Ciran Rehabilitation,

Agali Mert (amert@ciran.nl)

Alexander Garschagen

Improving health experience and RTW in patients with chronic pain

and fatigue: clinical effectiveness of bio-psycho-social-spiritual

rehabilitation.

CIRAN• CIRAN: Outpatient Centres for Integrated Rehabilitation and Occupational Activation

with multi-specialist care (The Netherlands).

• Is a foundation

• 5500 patients per year

• 19 out-patient facilities

• 500 employees, 4 physiatrists (of which two retired colonels )

• 7000 teleconferences per year

• Paper free environment

Ciran continued• 40% coverage of outpatient rehabilitation in The Netherlands

– Focus on chronic pain, fatigue, dysfunctioning, oncology, endocrinological problems

• Academic partner of Radboud University Nijmegen

• Rolling out serious gaming– LAKA: serious game on coping strategies

– CAREN motion platform

• 2017 Social Robotics– Structured interviewing combining psychophysiological, visual, EPF data

• 2017 E-health– EPF data, teleconferences, AI-datamining

• Dutch DoD project: spiritual leadership course

Ciran, 19 outpatient clinical facilities in the Netherlands

A few notes on the rehabilitation process

‐ Rehabilitation literally means “redressing” (Latin habitat – dress).

‐ To redress = to set right or repair.

‐ WHO has defined rehabilitation as:

“a process aimed at enabling disabled people to reach and maintain their optimal physical, sensory, intellectual, psychological and social functional levels. Rehabilitation provides disabled people with the tools they need to attain independence and self-determination.”

Rehabilitation

‐ The aim of Rehabilitation has traditionally been seen as facilitating the normalization of human functioning after injury, disease, or due to congenital defects. (bio-psycho-social)

Rehabilitation

The ability to transform oneself and others:

‐ by developing courage in order to better deal with uncertainty

‐ by the training of strength in overcoming adversity

‐ by increasing insight into the ever changing aspects of existence

‐ by striving for the happiness in oneself and others,

‐ by becoming convinced of positive outcomes and

‐ by living with confidence and energy in an open-minded and open-hearted way.

bio-psycho-social-spiritual rehabilitation.

Autonomy, mastery, purpose, solace,connection, meaning, pupose in midst of suffering

“Health is the individual art of reaching the personal, physical, mental and social balance again by being able to anticipate and react to events and

interactions in their own environment"

CIRAN’s definition of (positive) health

Other definitions: e.g. The ability to adapt and self manage, in the face of social, physical and emotional

challenges.

Positive health: covers a.o. autonomy, environmental mastery, personal growth, positive relations with others, having a purpose in life, and self-acceptance

Treatment frame- IT controlled

- e.g. Portals have to be finished before continuation of therapy is possible.

- Integral disciplinary treatment teams

- Psychologist also does physical sessions.

- Bio-Psycho-Socio-Spiritual

- Physiatrist, PT, PS and Spiritual counsellor

- Outcome-driven

- Highly protocolled

- 16 weeks (2x8) program, Treatment modules: neuroplasticity, Transformative dynamics, coping etc.

- appr. 10 hrs analysis prior to start treatment.

- Patients know their complete treatment program from day one on. They know what expect from

us, and they know what we expect from them.

- Therapists follow post-graduate mandatory training which they have to pass

Patient

Patient

Alleviating

pain and

fatique

Alleviating

pain and

fatiqueParticipation

Ciran perspective

Clinical perspective

Mediating and final objective Secondary objective

Mediating objective Final objective

Treatment strategy

Fordyce WE (1976). Behavioral Methods for Chronic Pain and Illness. Saint Louis. The C.V. Mosby Company,

Frank JD, Frank JB (1993). Persuasion and Healing. A Comparative Study of Psychotherapy Baltimore, The John Hopkins University Press.

Bellissimo, A, Tunks E (1984). Chronic Pain. The Psychotherapeutic Spectrum. New York Prager Publishers

Flor H, Turk DC (2011). Chronic pain: An Integrated Biobehavioral Approach. Seattle: IASP press.

Lebow JL (ed) (2008). Twenty-First Century Psychotherapies. Contemporary Approaches to Theory and Practice Hoboken, John Wiley and Sons

Participation

Input Process Outcome

Explanation Models:

Diagnostics & Treatment

Health Status:

- Pain and fatigue-Participation- Well-being

Patient Groups:

- Chronic pain - Chronic fatigue- Oncology

Diagnostics and treatment process (1)

Bio

Psycho

Social

Existential insights

Exercisetherapy, graded activity, graded exposure, breathing (relaxation exc.)

Cognitive behavioral reflection

Participation objectives

Therapeutic coaching

Confidence in capacities

Confidence in future perspectives Zelf-

management

Participation

Symptoms Well-being

Mental balance (resilience)

Mental balance (resilience)

Diagnostics and treatment process (2)

For therapeutic coaching see:

Cooper M (2012) Existential Therapies .SAGE Publications Ltd, London.

Van Deurzen E, Adams, M (2011) Skills in Existential Counselling & Therapy. SAGE Publications Ltd, London

Van Deurzen E (2002) Existential Counselling & Psychotherapy in Practice (SAGE Publications Ltd, London).

Care needs index

Diagnostics and treatment process (3)

Unpredictable environment

Predictable environment

Social judgements infused with negative affect

Social judgements infused with positive affect

Mental balance Participation

P

S E

P

S E

P

S E

P

S E

S = SymptomsE = Existential well-beingP = Participation

What we hope to see

Emotions and cognitions

Dealing with

challenges and changes

Diagram adapted from:

Garschagen, A Steegers, M

Van Bergen A, Jochijms J,

Skrabanja T, Smeets R,

Vissers K:

Pain Pract. 2015

Sep;15(7):671-87

Kent M, River CT, Wrenn G:

Goal-Directed Resilience in

Training (GRIT): A

Biopsychosocial Model of Self-

Regulation, Executive

Functions, and Personal

Growth (Eudaimonia) in

Evocative Contexts of PTSD,

Obesity, and Chronic Pain

Behav. Sci. 2015, 5, 264-304

Results

Excluded from treatment: 1.226 (=14%)

Referred

clients

in 2013 - 2014:

8.889 (=100%)

Included in rehabilitation:

7.663 (=86%)

ITT

Stops duringtreatment:

1.266 (= 14%)

Completedtreatment:

6.397 (= 72%)

CT

Client flow

Completeness, accuracy and statistical analyses audited by Profess BV and Osinga Actuarial Consulting BV in commission of Radboudumc , January 2016

Predominant

symptom(s)

Fatique:

2.226 (=29%)

Pain/fatique:

5.098 (= 67%)

Other:

339 (=4%)

Socio-

demographics

Female:

67%

Age(mean):

44

Education:

M/H: 78%

Working:

79%

Working:

79%

No absence:

14%

Partly absent:

20%

Fully absent:

45%

Background characteristics

Health experience

Improved:

70% ITT (84% CT)

No change ordeteriorated:

30% ITT (16% CT)

Return to workFully:

44% ITT

(52% CT)

Partly:

33% ITT

(36% CT)

No RTW:

23% ITT

(12% CT)

Subgroup with long absence: 35% no RTW

Main results

1. 84% of clients who complete treatment improve

2. Large observational effect sizes in prolongued fatigue, pain intensity and pain cognitions (pre post standardized mean differences > 1)

3. Benefits of RTW instead of Qualys serve as operational indicator for cost-effectiveness. (Client: income. Employer: productivity and wages. Disability insurer: deferred payments. Health insurer: ?)

4. Important caveat: results measured directly post treatment

Summary

Schultz IZ, Stowell AW, Feuerstein M, Gatchel RJ. (2007), Models of return to work for musculoskelletal disorders. J Occup Rehabil. 2007 Jun;17(2):327-52.

Gatchel RJ, Okifuji A ( 2006). Evidence-Based Scientific Data Documenting the Treatment and Cost-Effectiveness of Comprehensive Pain Programs for Chronic Nonmalignant

Pain. The Journal of Pain, Vol 7, No 11 (November), 2006: pp 779-793

Thank you