SUBJECT REVIEW SIGURNOST 51 (4) 313 - 320 (2009)

S. Rozman*

RETURN TO WORK INFLUENCED BY VOCATIONAL

REHABILITATION IN A MULTIDISCIPLINARY TEAM
UDK 613.6-085
RECEIVED: 2008-06-30
ACCEPTED: 2009-08-20

SUMMARY: In the Institute for Rehabilitation of Ljubljana (IRRS), Slovenia’s national centre
for rehabilitation, complex rehabilitation is organized as cooperation of medical rehabilitation
teams and vocational rehabilitation teams. This article describes the cooperation between the
medical and vocational rehabilitation teams in our institution. The process of vocational re-
habilitation begins with vocational evaluation – the assessment of the functional and working
abilities and capacities of the client, and it is followed by the elaboration of a rehabilitation
plan to optimize the disabled person’s return to work. All activities must be patient-centered.
The medical records of the candidates referred for vocational rehabilitation were analyzed to
explore the demographical, psychological, social and medical characteristics that influence the
return to work. The results show the prevalent characteristics of the persons who have problems
returning to work after medical rehabilitation. The most common suggestions for improvement
advised by the vocational rehabilitation team after assessment are also presented to give an idea
of rehabilitation outcomes.

Key words: vocational (occupational) rehabilitation, return to work, multidisciplinary team,

complex rehabilitation

INTRODUCTION sation of Opportunities for Persons with Disabili-

ties, United Nations General Assembly, 1993).
Rehabilitation is a process whose goal is to
enable disabled persons to achieve and retain Vocational rehabilitation is a process invol-
their optimal physical, emotional, intellectual, ving all activities that help the disabled person
spiritual and social functional level and thereby to obtain or retain a suitable employment (Kon-
improve their lives towards greater independen- vencija št. 159, 1987). In the process, medical
ce. When this process involves a wide spectrum information about permanent consequences of
of activities, starting with general medical reha- a disease/injury must be communicated to the
bilitation and progressing towards more goal-ori- institutions from the field of work, health and di-
ented activities such as vocational (occupational) sability insurance, and the client’s actual capaci-
rehabilitation, it is called holistic or complex re- ties, his legal rights, as well as the best way to re-
habilitation (The Standard Rules On The Equali- turn to work (or retire) must be planned. During
this transition the person experiences different
roles and relationships towards different instituti-
ons (patient, client, rehabilitant, disabled person,
*Sanja Rozman, MD, Specialist in Occupational, Traffic and Sports insurance policyholder and worker) and has dif-
Medicine Institute for Rehabilitation, Republic of Slovenia, Linhartova
51, 1000 Ljubljana (sanja.rozman@mail.ir-rs.si). ferent legal rights and obligations towards them.

313
S. ROZMAN: Return to work influenced ... SIGURNOST 51 (4) 313 - 320 (2009)

The basis for obtaining legal rights as a disabled Team of experts for vocational rehabilitation
person is the assessment of the consequences of
the disease and the residual working capacity, The Rehabilitation Institute in Ljubljana, Slo-
approved by deciding bodies (committees or venia, is the central national rehabilitation orga-
boards). This makes vocational rehabilitation a nization in Slovenia, with programs of medical
complex interaction of different factors, often rehabilitation for persons with disabilities of lo-
poorly coordinated in terminology as well as in comotor functions, and research and education
communication and action (Figure 1); (Berlingd in the field of rehabilitation. Vocational reha-
et al., in 1997, in Selander et al, 2002). The vo- bilitation has been a part of the programs since
cational rehabilitation team can help optimize the founding of the institution in 1954 and it is
the process by providing a thorough assessment based on conceptual framework as well as prac-
of the client’s functional and working abilities tical experience. We have come to the conclu-
and by setting up the rehabilitation plan. sion that only by programs of complex (holistic)
rehabilitation we can fulfill the goals of equality
and full participation of people with disabilities
in all areas of life. Through the years, the organi-
zation of vocational rehabilitation programs has
evolved into an up-to-date concept of work in
a multidisciplinary and transdisciplinary team in
the Centre for Vocational Rehabilitation (CPR).
Figure 1. The process of transition from patient to The following experts make up the Vocational
worker upon return to work after a disease/injury with Rehabilitation Team:
permanent consequences
• Social worker, who explores the client’s
Slika 1. Proces prijelaza od bolesnika do radnika po position in the world of work/employment,
povratku na posao nakon bolesti/ozljede s trajnim with regard to the level of his or her rights
posljedicama and social support systems
The role of vocational rehabilitation in the • Medical doctor specialist in vocational
process of returning to work is more than a mere (occupational) medicine, whose task is to
assessment of residual abilities and capacities. In assess the consequences of the patient’s
rehabilitation the aim is to restore, develop and disease matched to the demands of the
change the person’s abilities, to compare them to workplace
the demands of work, and to influence the balan- • Clinical psychologist, who explores in-
ce of the two, either by changing the demands or tellectual, emotional, and psychosocial
the person’s abilities (Brejc, 1996). The ability to abilities of the client, and tries to measure
work, by definition, means a balanced relation- the potentials and obstacles in returning
ship between the worker’s functional and execu- to work
tive abilities and the demands of the working en-
• Vocational therapist with tools to measure
vironment. It is defined by a number of physical
the client’s psycho-motor and motor abili-
and psychological capacities that are necessary
ties and skills
for the successful performance of certain wor-
king tasks while using certain tools. The worker’s • Vocational assessment specialist, an
capacity to tolerate adverse influences of envi- expert from the industry, who has experti-
ronment factors is especially important and often se to assess the client’s working ability by
represents an even greater health hazard than the using several work samples, some in ge-
work itself (Fatur-Videtič, 2000). neral use in industry (Workfactor, Ertomis)
and others of our own development.
Vocational rehabilitation is performed as a
process, based on the rehabilitation plan. The The technology of work in the vocational re-
client (the rehabilitant) is an active participant habilitation team is a product of our own deve-
throughout the process. lopment of 25 years. Each team member must

314
S. ROZMAN: Return to work influenced ... SIGURNOST 51 (4) 313 - 320 (2009)

choose among the assessment methods of their approximately 700 clients per year, 600 clients
professions to independently assess the client’s in vocational evaluation programs and 100 cli-
abilities and handicaps. After gathering the ne- ents in vocational training programs. The target
cessary information, the team members discuss groups are not only persons with locomotor di-
the case in a team conference to gain valuable sabilities, completing programs of medical re-
and multi-dimensional insight into the client’s habilitation in the Institute for Rehabilitation
unique status and consider various possible so- (referred by doctors from medical rehabilitation
lutions. The decisions are reached in consensus. programs), but also persons who are referred to
The decisions and options are always discussed vocational rehabilitation by GPs or by pension
with the client during every stage of the process, boards. Programs for unemployed persons with
a fact that is of utmost importance for the em- disabilities are also provided, and the persons are
powerment of the client. Whenever possible, the referred to the Institute by employment agencies.
employer is invited to participate (site visit) and In our article we purport to describe exclusively
is involved in choosing between different opti- the work with the patients of the Rehabilitation
ons. It usually takes two weeks (10 working days) Institute Ljubljana who almost continuously pro-
for basic tests and preliminary decisions to be gress from medical rehabilitation to vocational
elaborated. During this time the presence of the rehabilitation and back to work, making the pro-
client is required each day from 8 a.m. to 2 p.m. cess worthy of the title of continuous or complex
If the person lacks endurance, the daily durati- (holistic) rehabilitation.
on can be shortened or expanded according to
the individual’s needs. In the cases of employed
clients, the employer is contacted and the real- THE AIM OF OUR ANALYSIS
life situation and working requirements are exa-
The factors that influence successful return to
mined in a site visit (social worker and medical
work were explored, and the proportion of these
doctor). The task of the vocational rehabilitation
factors in the population of the clients of the Vo-
team evaluation is to translate the disabilities
cational Rehabilitation Team was analysed. Lite-
into work capacities and compare them to the
rature research indicated that there were several
demands of work. If permanent consequences
factors influencing the return to work. These can
can be proved at the pension board meeting, the
be divided into demographical, psychological,
client may be eligible for a form of disability pro-
social and medical factors, those connected to
tection rights: a pension, a right to work shorter
the rehabilitation process, those influenced by
hours, a different (less strenuous) job, or vocatio-
the characteristics of the work, and also those
nal training for a new, better suited career.
mostly influenced by the legislation that was su-
The final report (rehabilitation plan) should pposed to protect the disabled. These different
be written within 14 days from the conclusion of factors were interrelated in several ways. Accor-
the procedures. Each team member contributes ding to literature research, return to work after
a partial assessment, and then the team leader neck, back and shoulder problems was influen-
writes final conclusions and recommendations. ced by several risk factors that made return to
The Team works in cooperation with the Mini- work less likely (Selander et al, 2002). The fac-
stry of Labor, Family and Social Affairs, Health tors that positively influenced the return to work
Insurance, Disability Insurance and Employment were:
Services, and other vocational rehabilitation ser- • intervention of a multidisciplinary team,
vice providers. • early vocational rehabilitation,
The Institute for rehabilitation in Slovenia • understanding of the situation at work by
has three units, consisting of several teams, in the team experts,
Ljubljana, Maribor and Murska Sobota. The • extent to which the rehabilitation proce-
CPR Vocational Rehabilitation Teams evaluate dures had been completed,

315
S. ROZMAN: Return to work influenced ... SIGURNOST 51 (4) 313 - 320 (2009)

• patient’s satisfaction with the rehabilitati- and a perspective on the duration of further me-
on procedures, and dical treatments. For the vocational evaluation to
• patient’s opportunity to influence the pro- begin, all medical procedures have to be com-
cedures (patient centeredness). pleted. The doctor must also make some initial
assumptions about the candidate’s motivation to
As has been explained in the description of return to work. The decision to invite a client to
the procedures, all of these features have been join vocational rehabilitation programs is then
incorporated into the routine work of the vocati- communicated to his GP.
onal rehabilitation teams in the Ljubljana Reha-
The source of used data was the medical do-
bilitation Institute.
cumentation from our medical archives (OB CPR
030), (OB CPR 039) and the client’s medical fi-
MATERIALS AND METHODS les, routinely filled in by the team medical doctor
or by the team leader. This documentation con-
Personal data routinely collected and coded tained valuable information on the demograp-
in the medical documentation of the vocational hical, psychological, social and medical factors
rehabilitation clients was analysed. The candida- influencing the return to work. Basic statistics-
tes and the clients that were evaluated by the te- proportions were then calculated to illustrate the
ams in the years 2004 and 2005 were included. characteristics of our population with regard to
the factors influencing the return to work.
1. The candidates for vocational rehabilita-
tion (transition from medical rehabilitation ser-
vices): RESULTS
The candidates were referred to the programs
of vocational rehabilitation directly from the te- Results of candidates for vocational
ams for medical rehabilitation in the Institute for rehabilitation (transition from medical
Rehabilitation. The reasons for referral were that rehabilitation services)
the medical rehabilitation team of the instituti-
During the last couple of years a constant
on had evaluated their rehabilitation potentials
number of about 100 patients per year have been
at the end of the medical treatment/rehabilitati-
referred from the medical rehabilitation teams to
on and decided that there were permanent con-
the vocational rehabilitation teams. Within the
sequences in their functional abilities related to
time of our research, 185 candidates were exa-
their work.
mined by the medical doctor in the vocational
2. The vocational rehabilitation clients: rehabilitation team in order to assess whether
they have potential for vocational rehabilitation.
Out of the 185 candidates who had been
The majority were males (67%).
proposed for vocational evaluation, 102 (55%)
were accepted for assessment procedures and Table 1. Vocational rehabilitation referred candidates
are further referred to as “the clients”. The de- by gender
cision whether to accept a referred patient into Tablica 1. Spolna struktura kandidata upućenih na
the vocational rehabilitation program or not is radnu rehabilitaciju
made by a medical doctor – the team member
GENDER MALES FEMALES ALL
who first contacts the candidate. Based on the
available medical documentation, medical exa- N 123 52 185
mination and discussion about the candidate’s % 67% 29% 100%
position in regards to his/her work, employment
rights and pension rights, the doctor must gain Most candidates were in their thirties and
preliminary insight into the candidate’s status forties (65%) or younger, a sign of a very acti-

316
S. ROZMAN: Return to work influenced ... SIGURNOST 51 (4) 313 - 320 (2009)

ve population. It was expected that vocational As the result of vocational evaluation proce-
rehabilitation would be of particular interest to dures, we have assessed the clients’ functional
younger people. However, recent changes in disabilities of intellectual/emotional and bodily
the legislation have forced senior workers over functions. The selection of the parameters was
fifty to stay active. The changes also affect the made on the basis of the International Classifica-
younger population that needs to fulfill certain tion of Impairments, Disabilities and Handicaps
conditions to be granted protection by the disa- (ICIDH); (ICIDH, 1980), a classification that pre-
ceded the currently available International Cla-
bled protection laws or to be granted the right to
ssification of Functioning (ICF, 2001). They are
vocational training.
shown in Tables 4 and 5.
Table 2. Vocational rehabilitation referred candidates
Table 4. Functional disabilities (problems): intellectu-
by age al/emotional performance
Tablica 2. Dobna struktura kandidata upućenih na Tablica 4. Funkcionalne teškoće: intelektualna/
radnu rehabilitaciju emocionalna sposobnost
minus from 21 from 31 from 41 1. intellectual impairments
Age 50 plus
20 to 30 to 40 to 50 (psychological underdevelopment 5 6%
N 3 47 59 61 15 or deterioration
% 2% 26% 32% 33% 9% 2. mnestic impairments 20 22%

Most referred candidates were employed at 3. cognitive impairments 31 34%

the time of evaluation (77%). Literature research 4. impairments of consciousness 10 11%

(3) reveals that the chances for return to work are
5. perceptual disorders 5 6%
better for employed persons.
6. disorders of emotion and will 27 30%
Table 3. Referred candidates by employment status
7. behavioral disorders 6 7%
Tablica 3. Struktura kandidata prema radnom statusu
8. dependencies 1 1%
Employment
Employed Unemployed All Table 5. Functional disabilities (problems): bodily
status
functioning
N 107 32 139
Tablica 5. Funkcionalne teškoće: tjelesna sposobnost
% 77% 23% 100%
1. communication problems (speech,
Most candidates had never been assessed by 7 8%
listening, writing)
pension boards prior to this contact (123 candi-
dates or 88%). Some had problems with their sta- 2. impaired vision 11 12%

tus because their medical treatments had lasted 3. impairment of daily personal care
14 16%
for years and they repeatedly had to bring proof (personal hygiene, dressing, feeding…)
that they were unable to work. 4. impairment of motility (walking,
53 58%
transfer, transportation)
Results of vocational rehabilitation clients 5. special bodily postures intolerance
(lifting, reaching, pulling-pushing, 55 60%
After the initial selection of candidates, the kneeling)
chosen clients were invited to join vocational re- 6. problems with dexterity 45 49%
habilitation procedures and, by the end of 2006,
7. problems with endurance 70 76%
102 evaluations were completed. This is our
second population, selected from the referred 8. tolerance of environmental adverse

candidates with the potential to profit from our factors (temperature, climate, noise, 47 51%

programs. illumination, dust, working loads)

317
S. ROZMAN: Return to work influenced ... SIGURNOST 51 (4) 313 - 320 (2009)

It is interesting to note that 76% clients suf- blems 10th Revision (ICD-10, 1992.), the official
fered problems with endurance, and more than classification tool used by medical institutions
half had trouble with motility and intolerance of throughout WHO countries. All diagnoses were
specific body postures that are often necessary registered, but not all have the same effect on
for work. Half of the clients had problems with working abilities. The translation from diagnoses
dexterity and could not tolerate environmental to functional disabilities is not direct, so ICD is
adversities. This means that most vocational re- not the best tool for classification in rehabilitati-
habilitation clients were severely disabled and on, but is still used because of the international
comparability of data. In the Ljubljana Rehabi-
probably would never return to work without the
litation Institute we devote great efforts to intro-
help of vocational rehabilitation.
duce the International Classification of Functi-
The recommendations of the Vocational Re- oning, Disability and Health (ICF); (ICF, 2001)
habilitation Team are only of advisory nature, as into routine work, recommended by WHO as a
the final decision on the clients’ retirement or more advanced classification in rehabilitation.
On average, 9.13 diagnoses per patient were
return to work is made afterwards by a Pension
registered. Most of them concerned states after
Board of the National Insurance Institution. To
severe trauma or head injury.
avoid communication problems, however, the
recommendations are phrased in the pension Table 7. The medical factors that influenced the
board’s terminology. The results are shown in capacity for work of our clients coded
Table 6. The most frequent recommendation was according to the ICD-10
to shorten the working hours, which is compa- Tablica 7. Medicinski čimbenici koji su utjecali na
rable to a 76% of clients having endurance pro- radnu sposobnost naših kandidata prikazan
blems. One out of four clients was found incapa- prema dokumentu ICD-10
ble of work and retirement was recommended.
22% of recommendations for vocational training ICD No. of
Diseases
Category clients
was a rather high proportion indicating that the
Certain infectious and
general idea behind vocational rehabilitation is I 3
parasitic diseases
empowerment of the client.
II Neoplasms 5
Table 6. The Team recommendations for vocational Diseases of the blood and
rehabilitation measures blood-forming organs and
III 5
certain disorders involving the
Tablica 6. Preporučene mjere za radnu rehabilitaciju immune mechanism
Endocrine, nutritional and
RETIREMENT 23 25% IV 8
metabolic diseases
VOCATIONAL TRAINING 20 22% V Mental and behavioral disorders 20
SHORTER WORKING HOURS, SAME VI Diseases of the nervous system 56
37 41%
OR DIFFERENT JOB
VII Diseases of the eye and adnexa 18
CHANGES IN WORK DEMANDS, DIF-
10 11% Diseases of the ear and mastoid
FERENT JOB, FULL TIME VIII 3
process
OTHER (medical treatment not yet Diseases of the circulatory
2 3% IX 40
completed) system

ALL 92 100% Diseases of the respiratory

X 2
system
The medical factors that influence the capaci- XI Diseases of the digestive system 3
ty for work of our clients (Table 7) were classified Diseases of the skin and subcu-
XII -
according to the medical diagnoses and coded taneous tissue
according to the International Statistical Cla- Diseases of the musculoskeletal
XIII 96
ssification of Diseases and Related Health Pro- system and connective tissue

318
S. ROZMAN: Return to work influenced ... SIGURNOST 51 (4) 313 - 320 (2009)

ICD No. of can continue after the programs of medical reha-

Diseases
Category clients bilitation in the central rehabilitation institution
Diseases of the genitourinary in Slovenia have been completed. We have tried
XIV 4
system to explore the characteristics of our clients and
XV
Pregnancy, childbirth and the
- define the factors, medical as well as other, whi-
puerperium
ch contribute to a successful return to work. The
Certain conditions originating in results show the prevalent characteristics of the
XVI -
the perinatal period
persons who have problems returning to work
Congenital malformations,
XVII deformations and chromosomal 1 after medical rehabilitation, as well as the most
abnormalities common suggestions for vocational rehabilitati-
Symptoms, signs and abnormal on measures.
XVIII clinical and laboratory findings, 17
not elsewhere classified
Injury, poisoning and certain LITERATURE
XIX other consequences of external 139
causes
Brejc, T.: Kratek oris poklicne rehabilitacije in
All 420 skupinskega (timskega) pristopa, Inštitut republi-
ke Slovenije za rehabilitacijo, Ljubljana, 1996.

CONCLUSIONS Fatur-Videtič, A.: Poklicno rehabilitacijsko

ocenjevanje v strategiji razvoja usposabljanja in
Vocational rehabilitation is a process invol- zaposlovanja invalidov, Zbornik posveta Dnevi
ving all activities that help the disabled person poklicne rehabilitacije, 2000., str. 21-22.
to obtain or keep a suitable employment. Du-
ring this process there is an intensive interac- International Classification of Impairments,
tion of various institutions, but the laws in the Disabilities and Handicaps (ICIDH), WHO,
different areas (work, insurance, medicine) are 1980., dostupno na: http://www.who.int/classifi-
not perfectly coordinated and there is too much cations/apps/icd/icd10online/
room for complications and misunderstandings,
International Classification of Functioning,
leading to less than optimal results of return to
Disability and Health (ICF), WHO, 2001, dostu-
work. The process of vocational rehabilitation
pno na: http://www.who.int/classifications/apps/
should be patient (client)-centered. A working
icd/icd10online/
out of a rehabilitation plan and a coordination
of the vocational rehabilitation process by a Mednarodna organizacija dela, Konvencija
multidisciplinary team can be a positive factor št. 159 o poklicni rehabilitaciji in zaposlovanju
leading to better communication, assessment of invalidov, 1. člen. Uradni list SFRJ, Št. 3/1987.,
functional (dis)abilities and return to work. Li- dostupno na: http://ilolex.ilo.ch:1567/english/
terature research has shown that treatment in a convdispl.htm
multidisciplinary team, early vocational rehabili-
tation (direct referral from medical rehabilitation Selander, J., Marnetoft, S. –U., Bergroth, A.
ward), the team understanding the situation at and Ekholm, J.: Return to work following voca-
work (considering job analysis and relationships) tional rehabilitation for neck, back and shoulder
and the satisfaction of the patients – the ability problems: risk factors reviewed, Disability & Re-
to influence the result (patient-centeredness), are habilitation, 24, 2002., 14, 704-712.
all factors that positively influence the return to
work (Selander et at, 2002). The International Statistical Classification of Di-
seases and Related Health Problem, The Tenth Re-
In this article we have described the proce- vision, (ICD-10), 1992, dostupno na: http://www.
dure of vocational rehabilitation that (by referral) who.int/classifications/apps/icd/icd10online/

319
S. ROZMAN: Return to work influenced ... SIGURNOST 51 (4) 313 - 320 (2009)

The Standard Rules On The Equalisation of ssion, resolution 48/96, annex, 1993 dostupno
Opportunities for Persons with Disabilities, Uni- na: http://www.un.org/esa/socdev/enable/dis-
ted Nations General Assembly, forty-eighth se- sre00.htm

POVRATAK NA POSAO NAKON PROFESIONALNE

MULTIDISCIPLINARNE REHABILITACIJE

SAŽETAK: U slovenskom nacionalnom Institutu za rehabilitaciju u Ljubljani provodi se organi-

zirana suradnja timova za medicinsku rehabilitaciju i radnu rehabilitaciju. Članak je posvećen
suradnji između liječničkih timova i timova za radnu rehabilitaciju. Postupak radne rehabilitacije
počinje procjenom funkcionalnih i radnih sposobnosti, a slijedi ga razrada plana rehabilitacije
kako bi se invalidna osoba mogla vratiti na posao. Sve poduzete radnje moraju imati bolesnika u
središtu pažnje. Analizirana je medicinska dokumentacija kandidata upućenih na radnu rehabi-
litaciju kako bi se utvrdili demografski, psihološki, socijalni i medicinski čimbenici koji utječu na
povratak na posao. Rezultati pokazuju koji prevalentni čimbenici utječu da osoba ima teškoća pri
povratku na posao nakon medicinske rehabilitacije. Navedene su i najčešće preporuke radnog
rehabilitacijskog tima nakon procjene kako bi se prikazali rezultati rehabilitacije

Ključne riječi: radna (profesionalna) rehabilitacija, povratak na posao, multidisciplinarni tim,

kompleksna rehabilitacija

Pregledni rad
Primljeno: 30.6.2008.
Prihvaćeno: 20.8.2009.

320