Systematic review
The effect of rehabilitation on social and community participation
Systematic review
|Updated
The aim of the systematic review was clarified and narrowed down to focus on the effect of rehabilitation for patients who are in need of services for social and community participation.
Key message
The Norwegian Knowledge Centre for the Health Services was commissioned by the Norwegian Directorate of Health to perform a systematic review of the scientific evidence concerning effects of rehabilitation on social and community participation among patients with reduced functional capacity. All patients were included regardless of their diagnosis. According to a parliamentary bill, rehabilitation is defined as: time-limited, planned processes with clear objectives and means, in which several parties cooperate to provide necessary assistance to the user’s own efforts to achieve the best possible coping and functional ability, independence and social and community participation.
We searched for controlled studies of effect in databases for medical research literature. The criteria for inclusion were:
- Population: patients with reduced functional capacity regardless of diagnosis
- Intervention: multidisciplinary interventions based on the patient’s own aims and needs, and where the patients actively participate in their own rehabilitation process
- Outcome: participation socially and/or in the community
The search identified 4876 references; we included three controlled clinical trials and three controlled before and after studies in this report.
The included studies differed regarding various aspects. The patients had different diagnoses, the professional groups that participated in the multidisciplinary teams varied, the types of patient’s participation and which social activities or ways of participating in the community that was addressed all varied between the studies. The studies had different study designs, although they all included a control group. According to the quality assessment tool used the studies were all evaluated to have unclear or high risk of bias.
The quality of the documentation for the effect of the intervention is too low for us to draw conclusions on whether rehabilitation contributes to the patients social and community participation. Whether the results can be generalised to other groups or other interventions is unclear. We need larger end better studies before a clearer conclusion can be drawn.
Summary
Background
The Norwegian Knowledge Centre for the Health Services was commissioned by the Norwegian Directorate of Health, Department of Rehabilitation and Rare Disorders, to conduct a systematic review of the scientific evidence of effects of rehabilitation on patients social and community participation among patients who have reduced functional capacity regardless of diagnosis. This mandate is in line with the Norwegian Parliamentary Bill No 1 (2007-2008), Chapter 9 “National strategy for habilitation and rehabilitation 2008-2011” whose goal it is to strengthen the rehabilitation field in Norway.
Through discussions with the commissioner, the aim of the systematic review was clarified and narrowed down to focus on the effect of rehabilitation for patients who are in need of services for social and community participation. Rehabilitation should be defined as: Time-limited and planned processes with clear objectives and means, in which several parties cooperate to provide necessary assistance to the user’s own efforts to achieve the best possible coping and functional ability, independence and social and community participation. Studies with other definitions of rehabilitation were not be included in the report.
The aim of this report was to address the question whether the patient participated in his/her own rehabilitation in collaboration with a multidisciplinary team, would affect the patient social and community participation.
Methods
We searched for systematic reviews and primary studies in July 2008 and in September 2009 in the following databases: The Cochrane library, CENTRAL, Cinahl, DARE, EMBASE, MEDLINE, PsycINFO and Sociological and Social Services Abstracts.
The inclusion criteria were:
Study design: systematic reviews, randomised controlled studies (RCT), clinically controlled studies (CCT), controlled before and after studies (CBA), interrupted time series (ITS).
Population: Patients with reduced functional capacity regardless of diagnosis
Intervention: The patient’s participation in their own rehabilitation should be clearly described and the patient should participate in a process with multidisciplinary and/or transectorial involvement based on the patient’s aims and needs.
Outcome: the patient’s social and community participation.
We excluded studies that had functional capacity but not socially or community participation as outcomes. We also excluded studies that did not have a multidisciplinary aspect because the patient only collaborated with the physician. We have not searched for studies that addressed the effect of patient participation at a system level, e.g. through patient’s organizations.
Results
The search for literature was performed 10.7.2008 and 16.9.2009. We identified 404 titles when searching for systematic reviews in the Cochrane Library, Medline and Embase, and 4 472 primary studies in CENTRAL, Cinahl, EMBASE, Medline, PsycINFO and Sociological and Social Services Abstracts.
We included six articles; three CCTs and three CBAs. All the studies were assessed to have unclear or high risk of bias. All studies assessed the effect of an individual patient participation in their own rehabilitation. The interventions and participants in the included studies were too different to consider combining results, hence descriptive presentation.
The quality of documentation for the one outcome; Social and community participation was assessed by GRADE and was very low quality for all the interventions. The lower the quality, the less confidence we should have in the results. However, due to very low quality we cannot draw conclusion on whether rehabilitation contributes to the patients social and community participation, and it is highly probable that further research will influence our confidence in the results and will likely change the results.
A descriptive presentation of the results from the six included studies:
- Patients with renal disease that received interdisciplinary collaboration and support and who participated in goal setting, perceived a positive impact on their health status, do some household tasks, gardening and fishing. This was not significantly more than the control group participants.
- Patients with neurological injuries who recruited to “increased participation” goal setting perceived the goals to be more relevant. There were no differences between groups in functional outcomes; all patients demonstrated a significant improvement in all measures. The functional outcomes included social activities.
- Patients with various diagnoses with need for rehabilitation, who participated in goal setting, perceived that they were active participants in the goal formulation process, and perceived themselves better able to manage after completing the rehabilitation compared with patients in the control group.
- Diabetic patients with prolonged self-management difficulties improved their health-related quality of life including physical and social functioning by participating in a programme which aimed to empower patients to set and attain their own treatment goals.
- Stroke patients that participated in developing an individual care plan improved in functional abilities and social factors compared to the control group.
- Patients with traumatic brain injury that participated in multidisciplinary rehabilitation, where the goals were reviewed weekly, demonstrated better function with time compared to patient treated at a local hospital with a single discipline approach.
None of the interventions resulted in statistically significant changes.
Discussion
We employed many terms to cover the inclusion criteria in the search for literature, we may have missed some relevant studies because of the complexity of the definition of rehabilitation. The combination of concepts may have lead to possible associations being left out.
The studies comprised various types of patient participation. Whether the use of other types of patient participation in the studies may have given different results is unclear.
The six included studies implied that when the patient participated in the process it might contribute to increased social and community participation. Only some of the results were significant compared to the control group. The type of social and community participation that was studied varied, in some of the studies the outcome was not specifically described, only as an element in a group of factors. Such circumstances emphasized the need for further research of good quality.
Conclusion
The quality of documentation for the results is too low for us to draw conclusions on whether rehabilitation contributes to the patients social and community participation. The six included studies comprise various types of patients, comparisons and outcomes. Whether the results can be generalised to other groups or other interventions is unclear. We need larger end better studies before a clearer conclusion can be drawn.