Article

Changes in cognitive functioning in sick-listed participants in occupational rehabilitation: A feasibility study

Authors:
  • Norwegian National Advisory Unit on Occupational Rehabilitation
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Abstract

Background: Individuals on long-term sick leave attending occupational rehabilitation often complain about impairments in cognitive functions such as memory and attention. Knowledge of cognitive functioning in these individuals is limited. Such knowledge is clinically relevant for improving occupational rehabilitation programmes. Objective: The aims of this feasibility study were to assess the methodological design and to investigate changes in memory and attention on participants during occupational rehabilitation. Methods: Individuals attending occupational rehabilitation (n = 28) and individuals working full time (n = 25) matched for age, gender, and education participated. The two groups were administered cognitive tests targeting memory and attention and self-reported questionnaires at pre-test and post-test. Outcome measures were speed and accuracy of responses on the cognitive tests and self-reported work ability, subjective health complaints, and symptoms of depression and anxiety. Results: In total, 35% of all invited participants agreed to take part and 93% of these also completed the second test. The mean gain scores in the intervention group were significantly higher than in the control group in response latency on simple and choice reaction time and errors in spatial working memory. Conclusion: The results of this study indicate that the motivation of participants to complete testing was high. Improvements in memory and attention were evident in rehabilitation participants indicating that rehabilitation may have an effect on cognitive functions.

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... The referrals are commonly due to anxiety, depression, musculoskeletal pain and subjective health complaints. The rehabilitation programmes are tailored to improve the patients' level of functioning, physical fitness and work ability based on principles from cognitive behavioural therapy, here named as cognitive treatment components (Johansen et al., 2016). In Norway, a 3.5 week inpatient occupational rehabilitation programme has been found to increase RTW more for individuals with anxiety, depression and musculoskeletal pain compared to outpatient rehabilitation (Gismervik et al., 2020). ...
... Individuals reporting burnout, also report symptoms of anxiety, depression and somatic complaints (Österberg et al., 2009), which could persist even after recovery (Österberg et al., 2012). This is also the case for individuals reporting anxiety and depression presenting with comorbid pain and fatigue symptoms (Johansen et al., 2016(Johansen et al., , 2019. On a general note, the comparison of cognitive findings across studies is challenging due to the variety and number of cognitive tests employed and the generally low sample sizes in some studies (Snyder et al., 2015). ...
... Results of studies recruiting individuals on sick leave diagnosed with stress-related burnout seem to point towards impairments in executive function, working memory and sustained attention (Österberg et al., 2014). Individuals going through four-week inpatient occupational rehabilitation and reporting mild to moderate anxiety, depression, and pain improved more during rehabilitation than individuals working full time in working memory and selective and sustained attention (Johansen et al., 2016(Johansen et al., , 2019. However, these studies only conducted pretest and posttest assessments and improvements in cognitive functioning were not investigated in relation to RTW. ...
Chapter
The concept of work ability encompasses issues of individual workers’ abilities in light of their present job tasks taking into account the demands and resources that might be important in the future. Due to a rise in life expectancy in the EU, there has been an increase in the proportion of elderly workers. Aging workers put forth new challenges as aging is usually accompanied by chronic health issues and early exits from the labor market, which puts pressure on the social security systems. One of the ways to support social security systems is through reintegration of workers into the labor force (concept of “return to work”). Austria has been one of the EU member states recognised as having an inclusive return to work system with a strong emphasis on prevention. However, issues remain in lack of cross-policy communication and legislative framework. The following chapter provides an insight into the most common ways work ability is conceptualized, followed by a short analysis of the Austrian social insurance system with emphasis on issues of rehabilitation and return to work.
... The benefits of improved cognitive and emotional functioning are better flexibility, better regulation of our emotions and experiences, and increased quality of life [8][9][10]. Efforts have been made to better understand cognitive as well as emotional functioning in long-term sick-listed individuals participating in occupational rehabilitation [4,7,[11][12][13]. In Norway, the occupational rehabilitation programmes are designed to facilitate return to work (RTW) through physical and psychological empowerment and communication with the employer. ...
... Our ability to stay focused is more likely to increase if the demands at work on sustained attention and working memory are high [3,50] and when we perform complex tasks either at home or in work [2]. Therefore, occupational rehabilitation [7,13], physical activity [52], better emotion regulation [9,10] or attention bias modification training [53] also improve cognitive and emotional functions and seem likely to pave the way for better performances at work. ...
... The current study adds further knowledge about occupational rehabilitation and presents an association between cognition and RTW in the WAA and SL group. Previous findings from our group have demonstrated that focused and sustained attention and working memory improve more than executive function and emotion recognition during rehabilitation [7,13]. Although it cannot be elucidated at this stage which interventions in the rehabilitation programme improve attention and working memory, it can be claimed that the combined effects of all treatment components [54], such as physical activity, cognitive approach, collaboration with the workplace and following an RTW plan, improve certain cognitive functions more than others. ...
Article
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Purpose The objective of this study was to investigate the association between cognitive and emotional functioning and the number of days on health-related benefits such as sick leave, work assessment allowance and disability pension. We investigated whether cognitive and emotional functioning at the start of rehabilitation and the change from the start to the end of rehabilitation predicted the number of days on health-related benefits in the year after occupational rehabilitation. Methods A sample of 317 individuals (age 19–67 years), mainly diagnosed with a musculoskeletal or mental and behavioural ICD-10 disorder, participated. The sample was stratified depending on the benefit status in the year before rehabilitation. Those receiving health-related benefits for the full year comprised the work assessment allowance and disability pension (WAA) group and those receiving benefits for less than a year comprised the sick leave (SL) group. The participants were administered cognitive and emotional computerised tests and work and health questionnaires at the beginning and end of rehabilitation. The cumulative number of days on health-related benefits during 12 months after rehabilitation was the primary outcome variable and age, gender, educational level, subjective health complaints, anxiety, and depression were controlled for in multiple regression analyses. Results The WAA group (n = 179) was significantly impaired at baseline compared to the SL group (n = 135) in focused attention and executive function, and they also scored worse on work and health related variables. Higher baseline scores and change scores from the start to the end of rehabilitation, for sustained attention, were associated with fewer number of health-related benefit days in the WAA group, while higher baseline scores for working memory were associated with fewer number of health-related benefit days in the SL group. Conclusions New knowledge about attention and memory and return to work in individuals with different benefit status may pave the way for more targeted programme interventions. Rehabilitation programmes could benefit from designing interventions that respectively improve sustain attention and working memory related to working life in individuals on sick leave or work assessment allowance and disability pension.
... Workers on long-term sick leave referred to occupational rehabilitation report memory and attention problems, symptoms of anxiety, depression and pain, and reduced work ability (Aasvik et al., 2015;Johansen et al., 2016;Aasdahl et al., 2017). These factors are assumed to negatively affect the ability to concentrate on work tasks, process information and shift attention when required in working life. ...
... On the other hand, well-preserved cognitive functioning improves flexibility and the capacity to regulate our thoughts, emotions and behavior (Dajani and Uddin, 2015). Understanding how occupational rehabilitation affects cognitive functioning, work ability and health related factors is important because it can be assumed that improvements in these measures contribute positively to return to work (RTW) (Eskildsen et al., 2016;Johansen et al., 2016). However, the investigation of changes in cognitive functioning during occupational rehabilitation has so far been an understudied topic relying only on preliminary evidence (Johansen et al., 2016;Aasvik et al., 2017). ...
... Understanding how occupational rehabilitation affects cognitive functioning, work ability and health related factors is important because it can be assumed that improvements in these measures contribute positively to return to work (RTW) (Eskildsen et al., 2016;Johansen et al., 2016). However, the investigation of changes in cognitive functioning during occupational rehabilitation has so far been an understudied topic relying only on preliminary evidence (Johansen et al., 2016;Aasvik et al., 2017). This is a highly relevant topic because anxiety, depression and pain are associated with impairments in cognitive functioning (Yiend, 2010;Landrø et al., 2013;Snyder et al., 2015) and because maintaining good cognitive processing is an important premise for adaptive emotion regulation (Ochsner and Gross, 2005). ...
Article
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Introduction: Occupational rehabilitation may be offered to workers on long-term sick leave who often report problems with cognitive functioning, anxiety, depression, pain, and reduced work ability. The empirical knowledge is sparce on how occupational rehabilitation may influence cognitive and emotional functioning and patients have not previously been subjected to comprehensive objective testing. The main aim of this study was to assess possible changes in cognitive and emotional functioning such as memory, attention, executive function, and emotion recognition among patients in occupational rehabilitation. Methods: A large sample of 280 sick-listed workers referred to inpatient and outpatient occupational rehabilitation was recruited. The rehabilitation programs had a mean duration of 28 days and comprised physical activity, cognitive behavior treatment components and collaboration with the workplace. A pre-post design was applied to investigate possible changes in cognitive and emotional functioning (primary outcomes) and work and health measures (secondary outcomes), comparing the rehabilitation group with a control group of 70 healthy workers. Individuals in the control group were tested at random time points with an approximately 28 day interval between pre- and post-test, thus coinciding with the duration of rehabilitation. Repeated measures analysis of variance was used for the main analyses. Results: Compared to the control group, the rehabilitation group had greater gains from pre- to post-test in focused and sustained attention, as well as greater improvements in work ability and reduction in subjective health complaints (SHC), helplessness, pain, pain related to work, anxiety, and depression. In the rehabilitation group, exploratory correlational analysis indicated that improvements in focused and sustained attention were associated with improvements in return-to-work self-efficacy, work ability as well as a reduction in SHC. Conclusion: The sick-listed workers improved in focused and sustained attention and work and health measures after participating in occupational rehabilitation. This study is one of the first to systematically investigate changes in cognitive and emotional functioning during occupational rehabilitation. Clinical practice should benefit from increased knowledge about all cognitive functions and should be specifically aware of the improvements in focused and sustained attention, while memory, executive function and emotion recognition remained unchanged. The results can be used as a motivation to tailor specific interventions to gain further improvements in all cognitive and emotional functions.
... Anvendelse av kognitiv tilnaerming i ARR har også som mål å identifisere hvordan uhensiktsmessige tanker, følelser og atferd har sammenheng med arbeidsdeltagelse. Målet er å styrke deltagernes tro på å kunne fungere bedre i arbeid, øke mestring og kontroll av helseplager, noe som igjen påvirker kognitiv fungering og øker deltagernes mentale ressurser og kapasitet (Johansen et al., 2016). Metodene består av en kombinasjon av individuelle samtaler og veiledning, gruppesamlinger og undervisning. ...
... I en forstudie publisert av dette prosjektets forskningsgruppe ble det funnet at deltagere som gjennomførte ARR viste større bedring i hukommelse og oppmerksomhet enn deltagere som er i 100% jobb (Johansen et al., 2016). Deltagerne i ARR viste også bedring i psykisk helse målt med spørreskjema som kartlegger angst, depresjon og helseplager. ...
... Det ser ut til at kognitiv fungering relatert til oppmerksomhet og arbeidshukommelse er de funksjonene som ARR-deltagerne viser størst bedring i. Dette er også dokumentert tidligere i en mindre studie (Johansen et al., 2016). God arbeidshukommelse og oppmerksomhet er nødvendig for å prestere godt i arbeidslivet (Beier & Oswald 2012;Loisel & Anema 2013) og spesielt god oppmerksomhetsevne har sammenheng med god arbeidsevne (Karlsson et al., 2014). ...
Technical Report
Full-text available
This Norwegian report is about cognitive functioning and return to work in individuals who have received occupational rehabilitation.
... Inclusion was based on consecutive recruitment of participants aged between 18 and 67 and with the ability to understand the questionnaires and the instructions given by the examiner for each cognitive test. Exclusion criteria were history of head injury or having applied for disability pension (inclusion and exclusion criteria were the same as in Johansen et al., 2016). The study was approved by the South-East Regional Committee for Medical and Health Research Ethics (2013/1559). ...
... Thus, we are less certain that the results obtained here reflect clinically meaningful changes for the patients. However, effect sizes were well established in the moderate range and are stronger than results from comparable studies (Johansen et al., 2016;Nottingnes et al., 2019;Gismervik et al., 2020). ...
Article
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Objective: Musculoskeletal pain and common mental disorders constitute the largest proportion of people who are on sick leave. This study investigated the efficacy of two multidisciplinary occupational rehabilitation programs on self-rated health and work-related outcomes. The interventions were identical in content but differed in length. It was hypothesized that a longer inpatient program would yield greater improvements than a shorter outpatient program. Methods: Patients were sick-listed workers referred to occupational rehabilitation by the Norwegian Labor and Welfare Administration. A non-randomized 2 Condition (20 days, n = 64 versus 12 days, n = 62) × 4 repeated measures (start, end, 3 months, 12 months) between-subject design was used. Both programs were based on multimodal cognitive behavior therapy with a return-to-work focus. Health-related questionnaires were the Subjective Health Complaints inventory, Hospital Anxiety and Depression Scale, and SF-36 Bodily Pain. Work-related questionnaires were the Work Ability Index, the Fear-Avoidance Beliefs Questionnaire, Return To Work Self-Efficacy, and Return To Work expectations. Intervention effects were estimated using linear mixed models and Cohen's d. Results: The results revealed that both groups improved on the selected outcomes. Within-group contrasts and effect sizes showed that the inpatient group showed larger effect sizes at the end of rehabilitation and 12 months post-intervention for work-related outcomes than the outpatient group. Conclusion: Both programs were efficacious in improving health-and work-related outcomes during and after rehabilitation, but the inpatient group generally displayed stronger and more rapid improvements and was more stable at one-year postintervention.
Chapter
Occupational rehabilitation, part of the specialist health care services, has existed in Norway for more than 25 years. Individuals who are on long-term sick leave can be offered occupational rehabilitation, based on cognitive interventions and physical activity, aiming to improve functioning and work ability, self-efficacy related to home and work tasks and sustainable return to work. However, a surprisingly small number of empirical studies have been conducted to evaluate and document the quality and effect of the cognitive interventions. Thus, it is essential to investigate the relationship between cognitive and emotional factors and return to work; in particular memory, attention, executive function and appraisal of emotional stimuli from faces, pictures and words. Therefore, the application of the cognitive psychological approach in this field is original. The elucidation of which cognitive changes take place during occupational and work-related rehabilitation in individuals reporting anxiety, depression and musculoskeletal pain should improve the quality of rehabilitation programmes. Relevant empirical literature and its clinical implications along with recommendations for future studies are highlighted.
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Individuals who are not clinically diagnosed with obsessive-compulsive disorder (OCD) but still display obsessive-compulsive (OC) tendencies may show cognitive impairments. The present study investigated whether there are subgroups within a healthy group showing characteristic cognitive and emotional performance levels similar to those found in OCD patients and whether they differ from OCD subgroups regarding performance levels. Of interest are those cases showing subclinical symptomatology. The results revealed no impairments in the subclinical OC participants on the neuropsychological tasks, while evidence suggests that there exist high and low scores on two standardised clinical instruments (Yale-Brown Obsessive Compulsive Scale and Cognitive Assessment Instrument of Obsessions and Compulsions) in a healthy sample. OC symptoms may diminish the quality of life and prolong sustainable return to work. It may be that occupational rehabilitation programmes are more effective in rectifying subclinical OC tendencies compared to the often complex symptoms of diagnosed OCD patients. The relationship between cognitive style and subclinical OC symptoms is discussed in terms of how materials and information might be processed. Although subclinical OC tendencies would not seem to constitute a diagnosis of OCD, the quality of treatment programmes such as cognitive behavioural therapy can be improved based on the current investigation.
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There is clear evidence that cognitive performance is a correlate of functional outcome among patients with schizophrenia. However, few studies have specifically examined the cognitive correlates of competitive employment performance or the longer-term outcomes of vocational rehabilitation. The objective of the present study was to examine the cognitive predictors of vocational functioning in the context of a controlled clinical trial by comparing two approaches to vocational rehabilitation. A broad neuropsychological battery was administered to 150 patients upon entry into the vocational rehabilitation trial. Vocational performance was assessed over a 24-month follow-up interval. There were no differences in baseline cognitive performance between the 40 patients who obtained competitive employment and the 110 patients who remained unemployed over the follow-up interval. In contrast, multiple cognitive measures were significantly correlated with the total number of hours that patients were employed. The cognition-job tenure relationship appears to be fairly general, involving measures of IQ, attention, working memory, and problem solving. Cognitive performance was a significant predictor of job tenure but not job attainment in the context of a clinical trial of two vocational rehabilitation approaches. It appears that many persistently unemployed patients are capable of obtaining competitive employment with effective vocational services. Longer-term employment success, however, may be related to multiple aspects of baseline cognitive performance.
Article
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To address cognitive impairments that limit the effectiveness of supported employment services for patients with schizophrenia, a cognitive training program, the Thinking Skills for Work Program, was developed and integrated into supported employment services. Patients with severe mental illness (N=44) and prior histories of job failures who were enrolled in supported employment programs at two sites in New York City were randomly assigned to receive either supported employment alone or supported employment with cognitive training. Measures at baseline and 3 months included a brief cognitive and symptom assessment. Work outcomes were tracked for 2-3 years. Patients in the supported employment with cognitive training program demonstrated significantly greater improvements at 3 months in cognitive functioning, depression, and autistic preoccupation. Over 2-3 years, patients in the supported employment with cognitive training program were more likely to work, held more jobs, worked more weeks, worked more hours, and earned more wages than patients in the program offering supported employment alone. The findings support the feasibility of integrating cognitive rehabilitation into supported employment programs and suggest that more research is warranted to evaluate the effects of the Thinking Skills for Work Program.
Book
For persons with chronic illnesses and disabling injuries, work prospects--especially for meaningful work with decent conditions--have traditionally been poor. With global efforts from the UN, WHO, ILO, and other bodies focusing attention on this wide-reaching issue, innovative tools are needed to translate large-scale goals into real-world outcomes. The framework offered by the Handbook of Vocational Rehabilitation and Disability Evaluation highlights the complex challenges and opportunities involved in enabling re-entry into the workforce. Geared to ICF (International Classification of Functioning, Disability, and Health) standards, this timely reference outlines current science-based methods in assessing impairment and capabilities and emerging approaches to management specifically relating to work participation. Separate chapters are devoted to evaluation and rehabilitation guidelines for individuals with brain injury, chronic musculoskeletal pain, mental illness, and other disabling conditions. And the chapters on ICF-based functioning measurement review the data on widely-used clinician- and patient-reported instruments and the recent Work Rehabilitation Questionnaire (WORQ). Featured in the Handbook: • The impact of chronic disease on work participation and its implications for intervention and management. • Vocational assessment and job placement. • Spinal cord injury: vocational rehabilitation and disability evaluation. • Critical issues for mental health management in vocational rehabilitation. • Clinician-reported outcome measures: experiences from multicenter follow-up. • ICF-based tools in rehabilitation toward return-to-work. The Handbook of Vocational Rehabilitation and Disability Evaluation is of critical interest to researchers, educators, and students in disability- and work-related fields. It is also a practical resource outside the campus setting, aiding those providing services to, as well as policymakers involved in improving the lives of, persons with disabilities.
Article
Aims : As subjective health complaints are one of the major reasons for short- and long-term sickness absence it is important to know the prevalence of these conditions in the general population. Methods : In this cross-sectional study, 1,240 individuals (aged 15-84 years) from the normal population in Norway answered the Subjective Health Complaint (SHC) inventory in spring 1996. Results : The prevalence of reporting subjective health complaints was high: 80% reported musculoskeletal complaints, 65% reported “pseudoneurological” complaints (tiredness, depression, dizziness), 60% gastrointestinal complaints, 34% allergic complaints, and 54% flu-like complaints. The prevalence of substantial complaints was low: 13% reported musculoskeletal complaints, 5% reported “pseudoneurological”complaints, 4% gastrointestinal complaints, 2% allergic complaints, and 18% flu-like complaints. Women had higher prevalence of musculoskeletal, “pseudoneurological”, and allergic complaints compared with men, and reported more substantial complaints on all subscales. Individuals older than 50 years were less likely to report headache, tiredness, eczema, and fl u-like complaints compared with individuals younger than 30 years. However, they had higher risk of arm pain, shoulder pain, palpitations, and several gastrointestinal and allergic complaints. The intensity of musculoskeletal, gastrointestinal, and allergic complaints was signifi cantly higher in the oldest age group. Conclusions: Subjective health complaints are very common in the normal population; there are gender and age differences in both prevalence and degree of complaints. The intensity of subjective health complaints forms a continuum, and there are no obvious cut-off point to indicate what are “normal” complaints and what is illness.
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Emotion Focused Cognitive Therapy argues that it is time for a new focus in psychotherapy based on emotion, and presents an innovative approach to the treatment of clients with emotional disorders. Features an approach based on the latest work in cognition and emotion. Offers psychologists an innovative way of working in therapy. Draws on the strengths evidence-based cognitive behavioural and interpersonal approaches to psychotherapy. Provides relevant case examples throughout the text. Additional resources for the book available online here.
Article
Background The neuropsychological dysfunction associated with obsessive-compulsive disorder (OCD) has similarities to the deficits reported in other affective or anxiety disorders. We directly compared cognitive function in patients with OCD with that in matched patients with unipolar depression and panic disorder and healthy control subjects to establish the specific nature of neuropsychological deficits in OCD. Methods Thirty patients with OCD, 30 patients with panic disorder, 20 patients with unipolar depression, and 30 controls completed a computerized neuropsychological battery that assessed the accuracy and latency of executive, visual memory, and attentional functions. Results The groups did not differ according to age, years of education, or estimated IQ. However, we found group differences in cognitive performance. The patients with OCD were impaired on measures of spatial working memory, spatial recognition, and motor initiation and execution. In contrast, performance of these tasks by patients with panic disorder or depression did not differ from that of controls. There were no group differences for performance on the measures of planning, cognitive speed, pattern recognition, and delayed matching to sample, although patients with depression were impaired for attentional set shifting. Conclusions Neuropsychological deficits were observed in patients with OCD that were not observed in matched patients with panic disorder or unipolar depression. As such, the cognitive dysfunction in OCD appears to be related to the specific illness processes associated with the disorder.
Article
The nature of cognitive deficits in obsessive-compulsive disorder (OCD) is characterized by contradictory findings in terms of specific neuropsychological deficits. Selective impairments have been suggested to involve visuospatial memory, set shifting, decision-making and response inhibition. The aim of this study was to investigate cognitive deficits in decision-making and executive functioning in OCD. It was hypothesized that the OCD patients would be less accurate in their responses compared to the healthy controls in rational decision-making on a version of the Cambridge gambling task (CGT) and on the color-word interference test and on a version of the Tower of Hanoi test (tower test) of executive functioning. Thirteen participants with OCD were compared to a group of healthy controls (n = 13) matched for age, gender, education and verbal IQ. Results revealed significant differences between the OCD group and the healthy control group on quality of decision-making on the CGT and for achievement score on the tower test. On these two tasks the OCD group performed worse than the healthy control group. The symptom-dimension analysis revealed performance differences where safety checking patients were impaired on the tower test compared to contamination patients. Results are discussed in the framework of cognition and emotion processing and findings implicate that OCD models should address, specifically, the interaction between cognition and emotion. Here the emotional disruption hypothesis is forwarded to account for the dysfunctional behaviors in OCD. Further implications regarding methodological and inhibitory factors affecting cognitive information processing are highlighted.
Article
Purpose: To investigate fatigue as prognostic risk marker for identifying working employees at risk of long-term sickness absence (SA). Methods: At baseline, fatigue was measured in 633 white collar employees with the checklist individual strength (CIS) including scales for fatigue severity, reduced concentration, reduced motivation, and reduced physical activity. SA was medically certified by an occupational physician in the 3rd or 4th SA week with diagnostic codes according to the 10th version of the International Classification of Diseases. Medically certified SA was retrieved at the individual level from an occupational health register after 1-year follow-up. CIS scores were investigated as prognostic risk markers predicting medically certified SA and particularly SA certified as mental SA. Results: 614 employees (N = 378 men and N = 236 women) had complete data and were eligible for analysis; 63 (10 %) had medically certified SA of whom 39 (6 %) had mental SA. Fatigue severity and total CIS scores were associated with medically certified SA in men, but poorly discriminated between men with and without medically certified SA. Fatigue severity, reduced concentration, reduced motivation, and total CIS scores were also associated with mental SA in men. CIS and its reduced concentration scale were valid prognostic risk markers of mental SA. CONCLUSION Fatigue was a prognostic risk marker of mental SA in white collar men. The CIS should be further validated as a screening tool for the risk of mental SA in white collar working populations.
Article
Many factors can affect the successful implementation and validity of intervention studies. A primary purpose of feasibility and pilot studies is to assess the potential for successful implementation of the proposed main intervention studies and to reduce threats to the validity of these studies. This article describes a typology to guide the aims of feasibility and pilot studies designed to support the development of randomized controlled trials and provides an example of the studies underlying the development of one rehabilitation trial. The purpose of most feasibility and pilot studies should be to describe information and evidence related to the successful implementation and validity of a planned main trial. Null hypothesis significance testing is not appropriate for these studies unless the sample size is properly powered. The primary tests of the intervention effectiveness hypotheses should occur in the main study, not in the studies that are serving as feasibility or pilot studies.
Article
Objective: To examine and compare the prospective effect of the common mental disorders (CMD) anxiety and depression on duration and recurrence of sickness absence (SA), and to investigate whether the effect of CMD on SA is detectable over time. Method: Information from a large epidemiological health study (N = 13 436) was linked with official records of SA episodes lasting ≥16 days up to 6 years after participation. Common mental disorders were assessed with the Hospital Anxiety and Depression Scale (HADS). Associations were analysed with Cox regression and multinomial logistic regression models controlling for potential covariates. Results: Comorbid anxiety and depression, and anxiety only were significant risk factors for SA after adjusting for covariates, whilst depression only was not. Anxiety and depression were stronger predictors for longer duration of SA episodes compared with shorter duration and associated with more frequent recurrence of SA. There was a general trend toward the effect of CMD on SA becoming weaker over time; however, the effect of anxiety only on SA remained stable throughout the follow-up. Conclusion: Common mental disorders are long-lasting predictors of onset, duration and recurrence of SA. Anxiety appears to be a more important contributor to long-term SA than previously described in the literature.
Article
Twenty-six patients with unilateral or bilateral frontal lobe excisions were compared with age and IQ matched controls on a computerized battery of tests of spatial working memory and planning. A computerized test of spatial short term memory capacity revealed no significant impairment in the patients' ability to execute a given sequence of visuo-spatial moves. In contrast, a paradigm designed to assess spatial working memory capacity, revealed significant impairments in the patient group in both possible types of search errors. Furthermore, additional analysis showed that the frontal lobe patients were less efficient than controls in their usage of a strategy for improving performance on this test.Higher level planning was also investigated using a test based on the “Tower of London” problem [Shallice, T. Phil. Trans. R. Soc. Lond. B. 298, 199–209, 1982]. Patients with frontal lobe damage required more moves to complete the problems and a yoked motor control condition revealed that movement times were significantly increased in this group. Taking both of these factors into consideration, initial thinking (planning) time was unimpaired in the patient group although the thinking time subsequent to the first move was significantly prolonged. These data are compared to previous findings from patients with idiopathic Parkinson's disease and are discussed in terms of an impairment of higher cognitive functioning following frontal lobe damage.
Article
A growing body of literature suggests that physical activity beneficially influences brain function during adulthood, particularly frontal lobe-mediated cognitive processes, such as planning, scheduling, inhibition, and working memory. For our hunter-gatherer ancestors, times of famine interspersed with times of feast necessitated bouts of intense physical activity balanced by periods of rest. However, the sedentary lifestyle that pervades modern society has overridden the necessity for a physically active lifestyle. The impact of inactivity on disease processes has been the focus of much attention; the growing understanding that physical activity also has the benefit of enhancing cognitive performance strengthens the imperative for interventions that are successful in increasing physical activity, with the outcomes of promoting health and productivity. Population health and performance programs that promote physical activity provide benefits for employees and employers through improvements in worker health and performance and financial returns for the company. In this review, we examine the mechanisms by which physical activity improves cognition. We also review studies that evaluate the effects of physical activity on cognitive executive performance in adulthood, including longitudinal studies that address the impact of physical activity during early adulthood and midlife on preservation of cognition later in life. This is of particular importance given that adulthood represents prime working years and that physical activity promotion is a key component of population health and performance programs. Finally, we provide recommendations for maximizing the lasting benefits of movement and physical activity on cognition in adulthood.
Article
To measure the impact of the clinical course, the residual mood symptoms and the cognitive variables on the psychosocial and occupational functioning in bipolar disorder patients in remission. Forty-four euthymic DSM-IV-TR bipolar lithium-treated outpatients were assessed with a clinical interview and neuropsychological testing. To assess psychosocial function, some psychometric scales were administered (Global Assessment of Functioning Scale and World Health Organization Disability Assessment Schedule), and to evaluate occupational function, the sample was divided according to the current work status (active vs. inactive). Cognitive assessment was performed by means of a neuropsychological test battery tapping into the main cognitive domains (executive function, attention, processing speed, verbal memory and visual memory). Measures of psychosocial functioning were significantly correlated with cognition (processing speed, p = 0.004), clinical severity (p = 0.03) and residual depressive symptoms (p = 0.05). Occupational functioning showed a significant effect with a cognitive domain (visual memory, p = 0.006) and a clinical variable (chronicity, p = 0.04) but not with residual mood symptoms (p > 0.2). Remission in bipolar disorder is not synonymous with recovering in psychosocial and occupational functioning. Cognitive deficits, clinical course and persistent subsyndromal symptoms may compromise psychosocial functioning, and neurocognitive symptoms and chronicity may particularly affect occupational functioning.
Article
We recently reported marked hyporeactivity of the hypothalamo-pituitary-adrenal (HPA) axis in depressed women on job-stress-related long-term sick leave (LTSL). This unexpected finding prompted the question of whether HPA axis hypofunction in this group results from stress exposure or reflects preexisting vulnerability. Here, as a first step toward addressing this question, we assessed temporal stability of HPA axis reactivity in these subjects. We used the combined dexamethasone/corticotropin-releasing hormone (DEX-CRH) test to retest HPA axis reactivity in 29 patients and 27 control subjects after 12 months of follow-up. Clinical status and cognitive performance was also retested. Despite marked clinical improvement and normalization of initially observed impairments in attention and working memory, marked HPA axis hyporeactivity persisted in patients. A high test-retest correlation was found both at the level of corticotropin (R = .85, p < .001) and cortisol (R = .76, p < .001) responses. Hyporeactivity of the HPA was stable over 12 months in LTSL subjects, independent of clinical improvement and normalized cognitive function. The stability of this response over time suggests that decreased DEX-CRH responses in this group may be a trait rather than a state marker. This finding is compatible with a hypothesis that HPA axis hyporeactivity may reflect a preexisting vulnerability in these subjects.
Article
Nicotine in patients with dementia of the Alzheimer type (DAT) produced a significant and marked improvement in discriminative sensitivity and reaction times on a computerised test of attention and information processing. Nicotine also improved the ability of DAT patients to detect a flickering light in a critical flicker fusion test. These results suggest that nicotine may be acting on cortical mechanisms involved in visual perception and attention, and support the hypothesis that acetylcholine transmission modulates vigilance and discrimination. Nicotine may therefore be of some value in treating deficits in attention and information processing in DAT patients.
Article
A self-assessment scale has been developed and found to be a reliable instrument for detecting states of depression and anxiety in the setting of an hospital medical outpatient clinic. The anxiety and depressive subscales are also valid measures of severity of the emotional disorder. It is suggested that the introduction of the scales into general hospital practice would facilitate the large task of detection and management of emotional disorder in patients under investigation and treatment in medical and surgical departments.
Article
Pilot studies and a literature review suggested that fear-avoidance beliefs about physical activity and work might form specific cognitions intervening between low back pain and disability. A Fear-Avoidance Beliefs Questionnaire (FABQ) was developed, based on theories of fear and avoidance behaviour and focussed specifically on patients' beliefs about how physical activity and work affected their low back pain. Test-retest reproducibility in 26 patients was high. Principal-components analysis of the questionnaire in 210 patients identified 2 factors: fear-avoidance beliefs about work and fear-avoidance beliefs about physical activity with internal consistency (alpha) of 0.88 and 0.77 and accounting for 43.7% and 16.5% of the total variance, respectively. Regression analysis in 184 patients showed that fear-avoidance beliefs about work accounted for 23% of the variance of disability in activities of daily living and 26% of the variance of work loss, even after allowing for severity of pain; fear-avoidance beliefs about physical activity explained an additional 9% of the variance of disability. These results confirm the importance of fear-avoidance beliefs and demonstrate that specific fear-avoidance beliefs about work are strongly related to work loss due to low back pain. These findings are incorporated into a biopsychosocial model of the cognitive, affective and behavioural influences in low back pain and disability. It is recommended that fear-avoidance beliefs should be considered in the medical management of low back pain and disability.
Article
The neuropsychological dysfunction associated with obsessive-compulsive disorder (OCD) has similarities to the deficits reported in other affective or anxiety disorders. We directly compared cognitive function in patients with OCD with that in matched patients with unipolar depression and panic disorder and healthy control subjects to establish the specific nature of neuropsychological deficits in OCD. Thirty patients with OCD, 30 patients with panic disorder, 20 patients with unipolar depression, and 30 controls completed a computerized neuropsychological battery that assessed the accuracy and latency of executive, visual memory, and attentional functions. The groups did not differ according to age, years of education, or estimated IQ. However, we found group differences in cognitive performance. The patients with OCD were impaired on measures of spatial working memory, spatial recognition, and motor initiation and execution. In contrast, performance of these tasks by patients with panic disorder or depression did not differ from that of controls. There were no group differences for performance on the measures of planning, cognitive speed, pattern recognition, and delayed matching to sample, although patients with depression were impaired for attentional set shifting. Neuropsychological deficits were observed in patients with OCD that were not observed in matched patients with panic disorder or unipolar depression. As such, the cognitive dysfunction in OCD appears to be related to the specific illness processes associated with the disorder.
Article
The purpose of this study was to identify variables associated with employment status among persons with bipolar disorder, including cognitive functioning, severity of symptoms, demographic variables, and variables related to course of illness. The authors assessed the current employment status of 117 persons with bipolar disorder. Study participants' cognitive functioning was evaluated with the Repeatable Battery for the Assessment of Neuropsychological Status, the information and letter-number sequencing subtests of the Wechsler Adult Intelligence Scale III, and part A of the Trail Making Test. Symptoms were rated by using the Brief Psychiatric Rating Scale, the Hamilton Depression Scale, and the Young Mania Rating Scale. A stepwise multivariate logistic regression analysis was used to predict employment status. Fifty-one percent of the study participants had no current work activity, 21 percent worked part-time or as volunteers, and 27 percent had full-time competitive employment. Current employment status was significantly associated with cognitive performance, especially immediate verbal memory, total symptom severity, history of psychiatric hospitalization, and maternal education. No association was found between employment status and history of psychotic symptoms, number of years of education, or age at onset of illness. Vocational programs for persons with bipolar disorder would benefit from inclusion of a formal cognitive assessment to better assess work potential and to study the predictors of work-related outcomes.
Article
Cross-sectional study. To compare subjective health complaints in subacute patients with low back pain with reference values from a Norwegian normal population. Comorbidity is common with nonspecific low back pain. We wanted to investigate if these complaints were specific or part of a more general unspecific condition comparable to subjective health complaints in the normal population. The study group consisted of 457 patients sick-listed 8 to 12 weeks for low back pain. All subjects filled out questionnaires. The subjective health complaints in the study group were compared with reference values from a Norwegian normal population using logistic regression analysis. Compared with the normal reference population, the patients with low back pain had significantly more low back pain, neck pain, upper back pain, pain in the feet during exercise, headache, migraine, sleep problems, flushes/heat sensations, anxiety, and sadness/depression. The prevalence of pain in arms, pain in shoulders, and tiredness was also high, but not significantly higher than in the reference population. Our findings indicate that patients with low back pain suffer from what may be referred to as a "syndrome," consisting of muscle pain located to the whole spine as well as to legs and head, and accompanying sleep problems, anxiety, and sadness/depression.
Article
A recent increase in long-term sick leave (LTSL) in Sweden affects mostly women in the public sector. Depression-related diagnoses account for most of the increase, and work-related stress has been implicated. We examined dexamethasone/corticotropin-releasing hormone (dex/CRH) test responses, magnetic resonance imaging measures of prefrontocortical and hippocampal volumes, and cognitive performance in 29 female subjects fulfilling three core criteria: 1) LTSL > 90 days; 2) unipolar depression or maladaptive stress reaction with depressed mood; 3) job-related stress given as a reason for disability. This group was compared with 28 healthy matched controls. The cortisol response to CRH differed markedly between the two groups (p = .002), with a dampened response in patients. This difference remained after removing subjects on antidepressant drugs (p = .006) or smokers (p = .003). Neither hippocampal nor prefrontocortical volumes differed. Performance on hippocampus-dependent declarative memory tests did not differ between groups, but the LTSL group had impaired working memory. Our most salient finding is an attenuated dex-CRH response in patients on LTSL due to job-stress related depression. This is opposite to what has been described in major depression. It remains to be established whether this impairment is the end result of prolonged stress exposure, or a pre-existing susceptibility factor.
Article
Musculoskeletal disorders are among the most common causes of sickness absence, long-term incapacity for work and ill-health retirement. The number of Incapacity Benefit (IB) recipients in the United Kingdom has trebled since 1979, despite improvement in objective measures of health. Most of the trend is in non-specific conditions (largely subjective complaints, often with little objective pathology or impairment). Understanding incapacity requires a biopsychosocial model that addresses all the physical, psychological and social factors involved in human illness and disability. Rehabilitation should be directed to overcome biopsychosocial obstacles to recovery and return to work. These principles are fundamental to better clinical and occupational management and minimizing incapacity. Sickness absence and incapacity from non-specific musculoskeletal conditions could be reduced by 33–50%, but that depends on getting all stakeholders onside and a fundamental shift in thinking about these conditions—in health care, in the workplace and in society.
Article
Various risk factors associated with disability pensioning have been reported. This study investigated the relationship between the number of pain sites and risk of receiving a disability pension. We hypothesised that risk of work disability would increase as the number of pain sites increased, even after controlling for potential confounders. In 1990 and 2004, questionnaire on musculoskeletal pain was sent via post to six age groups in Ullensaker, Norway. Data on demographic, health and work-related variables were also collected. After excluding individuals due to reach retirement age in 2004, we followed 1354 (66%) persons who were classified in 1990 as "employed", "unemployed", "homemaker", or "student". Among them, 176 persons had received long-term or permanent work disability pension in 2004. Bivariate analyses showed that the prevalence of disability pensions was strongly associated with the number of pain sites. Controlling for gender and age almost unaltered the relationship. However, a model controlling for all significant confounders showed that general health and sick leave previous year captured almost all the predictive power of the number of pain sites on work disability. Since these variables could be seen as intermediate variables and not confounders, they were excluded in a new model which gave a strong "dose-response" relationship between number of pain sites and disability with a 10-fold increase from 0 to 9-10 pain sites. The predictive validity of the number of pain sites in determining future disability renders this simple measurement useful for future research on musculoskeletal pain and functioning.
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