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People Factors
Does multidisciplinary rehabilitation work? How does patient motivation affect outcomes?

At a glance:
People with long term musculoskeletal
musculoskeletal
Involving the muscles and the skeleton. This term includes the limbs, neck, shoulders and back. 'Musculoskeletal problem' refers to many different conditions that can affect the tendons, muscles and related structures.
 problems often enter rehabilitation
rehabilitation
The process of helping a person back to their former abilities and quality of life (or as close as possible) after injury or a medical condition.
 programs as part of their treatment. This study shows that these programs are more cost effective if they seek to treat the “whole person' rather than focusing purely on medical problems. This approach is common to interdisciplinary
interdisciplinary
Utilizing more than one discipline eg. combining psychology, physiotherapy and ergonomics
 rehabilitation programs, which involve physicians, specialists, physiotherapists, occupational therapists, psychologists, case managers, nurses and others.

Patients who are highly motivated for rehabilitation achieve better outcomes.
 
Perspectives:
Employee
This study found that a group program with treatment from a range of professionals helped improved level of function and quality of life. The improvement in the person's health and well-being was, however, relatively mild.

The researchers found that the person's motivation had a much greater impact on return to function and return to work than the treatment.

It is common for a person's motivation to go to work to be lower after a work injury. This is a common experience and can make a difficult situation harder. A professional athlete who has an injury is often extremely motivated to overcome the problem and return to their normal level of function and sport. Most people want to get better and return to their normal lives. However over time the level of motivation will often reduce.

Motivation can be increased or decreased. Some motivating factors come from within you (internal motivating factors), others are increased and decreased by those around you and influencing the situation. These factors are known as external motivating factors.

The following are some of the ways that motivation to return to work can be increased:

Seeing return to work as possible, probable, and setting goals. When a task seems large it is easier when broken down into manageable steps. When things look difficult with return to work it helps to identify the steps involved with return to work. People are more motivated to take on tasks if believe they are achievable.

A constructive return to work plan maps out a path to return to normal duties. There may be times where the plan cannot be followed exactly, but if you have an idea of the path forward the goal is more likely to be achieved. Success is then seen as possible and achievable. It also prompts a discussion about what will be needed to return to normal duties.

Confidence to overcome barriers.  People are more likely to take on a task and be successful if they are confident it is going to be achieved. Talk to others, find out what they have done to achieve success. Use others who have been successful as a role model. Talk to someone you trust about any difficulties and what they think you can do to overcome those difficulties.

Achieving success. You are more likely to be motivated when you recognise success in what you have achieved. By breaking down a rehabilitation program into steps each success can be seen and appreciated. Looking at how far you have come. You should not underestimate the challenge of dealing with pain, return to work, and all of the communication that needs to occur. Celebrate your positive accomplishment such as the first day back at work or first full time. And make sure others see the positive steps you have made.

Understanding what happens if return to work does not occur. People who remain off work in the long term suffer a range of health and well being problems. They often look back and say “if only I had known then what I know now.'

It is important to understand what happens to people who remain off work. Talk to your doctor about what happens to people who stay off work for more than a few months. Make sure you understand the compensation system and what happens to your level of pay.

Receiving a lump sum payment can sound attractive but it may not cover all costs and many people believe it doesn't compensate for the long-term change in their lifestyle.

Understanding what the individual can do. When a person off work realises what they can do to make a difference they are often more positive in their approach. You may believe that others are going to manage the situation. However, if you are positive and proactive and offer practical solutions you will be seen differently to a passive person waiting for the system to manage return to work. You motivate others by being positive, and in turn that helps you.

Being supported.  Ask those around you to support you. This might be your spouse, a family member you trust, or good friend.  If someone is there to offer support you will be more motivated to return to work.

Having a good understanding of the medical conditions.  Make sure you get high-quality advice about your medical condition, and that any fears about return to activity are addressed.  When people are fearful about hurting themselves or aggravating the problem by “doing something wrong' they avoid activity and work.  There are many myths about what you should and should not do when you have pain.

Make sure you get the best advice.  Speak to the receptionist and make a longer appointment to talk to your doctor or another trusted health professional about these issues. Being active is the best approach for many medical conditions.

People are more motivated to return to work when they understand it is good for their health.
Employer
Whilst treatments such as the researched multidisciplinary
multidisciplinary
Utilizing multiple treatment approaches at the same time. e.g. combined treatement with psychology, physiotherapy and hydrotherapy
 program can help an individual with their problem, motivation to return to work makes a greater difference. A patient's motivation for rehabilitation has a big effect on the outcomes they achieve. The workplaces approach influences the employee's motivation.

To assist rehabilitation many employers draw up a return to work plan. Engaging the employee in the development of the return to work plan helps both parties.

The employee often knows the jobs and can make positive suggestions

They know their condition, and can suggest what will be appropriate for their problem

If they are reluctant to work with you to develop the plan it gives you an opportunity to talk about barriers to return to work. Maybe they are fearful of their condition, are unhappy about workplace issues, do not trust the workplace to look after them, or maybe their motivation is low. All of these issues are worth exploring, if you identify the barriers to return to work you will be in a better position to overcome them.

People are more likely to participate in an activity if they have been involved from the start.

Having a plan that leads back to normal duties provides direction, helps set goals, and gives people something to work towards. Setting goals has been shown to help people's motivation with rehabilitation in a variety of areas.

This approach is most likely to be successful if modified duties are useful and meaningful, and the person is supported and encouraged. Factors that reduce peoples motivation include:
Workplace disputes

Delays or disputes about pay

Lack of trust

Worry about aggravating the condition

Not being aware of the problems of staying off work

Not understanding the longer term consequences of staying off work

The perception the workplace does not want them back
Treater
Return to work can be challenging. Treatment can help to some degree and this study showed there were benefits from a multidisciplinary program. However the study showed that motivation makes a much greater difference. The impact of motivation was positive regardless of whether the person was enrolled in the multidisciplinary program or not.

Treating practitioners are not surprised by this finding. However treating practitioners
treating practitioner
A health professional that treats patients. In return to work this may include doctors, physiotherapists, chiropractors, osteopaths, psychologists, masseurs, etc.
 are often surprised at the difference they can make to patients motivation levels.

Treating practitioners can help patients motivation by:

Explaining the medical condition and what the person can do to manage it

Explaining the importance of remaining active

Explaining the importance of remaining positive and presenting those in the workplace with suggestions and solutions for management of the situation

Acting as a patient advocate and an advocate for return to work

Involving family members in helping the person return to activity

Letting the employer know about the influence of motivation, and making sure the employer does what they can do to increase the patients motivation to return to work

Letting people know about the negative consequences of long-term absence from work. There is good evidence to show that long term work absence puts people at increased risk of death, depression,
depression
A symptom of mood disorder characterized by intense feelings of loss, sadness, hopelessness, failure, and rejection. Major depression is likely to interfere significantly with everyday activity, with symptoms including insomnia, irritability, weight loss, and a lack of interest in outside events. The disorder may last several months or longer and may recur, but it is generally reversible in the short run.
 social isolation, and poor financial circumstances. It is more deleterious to a persons health that working in the most dangerous of industries.
 
A structured return to work program is often helpful. It's important that such a program does not move too quickly or too slowly. If the program moves too slowly then pain levels often determine positive steps are taken. Goals become secondary to the way the person feels at the time, pain becomes the focus and there is no clear path forward.

It is a myth that patients should “let pain be their guide.' If this was applied routinely professional sport would be dead and we would have few people in the workforce.
 
Insurer
As most claims officers know, motivation has a big impact on return to work. This study demonstrated that those who highly motivated at the beginning of the rehabilitation programme achieved better outcomes and had better quality of life.

We tend to think of motivation as good or bad. People who do not have motivation are seen less positively. However motivation can be influenced. A system where it is difficult to communicate with others, where there are delays in getting treatment and where the individual does not feel supported, is demotivating.

In contrast, early positive communication and clarity about return to work issues increases motivation.

Delays are inevitable in the workers compensation system - they reduce everyone's motivation including yours. Claims officers can help by putting realistic but efficient timeframes in place, responding quickly, and expecting others to do likewise.
 
Original Article, Authors & Publication Details:
B. E. Grahn1,2, L. A. Borgquist3 and C. S. Ekdahl2 (2000).

Motivated patients are more cost-effectively rehabilitated. A two-year prospective controlled study of patients with prolonged musculoskeletal disorders diagnosed in primary care. International Journal of Technology Assessment in Health Care 16(3): 849-63.

1Kronoberg Occupational Rehabilitation Service
2Lund University
3Linköping University
Background, Study Objectives, How It Was Done:
This study investigated the effectiveness of a multidisciplinary rehabilitation program for patients with long-term musculoskeletal disorders. It compared this approach to traditional treatments with particular attention to economic cost and health-related quality of life. The study also looked at the effect of patient motivation on the outcome of rehabilitation.

95 patients with long-term musculoskeletal disorders were involved in a comprehensive, multidisciplinary rehabilitation program, and their outcomes compared to 97 patients who underwent traditional treatment. Each patient had taken a lot of sick leave over the previous year, and had undergone some rehabilitation during that time. At the beginning of the program, patients had been experiencing symptoms for an average of almost 6 years.

The multidisciplinary rehabilitation involved medical, social and psychological
psychological
Refers to a person's perceptions, thought processes, emotions, personality and behaviour. Psychologists can treat mental health problems.
 treatment, including education about coping skills, stress management and relaxation techniques, physical training and visits to the workplace. Patients were involved in goal-setting, and were treated by a senior physician, orthopaedic specialist, psychiatrist, physiotherapists, an occupational therapist, social advisor and nurse. Physiotherapy included Body Awareness Therapy, which aims to improve muscle tension, coordination, posture and breathing. The program also included creative and cultural activities. The program was full-time and lasted for four weeks, with at least four follow-ups over the following 2 years.

Patients who received traditional treatment were examined by their doctor, prescribed medicine and sometimes referred to a physiotherapist. Advice and medical certificates were provided as necessary. Physiotherapy usually involved massage, heat treatments, strength and mobility training, stretching and advice about exercises to do at home. It did not include Body Awareness Therapy.

Patient motivation was assessed by a physiotherapist and psychologist at the beginning of treatment, using a semi-structured written interview. Patients were considered to be highly motivated if they could identify:
  • Their goals
  • The efforts they needed to make to achieve these goals
  • The support they would need from others to achieve their goals
Patients were considered less highly motivated if they:

Had difficulty setting goals

Expected medical treatment to solve most of their problems

Were overwhelmed by obstacles to their goals

The patients were all followed up 2 years after treatment. The following outcomes were assessed.

1. Health-related quality of life: particularly the person's level of pain, physical mobility, their emotional reactions, sleep patterns, energy and social isolation. Results for each category were scored systematically using the Nottingham Health Profile.

2. Treatment costs

3. Indirect costs from time off work.
The over-all cost effectiveness of each treatment approach (multidisciplinary or traditional) was calculated as the total cost divided by the improvement in the patients quality-of-life score.
 
Study Findings:
Multidisciplinary versus traditional rehabilitation

Costs

Direct costs for the multidisciplinary rehabilitation were three times as high as those for the traditional rehabilitation program.

There were no significant differences in the indirect costs for the two groups. Time lost from work is the most significant cost associated with musculoskeletal conditions and accounts for most of these indirect costs.

Quality of life

Patients who participated in the multidisciplinary program seemed to show slightly more quality of life improvement than those in the traditional program. However, this difference was minor and both groups of patients showed improvement.

When total costs were compared to the improvement in quality of life, the researchers found that multidisciplinary rehabilitation was more cost-effective.

The impact of motivation

Motivation

Over 2 years, “highly motivated' patients reduced their indirect costs by four times as much as “less motivated' patients. Motivation did not affect the amount of healthcare sought or received.
 
Conclusions:
For patients with long-term musculoskeletal disorders, multidisciplinary rehabilitation programs are more expensive, but produce slightly greater improvements in quality of life when compared to traditional rehabilitation programs.

Regardless of the type of rehabilitation program used, patient motivation has a big effect on the outcomes achieved. Highly motivated patients take less time off work than those who are less motivated, and they also achieve better results in rehabilitation.
 
References:
PubMed Abstract
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