multidisciplinary team care in rehabilitation
DESCRIPTION
jurnal rehabilitasi multi teamTRANSCRIPT
Special RepoRt
J Rehabil Med 2012; 44: 901–912
J Rehabil Med 44© 2012 The Authors. doi: 10.2340/16501977-1040Journal Compilation © 2012 Foundation of Rehabilitation Information. ISSN 1650-1977
Objectives: To systematically investigate current scientific evidence about the effectiveness of multidisciplinary team rehabilitation for different health problems.Data sources: A comprehensive literature search was con-ducted in Cochrane, Medline, DARE, Embase, and Cinahl databases, and research from existing systematic reviews was critically appraised and summarized. Study selection: Using the search terms “rehabilitation”, “multidisciplinary teams” or “team care”, references were identified for existing studies published after 2000 that examined multidisciplinary rehabilitation team care for adults, without restrictions in terms of study population or outcomes. The most recent reviews examining a study popu-lation were selected. Data extraction: Two reviewers independently extracted in-formation about study populations, sample sizes, study de-signs, rehabilitation settings, the team, interventions, and findings. Data synthesis: A total of 14 reviews were included to sum-marize the findings of 12 different study populations. Evi-dence was found to support improved functioning following multidisciplinary rehabilitation team care for 10 of 12 dif-ferent study population: elderly people, elderly people with hip fracture, homeless people with mental illness, adults with multiple sclerosis, stroke, aquired brain injury, chronic arthropathy, chronic pain, low back pain, and fibromyalgia. Whereas evidence was not found for adults with amyetrophic lateral schlerosis, and neck and shoulder pain.Conclusion: Although these studies included heterogeneous patient groups the overall conclusion was that multidiscipli-nary rehabilitation team care effectively improves rehabili-tation intervention. However, further research in this area is needed. Key words: rehabilitation; patient care team; outcome assess-ment; multidisciplinary team.J Rehabil Med 2012; 44: 901–912
Correspondence address: A. M. Momsen, MarselisborgCentret, P. P. Oerums Gade 11, DK-8000 Aarhus C, Denmark. E-mail: [email protected] January 27, 2012; accepted June 7, 2012
IntRoductIon
In denmark, as in other Western countries, the population is ageing, and, consequently, chronic diseases are increasing. Yet problems with rehabilitation remain that cannot be adressed with medicine or surgery. Healthcare changes, including a reduction in the number of hospitals, increased numbers of specialized hospitals and shorter hospital stays, have resulted in a greater demand for rehabilitation. under the 2006 Dan-ish Health Act, responsibility for the rehabilitation of patients shifted towards local authorities in the municipalities (1). this shift of responsibility requires cooperation and coordination between health sectors and local authorities, and highlights the need for standards and guidelines for rehabilitation services. In addition, as rehabilitation requires the expertise of various disciplines, methods for improving the performance of inter-disciplinary teams are paramount.
Rehabilitation has been defined in the Danish White Paper as: “A goal-oriented, cooperative process involving a member of the public, his/her relatives, and professionals over a specified period of time. the aim of this process is to ensure that the person in ques-tion, who has, or is at risk of having, seriously diminished physi-cal, mental and social functions, can achieve independence and a meaningful life. Rehabilitation programmes consider the person’s situation and the decisions he or she must make, and consist of coordinated, coherent, and knowledge-based measures” (2).
The World Health Organization (WHO) has defined rehabili-tation as “the use of all means aimed at reducing the impact of disabling and handicapping conditions and at enabling people with disabilities to achieve optimal social integration” (3). A comprehensive description of Physical and Rehabilita-tion Medicine (PRM), which is the medical specialty with rehabilitation as its core health strategy, is well established in all Western countries except denmark (3).
WHO has created the International Classification of Func-tioning, Disability and Health (ICF) for assessing health status, for example in relation to rehabilitation (4). The ICF recognizes human functioning as a universal human experience focusing on the consequences and not on the causes of the limits of functioning (5).
MultIdIScIPlInARY teAM cARe In ReHAbIlItAtIon: AN OveRvIeW OF RevIeWs
Anne-Mette Momsen, PhD1, Jens Ole Rasmussen, PT2, Claus Vinther Nielsen, MD1,5, Maura Daly Iversen, DPT, SD3,4 and Hans Lund, PhD4
From the 1MarselisborgCentret, Public Health and Quality Improvement, Central Denmark Region, 2Clinic of Physiotherapy, Wichmandsgade, Odense, Denmark, 3Department of Physical Therapy, School of Health Professions, Bouve
College of Health Sciences, Northeastern University, and Section of Clinical Sciences, Division of Rheumatology, Brigham & Women’s Hospital, Harvard Medical School, Boston, USA, 4Research Unit for Musculoskeletal Function and
Physiotherapy, The Institute for Sports Science and Clinical Biomechanics, University of Southern Denmark and 5Section of Clinical Social Medicine and Rehabilitation, Institute of Public Health, Aarhus University, Aarhus, Denmark
902 A.-M. Momsen et al.
three perspectives regarding good rehabilitation process include: consideration of all aspects of a person’s life, recog-nizing the individual as the primary focus in the rehabilitation process, and ensuring continuity and related interventions across the sectors (2).
the present challenge is to implement evidence-based opti-mal rehabilitation interventions between health and social serv-ices. the focus of this review is multidisciplinary rehabilitative team care (MTC). MTC can be defined as “a group of diverse clinicians who communicate with each other regularly about the care of a defined group of patients and participate in that care” (6). the characteristics of optimal Mtc in rehabilita-tion include cooperation of all participants in a structured way and directed towards common goals to develop individualized plans, and to evaluate the processes used to achieve these goals (7–9). the purpose of this review is to link knowledge gained from existing work to provide insights into how best to coordinate rehabilitation services across the health and social services and across professions.
the aim of Mtc is to optimize the rehabilitation process at all levels according to ICF; body functioning, activity, and participation. levels of Mtc can be divided according to levels of cooperation (7), as follows:(A) Interdisciplinary – the highest level in which team mem-
bers work towards shared goals.(b) Multidisciplinary – different professionals work with the
same person, but within their own professional limits and often without knowledge about each other’s practice.
(c) transdisciplinary – professionals cross the border into another team member’s professionalism.
(d) unidisciplinary/intradisciplinary – only focused on one’s own profession.
this review highlights research addressing the cooperation of professionals defined in levels (A) and (B), using the overall term “multidisciplinary team care”. In Mtc the profession-als work towards shared goals using a common approach or strategy. Among PRM specialists, the preferred pattern of team working is “interdisciplinary working”. However, published studies have tended to use the term “multidisciplinary team” (10).
Aimthe primary aim of this literature review was to highlight cur-rent scientific evidence about MTC in rehabilitation in different categories of patient groups. A secondary aim was to evaluate whether rehabilitation based on Mtc is more effective com-pared with a control or usual rehabilitation intervention.
MetHodSInclusion criteria were: systematic review; no restrictions in type of populations, all types of patient groups considered; no restrictions in type of outcome measures, all types of outcome measures; and Mtc defined as cooperation of all participants in a structured way towards a common goal, development of individualized plans in order to attain this, and evaluation of the process towards the goals.
Literature searchData sources. We searched for critically appraised and summarized research from existing systematic reviews and meta-analyses without restrictions in terms of study population or outcomes, which were published between 2000 and July 2010 (table I). Agreement on the criteria for selecting studies, quality assessment, and data extraction and conclusions was reached by consensus. the types of rehabilitation interventions included in this review were either multidisciplinary, interdisciplinary team or team care, respectively. the main search terms used were “rehabilitation”, “interdisciplinary or multidisciplinary” and “health care team” or “patient care team”. the search was carried out in the cochrane database of Systematic Reviews, database of Abstract of Reviews of effects (dARe), Medline, embase and cinahl.
the search was carried out on 2 July and 5 July 2010. one re-viewer (JoR) used a common search strategy for cochrane, dARe, and Medline, while search strategies were modified appropriately by a librarian for embase and cinahl. the complete search strategy is available in Appendix S1 (available from http://www.medicaljournals.se/jrm/content/?doi=10.2340/16501977-1040).
two reviewers (A-MM, JoR) independently reviewed all titles and identified potentially relevant studies based on abstracts. Full papers were retrieved if the abstract provided insufficient data to enable selection. Inclusion criteria were applied to full papers of potential reviews by one of the reviewers.
Study selection. this review is based primarily on systematic reviews, inasmuch as they may be a better guide than original studies and they generally focus on randomized controlled trials (Rcts), which are regarded as providing the most reliable estimates of effects (11). In addition to the fact that systematic reviews are considered to be the highest level of evidence (11), a compilation of systematic reviews with the same focus will increase both implementation of the achieved knowledge, and thereby increase the quality of daily clinical practice. overviews compile evidence from multiple systematic reviews into a single accessible and usable document. each overview has its specific focus, for which there are two or more potential perspectives (for ex-ample different patient groups, but the same type of intervention).
Inclusion criteria for this review are shown in table I by the type of study, population, intervention, and outcome measures. to capture the most recent Rcts, only the most recent systematic reviews and meta-analysis for each study population were included. the search was not restricted to specific languages, but captured only english language reviews for inclusion. exclusion criteria were: single studies without a control group or without a description of the search strategy. to improve the consistency of the search strategy, preliminary criteria were pilot-tested in abstracts on a sample of articles from the initial search. Two reviewers independently assessed the scientific quality us-ing the 10-item overview Quality Assessment Questionnaire (oQAQ) and consensus was reached prior to reporting (12, 13).
Data extraction. data on study design, source population, sample size, setting, team, intervention, length of follow-up, and outcome were extracted from the selected reviews by one reviewer (JoR).
ReSultS
the initial search for rehabilitation and Mtc yielded a total of 1,892 articles (Fig. 1): 22 records in the Cochrane database, 8 in dARe, 1,372 in Medline, 437 in embase, and 53 in cinahl. All titles were screened after duplicates were removed (383), and abstracts of the potentially relevant articles (236) were reviewed.
A number of reviews represented the same study population, thus we included the most recent review. For elderly people we identified 2 reviews (14, 15). For arthropathy and hip fractures
J Rehabil Med 44
903Multidisciplinary rehabilitation – an overviewta
ble
I. O
verv
iew
of r
evie
ws o
n m
ultid
isci
plin
ary
team
car
e (M
TC) i
n re
habi
litat
ion
Aut
hor,
year
, c
ount
ryo
QA
Q-s
core
Patie
nt g
roup
(ti
tle)
Stud
ies
Sam
ple
size
cou
ntrie
sSe
tting
inte
rven
tions
team
prof
essi
ons
out
com
es a
tIC
F-le
vels
:b
ody
func
tioni
ng (b
)A
ctiv
ity (A
)Pa
rtici
patio
n (P
) Fi
ndin
gs a
nd c
oncl
usio
n
Joha
nsso
n et
al
.,20
10 (1
4)Sw
eden
Min
imal
flaw
s
elde
rly p
erso
nsM
ultid
isci
plin
ary
team
, w
orki
ng w
ith e
lder
ly
pers
ons l
ivin
g in
the
com
mun
ity.
28 st
udie
s (12
Rc
ts)
n = --
-7,1
73 in
Rc
tsW
este
rn c
ount
ries
(8 R
cts
from
uSA
)
a) In
-pat
ient
and
follo
w-u
p at
ho
me
(6 R
cts
)b)
Prim
ary
care
(5 R
cts
)c)
com
mun
ity c
are
(1 R
ct)
Apa
rt fr
om M
tc, v
ery
hete
roge
neou
s int
erve
ntio
nsc
ontro
ls: n
ot d
escr
ibed
Min
imum
2, m
ost o
ften
3–4
prof
essi
ons.
ord
er o
f fre
quen
cy o
f pr
ofes
sion
s:1.
nur
se2.
occ
upat
iona
l the
rapi
st3.
phy
siot
hera
pist
4. so
cial
wor
ker
5. p
hysi
cian
b:
A: F
unct
iona
l cap
acity
Ad
l,
soci
al a
ctiv
ityP:
Rat
e of
falls
H
ospi
tal s
tay
(day
s)R
e-ad
mis
sion
rate
No
spec
ific
clin
ical
ou
tcom
es
a) Im
prov
ed fu
nctio
nal c
apac
ity (3
Rc
ts),
men
tal h
ealth
(1 R
ct)
, and
self-
perc
eive
d he
alth
and
life
satis
fact
ion
(1 R
ct)
R
educ
ed e
piso
des o
f fal
ling
(2 R
cts
), an
d sh
orte
ned
stay
/del
ayed
re
adm
issi
on to
hos
pita
l or n
ursi
ng h
ome
(3 R
cts
)b)
Impr
oved
Ad
l (2
Rc
ts),
incr
ease
d so
cial
act
ivity
(2 R
cts
), an
d ge
nera
l w
ell-b
eing
and
life
-sat
isfa
ctio
n (3
Rc
ts)
Red
uced
det
erio
ratio
n of
hea
lth a
nd fu
nctio
nal a
bilit
y (3
Rc
ts).
Con
tinuo
us e
valu
atio
n an
d m
anag
emen
t ben
efitte
d th
e po
ssib
ility
of
mai
ntai
ning
hea
lth st
atus
and
impr
ovin
g of
hea
lth p
erce
ptio
n (4
Rc
ts)
c) Im
prov
ed su
rviv
al, A
DL,
use
of a
dapt
ive
stra
tegi
es, s
elf-
effic
acy,
and
re
duce
d fe
ar o
f fal
ling
Con
clus
ion:
In su
mm
ary
MTC
show
ed si
gnifi
cant
effe
cts v
s. co
ntro
l gro
up o
n he
alth
stat
us a
nd p
erce
ptio
n, a
ctiv
ity a
nd a
dmis
sion
to h
ospi
tal
Han
doll
et a
l.,20
09 (1
7)
uK
Min
imal
flaw
s
Hip
frac
ture
sM
ultid
isci
plin
ary
reha
bilit
atio
n fo
r old
er
peop
le w
ith h
ip fr
actu
res.
13 R
cts
n = 2,
498
Wes
tern
cou
ntrie
s, ta
iwan
(1
Rc
t)
a) In
-pat
ient
(11
Rc
ts):
b) o
ut-p
atie
nt a
mbu
lato
ry
reha
bilit
atio
n (2
Rc
ts)
Inte
rven
tions
ver
y he
tero
gene
ous a
part
from
M
tc
con
trols
:u
sual
car
e, b
ut v
ery
diffe
rent
Reh
abili
tatio
n de
liver
ed
by a
mul
tidis
cipl
inar
y te
am.
b:
A: b
arth
el In
dex
(3
Rc
ts)
mod
ified
Bar
thel
In
dex
(3 R
cts
)P:
Mor
talit
yR
ate
of fa
llsH
ospi
tal s
tay
(day
s)R
eadm
issi
on ra
teR
equi
rem
ent f
or
inst
itutio
nal c
are
a) D
ata
pool
ed fr
om 8
RC
Ts sh
owed
a n
on-s
tatis
tical
ly si
gnifi
cant
tend
ency
in
favo
ur o
f the
inte
rven
tion
for r
eadm
issi
on ra
te (R
R 0
.89,
95%
cI 0
.78–
1.01
) at
long
-term
follo
w-u
pM
orta
lity
data
wer
e re
porte
d fo
r all
11 R
CTs
, sho
w n
o st
atis
tical
ly si
gnifi
cant
di
ffere
nce
in m
orta
lity
at th
e sc
hedu
led
end
of fo
llow
-up
(RR
0.9
0, 9
5% c
I 0.
76–1
.07)
Indi
vidu
al tr
ials
foun
d be
tter r
esul
ts, o
ften
shor
t-ter
m o
nly,
in th
e in
terv
entio
n gr
oup
for A
dl
and
mob
ility
b) t
he tr
ial c
ompa
ring
prim
arily
hom
e-ba
sed
Mtc
with
usu
al in
patie
nt c
are
foun
d m
argi
nally
impr
oved
func
tion
and
a cl
inic
ally
sign
ifica
ntly
low
er
burd
en fo
r car
ers i
n th
e in
terv
entio
n gr
oup
One
tria
l fou
nd n
o si
gnifi
cant
effe
ct fr
om d
oubl
ing
the
num
ber o
f wee
kly
cont
acts
at t
he p
atie
nt’s
hom
e fr
om a
mul
tidis
cipl
inar
y re
habi
litat
ion
team
.C
oncl
usio
n: D
ata
show
ed si
gnifi
cant
ly lo
wer
bur
den
for c
arer
s, a
tend
ency
fo
r a d
ecre
ase
in re
quire
men
t for
inst
itutio
nal c
are,
and
mar
gina
lly im
prov
ed
func
tion
J Rehabil Med 44
904 A.-M. Momsen et al.ta
ble
I. C
ont.
Aut
hor,
year
, c
ount
ryo
QA
Q-s
core
Patie
nt g
roup
(ti
tle)
Stud
ies
Sam
ple
size
cou
ntrie
sSe
tting
inte
rven
tions
team
prof
essi
ons
out
com
es a
tIC
F-le
vels
:b
ody
func
tioni
ng (b
)A
ctiv
ity (A
)Pa
rtici
patio
n (P
) Fi
ndin
gs a
nd c
oncl
usio
n
lang
horn
e,20
07 (2
1)u
KM
inim
al fl
aws
Stro
keo
rgan
ised
inpa
tient
(s
troke
uni
t) ca
re fo
r st
roke
Stro
ke u
nit c
are
vers
us
gene
ral w
ards
:26
Rc
ts
n = 5,
592
Part
of 3
1 R
cts
, whi
ch
aim
was
to c
ompa
re
mor
e or
gani
zed
vs. l
ess
orga
nize
d se
rvic
esc
ount
ries n
ot g
iven
Mtc
in st
roke
uni
tsc
ontro
ls: a
) car
e in
gen
eral
w
ards
(acu
te m
edic
al o
r ne
urol
ogy
war
d w
ithou
t ro
utin
e m
ulti-
disc
iplin
ary
inpu
t)b)
car
e in
less
org
aniz
ed
serv
ices
A m
obile
stro
ke te
am
that
exc
lusi
vely
m
anag
e st
roke
pat
ient
s in
a d
edic
ated
war
d or
with
in a
gen
eric
di
sabi
lity
serv
ice
(mix
ed re
habi
litat
ion
war
d)
b:
A: b
arth
el in
dex
(15
Rc
ts)
Parti
cipa
tion:
Mor
talit
yM
any
diffe
rent
a) S
troke
uni
t vs.
gene
ral w
ards
show
ed re
duct
ions
in th
e od
ds o
f: d
eath
at f
ollo
w-u
p (m
edia
n 1
year
), o
R 0
.86;
95%
cI 0
.76–
0.98
; p =
0.02
, de
ath
or in
stitu
tiona
lised
car
e, o
R 0
.82;
95%
cI 0
.73–
0.92
; p =
0.00
06, d
eath
or
dep
ende
ncy,
oR
0.8
2; 9
5% c
I 0.7
3–0.
92; p
= 0.
001
b) S
troke
reha
bilit
atio
n vs
. alte
rnat
ive
serv
ices
(6 R
cts
) sho
wed
a p
atte
rn
of im
prov
ed o
utco
mes
in th
e st
roke
reha
bilit
atio
n w
ard
with
stat
istic
ally
si
gnifi
cant
ly fe
wer
dea
ths (
p < 0.
05) a
nd a
stat
istic
ally
non
-sig
nific
ant t
rend
fo
r few
er p
atie
nts w
ith th
e co
mpo
site
end
-poi
nts o
f dea
th o
r req
uirin
g in
stitu
tiona
l car
e an
d de
ath
or d
epen
denc
y. H
owev
er, t
he n
umbe
rs w
ere
smal
l an
d no
defi
nite
con
clus
ions
cou
ld b
e dr
awn
Con
clus
ion:
stro
ke u
nit (
MTC
reha
bilit
atio
n) sh
owed
sign
ifica
nt re
duct
ion
in m
orta
lity
and
a te
nden
cy to
war
ds d
ecre
ase
in re
quire
men
t for
inst
itutio
nal
care
Kha
n et
al.,
2007
(28)
Aus
tralia
2005
Min
imal
flaw
s
Mul
tiple
scle
rosi
sM
ultid
isci
plin
ary
reha
bilit
atio
n fo
r adu
lts
with
mul
tiple
scle
rosi
s8
(7 R
cts
)n =
747
engl
and,
Ital
y, u
SA
Mtc
– n
ot d
escr
ibed
a) In
-pat
ient
(3 R
cts
), b)
out
-pat
ient
s (4
Rc
ts)
c) H
ome
care
(1
Rc
t)c
ontro
ls: R
outin
ely
loca
l se
rvic
e, m
inim
al le
vel o
f in
terv
entio
ns, o
r wai
ting
list
two
or m
ore
prof
essi
ons i
n co
nnec
tion
with
a
doct
or’s
con
sulta
tion
b: S
ympt
oms
expa
nded
dis
abili
ty
stat
us sc
ale
(5 R
cts
) 13
oth
er o
utco
mes
(1
–2 R
cts
)A
: Fun
ctio
nal
inde
pend
ence
mea
sure
(3
Rc
ts)
6 ot
her o
utco
mes
(1–2
R
cts
)P:
sF-
36 (6
RC
Ts)
16 o
ther
out
com
es
(1–2
Rc
ts)
leng
th o
f sta
y7
othe
r out
com
es (1
–2
Rc
ts)
a) t
here
was
stro
ng e
vide
nce
that
des
pite
no
chan
ge in
the
leve
l of
impa
irmen
t, in
-pat
ient
Mtc
reha
bilit
atio
n ca
n pr
oduc
e sh
ort-t
erm
gai
ns a
t th
e le
vels
of a
ctiv
ity (d
isab
ility
) and
par
ticip
atio
n fo
r pat
ient
s with
mul
tiple
sc
lero
sis
b), c
) the
re w
as li
mite
d ev
iden
ce fo
r sho
rt-te
rm im
prov
emen
ts in
sym
ptom
s an
d di
sabi
lity
with
hig
h-in
tens
ity p
rogr
amm
es, w
hich
tran
slat
ed in
to
impr
ovem
ent i
n pa
rtici
patio
n an
d Q
olA
lthou
gh so
me
stud
ies r
epor
ted
pote
ntia
l for
cos
t-sav
ings
, the
re is
no
conv
inci
ng e
vide
nce
rega
rdin
g th
e lo
ng-te
rm c
ost-e
ffect
iven
ess o
f the
se
prog
ram
mes
con
clus
ion:
the
re w
as st
rong
evi
denc
e fo
r gai
ns in
Qol
for l
ow in
tens
ity
Mtc
pro
gram
mes
con
duct
ed o
ver a
long
er p
erio
d, a
nd fo
r Mtc
impr
ovin
g sh
ort-t
erm
leve
ls o
f act
ivity
and
par
ticip
atio
n
ng
et a
l.,20
09 (2
9)A
ustra
lia20
09M
inim
al fl
aws
Am
yotro
phic
late
ral
scle
rosi
s or m
otor
neu
ron
dise
ase
Mul
tidis
cipl
inar
y ca
re fo
r ad
ults
with
am
yotro
phic
la
tera
l scl
eros
is o
r mot
or
neur
one
dise
ase
5 ob
serv
atio
nal s
tudi
es (0
R
ct/
cc
t)4
Wes
tern
cou
ntrie
s, c
uba
a) l
ow-in
tens
ityb)
Hig
h-in
tens
ity
b:
A: d
isab
ility
P: M
orta
lity
Hos
pita
l sta
y
the
best
evi
denc
e to
dat
e is
bas
ed o
n th
ese
5 st
udie
s, 3
“low
” an
d 2
“ver
y lo
w
qual
ity”
obse
rvat
iona
l stu
dies
a)
the
y su
gges
t “ve
ry lo
w q
ualit
y ev
iden
ce”
for a
n ad
vant
age
for o
nly
men
tal h
ealth
dom
ains
of Q
ol w
ithou
t inc
reas
ing
heal
thca
re c
osts
, and
“lo
w
leve
l qua
lity”
evi
denc
e fo
r red
uced
hos
pita
lisat
ion
for M
tc in
low
-inte
nsity
ou
tpat
ient
setti
ngs;
b)
The
y fin
d “v
ery
low
qua
lity”
evi
denc
e fo
r im
prov
ed d
isab
ility
in h
igh-
inte
nsity
setti
ngs
con
clus
ion:
the
evi
denc
e is
low
qua
lity
for i
mpr
oved
dis
abili
ty a
nd m
enta
l Q
oL, a
nd th
e ev
iden
ce fo
r sur
viva
l is c
onfli
ctin
g
J Rehabil Med 44
905Multidisciplinary rehabilitation – an overviewta
ble
I. C
ont.
turn
er-S
toke
s et
al.,
2005
(30)
uK
2008
Min
imal
flaw
s
Acq
uire
d br
ain
inju
ryM
ulti-
disc
iplin
ary
reha
bilit
atio
n fo
r acq
uire
d br
ain
inju
ry in
adu
lts o
f w
orki
ng a
ge–
traum
atic
bra
in in
jury
– di
ffuse
acq
uire
d br
ain
inju
ry–
cere
brov
ascu
lar a
ccid
ent
(stro
ke)
– ot
her c
ause
s16
Rc
tsn =
1,78
9 c
ount
ries u
nkno
wn
a) In
-pat
ient
,m
ilder
am
bula
tory
pat
ient
(5
Rc
ts) n
= 12
58b)
In-p
atie
nt re
habi
litat
ion
(2 R
cts
) n =
111
c) o
ut-p
atie
nt p
hysi
othe
rapy
an
d oc
cupa
tiona
l the
rapy
(2
Rc
ts) n
= 18
2d)
com
mun
ity-b
ased
Mtc
ca
re
(3 R
cts
) n =
238
Het
erog
eneo
us in
terv
entio
ns
exce
pt M
tcc
ontro
ls: R
outin
ely
loca
l se
rvic
e,m
inim
al le
vel o
f in
terv
entio
ns, o
rw
aitin
g lis
tIn
-pat
ient
vs.
out-p
atie
nt
MTC
defi
ned
as a
ny
inte
rven
tion
deliv
ered
by
2 o
r mor
e di
scip
lines
w
orki
ng in
coo
rdin
ated
ef
fort
to m
eet t
hese
ob
ject
ives
b: R
iver
mea
d po
st-
conc
ussi
on sy
mpt
oms
ques
tionn
aire
(3
Rc
ts)
Mor
e ou
tcom
es
(1–2
Rc
ts)
A: b
arth
els I
ndex
(4
Rc
ts)
Func
tiona
l in
depe
nden
ce
mea
sure
s (3R
cts
) M
ore
outc
omes
(1–2
Rc
ts)
P: R
etur
n to
wor
ksF
-36
(3 R
CTs
)M
ore
outc
omes
(1–2
Rc
ts)
a) t
he g
ener
al c
oncl
usio
n w
as th
at in
terv
entio
n in
a to
tally
uns
elec
ted
grou
p of
pat
ient
s with
mild
trau
mat
ic b
rain
inju
ry w
as n
ot e
ffect
ive.
bot
h th
e tre
atm
ent g
roup
and
con
trol i
nter
vent
ion
grou
p m
ade
subs
tant
ial g
ains
in
term
s of r
educ
ed p
ost-c
oncu
ssio
n sy
mpt
oms a
nd e
nhan
ced
parti
cipa
tion,
in
clud
ing
retu
rn to
wor
k N
o si
gnifi
cant
diff
eren
ces w
ere
reco
rded
bet
wee
n gr
oups
a) t
here
is li
mite
d ev
iden
ce th
at sp
ecia
list i
n-pa
tient
reha
bilit
atio
n se
rvic
es
can
impr
ove
func
tiona
l out
com
e in
term
s of a
ctiv
ity (r
educ
ed d
isab
ility
) vs.
hom
e-ba
sed
or o
ther
reha
bilit
atio
n b)
the
re is
mod
erat
e ev
iden
ce th
at o
ut-p
atie
nt th
erap
y im
prov
es th
e ou
tcom
es
of st
roke
reha
bilit
atio
n, w
ith li
mite
d ev
iden
ce th
at m
ore
inte
nsiv
e tre
atm
ent
regi
men
s are
ass
ocia
ted
with
bet
ter o
utco
mes
th
ere
is in
dica
tive
evid
ence
that
this
type
of i
nter
vent
ion
may
be
effe
ctiv
e ev
en la
te (a
t lea
st 1
yea
r) a
fter s
troke
.In
gen
eral
, the
re is
mod
erat
e ev
iden
ce fo
r im
prov
ed fu
nctio
nal o
utco
me
and
indi
cativ
e ev
iden
ce fo
r Mtc
has
a lo
ng-te
rm e
ffect
c) t
here
is li
mite
d ev
iden
ce th
at m
ultid
isci
plin
ary,
com
mun
ity-b
ased
re
habi
litat
ion
can
impr
ove
func
tiona
l out
com
e (d
isab
ility
), es
peci
ally
whe
n ta
rget
ed to
war
ds sp
ecifi
c go
als
Con
clus
ion:
For
impr
ovem
ent o
f fun
ctio
nal o
utco
me
at th
e IC
F-le
vel o
f ac
tivity
ther
e is
lim
ited
evid
ence
for i
n-pa
tient
and
com
mun
ity-b
ased
Mtc
re
habi
litat
ion,
and
mod
erat
e ev
iden
ce fo
r out
-pat
ient
ther
apy
ther
e is
stro
ng e
vide
nce
that
mor
e in
tens
ive
reha
bilit
atio
n pr
ogra
mm
es (4
R
cts
, n =
360)
are
ass
ocia
ted
with
ear
lier f
unct
ion
gain
s, on
ce p
atie
nts a
re fi
t to
be
enga
ged
Kah
n et
al.,
2008
(18)
Aus
tralia
2006
Min
imal
flaw
s
chr
onic
arth
ropa
thy
(join
t rep
lace
men
t at t
he
hip
and
knee
) M
ultid
isci
plin
ary
reha
bilit
atio
n pr
ogra
mm
es
follo
win
g jo
int
repl
acem
ent a
t the
hip
an
d kn
ee in
chr
onic
ar
thro
path
y.5
Rc
tsn =
619
Wes
tern
cou
ntrie
s
In-p
atie
nt
(2 R
cts
) n =
261)
Hom
e-ba
sed
(3 R
cts
, n =
358)
:H
eter
ogen
eous
inte
rven
tions
ex
cept
Mtc
con
trols
: rou
tine
care
Min
imum
2 p
rofe
ssio
ns
in th
e te
amb
: oxf
ord
Hip
scor
e (2
Rc
ts)
A: t
rans
fer
Am
bula
tion
9 ot
her o
utco
mes
(1
Rc
t)P:
Hos
pita
l sta
yc
ompl
icat
ion
Rea
dmis
sion
rate
5 ot
her o
utco
mes
(1
Rc
t)
a) e
arly
com
men
cem
ent o
f reh
abili
tatio
n an
d cl
inic
al p
athw
ays l
ed to
mor
e ra
pid
atta
inm
ent o
f fun
ctio
nal m
ilest
ones
, Fun
ctio
nal I
ndep
ende
nce
Mea
sure
s (F
IM):
trans
fer W
MD
0.5
, 95%
CI 0
.15,
0.8
5, n
umbe
r nee
ded
to tr
eat t
o be
nefit
(NN
TB) =
6, a
mbu
latio
n W
MD
1.5
5 (9
5% C
I 0.9
6, 2
.14)
, NN
TB =
3),
shor
ter h
ospi
tal s
tay,
few
er p
ost-o
pera
tive
com
plic
atio
ns a
nd re
duce
d co
sts i
n th
e fir
st 3
–4 m
onth
sb)
Mtc
impr
oved
func
tiona
l gai
n: o
xfor
d H
ip S
core
(oH
S) W
Md
at 6
m
onth
s –7.
00 (9
5% c
I –10
.36,
–3.
64),
nn
t =
2, Q
ol a
nd re
duce
d le
ngth
of
hosp
ital s
tay
in th
e m
ediu
m te
rm (6
mon
ths)
con
clus
ion:
Silv
er le
vel e
vide
nce
that
ear
ly M
tc re
habi
litat
ion
can
impr
ove
outc
omes
at t
he le
vel o
f act
ivity
and
par
ticip
atio
n
J Rehabil Med 44
906 A.-M. Momsen et al.ta
ble
I. c
ont.
Aut
hor,
year
, c
ount
ryo
QA
Q-s
core
Patie
nt g
roup
(ti
tle)
Stud
ies
Sam
ple
size
cou
ntrie
sSe
tting
inte
rven
tions
team
prof
essi
ons
out
com
es a
tIC
F-le
vels
:b
ody
func
tioni
ng (b
)A
ctiv
ity (A
)Pa
rtici
patio
n (P
) Fi
ndin
gs a
nd c
oncl
usio
n
Scas
cigh
ini
et a
l.,20
08 (2
2)Sw
itzer
land
2006
Min
imal
flaw
s
chr
onic
pai
nM
ultid
isci
plin
ary
treat
men
t for
chr
onic
pai
n.
(bac
k pa
in, fi
brom
yalg
ia,
chro
nic
pain
synd
rom
e)35
Rc
tsn =
2,40
7c
ount
ries n
ot g
iven
a) In
-pat
ient
(5 R
cts
)b)
out
-pat
ient
(1
8 R
cts
) 4
Rc
ts c
ompa
red
the
2 se
tting
sIn
terv
entio
ns n
ot d
escr
ibed
c
ontro
ls: u
sual
car
e,w
aitin
g lis
t, or
atte
ntio
n co
ntro
l mon
o-di
scip
linar
y
Min
imum
3 o
f the
fo
llow
ing
ther
apie
s:ps
ycho
ther
apy,
phys
ioth
erap
y,re
laxa
tion,
tech
niqu
es,
med
ical
trea
tmen
t,pa
tient
edu
catio
n,vo
catio
nal t
hera
py
b: P
ain,
em
otio
nal s
train
A: P
ain
beha
viou
r, di
sabi
lity,
copi
ng,
phys
ical
cap
acity
P: Q
ol,
retu
rn to
wor
k,
sick
leav
e,
use
of m
edic
ine/
heal
thca
re sy
stem
Mtc
vs.
usua
l car
e or
vs.
wai
ting
list:
13 o
f 15
Rc
ts sh
owed
pos
itive
effe
cts
Mtc
vs.
othe
r con
trol g
roup
trea
tmen
t:10
of 1
5 R
cts
show
ed p
ositi
ve e
ffect
sC
oncl
usio
n: In
gen
eral
MTC
show
ed si
gnifi
cant
effe
cts o
n al
l IC
F-le
vels
of
outc
omes
nor
lund
et a
l.,20
09 (2
5)Sw
eden
Min
imal
flaw
s
low
bac
k pa
inM
ultid
isci
plin
ary
inte
rven
tions
: Rev
iew
of
stud
ies o
f ret
urn
to
wor
k af
ter r
ehab
ilita
tion
for l
ow b
ack
pain
7 R
cts
, n =
1,45
0W
este
rn c
ount
ries,
5 in
Sca
ndin
avia
Het
erog
eneo
us in
terv
entio
nsc
ontro
ls: o
ut-p
atie
nt
phys
ical
trai
ning
,gr
oup
educ
atio
nc
ontro
l tre
atm
ent a
s usu
al,
phys
ical
ther
apy
two
or m
ore
heal
thca
re
disc
iplin
esP:
Ret
urn
to w
ork
Sick
leav
e (d
ays)
sF-3
6
The
met
a-an
alys
is o
f all
7 R
CTs
show
s (de
spite
het
erog
enei
ty) a
sign
ifica
nt
diffe
renc
e of
effe
ct o
n re
turn
to w
ork
(15%
, i.e
. RR
1.1
5)th
e m
eta-
anal
ysis
incl
udin
g Sc
andi
navi
an R
cts
onl
y sh
ows a
n ev
en la
rger
di
ffere
nce
of e
ffect
(21%
, i.e
. RR
1.2
1), w
hich
is o
f rea
sona
ble
clin
ical
re
leva
nce
Con
clus
ion:
MTC
reha
bilit
atio
n fo
r low
bac
k pa
in sh
ows a
sign
ifica
nt e
ffect
on
retu
rn to
wor
k
Gee
n va
n et
al.,
2007
(26)
Min
imal
flaw
s
low
bac
k pa
in
(bac
k tra
inin
g)
the
long
-term
effe
ct o
f m
ultid
isci
plin
ary
back
tra
inin
g10
stud
ies (
5 R
cts
), n =
1,95
8W
este
rn c
ount
ries
Het
erog
eneo
us in
terv
entio
ns.
2–4
heal
thca
re p
rofe
ssio
nals
con
trols
: no
treat
men
t,lo
w-in
tens
ity
mul
tidis
cipl
inar
y ba
ck
train
ing
Invo
lvem
ent o
f se
vera
l dis
cipl
ines
: ps
ycho
logi
sts,
phys
ioth
erap
ists
, oc
cupa
tiona
l the
rapi
sts,
and/
or m
edic
al
spec
ialis
ts
b: P
ain
seve
rity
Func
tiona
l sta
tus
A: M
ore
outc
omes
P: A
bilit
y to
wor
kQ
olM
ore
outc
omes
thre
e of
the
4 hi
gh-q
ualit
y R
cts
that
use
d w
ork
parti
cipa
tion
as a
n ou
tcom
e re
porte
d a
posi
tive
effe
ct o
n th
is m
easu
re
All
the
high
-qua
lity
stud
ies f
ound
a p
ositi
ve e
ffect
on
at le
ast 1
of t
he 4
ou
tcom
e m
easu
res u
sed,
whe
reas
non
e of
the
low
-qua
lity
stud
ies r
epor
ted
effe
ctiv
enes
so
nly
1 of
7 st
udie
s rep
orte
d a
posi
tive
effe
ct o
n ex
perie
nced
pai
n an
d fu
nctio
nal s
tatu
s. o
nly
2 st
udie
s use
d Q
ol a
s an
outc
ome
mea
sure
, ef
fect
iven
ess w
as re
porte
d by
1 o
f the
sec
oncl
usio
n: t
he h
igh-
qual
ity R
cts
repo
rted
posi
tive
effe
cts o
n pa
rtici
patio
n ou
tcom
es, o
nly
1 st
udy
repo
rted
effe
cts o
n IC
F-le
vels
of i
mpa
irmen
t (B
) K
arja
lain
en
et a
l.,
2003
(24)
Finl
and
Min
imal
flaw
s
Suba
cute
low
-bac
kM
ultid
isci
plin
ary
bio
psyc
hoso
cial
reha
bilit
atio
n fo
r sub
acut
e lo
w b
ack
pain
am
ong
wor
king
age
ad
ults
2 R
cts
, n =
233
Swed
en, c
anad
a
a) G
rade
d 4-
part
activ
ity
prog
ram
.b)
occ
upat
iona
l and
clin
ical
in
terv
entio
nc
ontro
ls: t
radi
tiona
l car
e,oc
cupa
tiona
l int
erve
ntio
n,
clin
ical
inte
rven
tion
or u
sual
ca
re
Phys
icia
n’s c
onsu
ltatio
n pl
us e
ither
a
psyc
holo
gica
l, so
cial
or
voca
tiona
l int
erve
ntio
n,or
a c
ombi
natio
n of
th
ese
b: P
ain
inte
nsity
(M
cGill
)M
ore
outc
omes
A: F
unct
iona
l sta
tus
Mor
e ou
tcom
esP:
Ret
urn
to w
ork
Mor
e ou
tcom
es
Con
clus
ion:
The
re w
as m
oder
ate
scie
ntifi
c ev
iden
ce sh
owin
g th
at M
TC
reha
bilit
atio
n, w
hich
incl
udes
a w
orkp
lace
vis
it or
mor
e co
mpr
ehen
sive
oc
cupa
tiona
l hea
lthca
re in
terv
entio
n, h
elps
pat
ient
s to
retu
rn to
wor
k fa
ster
, re
sults
in fe
wer
per
iods
of s
ick
leav
e an
d al
levi
ates
subj
ectiv
e di
sabi
lity
J Rehabil Med 44
907Multidisciplinary rehabilitation – an overviewta
ble
I. C
ont.
Kar
jala
inen
et
al,
2003
(31)
Finl
and
2002
Min
imal
flaw
s
nec
k an
d sh
ould
er p
ain
Mul
tidis
cipl
inar
y bi
o ps
ycho
soci
alre
habi
litat
ion
for n
eck
and
shou
lder
pai
n am
ong
wor
king
age
adu
lts.
1 R
ct,
1 c
ct
n = 17
7
a) P
hysi
cal t
rain
ing,
in
form
atio
n, e
duca
tion,
so
cial
inte
r-act
ion,
wor
k pl
ace
visi
t. b)
Mul
timod
alc
ogni
tive
beha
viou
ral
treat
men
t, ad
min
iste
red
by a
cl
inic
al p
sych
olog
ist d
irect
ly
to p
atie
nts.
con
trols
: Phy
siot
hera
py,
med
icat
ion,
rest
and
sick
le
ave.
Psyc
holo
gist
(coa
chin
g ot
her
prof
essi
onal
s.
Mtc
had
to c
onsi
st o
f a
phys
icia
n’s c
onsu
ltatio
npl
us e
ither
a
psyc
holo
gica
l, so
cial
or
voca
tiona
l int
erve
ntio
n,
or a
com
bina
tion
of
thes
e
b: P
ain
(VA
S)
Mor
e ou
tcom
esA
: Hea
lth A
sses
smen
t Q
uest
ionn
aire
Gen
eric
func
tiona
l st
atus
P: S
ick
leav
ed
ays o
ff in
6 m
onth
s c
osts
uS$
/pat
ient
a) e
ffect
s of t
he M
tc p
rogr
amm
e di
d no
t diff
er fr
om tr
aditi
onal
car
e in
any
of
the
outc
omes
ass
esse
d at
12-
and
24-
mon
ths f
ollo
w-u
pb)
No
sign
ifica
nt d
iffer
ence
bet
wee
n th
e 2
grou
ps in
any
of t
he a
sses
sed
outc
omes
bes
ides
the
cost
of t
he re
habi
litat
ion
prog
ram
me.
the
inte
rven
tion
(whe
re a
psy
chol
ogis
t exe
cute
d th
e be
havi
oura
l com
pone
nt o
f the
re
habi
litat
ion)
was
less
cos
t-effe
ctiv
e th
an th
e co
ntro
l int
erve
ntio
n (w
here
a
psyc
holo
gist
mer
ely
advi
sed
the
reha
bilit
atio
n te
am)
con
clus
ion:
the
re w
as n
o di
ffere
nce
betw
een
effe
ct o
f the
Mtc
and
tra
ditio
nal c
are
bur
ckha
rdt
et a
l.,20
06 (2
3) u
SAM
ajor
flaw
s
Fibr
omya
lgia
Mul
tidis
cipl
inar
y A
ppro
ache
s for
M
anag
emen
t of
Fibr
omya
lgia
10 (8
Rc
ts, 2
cc
t)n =
1340
exer
cise
(7
Rc
ts),
exer
cise
com
bine
d w
ith
educ
atio
n (6
Rc
ts),
(3 o
f the
se w
ith c
ogni
tive
beha
viou
ral t
hera
py)
con
trols
: Mon
o-in
terv
entio
nno
trea
tmen
t, or
wai
ting
list
Not
defi
ned
Prof
essi
onal
s not
giv
enb
: Pai
n (V
AS,
nR
S)(8
Rc
ts)
A: d
iffer
ent o
utco
mes
P: F
ibro
mya
lgia
Im
pact
Que
stio
nnai
re
(FIQ
) (4
Rc
ts)
Arth
ritis
sel
f-ef
ficac
y Sc
ale
(4 R
cts
)se
lf-ef
ficac
y
self-
effic
acy
was
sign
ifica
ntly
enh
ance
d in
the
treat
ed g
roup
s in
4 of
the
5 gr
oups
, and
the
scor
e of
ove
rall
FIQ
was
sign
ifica
ntly
dec
reas
ed in
3 o
f 5
stud
ies
Pain
mea
sure
d by
a v
As
was
sign
ifica
ntly
dec
reas
ed in
4 o
f 8 tr
ials
eigh
t of t
he c
ontro
lled
trial
s col
lect
ed fo
llow
-up
data
bet
wee
n 3
mon
ths a
nd
1 ye
ar a
fter c
ompl
etio
n of
the
expe
rimen
tal t
reat
men
t. In
6 st
udie
s tre
atm
ent
gain
s wer
e m
aint
aine
dC
oncl
usio
n: s
tudi
es w
ith M
TC a
ppro
ache
s sho
w si
gnifi
cant
incr
ease
in se
lf-ef
ficac
y an
d de
crea
se in
tota
l sco
re o
f FIQ
and
pai
n at
3 m
onth
s and
1 y
ear
follo
w-u
p
col
dwel
l et a
l.,20
07 (3
2)u
SAM
inim
al fl
aws
Hom
eles
s with
seve
re
men
tal i
llnes
sth
e ef
fect
iven
ess o
f as
serti
ve c
omm
unity
tre
atm
ent f
or h
omel
ess
popu
latio
n w
ith se
vere
m
enta
l illn
ess:
a m
eta-
anal
ysis
10 st
udie
r (6
Rc
ts)
n = 57
75c
ount
ries n
ot g
iven
Ass
ertiv
e c
omm
unity
tr
eatm
ent.
con
trols
: Sta
ndar
d ca
se
man
agem
ent
team
of p
rofe
ssio
ns
with
in:
soci
al w
ork,
re
habi
litat
ion,
co
unse
lling
, nur
sing
an
d ps
ychi
atry
pro
vide
d A
sser
tive
com
mun
ity
trea
tmen
t ser
vice
s
b: c
olor
ado
Sym
ptom
In
vent
ory
scor
eb
rief P
sych
iatri
c R
atin
g Sc
ale
Glo
bal S
ever
ity In
dex
scor
e P:
diff
eren
t out
com
es
of h
omel
essn
ess
Hos
pita
lizat
ion
the
sum
mar
y ef
fect
acr
oss R
cts
was
37%
(95%
cI =
18%
–55%
, Z =
3.85
, p =
0.00
01),
sign
ifyin
g th
at a
sser
tive
com
mun
ity tr
eatm
ent s
ubje
cts,
expe
rienc
ed a
37%
gre
ater
redu
ctio
n in
hom
eles
snes
s com
pare
d w
ith st
anda
rd
case
man
agem
ent s
ubje
cts
The
sum
mar
y ef
fect
reve
aled
no
sign
ifica
nt d
iffer
ence
in h
ospi
taliz
atio
n, 1
0%
(95%
cI =
–7%
–27%
, Z =
1.17
, p =
0.24
).W
hen
com
bine
d, a
sser
tive
com
mun
ity tr
eatm
ent s
ubje
cts a
vera
ged
a 26
%
(95%
cI =
7%–4
4%, Z
= 2.
76, p
= 0.
006)
furth
er sy
mpt
om im
prov
emen
t in
rand
omiz
ed tr
ials
Con
clus
ion:
Ass
ertiv
e co
mm
unity
trea
tmen
t sub
ject
s had
sign
ifica
nt
redu
ctio
ns in
psy
chia
tric
sym
ptom
seve
rity
beyo
nd th
at e
xper
ienc
ed b
y co
mpa
rison
subj
ects
RC
Ts: r
ando
miz
ed co
ntro
lled
trial
(s);
CC
T: co
ntro
lled
clin
ical
tria
l(s);
AD
L: ac
tivity
of d
aily
livi
ng; R
R: r
elat
ive r
isk;
OR
: odd
s rat
io; C
I: co
nfide
nce i
nter
val;
QoL
: qua
lity
of li
fe; O
QA
Q: O
vera
ll Q
ualit
y A
sses
smen
t Qua
lity;
FIQ
: fibr
omya
lagi
a im
pact
.
J Rehabil Med 44
908 A.-M. Momsen et al.
there were 2 reviews, respectively (16–19). For stroke we found 3 reviews of interventions in different settings (either stroke units or at home) (15, 20, 21). For musculoskeletal diseases MTC re-views covered chronic pain (22) and fibromyalgia (23). some of the reviews did not include RCTs. For low back pain there were reviews on sub-acute and chronic pain (24, 25), respectively and a review on back training (26). After selecting 49 articles for full text reading, 14 articles met our inclusion criteria.
To summarize the findings of MTC in rehabilitation, 14 sys-tematic reviews were included, of which 7 were cochrane Re-views. this yielded a total of 182 studies and 26,819 participants. Results for Mtc for 12 different populations were reported: elderly persons living in the community, older people with hip fractures, adults with stroke, multiple sclerosis, amyotrophic lateral sclerosis, chronic arthropathy, acquired brain injury, chronic pain, back pain, neck and shoulder pain, fibromyalgia, and homeless people with severe mental illness. the extracted in-formation, the oQAQ score of the review, and conclusions about the effect of Mtc were organized by patient category (table I). The OQAQ score of review with fibromyalgia (24) showed major flaws, whereas the other reviews scored minor flaws.
table II presents some characteristics and examples of pos-sible changes by Mtc in rehabilitation with reference to the included studies.
table III shows a summation of results from the in cluded studies graded after the level of evidence (A: quantita tive analyses (meta-analyses) based on Rcts; b: qualitative analyses based on Rcts, qualitative or observational studies.)
A brief summary of potential implications for the practice of Mtc in rehabilitation is presented here:
For elderly people living in the community Mtc can lead to (14): • Increase in the elderly persons’ capacity (performance) and
participation.• Potential improvements in ADL, and self-reported life satis-
faction.• Decreased falls, removal from home.• Decreased length of hospital stay, and readmissions to hos-
pitals.
Home-based Mtc for elderly people with hip fractures showed favourable results compared with inpatient Mtc regarding (17): • Patient functioning.• Health professional strain.
length of hospital stay decreased, and rehabilitation time increased.
no conclusions can be drawn from the review due to study heterogeneity. the data suggest trends for effects on all out-comes, and Mtc does not increase the costs compared with standard treatment.
For adults with stroke, MTC showed significant improve-ment in (21): • Potential chances to survive (death rate).• being independent and living at home one year after the
stroke.• trend towards less required institutional care.
Fig. 1. Flow diagram.
Records identified through database searching
(n = 1892 )
Screen
ing
Includ
ed
Eligibility
Iden
tification Additional records identified
through other sources (n = 0)
Records’ titles screened n =1509
(n = 1509)
Records’ abstracts screened (n = 236)
Records not fulfilling the inclusion criteria
(n = 187)
Full-‐text articles assessed for eligibility
(n = 49)
Full-‐text articles excluded (n = 30)
Due to no control group, no description of the
search strategy
Studies included in qualitative synthesis
(n = 14)
Studies included in quantitative synthesis
(meta-‐analysis) (n = 0)
Duplicates removed (n = 383)
Exclusions of older reviews of four of the same study
groups as included (n = 5)
J Rehabil Med 44
909Multidisciplinary rehabilitation – an overview
However, no definite conclusion could be drawn due to small sample sizes.
the convincing impact of a stroke unit is probably due to a number of factors (27) including: the mixture of professional’s inasmuch to the structure and location of the unit, the fact that these professionals share a special interest in stroke and rehabilitation and regular educational programmes (conferences held at a minimum of once a week). A primary factor is the organization with integration of the nursing staff into rehabilitation, the training of professionals, and specialized nursing care these patients routinely receive.
For adults with multiple sclerosis there was strong evidence for benefits regarding (28): • Activity and participation outcomes with in-patient Mtc.
• Quality of life (Qol) from less intensive, but long-term, Mtc interventions.
• there was limited evidence for highly intensive home or municipality-based interventions.
Mtc for adults with amyotrophic lateral sclerosis revealed a lack of Rcts, but the authors mention a number of single interventions with published effects (29).
For adults with acquired brain injury there was evidence for effect on (30):• Participation (including return to work from intensive in-
patient Mtc and community-based Mtc rehabilitation).
For adults with chronic arthropathy Mtc improved the following outcomes (13): • Functional capacity.• Reduced hospital stay.
Mtc had to commence early after joint replacement.For adults with chronic pain there was strong evidence for
a number of different interventions’ positive effects at all ICF levels (22):• body functioning (e.g. pain).• Activity (e.g. physical capacity, pain behaviour, emotional
strain).• Participation (Qol, return to work, use of healthcare).
the programmes used in these studies varied from 3 to 15 weeks and involved a number of health professionals.
For adults with chronic low back pain the meta-analyses showed strong evidence of Mtc rehabilitation (25): • Return to work improved by 21%.
the Mtc rehabilitation was based on group intervention, workplace visit and involved 2 or more healthcare disciplines.
Multidisciplinary back training showed positive effects on participation outcomes only (26):• Work participation and Qol (1 Rct).
the intervention involved 2 or more professionals (26).For adults with sub-acute low back pain there was moderate
evidence (2 Rcts) on (24): • Faster return to work.
table III. Summation of the reviews’ results on multidisciplinary rehabilitation team care, graded after level of evidence
outcomes,ICF-levels
Results, review(s), level of evidenceA: based on meta-analysis, Rcts; b: based on Rcts, octs and observational studies
body functioning
More effect on functional status (18) A, (14) bFaster recovery of functional status (18) Aless reduction of function and health (14) bbetter mental status (14) bless psychiatric symptoms (32) AIncreased well being and satisfaction with life (14) A, (23) b
Activity Increased level of Adl and performance of Adl (14) bless falling and fear of falling (14) b
Participation less dependence on help from others (23) A, (21) bMore self-efficacy (21) A, (14) BIncreased social participation (1) bFaster return to work (24) Aless sickness absence (25) A
other outcomes
better survival (21) A, (14) bFewer admissions to hospitals (32) AShorter stay in hospital (18) A, (14) bFewer post-operative complications (18) Alater readmission to hospitals or moving to residential homes (14) b
ICF: International Classification of Functioning, Disability and Health; Rct: randomized controlled trials(s); Adl: activities of daily living; oct(s): observational controlled trial(s).
table II. Characteristics of rehabilitation and possible changes by multidisciplinary rehabilitation team care (MTC)
characteristics of rehabilitation Possible changes due to the Mtc interventions in the reviews
An individually adjusted intervention the person in need is the focus of the intervention (23)each professional is obliged to care for only a few persons in need, which leads to a more intensive contact with each person (32)offers in the local community, give a more direct contact instead of intermediate communication (32)A 24-h covering service provides possibilities for contact with professionals (32)
All relevant parts are involved the Mtc is either a trans- and/or an inter-disciplinary intervention (14, 21)Habitually, the nursing staff is involved in the rehabilitation (21)the workplace is more often involved in return to work after rehabilitation (24, 25)
Working towards a common goal and common assessment of efficiency
documents on common agreements, goals, guidelines for the team’s work are elaborated (14)Follow-up is regarded as important and realized (30)
Frequent contacts between all parties involved
Honest and continuous communication about planning and setting goals is taking place (14)there are close relations in cooperation, awareness of communication, and sharing of knowledge within the team (14)to coordinate Mtc joint conferences are held at least once a week (21)
A high professional standard Regular education and training programmes for the professionals are implemented (21)
J Rehabil Med 44
910 A.-M. Momsen et al.
Mtc interventions involved workplace visit or more com-prehensive occupational healthcare.
For adults with neck and shoulder pain the 2 Mtc interven-tions (1 RCT) showed no significant difference at 1–2 years follow-up (31).
For fibromyalgia Mtc interventions (4–24 weeks) showed significant effects on all ICF levels of outcomes (23): • Body functioning (symptoms). • Activity (self-efficacy). • Participation (return to work and QoL).
For homeless with severe mental illness, the meta-analysis showed significant effects on 2 ICF levels (32): • Psychiatric symptoms reduced by 26%. • Homelessness reduced by 37%.
In the following section we present 3 examples of Mtc studies in rehabilitation:
(i) Mtc intervention for adults with acquired brain injury (30).
“The study involved meetings with the principal investi-gator, neuropsychological and personality assessment, and consultation with a physical therapist who specializes in post-concussion problems.
The purpose of the study was to compare an education-oriented single session treatment (SS) to a more extensive assessment, education, and treatment-as-needed intervention (TAN) for adults with mild traumatic brain injury (MTBI).
Persons in the SS group met with the principal investigator and discussed any concerns they had about their injury. They also read the National Head Injury Foundation’s Minor Head Injury brochure, chosen because of its reported helpfulness in a previous MTBI treatment study, and discussed any ques-tions about it with the principal investigator.
Subjects were told that no further MTBI treatment would be provided as part of the study, and that any further con-cerns should be addressed with their family physician.
Persons in the TAN group received the same base treatment along with a 3–4 hour neuropsychological and personality assessment, consultation with a physical therapist who specializes in post-concussion problems (e.g. dizziness), a feedback session on the psychological test results, and thereafter treatment-as-needed for MTBI complaints. The treatment available included further psychological care and physical therapy and access as needed, to the Glenrose Rehabilitation Hospital’s full multidisciplinary outpatient brain injury treatment programme. Treatment for non-MTBI issues was coordinated by the patient’s family physician and provided by the usual community-based services for such non-MTBI problems.
Overall, the aim of SS treatment was to: • Legitimizetheparticipants’post-MTBIexperienceasbeing
“real”, and not brush aside their concerns or tell them that there was nothing wrong with them.
• Educate participants about common complaints afterMTBI.
• Provide participantswith suggestions about how to copewith common problems, especially by encouraging rest as needed and gradual reintegration into activities.
• Providereassuranceofagoodoutcome.• Inshort,theTANinterventionwasanabbreviatedmodelof
treatment commonly used, in this setting, with more severe TBIandwithMTBIsurvivorswhohavepersisting,significantcomplaints” (33).
(ii) A brief summary of an Mtc intervention for adults with fibromyalgia (23, 34).
“The professionals of the team were physiotherapists, psychologist, and nurses. The program lasted 6 weeks and consisted of 2 exercise classes and 2 multidisciplinary educational sessions per week. Exercise classes were con-ducted in a warm, therapeutic pool and were 30 minutes long. Each class consisted of 20 minutes of walking/jogging/side-stepping/arm exercises against water resistance and 5 minutes of stretching at the beginning and end of each class. Educational sessions were one hour long and were run in a group setting, immediately prior to pool classes. During edu-cational sessions, patients were provided with information on exercise, postural correction, activities of daily living, sleep, relaxation, medication, nutrition, and psychosocial coping strategies. The format for the educational sessions varied but included didactic lectures, interactive discussions, and hands-on learning (e.g. relaxation techniques)” (34).
(iii) A synopsis of a study of Assertive community treatment (Act) for homeless people with mental disorders (32).
“The team consisted of 12 full-time equivalent staff, including a program director with a masters’ degree in social work, a full-time psychiatrist and medical director, 6 clinical case managers (social workers, psychiatric nurses, and rehabilitation counsellors), 2 consumer advocates, a secretary-receptionist, a part-time family outreach worker from the Alliance for the Mentally Ill of Metropolitan Balti-more, and a part-time nurse practitioner who treats chronic medical problems. Each patient was assigned to a “mini-team” consisting of a clinical case manager (case load, 10–12 patients), an attending psychiatrist, and a consumer advocate. The entire ACT team, including the consumer advocates, worked together in decision making and each staff member was knowledgeable about most of the patients. Teamwork was fostered through daily sign-out rounds and twice-weekly treatment planning meetings. The ACT team’s long-term commitment was to promote continuity of care, and the team was available 24 hours every day”.
dIScuSSIon
In optimal rehabilitation, the focus is on the patient and his/her level of functioning, and not the diagnosis. the process of rehabilitation and the effectiveness of Mtc are presented in this review. specifically, the following elements have been described, and will be discussed (10, 35):
J Rehabil Med 44
911Multidisciplinary rehabilitation – an overview
• Identification of the need for rehabilitation.• Mutually agreed aims and outcomes of Mtc and a shared
understanding of how to achieve these aims.• establishing a team based on the patient’s need with the
person in need as a central actor.• communication and coordination between all parties in-
volved in the patient’s care including relatives and profes-sionals.
• An appropriate range of knowledge and skills of the Mtc team.
• Willingness to share knowledge and mutual trust to speak openly.
• evaluation of the aims and, if necessary, adjustment of these aims.
Identificationofneedsthe theory behind the interventions employed in these reviews is not described, except for Mtc being “based on the bio-psycho-social thinking” (24, 31). Apart from this theoretical basis there is little evidence about key elements of successful Mtc (10, 36).
It is suggested that the framework of the ICF provides ele-ments of a theory about rehabilitation (37, 38). the model provides a taxonomic system of human functioning, and may well be used to help prioritize and provide a description of the composition of the professionals needed to treat different sub-groups. The ICF can be used to test hypotheses about the composition of Mtc (39), and as a common framework in which to set criteria for the aim of rehabilitation and how to organize Mtc. the process surrounding the development of common goals is described in one review through participation in honest and continuous communication among the patient and professionals involved in the patient’s care (16).
Mutual aims and outcomesWithin the context of treating adults with fibromyalgia, (23, 34) an important goal is to change the patient’s perception of self-efficacy. Through patient education and the use of cogni-tive behavioural strategies and exercises, patients can learn to move from feelings of hopelessness to taking responsibility for their own health promotion.
As seen in table II, there are some common characteristics across studies. the diversity of interventions and professionals involved illustrate that MTC can be efficient in several forms. A generalization between different sub-groups is possible, because the interventions typically are focused on common functional problems despite the specific diagnoses.
Establishing a teamthe results (table I) show evidence for Mtc in rehabilitation in 10 of the 12 different patient groups. Most studies limited their description of Mtc to the professionals involved, and their general performance, such as close cooperation, aware-ness of communication and sharing of knowledge within the team (16). the element of close contact was described in a
review as assignment to a “mini-team” with 24-hour provision of local, direct and individual contact (28).
In certain situations, rehabilitation may require the par-ticipation of only one profession for certain periods. Whereas “effective team working produces better patient outcomes (including better survival rates) in a range of disorders, notably following stroke” (10).
Competencies the components of the Mtc interventions were most often described in general terms, such as educational sessions of group therapy, exercise, behavioural cognitive training, and assertive communicative training. We suggest that the con-SoRt criteria are used in order to improve the reporting of future RCTs performed in this field (40).
Evaluation of aimsthe results demonstrate the heterogeneity of outcomes em-ployed in clinical trials of non-pharmacological interventions. some reviews have outcomes at all ICF levels, but as Table I illustrates, the outcomes are highly variable and some are lacking the level of participation.
the lack of standard measures appropriate for studying proc-esses of care and the number of different outcomes is a limita-tion. A set of outcomes would be necessary to compare studies on effectiveness in clinical practice. We suggest use of the ICF to guide the selection of outcomes, and to define influencing factors on functioning. However, unfortunately data are not gathered consistently, and there is no common definition of dis-ability across countries (41). Functioning at all levels is relevant and is the main goal of rehabilitation, and is relevant to disease prevention, cure, and to target strategies for support.
there are some limitations of this review that should be noted. First, the external validity of the review can be questioned, as it presents research only on specific patient groups. However, as the person in need may have equal limitations of functioning no matter what their diagnosis, there are a number of characteristics from Mtc that can be generalized to other groups of patients.
the authors of the review on multiple sclerosis discuss the issue of applying the Rct design on assessment of Mtc in rehabilitation. It is questioned whether the evidence base for effectiveness coming from clinical trials and outcomes research can be applied to assessment of outcomes in the context of rehabilitation.
there is a need for more Rcts in other patient groups. Whereas there are reviews on both in-patient and out-patient Mtc rehabilitation programmes for a number of musculoskel-etal disorders, there is a lack of reviews on conditions such as pulmonary diseases (col) and different forms of cancer. As suggested by Groote, research within rehabilitation should address all dimensions of the ICF, and the WHO World Report on disability includes work in multi-professional teams (36). Although the literature provides limited evidence concerning the key components of Mtc, the theoretical basis of a multi-professional team is well described: agreed aims and shared
J Rehabil Med 44
912 A.-M. Momsen et al.
understanding on how to best achieve these, an appropriate range of knowledge and skills, mutual trust and respect, willingness to share knowledge and expertise; and to speak openly (10).
Conclusiondespite the variety of interventions and level of Mtc, the literature demonstrates that Mtc promotes the effects of rehabilitation compared with a control group or standard re-habilitative care in 10 of 12 patient groups. there is not one single Mtc method, but some general characteristics of Mtc in rehabilitation of different patient groups are presented.
ReFeReNCes
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