitation professionals were

only weakly correlated with functional limita-

tions experienced by rehabilitants.

Keywords: Occupational Reh abilitation;

Rehabilitation Assessment; Work Ability; Work

Capacity; Correlation

1. INTRODUCTION

To be successful, vocational rehabilitation evaluation

should be able to answer to at least three questions.

Firstly, if there is a need for rehabilitation measures at all,

secondly, if preconditions for such measures exist, and,

finally, what could be recommended as a concrete start

point of rehabilitation. All three issues may vary widely

in different settings depending on state and local politics,

insurance policies, believes, and economic and employ-

ment situation among other factors. Of these three goals

of vocational rehabilitation evaluation, the need for reha-

bilitation is probably less dependent on societal differ-

ences as it bases on person’s health and restricted func-

tioning and participation.

There are studies describing functional status of em-

ployees leading to a need for vocational rehabilitation, as

well as studies on impact of functioning on rehabilitation

success [1-3]. Different methods have been suggested to

describe the impact of employee’s health and social con-

ditions on his or her engaging in employment. Such

methods are, for example, Personal capability Assess-

ment (PCA), California Functional Capacity Protocol

(Cal-FCP), and International Classification of Function-

ing, Disability and Health (ICF). ICF is accepted by all

members of World Health Organization and it could be

regarded as the most standardized biopsychosocial frame-

work for describing functioning and participation [4,5].

M. Saltychev et al. / Open Journal of Therapy and Re habilitation 1 (2013) 36-39 37

During the evaluation of rehabilitation need, professional

team thoroughly collects data on rehabilitant’s functional

status. So far, however, it is unknown how much these

data on functioning affect the final decisions and rec-

ommendations given by a team. We are not aware of

reports on connection between functional limitations

experienced by rehabilitant and recommendations given

by a professional team. Is it really taken into account or

does the decision mostly base on objective data (like, e.g.,

changes on x-ray images, blood tests, or objectively

measured muscle strength)? Knowledge on how strongly

recommendations made by professionals are driven by

functional limitations which may help multidisciplinary

team focus on the most important topics of collected data.

The purpose of the study was to investigate correla-

tions between rehabilitants’ functional limitations ex-

pressed in the unified form of ICF categories and rec-

ommendations given by a multidisciplinary team during

vocational rehabilitation evaluation.

2. MATERIALS AND METHODS

The study was conducted in the out-patient clinic of

the Department of Rehabilitation in Turku University

Hospital, Finland. The clinic is specialized in compre-

hensive rehabilitation evaluation with an emphasis on

determining abilities, skills, and motivational factors for

the employment of persons with deteriorated work ability

due to chronic medical conditions. In this study, all pa-

tients, referred for this evaluation because of a chronic

musculoskeletal disorder and entered the clinic between

1 January 2011 and 31 December 2011, were included.

Data from the electronic patient records were obtained

for 32 persons (53% women). None was excluded from

the study .The study was approved by the Ethics Com-

mittee of the Turku University Hospital.

All participants had a history of a chronic muscu-

loskeletal disorder confirmed by a physician. Their ca-

pacity for work had started to deteriorate, and work dis-

ability was probable. The rehabilitation evaluation was

conducted by a multi-professional team consisting of a

physician, a rehabilitation planner, and a psychologist.

The main goal of the evaluation was to form a compre-

hensive rehabilitation plan regarding a diagnostic and

treatment strategy and appropriate medical and voca-

tional rehabilitation measures with an emphasis on the

vocational content. The final statement of the evaluation

contained an opinion on the severity of the unemploy-

ment handicap. Patients, their earning-related pension

insurance company, and the local employment agencies

carried the responsibility for the practical implementa-

tion of the rehabilitation plan. The process of evaluation,

the definitions of demographic variables, and the code

extraction process have been previously described [6].

Each rehabilitant’s electronic patient record was stud-

ied retrospectively, and each phrase that could poten-

tially be interpreted as an ICF code was extracted and

converted into appropriate ICF codes. The codes were

extracted with as high a precision as possible. Due to the

qualitative nature of the used patient records, no attempts

were made to define the ICF quantitative qualifiers. Due

to the retrospective nature of the study and the impre-

ciseness of descriptions of s- and e-components (s =

body structures and e = environmental factors), we

agreed to include only b- and d-components (b = body

functions, d = activities and participation) of ICF for

further analysis.

The recommendations given by a rehabilitation team

at the end of an evaluation process were defined by using

two dichotomous variables: “recommendation of a long-

term sick leave or disability pension—Yes/No”, and

“recommendation of further vocational rehabilitation

measures—Yes/No”.

Statistical Analysis

The identified ICF categories were truncated to a form

of second-level ICF category (letter with three digits).

For practical reasons, further analysis included only

categories which appeared >10 times in the study sam-

ple. Square contingency coefficient Phi (φ) was calcu-

lated for each frequent code along with a two-tailed

Fisher’s exact test for significance set at <0.05. Correla-

tion strength of 0 - 0.19 was regarded as very weak, 0.2 -

0.39 as weak, 0.40 - 0.59 as moderate, 0.6 - 0.79 as

strong, and 0.8 - 1 as very strong. All of the statistical

analyses were performed using IBM® SPSS® Statistics

version 21.

3. RESULTS

The mean age of rehabilitants (53% women) was 46.4

(range 29 - 60, standard deviation [SD] 8.9) years. The

general educational level was low, and only four persons

(13%) had a high school education. Most of the patients

(78%) had some vocational education, mostly compara-

ble to vocational school. Half of patients still had a valid

job contract. Over 60% had a work history >20 years,

and over 50% were manual workers.

In the study sample, 84 different ICF second-level

categories were identified (average 18 codes/subject,

range 9 - 25). Of these 84 categories, 18 were observed

for >10 times. The multidisciplinary team recommended

a long-term sick leave or disability pension for 8 and

vocational rehabilitation measures for 10 rehabilitants.

Three statistically significant correlations were observed

between these categories and conclusions made by a re-

habilitation team (Table 1). Of them, positive association

of moderate strength was found between joint mobility

M. Saltychev et al. / Open Journal of Therapy and Re habilitation 1 (2013) 36-39

Table 1. Correlations between frequent functional limitations identified during vocational rehabilitation evaluation and recommenda-

tions made by a professional team. Results are reported as mean square contingency coefficient Phi (φ) values and Fisher’s exact test

for significance.

Rehabilitation recommended Long-term sick leave or pension recommended

ICF category

φ Fisher’s exact testφ Fisher’s exact test

b130 Energy and drive functions −0.12 0.70 0.15 0.68

b134 Sleep functions 0.06 1.00 0.33 0.10

b140 Attention functions −0.20 0.43 −0.08 1.00

b152 Emotional functions −0.02 1.00 0.00 1.00

b265 Touch function 0.33 0.14 −0.14 0.69

b280 Sensation of pain −0.09 1.00 −0.15 0.44

b710 Joint mobility −0.20 0.45 0.55 <0.01

b730 Muscle power functions −0.25 0.25 0.49 0.01

d240 Handling stress and other psychological demands 0.22 0.25 −0.23 0.38

d410 Changing basic body position −0.02 1.00 0.18 0.42

d415 Maintaining a body position −0.12 0.70 −0.15 0.43

d430 Lifting and carrying objects 0.13 0.64 0.25 0.30

d450 Walking −0.39 0.05 0.15 0.68

d540 Dressing −0.15 0.47 0.30 0.12

d640 Doing housework −0.09 0.67 −0.04 1.00

d825 Vocational training −0.20 0.43 0.23 0.22

d850 Remunerative employment −0.22 0.27 0.19 0.56

d920 Recreation and leisure 0.06 1.00 −0.11 0.68

and muscle power functions and recommendation for

long-term sick leave or disability pension (φ = 0.55 and

0.49, respectively). Difficulties in walking showed weak

negative correlation (φ = −0.39) with recommendation

for vocational rehabilitation.

4. DISCUSSION

In this retrospective study of 32 participants in a voca-

tional rehabilitation evaluation due to chronic muscu-

loskeletal disorders, we found only few statistically sig-

nificant associations between different functional limita-

tions described in terms of ICF and final recommenda-

tions made by a multidisciplinary team. Namely, moder-

ate positive associations were observed between joint

mobility and muscle power functions and recommenda-

tion for long-term sick leave or disability pension. Diffi-

culties in walking showed a weak negative correlation

with recommended rehabilitation.

As far as we know, this is the first study on associa-

tions between functional limitations experienced by reha-

bilitants in vocational rehabilitation evaluation and con-

clusions made by a multidisciplinary team. We observed

that the associations between functioning and recom-

mendations may be described in unified terms of ICF and

also quantitatively assessed. As this study is a descriptive

evaluation of 32 cases, no strong inferences concerning

the entire population with need for vocational rehabilita-

tion should be made. The role of environment in person’s

participation level is one of the cornerstones of ICF, but

due to a retrospective design of the study, the obtained

data on environmental factors (e-component) were not

considered to be reliable.

There is no doubt that recommendations made during

vocational rehabilitation evaluation have to be affected

not only by functional limitations experienced by reha-

bilitant but also by more objective data on health status

collected through e.g. clinical examination, x-ray imag-

ing, laboratory testing, previous documented history of

illness etc. However, one could expect that experienced

difficulties in daily functioning and participation would

also have a great role in recommendations given by a

professional team. Surprisingly, in this study, no strong

M. Saltychev et al. / Open Journal of Therapy and Re habilitation 1 (2013) 36-39 39

correlations between experienced functional limitations

and final recommendations of disability or vocational

rehabilitation were found. We can speculate that in our

study settings, rehabilitation team made its decisions

knowing that insurance policy requires objective data on

rehabilitant’s functional restrictions before pension or

even vocational rehabilitation can be accepted. In this

situation, functional obstacles experienced by rehabili-

tant may play an important role in detecting rehabilita-

tion need but do not significantly affect the final recom-

mendation.

This kind of assessment can be suggested to any mul-

tidisciplinary team focusing on vocational rehabilitation

evaluation. While the exact results probably vary widely

depending on different settings, further studies, con-

ducted on larger samples and in prospective design, may

help professionals to recognize what type of data sig-

nificantly affects their recommendations.

5. ACKNOWLEDGEMENTS

We thank statistician Jaana Pentti from Finnish Institute of Occupa-

tional Health for her advices when planning statistical analysis of this

study.

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