Neurologische Berufstherapie : Evaluation kognitiver Leistungsdaten und beruflicher Wiedereingliederungsverläufe bei neurologischen Patienten

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Neurological Vocational Rehabilitation - Evaluation of Cognitive Assessment Data and Return to Work in Brain Damaged Patients
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Zusammenfassung

The vocational rehabilitation of neurological patients with cognitive disabilities is often difficult, even with those patients, whose deficits do not seem to be too severe.
By developing a specific rehabilitation program that prepares patients for their return to work within a clinical treatment setting the patients chances to reintegrate vocationally should be improved.
In order to find out how successful these job-related therapeutic interventions are, how cognitive disabilities interfere, how long return to work takes und to which extent a successful reintegration depends on the occupational status, neuropsychological and outcome data of patients who received a vocational therapy were evaluated.

Patients, whose place of work was preserved when starting the vocational therapy and who showed cognitive disorders according to a neuropsychological test battery in at least one attention-, memory- or intelligence subtest, were prepared individually for their return to work.
By comparing the special job requirements of each patient to the profile of his or her neuropsychological deficits job-related cognitive abilities, e.g. number processing or text comprehension, were trained. Specific (knowledge) resources, e.g. to handle a professional computer program, were proved. Compensatory means and adaptive strategies were developed prospectively to be used at one s individual place of work.
At the end of this vocational therapy patients were recommended how to start their return to work. Those patients who were recommended to start a stepwise work trial at their former place of work received written recommendations concerning the daily working time they should start with and how to increase this time step by step. On the task level these patients were also recommended with which (sub)task under which working conditions they should start their work trial.
The outcome of those patients who were recommended to reintegrate to their former place of work was evaluated about 12 months after discharge.

Out of 107 patients (52 female; age median: 47; 65 patients with cerebrovascular etiology; median time post onset: 8 months) 79 patients were recommended to return to work mostly by starting a graded work trial. The majority of these patients followed this recommendation and most of them were successful in returning stepwise to their former place of work. 58 patients managed to restart work.
Only one of those 28 patients who were not recommended to return to work because of insufficient recovery managed to regain his former work place.

By comparing cognitive test data of the 59 patients whose vocational reintegration was successful to the data of the 48 patients who did not manage to return to their former place of work significant differences in various subtests were found: the successful subgroup performed better.

A discriminant analysis showed that a few attention and memory tests discriminated best between the two subgroups (70 % correct re-classification with crossvalidated cases).
The outcome of vocational reintegration was not influenced by age and etiology, but some gender and education effects were observed:
Female patients were less successful concerning their vocational reintegration though their cognitive performance was higher than that of the male subgroup.
The patients with the lowest degree of education (8-9 years of schooling) were less successful too, but the comparison of their cognitive test data to those of the better educated subgroups revealed poorer results in the less educated subgroup.

The temporal distribution of vocational reintegration indicated that about one third of the successful reintegrated patients returned to work already between 6 and 8 months post onset, while another third needed more time: about 18 months post onset.

The occupational status of patients was described by formation (different types of schooling vs. university degree) and different job requirements (mainly physical vs. mainly cognitive/ socio-communicative vs. mainly cognitive / technical). Analyzing the distribution of successful and unsuccessful vocational rehabilitation on these occupational groups no clear effect was found.

Differences of cognitive performance as well as gender, education and some time post onset aspects may support the prediction of vocational outcome in brain-damaged patients. But these prediction variables will not be sufficient on the single case level. By analyzing the individual professional requirements, deficits and resources, by developing job-specific trainings and by planning suitable steps of reintegration a patient´s return to work can be supported more efficiently.

Zusammenfassung in einer weiteren Sprache

Die berufliche Wiedereingliederung neurologischer Patienten mit kognitiven Funktionsstörungen ist ein wesentliches Rehabilitationsziel, das häufig trotz umfassender klinischer Therapiemaßnahmen nicht erreicht wird.
Dargestellt und evaluiert wird ein Therapiekonzept, in dem das aktuelle Leistungsprofil eines Patienten auf sein individuelles berufliches Anforderungsprofil bezogen wurde. Die beobachteten kognitiven Defizite eines Patienten wurden auf ihre funktionale Relevanz für die Ausführung seiner beruflichen Anforderungen bewertet, um mögliche Behinderungen am Arbeitsplatz zu antizipieren. Auf der Basis eines solchen Profil-Abgleichs wurden berufsbezogene, therapeutische Interventionsmaßnahmen entwickelt, welche die Vorbereitung des einzelnen Patienten auf seine berufliche Reintegration beinhalten: Training beeinträchtigter berufsrelevanter Leistungen / Erprobung beruflicher Leistungsressourcen / Entwicklung berufsrelevanter Kompensations- und Adaptationsmöglichkeiten.

In einer Katamnese-Studie wurde erhoben, inwieweit die berufliche Wiedereingliederung erfolgreich war.
Die Patienten-Stichprobe umfasste 107 Patienten (weibl.: 52, Altersmedian: 47 Jahre, Patienten mit cerebrovaskulärer Ätiologie: 65, mittlere Zeit nach Ereignis: 8 Monate,) die mit der Zielsetzung einer möglichst zügigen beruflichen Reintegration an den bisherigen Arbeitsplatz behandelt wurde.
Alle Patienten verfügten über einen Arbeitsplatz und damit die gesetzlich verankerte Möglichkeit einer stufenweisen Wiedereingliederung (§ 74 SBG V, § 28 SBG IX).

Alle 107 Patienten nahmen an einer umfangreichen neuropsychologischen Gruppentestung teil.
86 Patienten wurden zusätzlich zu Beginn und am Ende der berufsbezogenen, neurokognitiven Therapie auf ihre Leistungsfähigkeit im Bereich Textverstehen geprüft.
Für 57 Patienten wurden außerdem Daten zur Zahlenverarbeitungs- und Rechenleistung erhoben, wiederum bei Therapiebeginn und ende.

Bei Therapie-Ende erhielten 79 Patienten eine berufliche Reintegrationsempfehlung, überwiegend für eine therapeutisch vorbereitete stufenweise Wiedereingliederung. 28 Patienten hatten aufgrund ihrer Therapieergebnisse keine Empfehlung für einen unmittelbaren beruflichen Wiedereinstieg erhalten. Nur einem dieser Patienten gelang die berufliche Reintegration.
Insgesamt gelang 59 der 107 Patienten die Rückkehr an den bisherigen Arbeitsplatz.

Die erfolgreiche Subgruppe erreichte ihre Wiedereingliederung ins Berufsleben in einem Zeitraum von 18 Monaten nach dem Hirnschädigungsereignis.
Etwa einem Drittel dieser Patienten gelang die Wiedereinarbeitung sogar in einem Zeitraum von 6-8 Monaten.

Aus der neuropsychologischen Basisdiagnostik ergaben sich nach Durchführung einer Diskriminanz-Analyse als Prädiktoren für eine beruflich erfolgreiche Rehabilitation verschiedene Aufmerksamkeits- und Gedächtnisvariabeln (Subtest 6 der Wechsler-Memory-Scale, der Gedächnisleistungen für figurales Material abprüfte, diejenige d2-Variable, die den Geschwindigkeitsaspekt innerhalb der visuellen Aufmerksamkeitstestung messen sollte, und die Variable des Revisionstest, die über Fehlerhäufigkeit und Sorgfalt bei der Bearbeitung der Konzentrationsaufgabe Aufschluss geben sollte). Die Reklassifizierungsrate betrug dabei rund 70%.

Die Zugehörigkeit zu einer von acht Berufsgruppen, die nach Ausbildung (betrieblich vs. schulisch vs. Studium) und Art der vorrangigen Anforderung (motorisch vs. kognitiv-sprachlich-sozial vs. kognitiv-technisch) unterschieden wurden, erwies sich für die Ergebnisse beruflicher Wiedereingliederung als eher nicht wesentlich.
Auch Alter und Ätiologie waren keine relevanten Einflussgrößen.

Die weiblichen Patienten jedoch reintegrierten sich weniger erfolgreich als die männlichen Patienten, obwohl sie bessere kognitive Leistungen zeigten: bei Anforderungen des verbalen Gedächtnisses und quantitativen Aspekten des Textverstehens erzielten die Patientinnen bessere Resultate.

Auch bei der Prüfung der Variable Bildung ergaben sich Unterschiede: die Patienten mit geringerem Bildungsgrad (Hauptschulabschluss) waren weniger erfolgreich reintegriert als die Patienten mit höherem Bildungsgrad (mittlerer Schulabschluss und Abitur zusammengefasst).

Insgesamt ist die Wiedereingliederungsrate von 55% aller berufsorientiert behandelten Patienten, die trotz kognitiver Leistungsdefizite an ihren bisherigen Arbeitsplatz zurückkehrten, als Hinweis für die Effektivität der neurologischen Berufstherapie zu werten.
Dabei ist der zeitliche Aspekt der Behandlungsmethode, die berufliche Wiedereingliederung möglichst frühzeitig, integriert in die Phase medizinischer Rehabilitation, einzuleiten und unter Nutzung von Maßnahmen wie stufenweiser Wiedereingliederung innerhalb des 18-Monate-Zeitraums abzuschließen, besonders hervorzuheben. Etwa 75% derjenigen Patienten, denen eine stufenweise Wiedereingliederung empfohlen wurde, hatten sich erfolgreich wieder eingearbeitet.

Fachgebiet (DDC)
150 Psychologie
Schlagwörter
Stufenweise Wiedereingliederung, Neurokognitive Leistungsdefizite, Neurological Rehabilitation, Return to Work, Cognitive Disabilities, Vocational Rehabilitation
Konferenz
Rezension
undefined / . - undefined, undefined
Zitieren
ISO 690CLAROS-SALINAS, Dolores, 2004. Neurologische Berufstherapie : Evaluation kognitiver Leistungsdaten und beruflicher Wiedereingliederungsverläufe bei neurologischen Patienten [Dissertation]. Konstanz: University of Konstanz
BibTex
@phdthesis{ClarosSalinas2004Neuro-11043,
  year={2004},
  title={Neurologische Berufstherapie : Evaluation kognitiver Leistungsdaten und beruflicher Wiedereingliederungsverläufe bei neurologischen Patienten},
  author={Claros-Salinas, Dolores},
  address={Konstanz},
  school={Universität Konstanz}
}
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