http://informahealthcare.com/dre ISSN 0963-8288 print/ISSN 1464-5165 online Disabil Rehabil, 2015; 37(6): 499–505 ! 2014 Informa UK Ltd. DOI: 10.3109/09638288.2014.923531

RESEARCH PAPER

Returning to work – a long-term process reaching beyond the time frames of multimodal non-specific back pain rehabilitation Therese Hellman, Irene Jensen, Gunnar Bergstro¨m, and Hillevi Busch

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Unit of Intervention and Implementation Research, Division of Occupational and Environmental Medicine, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden Abstract

Keywords

Purpose: To explore and describe health professionals’ experience of working with return to work (RTW) in multimodal rehabilitation for people with non-specific back pain. Method: An interview study using qualitative content analysis. Fifteen participants were interviewed, all were working with multimodal rehabilitation for people with non-specific back pain in eight different rehabilitation units. Results: The participants experienced RTW as a long-term process reaching beyond the time frames of the multimodal rehabilitation (MMR). Their attitudes and, their patients’ condition, impacted on their work which focused on psychological and physical well-being as well as participation in everyday life. They often created an action plan for the RTW process, however the responsibility for its realisation was transferred to other actors. The participants described limited interventions in connection with patients’ workplaces. Conclusions: Recommended support in the RTW process in MMR comprises the provision of continuous supervision of vocational issues for the health care professionals, the development of guidelines and a checklist for how to work in close collaboration with patients’ workplaces and employers, the provision of long-term follow-up in relation to the patients’ work, and the development of proper interventions in order to promote transitions between all the different actors involved.

Back pain, return to work, vocational rehabilitation History Received 29 November 2013 Revised 5 May 2014 Accepted 8 May 2014 Published online 4 June 2014

ä Implications for Rehabilitation  



Rehabilitation programs targeting return to work (RTW) for people with non-specific back pain needs to include features concretely focusing on vocational issues. Health and RTW is often seen as a linear process in which health comes before RTW. Rehabilitation programs could be tailored to better address the reciprocal relationship between health and work, in which they are interconnected and affect each other. The RTW process is reaching beyond the time frames of the multimodal rehabilitation but further support from the patients are asked for. The rehabilitation programs needs to be designed to provide long-term follow-up in relation to the patients’ work.

Introduction Back pain is a common health problem. The 1-year prevalence of low back pain was estimated to range from 0.8 to 82.5% [1], and ranged from 48% to 79.5% in neck pain [2]. Musculoskeletal disorders, in which back pain is included, account for 26% of all long-term sick leave (defined as more than 60 d of sick leave) in Sweden [3]. Furthermore, long-term back pain often exerts a negative impact on participation in everyday activities. One study found that people with back pain or stress perceived participation restrictions in twice as many everyday activities as did a reference group from the Swedish population [4]. In a sample of 152 people

Address for correspondence: Therese Hellman, PhD, Reg. Occupational Therapist, Unit of Intervention and Implementation Research, Division of Occupational and Environmental Medicine, Institute of Environmental Medicine, Karolinska Institutet, Box 210, 171 77 Stockholm, Sweden. Tel: +468 524 837 52. E-mail: [email protected]

with long-term pain, it was found that the majority identified problems in performing activities related to productivity (85%), self-care (77%) and leisure activities (78%) [5]. Results from previous research thus highlight the significant consequences long-term pain implies in everyday life. Harker et al. [6] conclude, in a review of the epidemiology of long-term pain, that it is a common health problem that needs to be addressed by various stakeholders such as healthcare workers, policy makers and researchers. To meet rehabilitation needs and to reduce the large number of people on sick leave, a rehabilitation warranty was introduced by the Swedish government in 2008 to provide financial support for evidence-based rehabilitation [7]. The rehabilitation warranty is available to individuals between 16 and 67 years of age who are expected to return to work (RTW) or remain at work after completing a multimodal rehabilitation (MMR) programme. Today, there is evidence in place for the effectiveness of MMR concerning people with back pain in terms of reducing symptoms,

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disability and sick leave [8,9] and cost-effectiveness [10] up to 10 years after the intervention [11], and thus the intervention is supported by the rehabilitation warranty in Sweden. Compared to other treatments, MMR is not superior in its pain-relieving effects [12]. The MMR conducted within the Swedish rehabilitation warranty is delivered by a team of various professionals and includes psychological, pedagogical and physical features and is grounded in the biopsychosocial model which places emphasis on the individual, the psychological factors related to the health problem, the actual health problem and the social context [13]. The primary aim of the rehabilitation warranty for people with non-specific back pain is to increase the RTW rate and reduce sickness absence. The effectiveness of the rehabilitation warranty has previously been evaluated and findings indicate that perceived health and work ability increased [14] and anxiety and depression decreased [15]. However, any effects on total reduced sickness absence were not identified [14,15]. Health professionals’ perceptions of RTW have previously been studied and it has been found that work ability is regarded in connection to a variety of factors in everyday life [16]. Further, it is indicated that health professionals strongly emphasise the importance of focusing rehabilitation on aspects that improve the patient’s well-being and quality of life. RTW might then be a possible, but not a necessary, feature of rehabilitation [16,17]. A study focusing on the process of implementing the rehabilitation warranty in Sweden supported these findings as it was found that the professionals who worked with MMR tended to apply a client-centred focus rather than emphasising the goal of the rehabilitation warranty [18]. This is given as one possible explanation for the modest effect the rehabilitation warranty has exerted on reduced sickness absence [14,15,18]. However, previous research has found that focusing on the patient’s everyday life is important in efforts aimed at reducing sickness absenteeism and in increasing RTW as well-functioning everyday life can promote RTW [19,20]. Still, other research has shown that patients may also experience uncertainty about how to proceed with the process of RTW after rehabilitation is completed [21], particularly when there has not been a clear connection between features in the rehabilitation and the patients’ work situations [22]. Furthermore, a systematic review identified that interventions that included structured meetings of employee, employer and health professional, that took up planning and agreements regarding suitable work modifications, appeared to be more effective in the promotion of RTW in people with back pain on long-term sick leave than the interventions that do not include these features [23]. In summary, health professionals do not traditionally focus their interventions on primarily vocational issues. However, as a consequence of the implementation of the rehabilitation warranty, the focus on facilitating RTW increased in rehabilitation. There is a need to develop scientific knowledge on how health professionals experience the introduction of the strong emphasis on RTW that emerged due to the introduction of the rehabilitation warranty, and how they have implemented the new guidelines in their clinical practice. The aim of this study was to explore and describe health professionals’ experience of working with RTW in MMR for people with non-specific back pain.

Methods Design This exploratory qualitative study is part of a larger project focused on identifying factors in multimodal pain rehabilitation that contribute to successful rehabilitation and RTW. The project also includes quantitative studies that are based on

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questionnaires focusing on the characteristics of the rehabilitation programmes and the health professionals’ attitudes to RTW, improved health and evidence-based practice. In addition, register data of sickness absence rates is used in order to examine which factors influence rehabilitation outcome in terms of reduced sickness absence rates. Using this design, the project will gain significant knowledge about the factors that facilitate RTW in MMR. Preliminary results indicate that the length of the rehabilitation programme, the rehabilitation team approach to the importance of their patients regaining health, whether the teams discuss evidence in their workplace and the patients’ amount of sickness absence in the three-month period before rehabilitation are factors that influence the results of rehabilitation [24]. This article focuses on the qualitative part of the project. The study was approved by the Regional Ethics Committee in Stockholm, Sweden (Reg. No. 2009/1750-31/1 & 2012/1773-32). Participants The sample consisted of 15 participants who worked with multimodal pain rehabilitation in seven rehabilitation units financed by the rehabilitation warranty in three county councils. The participants were selected by purposive sampling in collaboration with the rehabilitation unit process leaders in the three county councils to include a variety of participants regarding professional background and years of vocational experience. Criteria for inclusion were: (1) working with MMR financed by the rehabilitation warranty, (2) at least 6 months of professional experience in multimodal pain rehabilitation, and (3) able to understand Swedish and to share their experiences. The process leaders provided the first author with contact information on eligible individuals. The first author sent an invitation and information about the aim of the study to eligible subjects. At the time of the interviews they were once again informed verbally about the study and that they could withdraw at any time, and they gave their written informed consent. The participants (12 women and 3 men, age range 32–65 years old, mean age 52 years old) worked in MMR programmes that lasted for between four to eleven weeks with varying intensity. The patients attended rehabilitation sessions 2–5 times/week. A summary of participant characteristics is given in Table 1. Data collection The interviews were conducted by the first author at the participants’ workplaces, in private office space. Each participant was interviewed once and the interviews lasted 55–80 min. The interviews were semi-structured and based on an interview guide. The guide was developed based on guidelines by Kvale and Brinkmann [25] for how to create interview guides for semistructured interviews. The interviews focused on two themes in order to cover the research questions and the aim of the study. These were the participants’ experiences of working with the multimodal pain rehabilitation included in the rehabilitation warranty and their experience of working with aspects regarding RTW. Open-ended questions were asked during the interviews, e.g. ‘‘Please, tell me about your practical work within the multimodal pain rehabilitation’’, ‘‘Tell me about your experience of working with issues regarding RTW’’. In order to obtain in-depth information regarding the participants’ practical experience, follow-up questions were asked during the interviews [25]. Two pilot interviews were performed in order to test the interview guide, and minor changes were made in the structure of the interview, however the questions did not change. All interviews were recorded digitally and transcribed verbatim.

Return to work – a long-term process

DOI: 10.3109/09638288.2014.923531

Table 1. Participants’ characteristics.

Participants

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Anna Susanne Marie Daniel Sara Sofie Hanna Anders Gunilla Louise Eva Julia Josefine Erik Mona

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Table 2. Description of the theme, categories and sub-categories that are based on the participants experiences.

Profession

Years qualified

Years working with pain rehabilitation

Occupational therapist Physiotherapist Social worker Physician Occupational therapist Psychologist Physiotherapist Physician Social worker Psychologist Occupational therapist Occupational therapist Physiotherapist Physician Physiotherapist

9 29 34 20 35 4 19 38 30 2 26 37 30 30 13

2.5 20 3 7 3 3 3 3 7 1 26 13 10 17 13

Analysis The material was analysed using qualitative content analysis [26]. Initially, all transcribed interviews were read several times to grasp the content of the material, and meaning units that included aspects concerning the aim of the study were marked. As a second step, the meaning units were labelled with codes using terms that were close to the participants’ own wording. Codes identified in the separate interviews were then compared with each other and consolidated into categories. The credibility of the results was facilitated through triangulation of investigators as both the first and last author were involved in the analysis process and met several times to discuss the categories and alternative divisions of the codes thoroughly [27]. When the categories were agreed upon, the categories from each interview were compared in order to identify similarities and differences across all interviews. In this phase, new categories that were on a more abstract level were developed and more concretely described in sub-categories. A theme that described the findings on a more general level was identified. To further ensure credibility, the categories were constantly compared with the transcribed interviews to confirm that the categories compiled corresponded to the separate transcripts. Furthermore, in order to enhance the dependability of the results and to ensure that the analysis was consistent over time, the analysis process was performed over an extended period which enabled a repeated review of the results after a few weeks. All the authors also met on a regular basis during the analysis process to discuss the emerging codes and categories [27].

Results The analysis identified four categories that described the participants’ experience of how various aspects influenced their interventions targeting RTW, and their experience of how they worked practically with facilitating the RTW process in the MMR. Based on the categories and sub-categories, the theme Return to work – a long-term process reaching beyond the time frames of multimodal rehabilitation was formulated. An overview of the theme, categories and sub-categories is shown in Table 2. Return to work – a long-term process reaching beyond the time frames of multimodal rehabilitation The participants described how RTW often pervaded the entire rehabilitation programme even though it was an extended process. Due to their patients’ conditions, the participants described how

Return to work – a long-term process reaching beyond the time frames of multimodal rehabilitation The professionals’ attitudes directed features within rehabilitation Promoting health and well-being Conflicting interests between implicit attitudes and explicit guidelines The patients’ needs and conditions directed features within rehabilitation The multimodal rehabilitation created a foundation for a continuous return to work process Improving conditions for returning to work Creating a sustainable action plan A coherent link with external actors facilitated the return to work process Enabling collaboration Creating continuity in contact

they mostly focused on the patients’ psychological and physical well-being, as well as their participation in everyday life. These aspects were, however, considered to facilitate the patients’ ability to RTW as a secondary consequence. The participants viewed RTW as a long-term process that was seldom completed within the time frames of the MMR and thus reached beyond its time frame. The professionals’ attitudes directed features within rehabilitation This category contains two sub-categories and describes the participants’ attitudes to their responsibility as healthcare professionals in medical rehabilitation in relation to their responsibility to the rehabilitation warranty. This was identified as aspects that influenced their work in facilitating their patients’ RTW process. The first sub-category illustrates that the participants experienced how their primary task was to provide medical rehabilitation with the aim of Promoting health and wellbeing. For some patients this implied a pronounced focus on RTW but for others it was not the focus at all. Some participants even described how focusing on vocational issues could negatively influence their relationship with the patients and evoke feelings of stress. We are very careful about focusing too much on return to work at the beginning as we see that it frightens the patients, they feel immediate pressure. It’s not fair to start talking about work when they are here to start working with themselves. Mona Other participants described how they regularly directed discussions towards vocational issues. They experienced these discussions as valuable as the patients’ initiated their thought processes and thus began their long-term progress towards RTW. The second sub-category Conflicting interests between implicit attitudes and explicit guidelines describes how the participants experienced a conflict between their own attitudes and the aim of the Swedish rehabilitation warranty. Positioned between their inner attitudes and their external task, to promote RTW, was sometimes experienced as frustrating and stressful. This is about two worlds meeting up. What we want to do, within health care, our mission is really to, the goals within health care practice are not in line with the goals of the

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rehabilitation warranty. They just don’t line up, they’re almost incompatible as I see it. Josefine Even though some participants experienced this inner conflict, most of them described methods of handling it. For example, they reminded themselves that the rehabilitation had a positive impact on patient health and well-being, they focused on issues that they believed increased their patients’ work ability in the long run, and they shifted the responsibility for issues regarding RTW onto other actors.

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The patients’ needs and conditions directed features within rehabilitation The participants described that one of the most important features within rehabilitation was to meet patients’ individual needs. This is illustrated in the second category, which describes how participant perceptions of patients’ individual needs and conditions influenced the focus of their interventions in the MMR. The participants described that their patients were often far from accessing the labour market and that starting a RTW process during the rehabilitation programme was sometimes unrealistic. The participants expressed that their assignment was to support the patients in their current situations and to facilitate their feelings of self-worth, even though they were not working. It’s very important to be able to support the person, to assure them that they are still appreciated even if they cannot work, they are appreciated when it is really impossible for them (to return to work), otherwise there will of course be a great deal of suffering, because most of them feel very guilty when they are not able to work. Julia The participants were aware that patients on long-term sickness absence should not, per se, be included in the rehabilitation warranty. Still, some participants justified their inclusion by concluding that even though they did not get the patients back to work they did increase their health and well-being. Multimodal rehabilitation created a foundation for a continuous RTW process This category describes how participant perceptions and the patients’ conditions influenced the practical interventions in the MMR. The participants described how their focus was directed towards increasing participation in everyday life and psychological well-being in order to promote RTW in the distant future. This is further described in the following two sub-categories. The first sub-category, Improving conditions for returning to work, illustrates how the participants focused their interventions on aspects that were considered to promote RTW as a secondary consequence. The participants experienced that these aspects needed to be in focus before RTW was a realistic aspect on which to place the spotlight. They described how they focused their interventions on issues traditionally related to their own professions. The interventions could, for example, target changes in psychological functions, increases in physical activities or participation in social or leisure activities in everyday life. The overall goal everyone (in the team) has is return to work so // then maybe you can also have a goal concerning, for example, acceptance, which will facilitate everything, including a return to work. Louise In cases where the patient was closer to the labour market, the participants described how their interventions were characterised by a more pronounced focus on the RTW process. Still, they

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described how they seldom had the opportunity to support their patients after completed rehabilitation and this was experienced as an obstacle for successful RTW. Few examples where participants were able to support their patients when they returned to work were given. The ability to actively support their patients in the transition from rehabilitation to the workplace was expressed as a valuable feature of rehabilitation. Patients often say that it’s very important for them to have our support when they are just beginning, because it is easy to have small setbacks just when you start work again; if they had completed their rehabilitation a few weeks earlier they didn’t have any support to fall back on. Hanna It was thus only possible in exceptional cases to support patients in their long-term process and the participants experienced frustration at not being able to provide proper support. Instead they focused on initiating the RTW process and creating an action plan for this. The second sub-category, Creating a sustainable action plan, further describes how the participants theoretically worked together with their patients in order to strengthen their longterm action plan for RTW. They described the importance of creating a plan that also ensured patients’ health and well-being. This implies that the participants sometimes recommended that the patients slow down their processes towards RTW. In other cases, the participants needed to motivate their patients to focus on RTW. Trying to get them motivated to want to start to participate in some activity and work // you can see it a bit like turning things around a little. Sara The explicit focus was on creating the plan and not on supporting the patients in performing it. Rather, the participants described that other actors, such as the Social Insurance Office or Employment Service, were to provide the operational support in the phase after completed MMR. One important task that was highlighted by the participants was that of supporting the patients in establishing contact with representatives from these authorities. They experienced that facilitating a coherent link between rehabilitation and the actors that would take over reduced the risk of discontinuing the process of RTW after rehabilitation. A coherent link with external actors facilitated the return to work process This category describes the interaction with other actors as an important part of the participants’ work. These two sub-categories focus on the participants’ attitudes towards collaboration and their practical experience of this collaboration. The first sub-category, Enabling collaboration, illustrates that the participants were, in general, positive about this collaboration and they mostly tried to arrange meetings with the other actors during the MMR. They described the collaboration as a prerequisite for the patients continued process towards RTW. Then (when the rehabilitation period is completed), there must be a plan or you must know that the Social Insurance Office will take over now and take care of this person and accompany them to the Employment Service and that there is a plan. Anna However, when this collaboration did not work it could also be a potential obstacle to the patients’ progress in the process.

DOI: 10.3109/09638288.2014.923531

The collaboration was sometimes described as hindered by the various actors not understanding each other’s perspectives and languages. The second sub-category describes that Creating continuity in contact with other actors promoted the patient RTW process. The participants described how getting to know the people from the Social Insurance Office or the Employment Office facilitated mutual understanding. Having a person from the Social Insurance Office and one from the Employment Service who is our contact in this team is also a facilitator // then you know who they are and how they work. Hanna

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Continuity between actors also facilitated a calm and secure atmosphere at meetings with the patients, and this was described as important in order to increase the patients’ sense of trust in the process.

Discussion This qualitative study explored and described health professionals’ experience of working with RTW in MMR for people with non-specific back pain. The findings indicate that aspects such as the participants’ own attitudes and their perception of the patients’ conditions influenced their practical work. They experienced that they mostly had to focus on the patients’ psychological and physical well-being as well as participation in everyday life. It was, however, considered that focusing on these aspects facilitated the patients’ ability to RTW. The participants viewed RTW as a long-term process that could be initiated but seldom completed during the MMR. Thus, the participants felt that the responsibility for the actual RTW process should be placed with other actors. These findings contribute valuable knowledge in order to further develop the interventions targeting vocational issues in MMR and some clinical implications will be discussed below. The findings from this study indicate that the participants preferred to apply a traditional focus in their interventions aimed at increasing the patients’ health and well-being, and that they experienced that such a focus facilitated the RTW process in the long run. This is in line with previous research which indicates that there is a need to focus on several aspects of everyday life in order to facilitate RTW [19,28] and use the biopsychosocial model which emphasises the focus on a person’s entire lifesituation [13,29]. However, the RTW process cannot be regarded as a linear process in which increased health and well-being comes first followed by vocational issues. Rather, it needs to be considered as a reciprocal process where well-being and work are interconnected and affect each other. A limited focus on only one of these factors may impede optimal rehabilitation. Previous research has found that work engagement positively affects life satisfaction [30] and that an exclusion of vocational issues in rehabilitation might impede the RTW process [22]. Furthermore, the biopsychosocial model implies that rehabilitation should be implemented in close connection with the person’s proposed work when considering a realistic work environment and workrelated tasks [13] and such an approach has been found to be effective [23]. The findings from our study indicate that the participants were constantly balancing between interventions related to health and to RTW, and sometimes they even excluded a clear focus on RTW in respect to their patients’ needs. The reasons for the health professionals’ narrow focus on vocational issues were not explored in this study but it was indicated that both practical and personal aspects influenced their work. However, future studies are needed in order to expand knowledge

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on the underlying reasoning around vocational issues in MMR. Still, the findings from this study may imply that the participants sometimes experienced uncertainty about how to work with the RTW process, and thus indicate that continuous supervision on these issues would enhance MMR. The participants in our study described how the RTW process always pervaded rehabilitation, however they were seldom actively involved in their patients’ practical RTW or vocational training. Interventions in connection with patients’ workplaces and employers were carried out in exceptional cases, and when this collaboration was established it was experienced as facilitating the RTW process. This is further supported in studies that conclude that interventions need to focus on dialogue and interaction with the employer and the workplace [23,31–33] and that practical support at the workplace needs to continue after rehabilitation is completed [34,35]. This highlights that clear and effective interaction with workplaces is essential and that MMR would benefit from guidelines that clarify such measures. Furthermore, the findings revealed that the participants experienced that they did not have time to provide practical support in the RTW process. Rather they placed great emphasis on creating an action plan for the RTW process and such interventions have been found to promote RTW in people on longterm sickness absence [36]. However, in this study the participants felt that this action plan was intended for after MMR, and thus placed the responsibility for operational support on other actors such as the Employment Service and the Social Insurance Office. These findings are interesting to reflect upon in relation to two aspects: the patients’ experience of the entire RTW process and collaboration between the various stakeholders. First, previous research has found that patients experience that a lack of practical interventions targeting vocational issues during rehabilitation hampers the RTW process [22]. Furthermore, a meta-synthesis identified that people with common mental disorders often experience a gap between the intentions and the implementation of the action plan which might hinder or repress the RTW process [31]. The patients’ experiences were not explored in this study but our findings indicate that there was a broken link in the entire RTW process when MMR was completed. Future studies are thus needed in order to extend knowledge on how this broken link is experienced and might be repaired in the RTW process. Second, collaboration with other actors became an important feature of MMR. The participants in our study highlighted the importance of creating a solid link between the various actors and this has also been indicated in previous research [37]. However, the involvement of several actors within the RTW process has been discussed elsewhere and is described as challenging due to the various perspectives and interests each actor represents [16,31,38]. In order to overcome these difficulties, it may be beneficial to establish a position in which a health professional acts as a case manager and assists the patients in their transitions between various actors and phases in the RTW process. Further research within this area is essential. Methodological considerations Only 15 participants were included and this number limits the generalisability of the study. However, the participants differed in their characteristics and worked in three different county councils and all of them worked according to the same guidelines from the rehabilitation warranty, implying that rehabilitation programmes and settings have, relatively speaking, many similarities. Thus, we consider that the findings of this study may be transferred to other rehabilitation settings that conduct MMR within the

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rehabilitation warranty [39]. The fact that the participants knew that their interviews would be used as one step in a larger evaluation of the rehabilitation warranty might have influenced their answers, leading to descriptions of how it ‘‘should be’’ rather than focusing on their own experience. However, all the participants were encouraged to talk about their negative and positive experiences of working with RTW in MMR. Furthermore, they were informed about the confidentiality of their answers before the interview and the findings in this study indicate that the participants felt free to express their personal experience during the interviews. In order to ensure the credibility of the findings, the meaning units and codes were kept close to the interview data and the analysis process went back and forth between codes and interviews in several steps [27]. The analysis has been discussed within the interprofessional research group on several occasions. Having various professions represented in the research group is an advantage for the study as the risk of one specific perspective dominating the findings is thus limited. Our study focuses solely on the experience of the health professionals within the rehabilitation unit, however there are several actors involved in the RTW process [37,38]. Future research focusing on the experience of all the actors involved is needed and a focus group study consisting of participants from the various actors would be valuable in order to further develop the overall RTW process for people with non-specific, long-term back pain. In conclusion, this study shows that the health professionals’ attitudes and experiences in working towards RTW in MMR influenced the interventions the patient actually received during rehabilitation. The participants focused on increasing patient health and on creating an action plan for the RTW process, but considered that other actors should implement the plan. The participants described limited interventions in connection with patient workplaces and employers. Based on these findings, and on previous research, important implications for the further improvement of the aim of the rehabilitation warranty might be to strengthen collaboration between the health professionals, the patients and the employers. While developing such collaboration, it might be beneficial to establish guidelines and a checklist on how to work in close collaboration with the patients’ workplaces and employers. Still, further research regarding this area is needed. Furthermore, participants in this study expressed the value of providing long-term support for their patients, even though this seldom occurred. Thus, it might be beneficial to provide long-term follow-up in relation to the patients’ work and develop and evaluate interventions that involve all relevant actors in order to promote smooth transitions.

Acknowledgements

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5. 6. 7.

8. 9. 10. 11. 12.

13. 14.

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We wish to acknowledge the rehabilitation professionals for sharing their experience with us and the process leaders for their participation.

Declaration of interest

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The authors report no declarations of interest. This study was financed by a grant from the Ministry of Health and Social Affairs.

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References

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