Special communications: state-of-the-science on postacute rehabilitation: setting a research agenda and developing an evidence base for practice and public policy. An introduction

Rehabilitation of compensable workplace injuries: effective payment models for quality vocational rehabilitation outcomes in a changing social landscape

PURPOSE

With social and economic costs of workplace injury on the increase, efficient payment models that deliver quality rehabilitation outcomes are of increasing interest. This paper provides a perspective on the issue informed by both refereed literature and published research material not available commercially (gray literature).

METHODS

A review of payment models, workers' compensation and compensable injury identified relevant peer-reviewed and gray literature that informed our discussion.

RESULTS

Fee-for-service and performance-based payment models dominate the health and rehabilitation literature, each described as having benefits and challenges to achieving quality outcomes for consumers. There appears to be a movement toward performance-based payments in compensable workplace injury settings as they are perceived to promote time-efficient services and support innovation in rehabilitation practice. However, it appears that the challenges that arise for workplace-based rehabilitation providers and professionals when working under the various payment models, such as staff retention and quality of client-practitioner relationship, are absent from the literature and this could lead to flawed policy decisions.

CONCLUSIONS

Robust evidence of the benefits and costs associated with different payment models - from the perspectives of clients/consumers, funders and service providers - is needed to inform best practice in rehabilitation of compensable workplace injuries.

IMPLICATIONS FOR REHABILITATION

Available but limited evidence suggests that payment models providing financial incentives for stakeholder-agreed vocational rehabilitation outcomes tend to improve service effectiveness in workers' compensation settings, although there is little evidence of service quality or client satisfaction. Working in a system that identifies payments for stakeholder-agreed outcomes may be more satisfying for rehabilitation practitioners in workers' compensation settings by allowing more clinical autonomy and innovative practice. Researchers need to work closely with the compensation and rehabilitation sector as well as governments to establish robust evidence of the benefits and costs of payment models, from the perspectives of clients/consumers, funders, service providers and rehabilitation professionals.

Successful treatment of long-term, poststroke, upper-limb spasticity with onabotulinumtoxinA

BACKGROUND AND PURPOSE

Poststroke spasticity often negatively affects functional activities and daily living and frequently is accompanied by pain, abnormal limb postures, and contractures. The purpose of this case report is to describe the long-term benefit of botulinum toxin A in a patient with poststroke spasticity.

CASE DESCRIPTION

A 35-year-old woman with poststroke upper-limb spasticity who had lost function in her left hand was treated with onabotulinumtoxinA and physical therapy. Over 25 months, the patient received a physical therapy and occupational therapy program and received onabotulinumtoxinA injections into muscles of the left hand and arm, significantly reducing tone and facilitating recovery of function. Practical assessments, the Ashworth Scale, and electrophysiology were used to measure changes over time. No functional scales or dexterity scales were used to measure changes.

OUTCOMES

OnabotulinumtoxinA injections were discontinued when treatment goals were attained, and no further improvements were achieved. After more than 2½ years without further onabotulinumtoxinA treatments, the patient maintained range of motion and some functional use and dexterity in her left hand.

DISCUSSION

This case report illustrates the efficacy and long-term benefit of onabotulinumtoxinA, combined with physical therapy and occupational therapy, in the successful treatment of poststroke spasticity.