KONGRES MEDICINSKIH IZVEDENCEV

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1 POVZETKI april 2019 Laško, Slovenija 5. MEDNARODNI KONGRES MEDICINSKIH IZVEDENCEV Republike Slovenije 2019, LASKO, S LO RIL AP JA NI VE ZIZRS Združenje izvajalcev zaposlitvene rehabilitacije v Republiki Sloveniji

2 SUMMARY April 2019 Laško, Slovenia 5th International CONGRESS OF MEDICAL ASSESSORS in the Republic of Slovenia ZIZRS Združenje izvajalcev zaposlitvene rehabilitacije v Republiki Sloveniji

3 Člani Strokovnega odbora: Emilija Pirc Čurić, dr. med. Izr. Prof. Dr. Breda Jesenšek Papež, dr. med. Boris Kramžar, dr. med. Metka Teržan, dr. med. Mag. Olivera Masten Cuznar, dr. med. Tanja Jordan, dr. med. Dr. Ticijana Prijon, dr. med. Života Lovrenov, dr. med. Člani Organizacijskega odbora: Mag. Dean Premik, ZPIZ Marijan Papež, generalni director, ZPIZ Marjan Sušelj, generalni director, ZZZS Karl Destovnik, predsednik skupščine, ZIZRS Mojca Leskovar, predsednica uprave, Thermana d.d. Života Lovrenov, dr. med. Blaž Kavčič, tajnik in prevajalec kongresa, ZPIZ Uredniški odbor: Emilija Pirc Ćurić, dr. med. Mag. Dean Premik Života Lovrenov, dr. med. Tanja Jordan, dr. med. Urednik: Emilija Pirc Ćurić, dr. med. Oblikovanje: Maja Ptičar s.p. Izdelal in založil: Zavod za pokojninsko in invalidsko zavarovanje Slovenije Kolodvorska Ljubljana R. Slovenija Leto izdaje: Laško, april 2019 Members of the Scientific Committee: Emilija Pirc Čurić, MD. Slovenia Prim. Assoc. Prof. Dr. Breda Jesenšek Papež, MD., Slovenia Boris Kramžar, MD. Slovenia Metka Teržan, MD. Slovenia MsC. Olivera Masten Cuznar, MD. Slovenia Tanja Jordan, MD. Slovenia PhD. Ticijana Prijon, MD. Slovenia Života Lovrenov, MD. Slovenia Members of the Organizing Committee: MsC. Dean Premik, ZPIZ, Slovenia Marijan Papež, ZPIZ, Slovenia Marjan Sušelj, ZZZS, Slovenia Karl Destovnik, ZIZRS, Slovenia Mojca Leskovar, Thermana d..d, Slovenia Života Lovrenov, MD., Slovenia Blaž Kavčič ZPIZ, Congress Secretary and Translator, Slovenia Editorial Board: Emilija Pirc Ćurić, MD, MSc. Dean Premik, Života Lovrenov, MD Tanja Jordan, MD Editor: Emilija Pirc Ćurić, MD, MD Design: Maja Ptičar s.p. Publisher: Pension and disability insurance institute of Slovenia Kolodvorska Ljubljana R. Slovenija Year of publication: Laško April 2019 Kataložni zapis o publikaciji (CIP) pripravili v Narodni in univerzitetni knjižnici v Ljubljani COBISS.SI-ID= ISBN (pdf) The Cataloging in Publication (CIP) record was prepared at the National and University Library in Ljubljana COBISS.SI-ID= ISBN (pdf)

4 ORGANIZATORJI Organizers ZAVOD ZA POKOJNINSKO IN INVALIDSKO ZAVAROVANJE SLOVENIJE Pension and Disability Insurance Institute of Slovenia ZAVOD ZA ZDRAVSTVENO ZAVAROVANJE SLOVENIJE Health Insurance Institute of Slovenia ZDRUŽENJE IZVAJALCEV ZAPOSLITVENE REHABILITACIJE SLOVENIJE ASSEMBLY OF Employment Rehabilitation Providers in the Republic of Slovenia ZIZRS Združenje izvajalcev zaposlitvene rehabilitacije v Republiki Sloveniji THERMANA LAŠKO d. d. ČASTNA POKROVITELJA Honorary sponsors MINISTRSTVO ZA ZDRAVJE Ministry of Health REPUBLIKA SLOVENIJA MINISTRSTVO ZA DELO, DRUŽINO, SOCIALNE ZADEVE IN ENAKE MOŽNOSTI MINISTRSTVO ZA DELO, DRUŽINO, SOCIALNE ZADEVE IN ENAKE MOŽNOSTI Ministry of Labour, Family, Social Affairs and Equal Opportunities

5 PREDGOVOR V Laškem bo med 11. in 13. Aprilom 2019 organiziran že 5. Mednarodni kongres medicinskih izvedencev Slovenije, ki je prerastel v tradicionalno srečanje strokovnjakov s področja medicinskega izvedenstva in vseh, ki so v Sloveniji na kakršen koli način povezani s to dejavnostjo. Kongres medicinskih izvedencev kot vodilni dogodek s tega področja bodo organizirali Zavod za pokojninsko in invalidsko zavarovanje, Zavod za zdravstveno zavarovanje, Združenje izvajalcev zaposlitvene rehabilitacije Slovenije in Thermana Laško d.o.o., kjer nas bodo prijazno sprejeli v njihovem Kongresnem centru. Kongres je namenjen medicinskim in nemedicinskim izvedencem, ki sodelujejo pri oceni začasne in trajne nezmožnosti za delo, sodnim izvedencem, zdravnikom družinske medicine, specialistom medicine dela, prometa in športa, specialistom nevrologije in onkologije, sodnikom Delovnega in socialnega sodišča v Ljubljani in vsem, ki se ukvarjajo z zaposlitveno in poklicno rehabilitacijo. Na letošnjem dogodku bodo v ospredju novosti s področja diagnostike, zdravljenja in rehabilitacije nevroloških in onkoloških bolnikov z vidika ocenjevanja njihove začasne in trajne nezmožnosti za delo, vračanja na delo ter možnosti poklicne in zaposlitvene rehabilitacije. Predstavljene bodo novosti zdravljenja bolezni s področja nevrologije in onkologije in napredek pri rehabilitaciji teh bolnikov in kako vse to vpliva na njihove možnosti za čim prejšnje in uspešno vračanje na delo. Zaradi aktualnosti tem in velike udeležbe na dosedanjih kongresih se nam bo pri organizaciji pridružilo Združenje izvajalcev zaposlitvene rehabilitacije, ki s svojimi prispevki podaja širok vpogled v možnosti invalidnih oseb, da se skozi zaposlitveno in poklicno rehabilitacijo ponovno vključijo v delovni proces in začnejo samostojno skrbeti za svojo socialno varnost. Na 5. kongresu bomo uvedli kot novost Okroglo mizo, kjer bodo različni strokovnjaki, ki najbolj poznajo trenutne razmere na področju medicinskega izvedenstva, podali svoja mnenja o sedanjem in možnem bodočem načinu dela ter organizacije medicinskega izvedenstva v R. Sloveniji. Na kongresu pričakujemo aktivno udeležbo preko 60 predavateljev in udeležencev s poster predstavitvijo, med drugimi tudi predavatelje iz tujine. Medicinsko izvedenstvo je specializirana interdisciplinarna zdravstvena dejavnost, ki v Sloveniji trenutno nima svojega pravega mesta, saj je še vedno odprtih veliko vprašanj glede potrebnih sprememb zakonodaje, poenotenja kriterijev ocenjevanja in izobraževanja izvedencev. Upamo, da bo naš kongres v dobršni meri prispeval k uresničitvi želja vseh izvedencev Slovenije, da bi se z oblikovanjem enotne doktrine izvedenskega dela ter ureditvijo statusa zdravnikov izvedencev dosegla večja razpoznavnost in uveljavitev te dejavnosti v širši strokovni javnosti doma in v tujini APRIL 2019, LASKO, SLOVENIJA

6 FOREWORD Between the 11th and 13th April 2019, Laško will host the 5th International Congress of Medical Assessors, which has grown to be a traditional meeting of insurance medicine professionals and all who are in any way connected to this sector. The congress of medical assessors is a leading event in this area and is organised by the Pension and Disability Insurance Institute, the Health Insurance Institute, the Assembly of Employment Rehabilitation Providers in the Republic of Slovenia and Thermana Laško, where we shall be welcomed in their congress centre. The congress is meant for medical and non-medical assessors participating in the work ability assessment processes, court experts, family medicine specialists, occupational medicine specialists, neurologists, oncologists, judges at the Ljubljana labour court and all those who are involved with the employment and vocational rehabilitation. At the forefront of this year s event will be novelties in diagnostics, treatment and rehabilitation of neurology and oncology patients from the viewpoint of assessing their remaining work ability, return to work and the possibility of a vocational or employment rehabilitation. Presented will be the novelties in the treatment of neurology and oncology diseases and the progress in the rehabilitation of such patients and how everything affects their capability to return to work as soon as possible. Due to the current relevance of topics and the large participation at the previous congresses, we will be joined by the Assembly of Employment Rehabilitation Providers in the Republic of Slovenia, whose contributions offer a broad insight into the possibilities of disabled persons to re-integrate themselves into the working process through employment and vocational rehabilitation and to take care of their social security themselves. The Congress will also host a round table where various experts, who are familiar with the current events in medical assessment, shall give their views on the current and possible future way of work and organisation of medical assessment in the Republic of Slovenia. We expect an active participation from around 60 speakers and poster section presenters at the Congress, also those from abroad. Medical assessment is a specialised interdisciplinary medical branch with no rightful place in Slovenia because there are still many open questions regarding the change to the legislation, unification of the assessment criteria and training of assessors. We hope that our Congress will significantly contribute to the realisation of wishes of all assessors in Slovenia in order to achieve better recognition and implementation of this branch in the broader professional public at home and abroad through the formation of a unified doctrine of medical assessment and the regulatisation of medical assessors APRIL 2019, LASKO, SLOVENIA

7 Plenarna sekcija Četrtek, Plenary Session - Thursday 11th

8 Plenarna sekcija Četrtek, Plenary Session - Thursday 11 th Razvoj in primerjava ocene delazmožosti v Evropi in nekaj več Avtor: Gert Lindenger, dr. med., Predsednik Švedske zbornice zdravnikov v zavarovalniški medicini in podpredsednik Evropskega združenja zdravnikov v zavarovalniški in socialni medicine, Švedska Ozadje: Potrebe po učinkovitih metodah ocenjevanja delovne zmožnosti se v Evropi povečujejo in spreminjajo, saj je pri zdravljenju duševnih bolezni potreben drugačen pristop. Na ta stanja očitno vplivajo tudi drugi dejavniki od običajno opisanih v medicini, ki temelji na dokazih. Raziskave v prejšnjih desetletjih so pokazale, da je potrebno poleg zdravstvenih dejavnikov pri ocenjevanju delovne zmožnosti upoštevati tudi druge dejavnike, kot npr. osebne, družbene in okoljske dejavnike, zato je viden preklop na biopsihološki model. Cilj: Cilj je opisati in primerjati različne pristope k ocenjevanju delovne zmogljivosti, še posebej v Evropi, in obravnavati potekajoče spremembe zdravstvene panorame s pogoji, ki so psihične in osebne narave. Metode: Neformalna ocena z osebnimi vložki glede različnih pristopov k metodam ocenjevanja delovne zmogljivosti v različnih državah v primerjavi z ICF in biopsihološkim modelom za razumevanje. Rezultati: Na podlagi primerjave različnih metod ocenjevanja v Evropi je postalo očitno, da lahko nekatere dejavnike, ki igrajo vlogo pri odobritvi bolniške odsotnosti ocenjujejo tudi druge panoge poleg zdravnikov v zavarovalniški medicini, kar spodbuja učinkovitejšo oceno. Zaključki: Dobri argumenti očitno obstajajo za smiselnost razširitve trenutnih metod ocenjevanja delazmožnosti, in sicer z analizo nekaterih osebnih psiholoških in družbenih dejavnikov, s čimer se poudarijo vidiki upoštevanja splošnih zdravstvenih težav in psihološkega nelagodja v kontekstu delazmožnosti. 8

9 Plenarna sekcija Četrtek, Plenary Session - Thursday 11 th Development and Comparison of Workability Assessment in Europe and some more Author: Gert Lindenger, MD., President of The Swedish Physicians Association of Insurance Medicine and Vice President of EUMASS (European Union of Medicine in Assurance and Social Security), Sweden Background In Europe the need for more effective assessment methods of work ability is increasing and changing, since the sickness panorama is altering towards more mental health a different approach is called for. These conditions seem to also be influenced by other factors than are usually described in evidence based medicine. Over the past decades research has shown that beside the pure medical factors, other factors such as personal, social and environmental factors have to be taken into account when assessing work disability, hence causing a paradigm shift to the biopsychosocial model. Aim The aim is to describe and compare the different approaches of work ability assessments in especially Europe, and reflect on the ongoing changes of the sickness panorama with more mental and personally influenced conditions. Methods An informal review with personal reflections on the various approaches of Work ability assessments methods in differed countries are set against ICF and the biopsychosocial model for understanding. Results By comparing the different assessment methods in Europe it became obvious that other disciplines but insurance physicians can assess some of the factors that play a role in the sick leave, thus contributing to a more efficient assessment. Conclusions Good arguments seem to exist for the reasoning of expanding current methods for assessments of work ability with the mapping of some personal psychological and social factors, thus highlighting aspects for considerations within evaluations and assessments of common health problems and mental non wellbeing in the context of workability. 9

10 Plenarna sekcija Četrtek, Plenary Session - Thursday 11 th Zaposlitvena rehabilitacija v Sloveniji Avtor: Lea Kovač, prof. defektologije, svetovalka generalne direktorice Zavoda Republike Slovenije za zaposlovanje; Karl Destovnik, predsednik skupščine Združenja izvajalcev zaposlitvene rehabilitacije v Republiki Sloveniji Ključne besede: Brezposelne osebe, invalid, storitve zaposlitvene rehabilitacije, usposabljanje, zaposlitev, multidisciplinarni tim. Ozadje: V Sloveniji se rehabilitacija in zaposlovanje invalidov izvaja preko poklicne rehabilitacije, ki jo opredeljuje zakon o pokojninsko invalidskem zavarovanju in zaposlitvene rehabilitacije, ki jo opredeljuje zakon o zaposlitveni rehabilitaciji in zaposlovanju invalidov. Razlika med obema je pri statusu vključene osebe in sicer pri poklicni rehabilitaciji so obravnavane osebe v delovnem razmerju, pri zaposlitveni rehabilitaciji pa so vključene v obravnavo kot brezposelne osebe. Različne so tudi storitve, ki se izvajajo in sicer pri poklicni rehabilitaciji gre predvsem za strokovno podporo pri spremembi poklica, usposobitvi in ponovni vrnitvi na delo, pri zaposlitveni rehabilitaciji pa gre za sklop storitev, s katerimi se povečuje zaposljivost invalida, in to tako, da se usposobi za ustrezno delo, se zaposli, zaposlitev obdrži oziroma v njej napreduje ali da spremeni svojo poklicno kariero. Metode: Storitve zaposlitvene rehabilitacije izvajajo usposobljeni multidisciplinarni strokovni timi pri izvajalcih zaposlitvene rehabilitacije. Zaposlitvena rehabilitacija se izvaja kot javna služba v okviru mreže izvajalcev zaposlitvene rehabilitacije, ki jo je za večletno obdobje sprejema minister, pristojen za invalidsko varstvo. Rezultati: V prispevku bo prestavljen sistem zaposlitvene rehabilitacije, nekatere storitve ter postopki znotraj procesa od vključitve do izhoda v različne oblike dela in zaposlitve ter socialnega vključevanja. Pri storitvah zaposlitvene rehabilitacije bodo prestavljene predvsem storitve s katerimi se konkretno prispeva pri izboru ustreznih poklicnih ciljev, usposabljanje na konkretnem delovnem mestu oziroma v izbranem poklicu ter pomoč pri iskanju ustreznega dela oziroma zaposlitve. V Sloveniji storitve zaposlitvene rehabilitacije izvaja je 14 izvajalcev zaposlitvene rehabilitacije, ki na letni ravni obravnavajo okoli 2100 uporabnikov, brezposelnih oseb s statusom invalida. Zaključki: Poklicna in zaposlitvena rehabilitaciji skupaj omogočata sistemsko in celovito reševanje problematike zaposlovanja invalidov ter njihovo ponovno vključevanje v delo oziroma reintegracijo na trg dela. 10

11 Plenarna sekcija Četrtek, Plenary Session - Thursday 11 th Employment Rehabilitation in Slovenia Author: Lea Kovač, prof. defectologist, Director-General Adviser, Employment Service of Slovenia; Karl Destovnik, Chairman of the Assembly of Employment Rehabilitation Providers in the Republic of Slovenia Key words: Unemployed persons, disabled persons, employment rehabilitation services, training, employment, multidisciplinary team Background Rehabilitation and employment of disabled persons in Slovenia is performed through vocational rehabilitation, which is governed by the law on pension and invalidity insurance and employment rehabilitation, defined by the Vocational Rehabilitation and Employment of Disabled Persons Act. The difference between the two laws is the status of the person involved, namely vocational rehabilitation treats persons who have a valid employment relationship, while employment rehabilitation deals with persons who are unemployed. The provided services are also different, namely vocational rehabilitation deals especially with the professional support at the change of a person s profession, training and return to work, while employment rehabilitation includes a set of services with which a disabled person s employability is increased by having the person trained for a specific work and helping the person gain and keep employment, advance in their employment or to change their professional career. Methods The services of employment rehabilitation are performed by trained multidisciplinary professional teams at the providers of employment rehabilitation. Employment rehabilitation is performed as a public service within the network of employment rehabilitation providers, approved by the minister responsible for the protection of disabled persons for a multi-annual period. Results The contribution shall present the employment rehabilitation system, certain services and procedures within the process, from the inclusion until the end into the various forms of work and employment, as well as social inclusion. In the framework of employment rehabilitation services, services with which concrete contributions are made in the selection of appropriate professional goals will be presented, as well as training at specific work places or selected profession and help in seeking appropriate work or employment. There are only 14 providers of employment rehabilitation in Slovenia who service more than 2100 users (unemployed disabled persons) per annum. Conclusions The vocational and employment rehabilitation allow for a systemic and comprehensive resolution of the issue of employing disabled persons and their return to work or reintegration onto the labour market. 11

12 Plenarna sekcija Četrtek, Plenary Session - Thursday 11 th Novi izzivi medicinskega izvedenstva in zavarovalniške medicine v Sloveniji Avtor: prof. Mag. Jana Mrak, vodja Oddelka za nadzor, Zavod za zdravstvno zavarovanje Slovenije; Dr. Ticijana Prijon, dr. med., višji specialist, Nacionalni inštitut z a javno zdravje (NIJZ), Slovenija Ključne besede: medicinsko izvedenstvo, zavarovalniška medicina, posebna znanja Ozadje: Zdravniki zaposleni na ZZZS in ZPIZ smo pomemben aktivni člen v procesu zagotavljanja zdravstvenega varstva zavarovanih oseb, saj izvajamo naloge, ki po svoji vsebini sodijo v zdravniško službo. Pa vendar zdravniška javnost tega dela dolgo ni prepoznala kot del svoje stroke. Metode: Na pobudo iniciativnega odbora zdravnikov ZZZS je Generalni strokovni svet Slovenskega zdravniškega društva (GSS SZD) podprl ustanovitev Sekcije za medicinsko izvedenstvo in zavarovalniško medicino (SMIZM). Na ustanovni skupščini SMIZM smo tako tudi redno zaposleni in pogodbeni sodelavci ZZZS in ZPIZ postali del strokovne javnosti kot šestinšestedeseta sekcija SZD. Rezultati: SMIZM zagotavlja prenosa strokovnih znanj in oblikuje doktrine, ki je potrebna za delo na področju medicinskega izvedenstva in zavarovalniške medicine, zato od ustanovitve v sodelovanju z ZZZS večkrat letno organizira učne delavnice. Vseh znanj in veščin, ki so potrebna za to delo pa v okviru študija na Medicinski fakulteti ali obstoječih specializacij oziroma podiplomskih izobraževanj ni mogoče osvojiti, zato je zaživela ideja o posebni strokovni usposobljenosti za področje. SMIZM je pripravila program posebnih znanj v obsegu 400 ur, ki ga je GSS SZD tudi potrdil, in v septembru 2018 je steklo prvo tako izobraževanje, ki bo trajalo do septembra Program je sestavljen kot preplet znanj klasične medicine, ekonomije in prava, ter obsega teoretični in praktični del. Zaključki: Medicinsko izvedenstvo in zavarovalniška medicina je stroka na začetku razvoja, zato je še v kosih, ki se morajo v prihodnosti tesneje medsebojno povezati in s tem tudi preoblikovati. Vendar so že prisotni vsi elementi: znanje klasične medicine, modeli plačevanja zdravstvenih storitev oziroma finančni učinki uresničevanja pravic zavarovanih oseb, ter pravni akti, ki predstavljajo osnovo za družbeni dogovor o pravicah zavarovanih oseb in financiranju zdravstvenega varstva iz javnih sredstev. Vsakdanja praksa kaže, da našteti elementi vplivajo drug na drugega, na stroki pa je, da te medsebojne vplive prouči in predstavi. 12

13 Plenarna sekcija Četrtek, Plenary Session - Thursday 11 th New Challenges in Medical Assessment and Insurance Medicine in Slovenia Author: Jana Mrak, MD MSc, Head of the Department for Supervision, Health Insurance Institute of Slovenia; Ticijana Prijon, MD PhD, senior specialist, National Institute of Public Health of Slovenia (NIJZ) Key words: medical expertise, insurance medicine, special skills Background Physicians employed at ZZZS and ZPIZ play an important active part in the process of ensuring healthcare for insured persons because we are performing tasks which, context-wise, are part of medical services. Medical professionals, however, refused to recognise this as part of their profession for a very long time. Methods At the initiative of the committee of physicians at ZZZS, the general scientific council of the Slovenian society of physicians (GSS SZD) supported the establishment of a section for medical assessment and insurance medicine (SMIZM). At the founding general meeting of SMIZM on 16 July 2015, those fully employed as well as contractors to ZZZS and ZPIZ became part of the professional public as the 66th section of SZD. Results SMIZM ensures the transfer of professional know-how and forms doctrines necessary for medical assessment and insurance medicine practices, which is why it has been organising multiple yearly workshops in cooperation with ZZZS from its foundation onwards. However, not all skills and know-how necessary for the work in the framework of the study programme at the Faculty of Medicine or existing specialisations or postgraduate education can be achieved, therefore the idea of a special professional qualification for this area was established. SMIZM has prepared a program of special know-how in the scope of 400 hours, which was also approved by GSS SDZ and the first such education started in September 2018 and will finish in September The program is a mix of conventional medicine, economy and law and is comprised of both the theoretical as well as the practical part. Conclusions Medical assessment and insurance medicine is a branch at the very beginning of its development, therefore it is still in pieces which will have to interconnect in the future and take on new shapes. However, all elements are already present: conventional medicine, payment models of healthcare services or financial impacts of exercising rights of insured persons and legal acts which serve as the basis for the social agreement on rights of insured persons and the financing of healthcare from public funds. Everyday practice shows that the listed elements affect one another and the profession must study and present these 13

14 Plenarna sekcija Četrtek, Plenary Session - Thursday 11 th Verifikacija usposobljenosti izvedencev za izvedensko delo v Republiki Sloveniji Avtor: Dr. Zdenka Čebašek-Travnik, dr. med., spec. psihiatrije, Zdravniška zbornica Slovenije Ključne besede: licenca, specializacija, kompetence Za izvajanje dejavnosti Zavoda za pokojninsko in invalidsko zavarovanje (ZPIZ) in Zavoda za zdravstveno zavarovanje Slovenije (ZZZS) je nujno potrebno strokovno znanje zdravnikov in zobozdravnikov. Njihov položaj znotraj omenjenih ustanov je različen, saj v ZPIZ-u nastopajo v vlogi izvedencev, v ZZZS pa v vlogi imenovanih zdravnikov. Ker v Sloveniji nimamo specializacije iz medicinskega izvedenstva in zavarovalniške medicine, izvajalci nimajo predpisanega kurikuluma za usposabljanje, zaradi odsotnosti neposrednega kliničnega dela, pa je problematično tudi njihovo podaljševanje licenc za opravljanje zdravniškega dela, ki jih v skladu s pravilnikom izdaja Zdravniška zbornica Slovenije. Pregled nad podobnimi zdravniškimi opravili v drugih državah EU pokaže, da področje ni enotno urejeno in ga zato ne moremo povzeti na način, kot je to mogoče za druge specializacije v okviru UEMS-a (European Union of Medical Specialists). Zahtevnost tega dela je tudi v tem, da ti zdravniki ocenjuje tako kratkotrajno kot dolgotrajno nesposobnost za delo (invalidnost), in odločajo tudi o drugih pravicah, za katere se potegujejo različni pacienti (razni finančni dodatki in medicinski pripomočki). Za izvajanje teh nalog pa potrebujejo tudi določeno stopnjo pravniškega znanja. Za zdravnike, ki delajo na tem področju, je pomembno, da dobijo možnost pridobivanja poenotenega znanja in kompetenc ter hkrati ohranijo pravico do zdravniške licence, ki v Sloveniji temelji izključno na specializaciji. Zato kaže podpreti iniciativo Sekcije za medicinsko izvedenstvo in zavarovalniško medicino pri Slovenskem zdravniškem društvu, da bi uvedli zanje specifično specializacijo. Ta bi lahko potekala v obliki specializacije, pri čemer bi bil pogoj za odobritev že pridobljena licenca iz določene druge specialnosti. Zdravniška zbornica Slovenije ima pri sprejemanju te specializacije pomembno vlogo, vendar šele po tem, ko vsebino specializacije pripravi in sprejme Slovensko zdravniško društvo. V primeru specializacije iz medicinskega izvedenstva in zavarovalniške medicine pa bi bil omogočen tudi specifičen strokovni nadzor nad delom tako usposobljenih specialistov. 14

15 Plenarna sekcija Četrtek, Plenary Session - Thursday 11 th Qualification Verification of Medical Assessors for Medical Assessment in the Republic of Slovenia Author: PhD Zdenka Čebašek-Travnik, MD, psychiatrist, President of the Medical Chamber of Slovenia Key words: licence, specialisation, competences Professional knowledge of physicians and dentists is crucial for performing tasks at the Pension and Invalidity Insurance Institute (ZPIZ) and the Health Insurance Institute of Slovenia (ZZZS). Their position within the aforementioned institutes varies because they act as medical assessors at ZPIZ and as appointed doctors at ZZZS. Because Slovenia does not have a specialisation in medical assessment and insurance medicine, the performers do not have a prescribed curriculum for obtaining the necessary qualification and due to the absence of direct clinical work the process of extending their medical licences, which is issued by the Medical Chamber of Slovenia as per the rules, is also problematic. A review of similar medical tasks in other EU countries has shown that the area is not uniformly egulated and therefore cannot be summarised as other specialisations within the UEMS (European Union of Medical Specialists) specialisations. The complexity of such works lies also in the fact that such physicians assess both the short-term as well as the long-term inability to work (disability) and also decide on other rights of patients (the various financial benefits and medical devices). In order to perform these tasks, they also need a fair amount of legal knowledge. Physicians working in this area need to acquire a uniform knowledge and competences and retain their right to a medical licence which, in Slovenia, is based solely on the specialisation. Therefore, it would be reasonable to support the initiative of the Section for medical assessment and insurance medicine at the Slovenian society of physicians in order to implement the specific specialisation for them. Such could be organised in the form of a specialisation, where the prerequisite for the approval would be the already acquired licence in a certain other specialisation. The Health Chamber of Slovenia has an important role in adopting this specialisation, but only after the content of such specialisation has been prepared by the Slovenian society of physicians. If the specialisation from medical assessment and insurance medicine passes, then this would allow for a specific expert supervision over the work of such qualified specialists. 15

16 Plenarna sekcija Četrtek, Plenary Session - Thursday 11 th Multidisciplinarno sodelovanje pri ocenjevanju na področju zavarovalniške medicine Komparativna študija nadomeščanja nalog v Evropi Avtor: Dr. Brage Søren, dr. med., Predsednik delovne grupe ICF EUMASS, Član Strokovnega odbora EUMASS, Norveška; de Wind A, Latil F, Williams N. Ozadje: Veliko evropskih institucij za socialno varnost predvideva pomanjkanje medicinskih izvedencev v svojih organizacijah. Prav tako imajo omejene finančne resurse, zaščititi morajo kakovost svojih ocen in uvesti morajo posodobljene in učinkovite postopke ocenjevanja invalidnosti, kar vključuje multidisciplinsko sodelovanje. Evropska komisija je člane združenja EUMASS pozvala k izvedbi raziskave in komparativne študije o nadomeščanju nalog (menjava delovnih nalog, delegacija, podpora) v evropskem socialnem zavarovanju. Cilj: Cilj je bil opisati in primerjati uporabo nadomeščanja nalog pri ocenjevanju invalidnosti. Metode: Pristop je bil trojni: članom EUMASS je bil poslan vprašalnik, kjer so člani bili povprašani o trenutni in načrtovani uporabi nadomeščanja nalog pri ocenjevanju invalidnosti in način ocenjevanja. 2. Literarna študija glede nadomeščanja nalog. 3. Študija primerov v izbranih državah (Francija, Nizozemska, Norveška, Združeno kraljestvo), kjer so bili uporabljeni različni pristopi k nadomeščanju nalog. Rezultati: Nadomeščanje nalog pri ocenjevanju invalidnosti je bilo predstavljeno v sedmih državah članicah EUMASS, večinoma v zahodni Evropi. Uporabljena je bila mešanica menjave delovnih nalog in podpore. Prevladujoča skupina pri prevzemanju novih nalog so bile medicinske sestre, pa tudi različne vrste zdravstvenih delavcev. Za uspešno menjavo delovnih nalog je bila pomembna izobrazba in usposabljanje. Spremembe so večinoma bile pozitivne. Pri študijah primerov so bili opisani inovativni in fleksibilni pristopi, ki so lahko primeri dobre prakse za druge države. Zaključki: Menjava delovnih nalog je bila predstavljena v državah Evrope. Njihove izkušnje in inovacije predstavljajo pomembna področja študije. Pomembno je izvesti ocene postopka in rezultatov sprememb. 16

17 Plenarna sekcija Četrtek, Plenary Session - Thursday 11 th Multidisciplinary participation in social insurance assessments. A comparative study on task substitution in Europe Author: PhD. Brage Søren, MD, de Wind A, Latil F, Williams N. Background Many European social security administrations foresee a shortage of medical assessors in their organizations. They also have strained financial resources, they need to safeguard the quality of assessments, and they need to introduce more updated and efficient disability assessment procedures, including multi-professional teamwork. Members of the European Union of Medicine in Assurance and Social Security (EUMASS) have been contracted by the European Commission to do an exploratory survey and comparative case studies on task substitution (task shifting, delegation, and support) in European Social Security. Aim The aim was to describe and compare the use of task substitution in disability assessments. Methods The approach was threefold: 1. A survey questionnaire was sent to all 20 EUMASS members, inquiring about the present and planned use of task substitution in disability assessments, and how it has been evaluated. 2. A literature study on task substitution. 3. Case studies in selected countries (France, the Netherlands, Norway, the United Kingdom) where different approaches to task substitution have been used. Results Task substitution in disability assessments has been introduced in seven EUMASS member states, mostly in Western Europe. A mixture of task shifting and support was usually used. Nurses were the dominant group taking over new tasks, but many kinds of health professionals were used. Education and training was important for a successful change of tasks. The changes were mostly seen as positive. In the case studies, innovative and flexible approaches were described and they can provide examples for other countries. Conclusions Task substitution has been introduced in European countries. Their experience and innovations are important fields of study. It is important to conduct process and outcome evaluations of the changes. 17

18 Plenarna sekcija Četrtek, Plenary Session - Thursday 11 th Finski sistem ocene začasne in trajne nezmožnosti za delo Avtor: Krisi Vainiemi,dr. med., zdravnica svetovalka pri finskem inštitutu za poklicno zdravje in splošno medicino, Finska Povzetek: Financiranje finskega zdravstvenega sistema je večinoma obdavčeno in prihaja z več strani. Zdravstvene storitve se delijo na primarne in specializirane. Občine lahko organizirajo primarne zdravstvene storitve. Dvajset bolnišničnih okrajev nudi specializirano zdravstveno oskrbo, ki jo tvorijo specialistične preiskave in zdravljenje. Specialistična zdravstvena oskrba zahteva napotitev zdravnika, razen urgentnih primerov. Na Finskem obstaja tudi zasebna zdravstvena oskrba. Pacienti plačajo sami ali imajo sklenjeno zasebno zdravstveno zavarovanje. Zdravniki ocenijo pacientovo preostalo delazmožnost. Bolezen in nezmožnost za delo nista nujno ena in ista stvar. Tudi če ima pacient postavljeno diagnozo, to še ne pomeni, da je nezmožen za delo. Nadomestilo zaradi bolezni, subvencija za rehabilitacijo in invalidska pokojnina se podelijo samo, če pacient ni več zmožen za delo. Delodajalci imajo dolžnost, po zakonu o varovanju zdravja pri delu, urediti preventivno poklicno zavarovanje za svoje zaposlene (enega ali več zaposlenih), ne glede na delovne ure ali trajanje zaposlitve. Poleg tega lahko zaposlenim omogočijo dostop do zdravstvene oskrbe pri na stopnji splošnega zdravnika. Na Finskem so metode, ki olajšujejo vrnitev na delo, v obliki začasnega dela oz. zmanjšane obremenitve na delu, poklicna in zdravstvena rehabilitacija. Na Finskem so ugodnosti odvisne od prebivališča in zaposlitve. Finski inštitut za poklicno zdravje in splošno medicino pokirva bolniške odsotnosti in poklicno rehabilitacijo. Zasebne zdravstvene institucije (pokojnine) pokrivajo tako zaposlitvene pokojnine kot tudi poklicne rehabilitacije. Finski inštitut za poklicno zdravje in splošno medicino pokriva: Ugodnosti glede delazmožnosti: delno nadomestilo zaradi bolezni, nadomestilo zaradi bolezni (do 60 dni), invalidske pokojnine/subvencije za rehabilitacijo in zagotovljene pokojnine. Rehabilitacija: medicinska rehabilitacija, rehabilitacijska psihoterapija, poklicna rehabilitacija, nadomestilo za rehabilitacijo mladih oseb. Povračila zdravstvenih stroškov: posebno povračilo, omejeno povračilo. Običajno lahko prva potrdila za bolniško odsotnost napiše zdravnik. Na splošno obstaja velika izbira glede dolžine priporočene odsotnosti zaradi bolezni brez medicinskega razloga (lokalno/profesionalno). Finski inštitut za poklicno zdravje in splošno medicino pokriva ocenjuje potrebo po rehabilitaciji, ko je bolniška odsotnost daljša od 60 dni. Pooblaščeni zdravnik medicine dela vrnitev na delo oceni, ko je bolniška odsotnost daljša od 90 dni. Splošne smernice za določanje dolžine bolniške odsotnosti se še pripravljajo. 18

19 Plenarna sekcija Četrtek, Plenary Session - Thursday 11 th The Finnish System for assessing Temporary and Permanent Inability to Work Author: Krisi Vainiemi,MD, Senior chief physician, Medical advisor Specialist in occupational health and general medicine The Social Insurance Institution of Finland Abstract: The Finnish healthcare financing system is mostly taxed based and financing comes from many channels. Health care services are divided into primary health care and specialised medical care. Municipalities may organize primary health care services. Twenty hospital districts provides specialized medical care, which care comprises specialist examinations and treatment. Specialised medical care requires a physician s referral with the exception of urgent cases. There is also private health care in Finland. Patients pay themselves or they have private health care insurance. Doctors assess patients remaining capacity for work. Illness and incapacity for work are not exactly the same thing. Even if patient have a diagnosed illness, he/she is not necessarily incapable of work. Sickness allowance, rehabilitation subsidy and disability pension are only awarded on the basis of incapacity for work. Employers have an obligation (The Occupational Health Care Act) to arrange preventive occupational health care coverage for their employees (one or more employees) regardless of working hours or duration of employment. Additionally, they can choose to provide employees with access to medical care at the general practitioner level. In Finland, methods to facilitate a return to work are part time work and reduced workload, vocational rehabilitation and medical rehabilitation. In Finland we have benefit based on residence and on employment. The Social Insurance Institution of Finland covers sick leaves and vocational rehabilitation. Private insurance institutions (employment pensions) cover employment pensions and also vocational rehabilitation. The Social Insurance Institution of Finland covers: Work ability benefits: partial sickness allowance, sickness allowance (up to 60 days), disability pension / rehabilitation subsidy and guarantee pension. Rehabilitation: medical rehabilitation, rehabilitative psychotherapy, vocational rehabilitation, rehabilitation allowance for young persons. Reimbursements for medicine expenses: special reimbursement, limited reimbursement Usually the first sickness absence certificate/s can be written by any physician. There is in general large variety in the length of sickness absence recommendations without medical explanation (local/professional). The Social Insurance Institution of Finland evaluate rehabilitation needs when sick leave has lasted 60 days. Occupational doctor assess return to work when sick leave has lasted 90 days. Generic guidelines on how to determine length of sick leave under construction. 19

20 Plenarna sekcija Petek, Plenary Session - Friday 12th

21 Plenarna sekcija Petek, Plenary Session - Friday 12 th Epilepsija: klasifikacija, zdravljenje in zmožnost za delo Avtor: Izrd. Prof. Dr. Dušan Butinar, dr. med.; Univerzitetni klinični center Ljubljana, Slovenija Ključne besede: Klasifikacija, napadi, žariščna, generalizirana, epilepsija, zdravljenje, zaposlovanje Namen nove klasifikacije iz leta 2017 in primerjava s klasifikacijo iz leta 1981 vsebuje nekatere manjkajoče oblike napadov in je bolj pregledna. Spremembe so naslednje: (1) parcialno je postalo fokalno ; (2) zavest se uporablja za razdelitev fokalnih napadov; (3) izrazi diskognitvni, enostavni parcialni, kompleksni parcialni, psihotični in sekundarno generalizirani napadi so črtani; (4) nove oblike fokalnih napadov zajemajo avtomatizme, spremenjeno obnašanje, hiperkinetične, avtonomne, kognitivne in čustvene napade; (5) atonični, klonični krči, epileptični spazmi, mioklozmi in tonični napadi lahko začnejo žariščno ali generalizirano; (6) fokalni napadi, ki preidejo v obojestransko tonično - klonične napade zamenjajo sekundarno generalizirane napade; (7)nove generalizirane oblike napadov so odsotnosti z mioklonijo vek, mioklonične odsotnosti, mioklonično atonični napadi in mioklonično tonično klonični napadi; in (8) napadi neznanega izvora imajo še vedno lahko lastnosti nadaljnje razporeditve. Ko nekomu postavijo diagnozo epilepsija, je na voljo več načinov zdravljenja: ti so tablete proti epileptična zdravila, ki pomagajo v 7 od 10 primerov, posebna dieta Ketogena dieta, vsadek, ki deluje na vaše živce vagus stimulator, kirurgija ki odstrani del obolelega živčevja ali prereže poti, ki povezujejo posamezne dele možganov in končno v zadnjih letih konopljino olje z malim vsebkom THC. Vpliv epilepsije na zaposlovanje je raznoliko. Delodajalci neradi zaposlijo osebo, ki ima diagnozo epilepsija, četudi so napadi povsem kontrolirani z zdravili. Če zaposleni utrpi napad na delu, največkrat poškoduje sebe. Delodajalec ni pripravljen nositi nobenih finančnih bremen, ki bi lahko nastala n.pr. zavarovalni stroški, plačana bolniška odsotnost itd. Razen tega veliko ljudi, katerih napadi so z zdravili povsem kontrolirani, trpi zaradi stranskih učinkov zdravljenja, predvsem zaspanosti, ki lahko vpliva na delovno uspešnost. Mnogi zakoni prepovedujejo oz. omejujejo vožnjo, upravljanje z nevarnimi stroji, delo na višini ali v vodi, kar vse omejuje izbiro poklicev. Osebe z epilepsijo se ne smejo pridružiti oboroženim silam. 21

22 Plenarna sekcija Petek, Plenary Session - Friday 12 th Epilepsy: classification, treatment and ability to work Author: Assoc. Prof. PhD. Dušan Butinar, MD.; University Medical Centre Ljubljana, Slovenia Key words: Classification, Seizures, Focal, Generalized, Epilepsy, Treatment, Employment The aim of the new classification from 2017 and comparison to classification from 1981, is to include some missing seizures types, and to adopt more transparent names. Changes include the following: (1) partial becomes focal ; (2) awareness is used as a classifier of focal seizures; (3) the terms dyscognitive, simple partial, complex partial, psychic and secondarily generalized are eliminated; (4) new focal seizure types include automatisms, behavior arrest, hyperkinetic, autonomic, cognitive and emotional; (5) atonic, clonic, epileptic spasms, myoclonic, and tonic seizures can be either focal or generalized onset; (6) focal to bilateral tonic-clonic seizures replaces secondarily generalized seizures; (7) new generalized seizure types are absence with eyelid myoclonia, myoclonic absence, myoclonic-atonic, myoclonic-tonic-clonic; and (8) seizures of unknown origin may have features that can still be classified. After one is diagnosed with epilepsy, there are several ways to get treatment. Medication helps in 7 out 10 people with epilepsy, a special, Ketogenic diet, an implant that works on your nerves vagus nerve stimulator, lesional or disconnective surgery and in the last few years cannabis oil with a small amount of THC. The effect of epilepsy on employment are diverse. The employers are reluctant to hire a person with epilepsy, even if the seizures are completely controlled by medication. If the employee suffers a seizure at work, they could harm mainly themselves. Employers are unwilling to bear any financial cost that may arise employing a person with epilepsy i.e. insurance cost, paid sick leave etc. Many people whose seizures are completely controlled by medication suffer a variety of side effects especially drowsiness which may affect job performance. Many laws prohibit them of driving or operating dangerous machinery, working on high attitudes or in water, lowering the pool of jobs available. These people are also prohibited of joining the armed forces. 22

23 Plenarna sekcija Petek, Plenary Session - Friday 12 th Multipla skleroza in pridobitno delo Avtor: Izrd. Prof. Dr. Uroš Rot, dr. med.; Klinični oddelek za bolezni živčevja, Nevrološka klinika, UKC Ljubljana in Medicinska fakulteta, Univerza v Ljubljani, Slovenija Ključne besede: MS, diagnostika, zdravljenje, delazmožnost Multipla skleroza (MS) je kronična, vnetna, demielinizacijska bolezen osrednjega živčevja, ki prizadene različne dele osrednjega živčevja in posledično povzroča številne nevrološke simptome in deficite. Zaradi zgodnje diagnoze bolezni in številnih zdravil, ki vplivajo na potek MS je prognoza danes bistveno boljša kot v preteklosti. Vseeno MS pomembno vpliva na zmožnost za delo pri posamezniku. Ob diagnozi večina bolnikov opravlja pridobitno delo, že po približno 3 letih pa se delež zaposlenih prepolovi, po 10 letih pa jih le četrtina dela v polnem obsegu. Na delazmožnost vpliva potek bolezni ter klinični simptomi, tudi manj vidni kot sta utrudljivost in kognitivni upad. Več težav z zaposljivostjo imajo ženske in mlade ali starejše ter manj izobražene osebe z boleznijo. Med dejavniki delovnega mesta, ki pomembno vplivajo na zaposlitev so fleksibilnost dela, sedeče delo, oddaljenost od delovnega mesta, zadovoljstvo z delom in pomanjkanje podpore s strani delodajalca. S poklicno rehabilitacijo želimo izboljšati zaposlitvene možnosti zaposlene osebe z MS. Poklicna rehabilitacija vključuje aktivnosti za izboljšanje zmogljivosti posameznika, aktivnosti s katerimi skušamo kompenzirati deficite posameznika in oceno potrebe po modifikaciji zahtev delovnega mesta. Pri oceni zmožnosti za delo je pomembno upoštevati manj vidne simptome MS, kot so utrudljivost, kognitivni upad in psihiatrični simptomi. 23

24 Plenarna sekcija Petek, Plenary Session - Friday 12 th Multiple Sclerosis and Gainful Employment Author: Assoc. Prof. PhD Uroš Rot, MD, Department of Neurology, Neurology Clinic, UMC Ljubljana and the Faculty of Medicine, University of Ljubljana, Slovenia Key words: MS, diagnostics, treatment, work capability Multiple sclerosis (MS) is a chronic, inflamed, demyelinating disease of the central nervous system which affects the various parts of the central nervous system and causes numerous neurological symptoms and deficits. Due to the early diagnosis of the disease and several drugs which affect the process of MS, the prognosis today is much better than it was in the past. Regardless, MS has a major impact on a person s work capability. Most patients, when diagnosed, are people performing gainful employment, however the share of employees is halved after approx. 3 years, and only about 1/4 of them are in full gainful employment after 10 years. The process of the disease and clinical symptoms, even those less visible, such as tiredness and cognitive collapse, also have an impact on the a person s work capability. Women and younger or older persons and less educated persons experience more problems with employment when diagnosed than any other person. Among the factors of the work place which significantly affect employment are the flexibility of work, work requiring sitting, distance from the work place, satisfaction with one s work and little support from the employer. Vocational rehabilitation is aimed at improving the employment chances of those diagnosed with MS. Vocational rehabilitation includes activities for improving the capabilities of an individual, activities with which we wish to compensate the individual s deficits and the assessment of the necessary modification of requirements at one s work place. When assessing one s work capability, it is important to note the less visible MS symptoms, such as tiredness, cognitive collapse and mental symptoms. 24

25 Plenarna sekcija Petek, Plenary Session - Friday 12 th Možganska kap nekoč in danes Avtor: Igor Rigler, dr. med., Nevrološka klinika, Univerzitetni klinični center Ljubljana, Slovenija Ključne besede: možganska kap, intravenska tromboliza, mehanična revaskularizacija, zdravljenje, strdki Ozadje: V zadnjih 20. letih so se na področju zdravljenja ishemične možganske kapi zgodile izjemne spremembe. V 90. letih prejšnjega stoletja se je množično pričela uvajati intravenska tromboliza, s katero smo lahko raztopili določene strdke, ne pa vseh. Uspešni smo bili predvsem pri manjših, večje pa večinoma nismo uspeli raztopiti, zaradi česar so nekateri pacienti ostali trajno nevrološko prizadeti. Od leta 2010 v Sloveniji za odstranjevanje večjih strdkov uporabljamo mehanično revaskularizacijo, ki je bistveno povečala učinkovitost zdravljenja. Invalidnost bolnikov se je od takrat zmanjšala, padla je tudi umrljivost, nekateri odidejo iz bolnišnice povsem ozdravljeni. Glavni dejavnik, ki vpliva na učinkovitost zdravljenja, je čas, kako hitro pacienti z možgansko kapjo pridejo do nevrologa, zato je pomembno, da laična in zdravniška javnost uspe prepoznati znake možganske kapi in da se ustrezno ukrepa čim hitreje. 25

26 Plenarna sekcija Petek, Plenary Session - Friday 12 th Brain Stroke in the Past and Today Author: Igor Rigler, MD, Division of Neurology, University Medical Centre Ljubljana, Slovenia Key words: stroke, intravenous thrombolysis, mechanical revascularisation, treatment, clots Background: In the last two decades, extraordinary developments were made in the treatment of ischemic stroke. In the 1990s, intravenous thrombolysis began to be widely introduced, making it possible to dissolve some clots, but not all. Success was achieved mostly with minor clots, while major clots could not be dissolved, which is why some patients suffered permanent neurological damage. Since 2010, mechanical revascularisation has been used in Slovenia to remove large clots, which substantially increased the efficiency of treatment. Patient disabilities have decreased since then and so has mortality, whereas some patients leave the hospital fully recovered. The main factor affecting the efficiency of treatment is the time in which patients suffering a stroke get to a neurologist, which is why it is important that the general public and health professionals identify the symptoms of a stroke and take action as quickly as possible. 26

27 Plenarna sekcija Petek, Plenary Session - Friday 12 th Poklicna rehabilitacija hitro vračanje zaposlenih na delo, mesto in vloga medicine dela Avtor: Prim. Bojan Pelhan, dr. med., Univerzitetnim rehabilitacijskim inštitutom RS- Soča Ljubljana, Slovenija Učinkovito in hitro reševanje vprašanja delazmožnosti oseb, ki imajo zdravstvene težave in posledično zmanjšano oz. spremenjeno zmožnost za delo, je zagotovo eden najpomembnejših izzivov vseh družbenih sistemov in skupnosti. V dveh tretjinah primerov so razlogi za daljše odsotnosti z dela mišično-kostne, duševne in kardio-respiratorne bolezni. Več kot 90 % osebam z zdravstvenimi težavami lahko pomagamo pri vračanju na delovno mesto, če uporabljamo načela dobre medicinske prakse in upravljanja delovnih mest. Poklicna rehabilitacija strokovno vodeno vračanje zaposlenih na delo je strokovna dejavnost, ki osebi z zdravstvenimi težavami pomaga ostati na delovnem mestu oz. se vrniti in ostati na delovnem mestu; pomeni pa iskanje ravnovesja med zmožnostmi in omejitvami zaradi bolezni ter zahtevami dela in delovnega okolja, upoštevaje vplive: fizičnih, čustvenih, kognitivnih, okoljskih, organizacijskih in socialnih dejavnikov na zmožnost za delo. Za strokovno vodeno vračanje oseb z zdravstvenimi težavami na delovno mesto je pomembno: zgodnje zdravljenje in svetovanje glede aktivnosti ter dela in/ali prilagajanje delovnega mesta, programi strukturirane, multidisciplinarne rehabilitacije, sodelovanje s svetovalci za varnost in zdravje pri delu, možnost začasne spremembe delovnih obremenitev, zagotavljanje kombinacije dobrega kliničnega zdravljenja, rehabilitacijskih programov in ukrepov za vračanje na delovno mesto. Poklicna rehabilitacija je torej učinkovita le, kadar je bolnik/poškodovani motiviran za vrnitev na delo, če rehabilitacijo pričnemo izvajati v 4 6 tednih, kadar dosežemo sodelovanje vseh terapevtov in sodelovanje delodajalca, ter uporabljamo vse znane in preizkušene metode in postopke, ki so dokazano učinkoviti. V Sloveniji je neustrezno urejeno strokovno vodeno vračanje na delo. Za izvajanje dejavnosti so izobraženi le specialisti medicine dela. V sistemu zdravstvenega varstva poklicno rehabilitacijo izvaja le terciarna ustanova URI Soča, Center za poklicno rehabilitacijo. Na primarnem in sekundarnem nivoju storitev ni priznana in se izvaja le posamično v dogovoru z delodajalcem kot plačnikom. 27

28 Plenarna sekcija Petek, Plenary Session - Friday 12 th Vocational Rehabilitation Rapid Return to Work, Occupational Medicine s Place and Role Author: Prim. Bojan Pelhan, MD., University Rehabilitation Institute, Republic of Slovenia, Ljubljana, Slovenia The effective and timely return to work of those with medical problems and related reduced or changed work ability is undoubtedly one of the most pressing challenges faced by contemporary society. In two thirds of all cases, the reasons for longer absenteeism are accounted for by musculoskeletal, mental and cardiorespiratory diseases, and it is possible help more than 90% of those with medical problems to return to the workplace by applying the principles of good medical practice and workplace management. Vocational rehabilitation, professionally-guided return to work, is an activity that assists those with medical problems to stay or be rehabilitated at the workplace; it means finding a balance between abilities and illness-induced limitations and employment requirements, taking into consideration the effects of physical, emotional, cognitive, environmental, organisational and social factors on ability to work. The following is important for professionally-guided return to work of those with medical problems: early treatment and counselling related to activities and work and/or job adaptation, structured, multidisciplinary rehabilitation programmes, cooperation with occupational safety and health advisers, temporary change of work obligation possibility, and assuring a combination of good clinical treatment, rehabilitation programmes and action for return to work. Vocational rehabilitation is only effective for those concerned who are motivated to return to work, and this is best facilitated if rehabilitation commences within four to six weeks of rehabilitation need, and that said rehabilitation is based on the full cooperation of therapists and employers and that it makes use of all that is best in the field. In Slovenia, contemporary professionally-guided return to work is not fit-for-purpose, pursuant to occupational medicine specialists being the only professionals facilitating rehabilitation, that is the tertiary University Rehabilitation Institute, Republic of Slovenia. At the primary and secondary levels, such service is not recognised and it is only implemented individually upon agreement with those employers willing to pay for the service. 28

29 Plenarna sekcija Petek, Plenary Session - Friday 12 th Analiza epidemiologije možganske kapi in njenih posledic pri osebah mlajših od 45 let v Sloveniji Avtor: Dr. Ticijana Prijon, dr. med., višji specialist, Nacionalni inštitut za javno zdravje (NIJZ), Slovenija Ključne besede: možganska kap, epidemiologija, posledice, osebe, mlajše od 45 let Problem: Možganska kap (MK) sodi med najpogostejše vzroke umrljivosti. Za MK običajno zbolevajo starejši bolniki, vendar MK tudi v mlajši populaciji ni redkost. Večina raziskav postavlja mejo za MK pri mladih pri 45 letih. V razvitem svetu je incidenca MK v tej populaciji 10-13/ prebivalcev, mednarodne študije pa kažejo, da se v zadnjem času pojavnost MK pri mladih povečuje, predvsem zaradi nezdravega načina življenja in epidemije debelosti. Najpomembnejši vzrok za MK pri starejših je ateroskleroza, pri mlajših pa je prisotna širša paleta vzrokov, velik delež MK pri mladih pa ostane etiološko tudi nepojasnjen. V primerjavi s starejšimi, je pri mlajših odstotek hemoragičnih MK višji, ishemična MK pa je prisotna le v 40%-50% primerov. Kljub izvajanju preventivnih ukrepov in uvedbi novih metod zdravljenja, ostaja MK najpogostejši vzrok invalidnosti. Zaradi zdravstvenih in ostalih posledic predstavlja MK, predvsem pri mlajši populaciji, veliko socialno in ekonomsko breme, tako za posameznika, kot za družno v celoti. Metode in preiskovanci: Retrospektivno smo analizirali pojavnost ishemične in hemoragične MK in njenih posledic pri bolnikih, mlajših od 45 let. Rezultati: V obdobju od leta 2008 do leta 2017 je bilo zaradi akutne MK obravnavanih 1442 oseb, mlajših od 45 let, kar predstavlja 3,7% MK v celotni populaciji. MK je utrpelo 616 žensk (43%) in 826 moških (57%), pri ženskah je prevladovala hemoragična MK, pri moških pa je bilo nekoliko več ishemičnih MK. Incidenca ishemične MK je bila 4-8/ prebivalcev, hemoragične MK pa 5-9/ prebivalcev, trend incidence pa se v opazovanem obdobju ni bistveno spreminjal. Umrljivost zaradi MK v tej starost je bila 4,2%, zaradi posledic MK je 63,9% oseb ostalo trajno nezmožnih za delo. Zaključki: Pojavnost MK lahko zmanjšamo le z učinkovito preventivo, ki je usmerjena v prepoznavanje vzrokov in zgodnje odkrivanje dejavnikov tveganja. Z analizo trendov incidence MK lahko spremljamo učinkovitost preventivnih programov ter načrtujemo nadaljnje ukrepe. 29

30 Plenarna sekcija Petek, Plenary Session - Friday 12 th Analysis of Epidemiology of Brain Stroke and its Consequences for Slovenia s Under 45s Author: PhD. Ticijana Prijon, MD, Senior Specialist, National Institute of Public Health, Slovenia Key words: brain stroke, epidemiology, consequences, the Under 45s, the Over 45s Problem: Brain stroke is one of the most frequent causes of mortality, usually affecting the elderly, but is not uncommon in those younger. The majority of studies thus far have determined that 45-years is an important age in terms of brain stroke. In the developed world, the incidence of brain stroke in this population is 10-13/100,000 inhabitants, but international studies evidence an increasing incidence of brain stroke in the Under 45s, especially as result of unhealthy lifestyle, including the obesity epidemic. The most important cause of brain stroke in the Over 45s is atherosclerosis, the causes for the Under 45s broader, with some remaining etiologically unexplained. In comparison with the elderly, the percentage of haemorrhagic brain strokes is higher in those younger, with ischaemic brain stroke only present in 40-50% of all cases. Despite the performing of prevention measures and introducing new treatments, brain stroke has remained the most common cause of disability, its medical and other consequences representing, especially in terms of the Under 45s, a large social and economic burden for both individuals and society as a whole. Methods and analysed patients: We retrospectively analysed the incidence of ischaemic and haemorrhagic brain stroke and its consequences in the Under 45s. Results: Between 2008 and 2017, 1,442 Under 45s were treated for acute brain stroke, accounting for 3.7% of all brain strokes. Brain stroke affected 616 women (43%) and 826 men (57%); haemorrhagic brain stroke prevailing amongst women, ischaemic marginally amongst men. The incidence of ischaemic brain stroke was 4-8/100,000, and haemorrhagic 5-9/100,000. In the observed period, the incidence trend did not change materially. In this age group, brain stroke mortality stood at 4.2%, with 63.9% left permanently unable to work pursuant to brain stroke consequence. Conclusions: The incidence of brain stroke can only be mitigated with effective prevention focused on cause identification and early risk factor detection. The analysis of brain stroke incidence trends can be used to monitor prevention programme effectiveness and follow-up measure planning. 30

31 Plenarna sekcija Petek, Plenary Session - Friday 12 th Zdravljenje in vodenje bolnikov v protibolečinski ambulanti, možnosti in pričakovanja Avtor: Gorazd Požlep, dr.med, UKC Ljubljana Ključne besede: kronična bolečina, protibolečinska ambulanta, interdisciplinarno zdravljenje bolečine Opis problema: Kronična bolečina prizadene milijone ljudi po svetu in predstavlja pomemben globalni vzrok za onesposobljenost tako v razvitem kot tudi nerazvitem svetu. Na grobo ocenjeni posredni in neposredni stroški povezani z zdravljenjem bolečine v EU znašajo okoli 441 milijard evrov letno (EFIC 2017). Večino bolnikov s kronično bolečino vodijo družinski zdravniki, le tiste s težko vodljivo akutno, predvsem pa kronično bolečino pa pošljejo na obravnavo v protibolečinsko ambulanto. V protibolečinski ambulanti obravnavamo bolnike z različnimi vrstami bolečin: glavoboli (migrena, glavobol tenzijskega tipa,...), obraznimi bolečinami, bolečinami vzdolž hrbtenice, bolečinami v udih, sklepih in še mnogimi drugimi vrstami bolečine, ki so nastale kot posledica degenerativnih procesov, poškodb ali pa bolezni. Zdravimo tako enostavno nociceptivno, kot tudi nevropatsko bolečino in seveda tudi bolnike, katerih bolečina je posledica raka. Najboljši način, da bolniku vzamemo bolečino je, da odpravimo vzrok zanjo. Pogosto to žal ni mogoče, včasih pa pravega vzroka za bolnikove bolečine, kljub obširni diagnostiki ne uspemo odkriti. Takrat bolečino zdravimo simptomatsko. Na voljo imamo kar nekaj metod za simptomatsko zdravljenje bolečine, od predpisovanja zdravil, kot tudi različnih nemedikamentoznih načinov zdravljenja. Žal pa pogosto pri bolnikih s kronično bolečino nismo tako uspešni, kot bi si to želeli. Pogled na kronično bolečino se je v zadnjih letih precej spremenil. Danes mislimo, da je kronična bolečina v določenih primerih lahko samostojna bolezen in ne le njen simptom. Pri dolgotrajni kronični bolečini gre za biopsihosocialni pojav. To pomeni, da na zavestno zaznavo bolečine ne vplivajo le biološki ampak v veliki meri tudi psihološki in socialni dejavniki. Le če bo zdravljenje zajelo vse tri komponente bo uspešno. Za tak način zdravljenja je potrebno sodelovanje med različnimi specialisti in tudi strokovnjaki drugih strok. Gre za interdisciplinaren pristop k zdravljenju bolečine. Žal pa v Sloveniji skorajda nimamo pravih možnosti za tak način zdravljenja. Tako velika večina bolnikov namesto kompleksne interdisciplinarne obravnave še vedno tava med posameznimi specialisti, ki bolečino obravnavajo individualno. Tak postopek pa je precej dolgotrajen, drag in manj uspešen. Zaključek: V protibolečinski ambulanti zelo pogosto zdravimo težke bolnike, ki so pred tem obiskali že številne specialiste. Mnogim od njih lahko zmanjšamo njihovo bolečino, težko pa jo popolnoma odvzamemo. Stanje bi se lahko izboljšalo z uvedbo interdisciplinarnega pristopa k lajšanju težko obvladljive bolečine. 31

32 Plenarna sekcija Petek, Plenary Session - Friday 12 th Patient Treatment and Management at a Pain Clinic, Possibilities and Expectations Author: Gorazd Požlep, MD., University Clinical Centre Ljubljana, Slovenia Key words: chronic pain, pain clinic, interdisciplinary pain treatment Description of problem: Chronic pain globally affects millions and represents an important global cause of disability in both the developed and developing world. A rough estimate of indirect and direct pain treatment related costs in the EU stands at 441 billion per annum (EFIC 2017). The majority of chronic pain patients are treated by family doctors, with only those with difficult, acute and, particularly, chronic pain being referred for treatment at pain clinics. At pain clinics, we treat patients with various types of pain, such as, headaches (migraine, tension headaches, and the like), facial pain, spinal pain, pain in the extremities and joints, and many other types of pain, particularly those resulting from degenerative processes, injury or disease. We treat nociceptive as well as neuropathic pain and, naturally, patients suffering from cancer induced pain. The best way to eliminate pain in patients is to treat its cause. This is, however, often impossible. We are often unable to detect the cause of patient pain despite extensive diagnostics. In such cases, we treat pain symptomatically. We have several symptomatic pain treatment methods available, from prescribing medicine to non-medication methods, but in the case of chronic pain patients, we are often not as successful as we would wish to be. In recent years, we have started seeing chronic pain differently. Today, we believe that chronic pain can be an independent disease and not merely a symptom thereof. Long-term chronic pain is a biopsychosocial phenomenon, meaning that the conscious feeling of pain is not only affected biologically, but also, to a large extent, psychologically and socially. Treatment can only be successful when it includes all three components. Such methods require cooperation amongst various specialists and experts from different fields. This is an interdisciplinary approach to pain treatment. Unfortunately, there is currently little prospect for this in Slovenia, the current model being that a large majority of patients still go from one specialist to another, each treating individual aspects, rather than being offered more complex interdisciplinary treatments. Such procedures are quite time consuming, expensive and less successful. Conclusion: Pain clinics often treat patients with severe pain who have previously visited many specialists. We can alleviate pain in many of them, but it is difficult to completely eliminate it. The situation could be improved with the introduction of an interdisciplinary approach to soothing difficultlymanaged pain. 32

33 Plenarna sekcija Petek, Plenary Session - Friday 12 th Pomagati ljudem s kronično ne-rakavo bolečino kaj učinkuje, kaj ne in odprta vprašanja Avtor: Helena Jamnik, dr. med. URI Soča, Linhartova 51, 1000 Ljubljana, Slovenija Ključne besede: Kronična bolećina, diagnosticiranje, zdravljenje Povzetek: Lajšanje bolečine predstavlja eno temeljnih nalog zdravnikov nasploh. Trajna oz. kronična bolečina se pojavlja pogosto kot najtežje obvladljiva zdravstvena težava. Vse od leta 1977, ko je George L. Engel pozval k paradigmalnim spremembam veljavnega biomedicinskega modela, si v klinični praksi prizadevamo oblikovati obravnave, ki bi sodile v t.i. bio-psihosocialni model, ki naj bi bil za področje kronične ne-rakave bolečine edini smiseln in priporočen. Osebe s kronično bolečino moramo torej obravnavati celostno, upoštevajoč njihove biološke, psihološke, socialne in duhovne dimenzije. Obenem je trajna bolečina še vedno težko razumljiv fenomen, medicina se na tem področju v zadnjem času sooča s hitrim razvojem. Z biološkega vidika v medicini potrebujemo na bioloških mehanizmih osnovane diagnostične postopke za preverjanje t.i. bioloških markerjev. Mehanizmi centralne in periferne senzibilizacije in reorganizacija somatosenzornega sistema tekom razvoja bolečinske motnje so znanstveno potrjena dejstva. Razvoj na tem področju še vedno ne zadošča za uveljavitev zlatih diagnostičnih standardov. Veliko že vemo, zakaj do sedaj uveljavljena klinična praksa diagnosticiranja (npr. z uporabo radioloških- slikovnih preiskovalnih metod) pogosto ne koristi tem bolnikom, marsikdaj ne»objektivizira«telesne bolečine, kot jo doživljajo bolniki in kot vpliva na njihovo funkcioniranje. Podobno velja za terapevtsko stran klinične prakse. Za danes uveljavljene kirurške in druge interventne načine reševanja težav bolnikov s kroničnimi bolečinskimi sindromi ne-rakavega izvora, vemo, da delujejo v omejenem obsegu (za posebej in dobro izbrane primere), sicer so možni izidi tovrstnih zdravljenj tudi poslabšanje funkcioniranja in samega zdravstvenega stanja. Zgolj farmakološki načini obravnave so učinkoviti na podoben način kot prej navedeni načini zdravljenja. V prispevku bom predstavila znanstveno literaturo na temo diagnosticiranja in zdravljenja na primerih izbranih oblik kronične ne-rakave bolečine (npr. kronična bolečina v križu, sindrom fibromialgije) in možnosti, ki se nam obetajo v prihodnosti (npr. funkcionalne slikovne preiskave, metode kvantitativne senzorimetrije, sodobnejše elktrofiziološke metode diagnostike, strojno učenje, personalizirana medicina, metode nevromodulacije in dr.). 33

34 Plenarna sekcija Petek, Plenary Session - Friday 12 th Helping People with Chronic Non-Cancerous Pain: What Works, What Doesn t, Open Issues Author: Helena Jamnik, MD., University Rehabilitation Institute Republic of Slovenia SOČA, Ljubljana, Slovenia Key words: chronic pain, diagnosing, treatment Abstract: Pain relief is a fundamental task for all doctors. Permanent or chronic pain often appears as the most difficult medical problem to manage. Since 1977, when George L. Engel called for a new biomedical model, clinical practice has endeavoured to develop treatments to be included in the biopsychosocial model, which is believed to be the only reasonable recommendation for chronic non-cancerous pain. People suffering from chronic pain should, therefore, be treated holistically, taking into consideration the biological, psychological, social and spiritual dimensions. At the same time, permanent pain remains a difficult to understand phenomenon. And in this field, medicine has seen rapid development in recent times. Biologically, medicine needs biological mechanism-based diagnostic procedures to verify so-called biomarkers. During pain disorder development, central and peripheral sensitisation and somatosensory system reorganisation are scientifically confirmed facts. Development in this field is still insufficient to implement golden-diagnostic standards. We already know a great deal as to why the current model for diagnosis, including radiologic-image screening, is often not useful for these patients, often failing to objectivise the physical pain suffered by patients that affects functioning. This also applies to the therapeutic side of clinical practice. In terms of current surgical and other intervention methods for solving the problems of those with non-cancerous origin chronic pain syndrome, we know that they work to a limited extent, for specific and carefully selected cases, otherwise such treatment can be detrimental to functioning and the medical condition itself. Pharmacologic treatment methods on their own are similarly effective as the aforementioned treatment methods. In the paper, I will present scientific literature on the topic of diagnosing and treating selected types of chronic non-cancerous pain, such as, chronic lower back pain and fibromyalgia syndrome, and options we can expect in the future, e.g. functional image screening, quantitative sensorimetry methods, modern electrophysiological diagnostic methods, machine learning, personalised medicine, neuromodulation methods, and the like. 34

35 Plenarna sekcija Petek, Plenary Session - Friday 12 th Kronična bolečina pri bolnikih z rakom Avtor: Prim. mag. Slavica Lahajnar Čavlovič, dr. med. Onkološki inštitut Ljubljana Ključne besede: rak, preživeli, kronična bolečina Bolniki z rakom danes živijo dlje zaradi zgodnejšega odkritja bolezni in boljšega zdravljenja. Zaradi raka in njegovega zdravljenja imajo lahko kronične posledice. Med te sodi kronična bolečina, ki je poleg depresije, anksioznosti in utrujenosti najbolj pogosta. Kronična bolečina je posledica raka in/ali kirurškega, obsevalnega ter sistemskega zdravljenja le tega. Zdravimo jo z analgetiki, to je neopioidi, opioidi in dodatnimi zdravili za nevropatsko bolečino glede na jakost in vrsto bolečine. Pri preživelih od raka upoštevamo smernice za uporabo opioidov pri neokoloških bolnikih. Skoraj štirideset odstotkov bolnic z rakom dojke ima po operaciji kronično bolečino. Od teh jih več kot polovica navaja srednje močno ali močno bolečino, ki jim zmanjšuje kakovost življenja ter povzroča bolniško odsotnost in invalidnost. Kronična bolečina po kirurškem posegu traja več kot tri mesece po operaciji in je posledica periferne in centralne senzitizacije, ki sledi akutni poškodbi tkiva. Poskušamo jo preprečiti z dobrim zdravljenjem akutne peri- in pooperativne bolečine. Uporabljamo multimodalni farmakološki pristop, to je infiltracijo kirurško poškodovanega živca ali infuzijo lokalnega anestetika v kirurško rano, protivnetna zdravila in zdravila, ki delujejo na mediatorje, ki so soudeleženi pri centralni senzitizaciji. Na doživljanje bolečine, poleg obsega poškodovanega tkiva, vplivajo psiho-socialni dejavniki. Z uporabo kognitivno-vedenjske terapije pri zdravljenju kronične bolečine, lahko izboljšamo učinkovitost in zmanjšamo uporabo zdravil za zdravljenje bolečine, predvsem opioidov. Zdravljenje depresije in drugih pridruženih zdravstvenih težav zaradi raka, njegovega zdravljenja ali starosti bolnika pripomorejo k obvladovanju bolečine. Progres ali ponovitev raka običajno povečata jakost bolečine. Zaključek: Z vse bolj uspešnim zdravljenjem rak postaja kronična bolezen. Za kakovostno preživetje je potrebno sistematično spremljanje preživelih in dobra obravnava posledic raka, kot je kronična bolečina. Z dobrim zdravljenjem lahko preprečimo ali vsaj omilimo posledice kronične bolečine. 35

36 Plenarna sekcija Petek, Plenary Session - Friday 12 th Chronic Pain in Cancer Patients Author: Prim. MsC. Slavica Lahajnar Čavlovič, MD., Institute of Oncology, University Medical Centre Ljubljana, Slovenia Key words: cancer, survivors, chronic pain Contemporary cancer patients live longer than those previous pursuant to early detection and better treatment. Cancer and its treatment may lead to chronic consequence, the most common being chronic pain, additionally depression, anxiety and fatigue. Chronic pain is a consequence of cancer and/or surgical, radiation and systemic treatment. It is treated with analgesics, such as non-opioid and opioid analgesics and additional medicine for neuropathic pain related to severity and pain type. We observe the same guidelines for opioid use for cancer survivors as we do for non-oncological patients. Almost forty percent of breast cancer patients suffer from post-surgery chronic pain. More than a half of them indicate semi-strong or strong pain, which reduces quality of life, leading to sick leave and disability. Post-surgery chronic pain lasts more than three months and is a consequence of peripheral and central sensitisation following acute tissue damage. We try to prevent this by means of optimal acute peri- and post-operative pain treatment, using a multimodal pharmacological approach, i.e. surgically-damaged nerve infiltration, local anaesthetic infusion into surgical wounds, anti-inflammatory medicine and drugs affecting central sensitisation mediators. In addition to the damaged tissue, pain severity is affected by psychosocial factors. Cognitivebehavioural therapy as an integral part of chronic pain treatment can improve painkiller effectiveness and reduces utilisation, especially in terms of opioids. The treatment of depression and other associated medical problems caused by cancer, its treatment and patient age contribute to pain management. Cancer progress or recurrence usually increase pain severity. Conclusion: With increasingly successful treatment, cancer is turning into a chronic disease. Quality survival requires the systematic monitoring of survivors and the optimal treatment of cancer consequences, such as chronic pain. Good treatment may prevent, or at least soothe, chronic pain consequences. 36

37 Plenarna sekcija Petek, Plenary Session - Friday 12 th Psihiatrično vodenje bolnikov s kronično bolečinsko simptomatiko in ocena trajne nezmožnosti za delo Trajna somatoformna bolečinska motnja Avtor: Prof. Dr. Peter Pregelj, dr. med., spec. psih., Univerza v Ljubljani, Medicinska fakulteta; Univerzitetna psihiatrična klinika Ljubljana Ključne besede: kronična bolečina, somatizacija, celostna obravnava Bolečina se pojavlja tako pri številnih telesnih boleznih kot tudi pri različnih psihičnih motnjah. Spremenjeno dojemanje bolečine je zlasti značilno pri nekaterih somatoformnih motnjah, pa tudi pri razpoloženjskih in psihotičnih motnjah ter pri boleznih odvisnosti. Trajna somatoformna bolečinska motnja se klinično kaže s hudo in zaskrbljujočo bolečino, ki je ni mogoče razložiti s kakim fiziološkim procesom ali telesno boleznijo in ki nastopa v povezavi s čustvenim konfliktom ali psihosocialnimi problem. Ta psihična motnja navadno privede do povečane opore in pozornost, tako bližnjih kot zdravstvenih delavcev. Pomemben psihopatološki pojav je somatizacija, ki opredeljuje način iskanja pomoči za telesne simptome, pri čemer oseba zanemarja duševne simptome in neugodne psihosocialne okoliščine, v katerih se je znašla in simptome, ki jih doživlja v sklopu duševne motnje, pripisuje izključno telesni bolezni. Ločevanje kronične telesne bolečine od psihogene bolečine ali hlinjenja bolečine utegne biti zapleteno, saj sloni ocenjevanje v glavnem na bolnikovem poročanju. Bolnike z izrazito bolečino brez jasnega vzroka kot osnovnim simptomom uvrščamo v različne diagnostične entitete, katerih meje se med seboj pogosto prekrivajo. Tako se utegnejo ob kronični bolečini zaradi organskih vzrokov pojavljati anksiozno depresivna simptomatika ter se obratno utegne depresivna epizoda kazati tudi s pojavljanjem bolečine. Obravnava oseb s kronično bolečino je celostna, multidisciplinarna in zajema biološke, psihološke in sociološke ukrepe za odpravljanje tako bolečine kot psihičnih vzrokov ali posledic le-te s ciljem ne le lajšanja oziroma odpravljanja bolečine, ampak k doseganju čim boljšega funkcioniranja oseb s kronično bolečino. V primeru, da tovrsten cilj ni dosežen in je kljub terapevtskemu postopku okrnjenost funkcioniranja še prisotna, je smiselna ocena preostale delazmožnosti. 37

38 Plenarna sekcija Petek, Plenary Session - Friday 12 th The Psychiatric Management of Patients with Chronic Pain Symptomatology and Assessment of Permanent Inability to Work: Permanent Somatoform Pain Disorder Author: Prof. PhD. Peter Pregelj, MD., University Psychiatric Hospital, University Medical Centre Ljubljana, Slovenia Key words: chronic pain, somatisation, holistic treatment Pain is a part of many physical diseases, as well as various mental disorders. Changed pain perception is especially typical in certain somatoform disorders, as well as in mood and psychotic disorders and addictions. Permanent somatoform pain disorder is clinically expressed by means of severe and worrying pain, which cannot be explained by any physiological process and/or physical disease occurring in combination with emotional conflict and/or psychosocial problems. Such mental disorder usually necessitates increased relatives and health worker support and attention. Somatisation is an important psychopathological phenomenon which defines a method for seeking help for physical symptoms whereby the affected person neglects mental symptoms and attributes unfavourable psychosocial circumstances and symptoms experienced as part of mental disorder exclusively to physical disease. Separating chronic physical pain from psychogenic pain and/or pain simulation can be complicated as assessment is mainly based on patient reporting. Patients with explicit pain without clear cause are categorised into various diagnostic entities with borders often overlapping; in this way, organic chronic pain may be accompanied by anxiety/depression symptoms and, vice versa, depression may be accompanied by pain. The treatment of those with chronic pain is holistic, multidisciplinary, including biological, psychological and sociological measures to eliminate pain and its mental causes and/or consequences not only in order to soothe or eliminate pain, but also to maximise the functioning of persons with chronic pain. In cases where such goals are not achieved and reduced functioning is still present despite therapeutic procedures, the degree of ability to work should be assessed. 38

39 Plenarna sekcija Sobota, Plenary Session - Saturday 13th

40 Plenarna sekcija Sobota, Plenary Session - Saturday 13 th Zakaj mora biti načrt vračanja na delo sestavni del uspešne rehabilitacije bolnika z rakom? Avtor: Mag. Olivera Masten Cuznar, dr.med., spec.spl.med., vodja oddelka nadzornih zdravnikov OE Ljubljana, Zavod za zdravstveno zavarovanje Slovenije, Ključne besede: začasna nezmožnost za delo, bolnik z rakom, načrt vračanja na delo Primerjava statističnih podatkov za Slovenijo med letoma 2013 in 2018 govori za 8,3% višjo zaposlenost, delovno aktivna populacija se stara. V strostni skupini nad 60 let je od leta 2013 do 2016 za 72% več izgubljenih koledarskih dni zaradi bolezni in poškodb, do leta 2018 se je več kot podvojilo število primerov dolgotrajnih odsotnosti z dela (nad 6 mesecev). Od leta 2013 do 2018 beležimo vztrajno rast deleža odsotnosti z dela zaradi poškodb in bolezni (iz 3,94% na 4,54%) in z rastjo povprečne plače se posledično zvišujejo stroški za nodmestila plač zaradi začasne nezmožnosti za delo. Potrebujemo sistemske ukrepe za učinkovitejšo porabo zdravstvene oskrbe in javnih financ. V 14 študijah MEDLINE in PSYCLIT v času od 1985 do 1999 podatki o vračanju na delo pri bolnikih z rakom kažejo 62% povprečen delež povratnikov na delo - z razponom od 30% do 93%: 30% pri starejših od 50 let, 74% pri bolnikih mlajših od 50 let. Zgodnja diagnostika, nove terapevtske možnosti in uspešnejše zdravljenje omogočajo bolnikom z rakom, da se jih vse večji delež po zdravljenju raka v celoti ali vsaj delno vrne na delo. Dejavniki, ki pomembno vplivajo na delež povratnikov na delo, so povezani s potekom oziroma remisijo ali progresom bolezni, učinki in posledicami zdravljenja, osebnostnimi lastnostmi bolnika, s pozitivnim odnosom delovnega okolja do bolnika po zdravljenju raka, z naravo in pogoji dela. Neposredne in posredne posledice rakave bolezni so lahko obsežne ali trajne, posledično je začasna nezmožnost za delo dolgotrajnejša ali trajna. V poteku zdravljenja je za uspešen zaključek rehabilitacije potrebna vztrajna motivacija bolnika kot tudi sodelovanje njegovega delodajalca in vključevanje specialista medicine dela, prometa in športa v proces vračanja na delo. Pravočasno načrtovanje in uspešno odpravljenje ovir pri vračanju na delo prinaša boljšo kvaliteto življenja za bolnika in njegove bližnje ter s tem korist družbi kot celoti. 1. The Institution of Occupational safety and health. Occupational safety and health considerations of returning to work after cancer. Pridobljeno s spletne strani: 2. Spelte ER, Sprangers MAG, Verbeek HAM. Factors reported to influence the return to work of cancer survivors: A litertaure review. Psycho Oncol 2002 (11): Pridobljeno s spletne strani: 40

41 Plenarna sekcija Sobota, Plenary Session - Saturday 13 th Why should Return to Work Plan be a Part of Successful Rehabilitation of the Patient with Cancer Author: MsC. Olivera Masten Cuznar, MD., Head of Supervising Physicians, Ljubljana Regional Unit, Health Insurance Institute of Slovenia, Key words: temporary incapacity for work, cancer patient, plan for returning to work A comparison of statistics for Slovenia between 2013 and 2018 shows a higher rate of employment by 8.3%, indicating also the aging of the working age population. As to the age group over 60, there were by 72% more calendar days lost due to illness and injuries in the period between 2013 and 2016, by 2018 long-term absence from work (over 6 months) more than doubled. From 2013 to 2018 a constant growth in absence from work due to illness or injury (from 3.94% to 4.54%) has been recorded, which, with the rise of average earnings, impacts the costs for sick pay in the event of temporary work incapacity. Systemic measures for more efficient use of medical care and public funds are required. Data on returning to work in cancer patients in 14 studies made by MEDELINE and PSYCLIT between 1985 and 1999 show their share being 62% on the average ranging from 30% to 93%: 30% in patients over the age of 50, 74% in patients under 50. Screening programs, new therapeutic possibilities and successful treatment enable that an ever increasing share of cancer patients fully or partially return to work after treatment. Factors which significantly affect the share of those who return to work are closely linked to the course of the disease, remission or disease progress, effects and consequences of treatment, patient s character, positive attitude of the work environment towards the patient after treatment, the nature of work and labour conditions. Direct and indirect implications of cancer can be wide-ranging or permanent, so temporary absence from work is longer or even permanent. Successful rehabilitation conclusion in the course of treatment requires patient s constant motivation as well as collaboration of their employer and the participation of a specialist in occupational medicine, traffic and sports in the process of returning patients to work. Timely planning and removing of obstacles in returning patients to work brings better quality of life for a patient and their family members, thus representing a benefit for the entire society. 1. The Institution of Occupational safety and health. Occupational safety and health considerations of returning to work after cancer. Downloaded from on 22 December Spelte ER, Sprangers MAG, Verbeek HAM. Factors reported to influence the return to work of cancer survivors: A litertaure review. Psycho Oncol 2002 (11): Downloaded from on 22 December

42 Plenarna sekcija Sobota, Plenary Session - Saturday 13 th Poklicni rak Avtor: Izr. Prof. Dr. Alenka Franko, dr. med.; Klinični inštitut za medicino dela, prometa in športa, Univerzitetni klinični center Ljubljana, Klinični inštitut za medicino dela, prometa in športa, Slovenija, Emilija Pirc Ćurić, dr. med., Zavod za pokojninsko in invalidsko zavarovanje Slovenije Ključne besede: rak, poklicna izpostavljenost, karcinogen Ozadje: Poklicni rak povzroča izpostavljenost rakotvornim (karcinogenim) dejavnikom na delovnem mestu ali pa posebne okoliščine pri delu. Odkrivanje in priznavanje poklicnega raka v Sloveniji še vedno predstavlja velik problem, kljub temu da so verifikacijski pogoji jasno znani. Razlog za to je predvsem neučinkovit sistem financiranja verifikacij poklicnih bolezni. Edina izjema so raki, povezani z izpostavljenostjo azbestu (kot so pljučni rak, maligni mezoteliom, rak drugih lokacij), ki jih redno priznavajo strokovnjaki Interdisciplinarne skupine strokovnjakov za verifikacijo poklicnih bolezni zaradi izpostavljenosti azbestu. Pomembna institucija, odgovorna za priznavanje poklicnega raka, je tudi Zavod za pokojninsko in invalidsko zavarovanje Slovenije. Metode: V raziskavo so bile vključene vse zavarovane osebe (zavarovanci), ki so bile v obdobju od 1. januarja 2008 do 31. decembra 2017 obravnavane na Zavodu za invalidsko in pokojninsko zavarovanje Slovenije zaradi ocene invalidnosti. Podatki so bili analizirani s pomočjo statističnega programa Zavoda za invalidsko in pokojninsko zavarovanje Slovenije. Rezultati: V opazovanem obdobju je bilo na Zavodu za pokojninsko in invalidsko zavarovanje Slovenije glede invalidnosti ocenjeno skupno zavarovancev. Pri tem je bila invalidnost potrjena pri zavarovancih z rakom, pri 18 od njih je bila kot vzrok dokazana in navedena poklicna izpostavljenost različnim škodljivim dejavnikom na delovnem mestu. Med zavarovanci z dokazanim poklicnim rakom je imelo sedem zavarovancev rak pljuč, osem jih je imelo maligni mezoteliom, povezan z izpostavljenosti azbestu, dva sta imela maligno neoplazmo nosnih sinusov zaradi izpostavljenosti lesnemu prahu, eden pa rak prostate, povzročen s poklicno izpostavljenostjo kemični snovi. Zaključki: Ugotovitve analize kažejo, da je bilo do sedaj v Sloveniji relativno malo rakastih obolenj povezanih z izpostavljenostjo škodljivim dejavnikom na delovnem mestu. Pričakujemo, da bo nov pravilnik o seznamu poklicnih bolezni, verifikaciji in registraciji poklicnih bolezni izboljšal stanje na tem področju in bo odkritih in verificiranih več poklicnih rakov. 42

43 Plenarna sekcija Sobota, Plenary Session - Saturday 13 th Occupational cancer Author: Assoc. Prof. PhD. Alenka Franko,, MD., Clinical Institute of Occupational Medicine, University Medical Centre Ljubljana, Slovenia Emilija Pirc Ćurić, MD, Pension and Invalidity Insurance Institute of Slovenia Key words: cancer, occupational exposure, carcinogen Background: Occupational cancer is caused by exposure to cancer causing agent (carcinogen) at work or by a particular set of circumstances at work. The recognition of occupational cancer is still a major problem in Slovenia although the guidelines for the verification are clearly stated. The reason is primarily a dysfunctional funding system of verifications of occupational diseases. The only exception is the asbestos related cancers (lung cancer, malignant mesothelioma, cancers of other location) that are regularly recognized by the experts of the State Board for the Recognition of Occupational Asbestos Diseases. An important institution responsible for the recognition of occupation cancers is also Pension and Invalidity Insurance Institute of Slovenia. Methods: The study population included all subjects who applied for the recognition of disability at the Pension and Invalidity Insurance Institute of Slovenia in the period from 1 January 2008 to 31 December The data were analysed using the statistical programme of the Pension and Invalidity Insurance Institute of Slovenia. Results: In the observed period, disability was assessed in 214,215 insured persons at the Pension and Invalidity Insurance Institute of Slovenia. The disability was confirmed for 20,836 persons with cancer; in 18 of them, it was proved to have been caused by occupational exposure. Among the subjects with verified occupation cancer, seven had lung cancers and eight malignant mesotheliomas caused by asbestos exposure, two had malignant neoplasms of nasal sinuses caused by wood dust and one had prostate cancer associated with chemical exposure. Conclusion: The findings of the analysis show that so far relatively few cancers have been associated with the exposure to hazards at the workplace. We expect that the new policy on occupational diseases, verification and registration of occupational diseases will improve the situation in this area and that more cancers will be recognized as occupational. 43

44 Plenarna sekcija Sobota, Plenary Session - Saturday 13 th Izzivi in problemi onkološke rehabilitacije Avtor: Prim. Izr. Prof. Dr. Breda Jesenšek Papež, dr. med., Predstojnica Inštituta za FRM UKC Maribor, Slovenija Ključne besede: onkološka rehabilitacija, bio-psiho-socialni pristop, interdisciplinarni tim, prehabilitacija Število obolelih za rakom konstantno narašča. V zadnjih desetletjih sta napredek na področju bazičnih medicinskih znanosti in razvoj novih farmakoloških in ne farmakoloških oblik zdravljenja učinkovito prispevala k podaljšanju življenjske dobe obolelih in k povečanemu številu ljudi, ki so raka preživeli. Tako rakasta obolenja že uvrščamo med kronične bolezni in zahtevajo vseživljenjsko obravnavo bolnikov, vključno z rehabilitacijo ter rednim spremljanjem njihovega funkcioniranja. Onkološka rehabilitacija presega parcialno obravnavo simptomov, znakov in posledic zdravljenja in vključuje tudi psihološko, socialno in poklicno rehabilitacijo. Poudarek je na izboljšanju funkcioniranja bolnikov in preživelih po raku, s ciljem učinkovite socialne reintegracije. Tako je že v sklopu interdisciplinarne obravnave aktualno vključevanje zgodnjih terapevtskih programov za čimprejšnjo vrnitev bolnikov v domače in delovno okolje. Za načrtovanje onkološke rehabilitacije, za sporazumevanje med člani rehabilitacijskega tima, za določanje rehabilitacijskih ciljev in za preverjanje uspeha terapevtskih postopkov uporabljamo Mednarodno klasifikacijo funkcioniranja, zmanjšane zmožnosti in zdravja. Z uveljavitvijo bio-psiho-socialnega modela bolezni postaja onkološka rehabilitacija vse bolj prepoznavna in zahteva subspecialna znanja, prilagojene kadrovske normative, prostore in opremo tako za stacionarno kot ambulantno obravnavo. Z onkološko rehabilitacijo je potrebno začeti takoj ob postavitvi diagnoze, že v času načrtovanja in čakanja na začetek osnovnega zdravljenja. Uveljavil se je nov pristop, govorimo o prehabilitaciji rakavih bolnikov, ki odločujoče vpliva na končni izid zdravljenja, kakovost življenja in delazmožnost obolelih. Strokovnjaki znotraj rehabilitacijskega tima v Sloveniji poznajo doktrinarne in teoretične smernice onkološke rehabilitacije, obvladajo tudi specialna znanja, zaplete pa se pri številu timov in pri dostopnosti rehabilitacijskih storitev na vseh nivojih. V prispevku bo predstavljena aktualna klinična praksa in izzivi onkološke rehabilitacije na primarnem, sekundarnem in terciarnem nivoju. Izpostavljene bodo ovire zaradi pomanjkljive zdravstvene zakonodaje, standardov in normativov ter zaradi odsotnosti mreže rehabilitacije v slovenskem prostoru. Nakazane bodo potrebne organizacijske in strokovne aktivnosti za izboljšanje celostne onkološke rehabilitacije in posledično kakovosti življenja rakavih bolnikov in njihovih svojcev. 44

45 Plenarna sekcija Sobota, Plenary Session - Saturday 13 th Challenges and Problems of Oncological Rehabilitation Author: Prim. Assoc. Prof. PhD Breda Jesenšek Papež, MD. Head of the Institute for Physical and Rehabilitation Medicine, University Medical Center Maribor Key words: oncological rehabilitation. biopsychosocial approach, interdisciplinary team, prehabilitation Cancer incidence rate has steadily been increasing. Over the past few decades the progress in the field of basic research in medical sciences and development of new pharmacological and nonpharmacological therapies have contributed to the prolongation of the lifespan of patients and an increased number of those who survived cancer. Cancer has thus been considered a chronic condition, requiring a lifelong care of patients, including rehabilitation and regular monitoring of their condition. Oncological rehabilitation extends beyond the treatment of symptoms, indices and their consequences, by including psychological, social and occupational rehabilitation. The emphasis is laid on better functioning of cancer patients and cancer survivors, towards efficient social reintegration. An interdisciplinary approach thus includes therapeutic programs already at an early stage, with the aim of returning patients home and to their work environment. The International Classification of Functioning, Disability and Health is used for the planning of oncological rehabilitation, communication between the rehabilitation team members, setting rehabilitation goals and testing of successful therapeutic procedures. By the introduction of the biopsychosocio disease model, oncological rehabilitation has been gaining in importance, requiring subspecialist knowledge, adapted norms regarding the staff, premises and equipment for inpatient as well as outpatient treatment. Oncological rehabilitation has to be started as soon as diagnosis has been made, already during the time treatment plans are made and before the basic treatment begins. A new concept has been introduced, i.e. prehabilitation of cancer patients, which has a decisive role in the final outcome of treatment, quality of life and work capacity of patients. Professionals of rehabilitation teams in Slovenia are familiar with doctrinal and theoretical guidelines for oncological rehabilitation and possess extensive specialist knowledge. The problem, however, is the number of teams and accessibility of rehabilitation services at all levels. The article offers a presentation of the relevant clinical practice and challenges of oncological rehabilitation at primary, secondary and tertiary levels. Obstacles due to inadequate health legislation, standards and norms and the lack of rehabilitation network in Slovenia are set out. It brings forward organizational and professional activities necessary for the improving of entire oncological rehabilitation and, as a consequence, better life quality for cancer patients and their families. 45

46 Plenarna sekcija Sobota, Plenary Session - Saturday 13 th Onkološko zdravljenje in rehabilitacija bolnic z rakom dojke in potrebne razbremenitve pri delu Avtor: Prof. Dr. Nikola Bešić, dr. med., Vodja oddelka za kirurgijo naonkološkem inštitutu, Univerzitetni klinični center Ljubljana, Slovenija Strokovno sodelovanje: Onkološki inštitut Ljubljana, UKC Ljubljana, Ministrstvo za zdravje, ZZZS, URI Soča, Europa Donna Ključne besede: Rak dojke, Zdravljenje, Rehabilitacija, Razbremenitve pri delu Ozadje: Rak dojke je najpogostejši rak pri ženskah. V Sloveniji za rakom dojk letno zboli približno oseb. Leta 2015 je po podatkih Registra raka RS v Sloveniji živelo oseb, ki so jim postavili diagnozo raka dojke. Na leto je povprečno primerov bolniških staležev zaradi diagnoze raka, od tega skoraj primerov zaradi raka dojke. Povprečno trajanje bolniške odsotnosti je pri bolnicah z rakom dojke 174 dni. Postavlja se vprašanje, kako skrajšati bolniško odsotnost in zmanjšati delež invalidskih upokojitev, saj je sodobno zdravljenje raka dojke vedno bolj agresivno. Metode: Pregled strokovne literature, mednarodnih smernic in predloga pilotnega projekta celostne rehabilitacije za onkološke bolnike v obdobju glede načinov zdravljenja, stranskih učinkov in posledic, ki jih imajo bolnice in predlog razbremenitev pri delu. Rezultati: Zdravljenje raka dojk je multidisciplinarno, rehabilitacija pa interdisciplinarna. Kirurško zdravljenje lahko povzroči težave zaradi bolečin, omejeno gibljivost rame, težave zaradi spremenjene drže telesa in limfedem zgornje okončine. Obsevanje področja pazduhe poveča možnost limfedema. Sistemsko zdravljenje s citostatiki, hormoni, tarčnimi zdravili in imunoterapijo ima pogosto številne dolgotrajne posledice, ki zelo omejujejo delazmožnost bolnic. Omejena funkcionalnost nastane zaradi limfedema, omejene in boleče gibljivosti v rami ali drugih bolečin. Pogoste dolgotrajne težave so: anksioznost, depresivnost, psihična stiska, motnje kognitivne funkcije, utrudljivost in nespečnost. Zdravljenje z antraciklini in anti-her2 zdravili lahko okvari srce. Zaradi citostatikov in hormonov imajo bolnice težave z alopecijo. Predvsem mlajše bolnice imajo lahko zelo izrazite simptome povezane s pomanjkanjem ženskih spolnih hormonov in zato težave na področju spolnosti. Težave bi lahko preprečili ali omilili z boljšo zgodnjo in kasno celostno rehabilitacijo, krepitvijo zdravega življenjskega sloga in zgodnjo poklicno rehabilitacijo. Zaključki: Sodobno zdravljenje raka dojk močno poslabša delazmožnost bolnic. V Sloveniji je potrebno vzpostaviti sistem organizirane interdisciplinarne zgodnje in kasne celostne rehabilitacije. Zelo smiselno bi bilo vzpostaviti tudi poklicno rehabilitacijo bolnic z rakom dojk. 46

47 Plenarna sekcija Sobota, Plenary Session - Saturday 13 th Oncological Treatment and Rehabilitation of Patients with Breast Cancer and the Required Unburdening at Work Author: Prof. PhD. Nikola Bešić, MD., Head of Division of Surgery at the Institute of Oncology, University Medical Centre Ljubljana, Slovenia Expert collaboration: Oncology Institute Ljubljana, University Medical Centre Ljubljana, Ministry of Health of the Republic of Slovenia, Health Insurance Institute of Slovenia, University Rehabilitation Institute Republic of Slovenia - SOČA, Europa Donna Key words: breast cancer, treatment, rehabilitation, disability at work Background: Breast cancer is the most common cancer in women. Approximately 1300 persons contract breast cancer every year. According to Cancer Registry of Slovenia, persons with breast cancer diagnosis lived in Slovenia in On an annual basis there are sick leaves on the average due to cancer diagnosis, 1000 of them due to breast cancer. On the average, the duration of sick leave with breast cancer patients is 174 days. The issue to be addressed is how to reduce sick leave periods and the share of disability pensions because modern treatment of breast cancer is becoming more aggressive. Methods: A review of scientific literature, international guidelines and pilot project proposal regarding integral rehabilitation for oncological patients in the period as to treatment methods, side effects and the consequences patients are faced with, and a proposal regarding unburdening at work. Results: Breast cancer treatment is multidisciplinary while rehabilitation is interdisciplinary. Surgical treatment can cause discomfort due to pain, limited shoulder mobility, problems due to changed body posture and lymphedema of the upper extremity. Ray therapy of the armpit increases the possibility of lymphedema. System treatment with cytostatic medicines, hormones, targeted cancer drugs and immunotherapy often has numerous long-term effects, highly limiting the work capacity of patients. Limited functionality occurs due to lymphedema, limited and painful shoulder mobility or other pain. Frequent longstanding problems are anxiety, depression, psychic distress, cognitive function disorders, fatigue and insomnia. Antracycline and anti-her2 therapy may cause heart damage. Cytostatic medicines and hormones can cause alopecia in patients. Primarily young patients can develop strong symptoms related to low feminine hormone levels, thus resulting into sexual problems. The problem could be alleviated by better early as well as late integral rehabilitation, promotion of healthy lifestyle, early occupational rehabilitation. Conclusion: Modern treatment of breast cancer considerably reduces work capacity of patients. A system of organised interdisciplinary early and late integral rehabilitation should be established in Slovenia. It would also be valuable to set up occupational rehabilitation for patients with breast cancer. 47

48 Plenarna sekcija Sobota, Plenary Session - Saturday 13 th Ginekološka onkologija in vračanje na delo Avtor: Izred. Prof. Dr. Erik Škof, dr. med., Onkološki Inštitut, Univerzitetni klinični center Ljubljana, Slovenija Ključne besede: specifično onkološko zdravljenje, neželeni učinki, rehabilitacija Ko govorimo o ginekološki onkologiji, imamo v mislih zdravljenje bolnic z rakom materničnega telesa, rakom jajčnikov in rakom materničnega vratu. Rak materničnega telesa in rak jajčnikov sta večinoma bolezen starejših, medtem ko rak materničnega vratu pogosteje prizadene mlajše bolnice. Uporabljamo tri vrste specifičnega onkološkega zdravljenja kirurško zdravljenje, zdravljenje z obsevanjem in sistemsko zdravljenje. Zdravljenje je povezano z neželenimi učinki oz. zapleti, ki so večinoma akutni in prehodni. Lahko pa pride do kroničnih neželenih učinkov s trajnimi posledicami. Ker gre pogosto za kombinacijo več vrst zdravljenja, se lahko neželeni učinki med zdravljenjem potencirajo npr. kronični limfedem spodnjih okončin kot posledica limfadenektomije in obsevanja. Rak jajčnikov je običajno odkrit v napredovalem stadiju, zato je večinoma potrebno agresivno kirurško in sistemsko zdravljenje. Pri operaciji se odstranijo rodila, bezgavke, pogosto so potrebne multivisceralne resekcije. Po operaciji bolnice nadaljujejo zdravljenje s kemoterapijo (kombinacija paklitaksela in karboplatina), ki traja 6 mesecev. Pri zdravljenju raka materničnega telesa in raka materničnega vratu je običajno kirurški poseg manj obsežen, je pa pogosto potrebno dodatno zdravljenje z obsevanjem, včasih tudi s kemoterapijo. Zaradi akutnih neželenih učinkov (slabost, utrujenost, okužbe, slabokrvnost, nevropatija), priporočamo bolniški stalež ves čas onkološkega zdravljenja. Kombinacija paklitaksela in karboplatina lahko povzroča kronične težave (senzorična nevropatija, utrujenost, slabokrvnost), ki lahko trajajo tudi več tednov ali mesecev, zato v tem primeru priporočamo odsotnost z delovnega mesta do prve kontrole, ki je običajno 3 mesece po zaključku zdravljenja. V tem času prihaja v poštev rehabilitacija - fizioterapija in balneoterapija v zdravilišču. V primeru, da so neželeni učinki prisotni več mesecev, priporočamo postopen pričetek dela s skrajšanim delovnim časom za določeno obdobje. V obdobju sledenja pogosto opažamo pojav različnih psihofizičnih težav, ki so posledica kombinacije neželenih učinkov zdravljenja in strahu pred ponovitvijo bolezni. Zato je rehabilitacija (fizična in/ali psihična) po zaključenem zdravljenju zelo pomembna. 48

49 Plenarna sekcija Sobota, Plenary Session - Saturday 13 th Gynecologic Oncology and Return to Work Author: Assoc. Prof. PhD. Erik Škof, MD., Institute of Oncology, University Medical Centre Ljubljana, Slovenia Key words: specific oncological treatment, side effects, rehabilitation Gynecological oncology is treating of patients with uterine cancer, ovarian cancer and cervical cancer. Uterine cancer and ovarian cancer usually affect older patients, while younger ones contract cervical cancer more frequently. There are three types of specific oncologic therapy: surgery, radiation therapy and systemic treatment. Cancer treatment can induce adverse effects or complications, most of them being acute and transitory. It is also possible that adverse effects become chronic, with permanent consequences. Since there is usually the case of a combination of several treatment options, adverse effects may be intensified during treatment e.g. chronic lymphedema of lower extremities as the effect of lymphadenectomia and radiation therapy. Ovarian cancer is usually detected in an advanced-stage, thus usually demanding aggressive surgical and systemic treatment. Reproductive organs, lymphatic glands are surgically removed, often multivisceral resections are required. Surgery is followed by chemotherapy (combination of paclitaxel and carboplatin), which lasts 6 months. Uterine and cervical cancer usually require less extensive surgery, however, additional ray therapy or chemotherapy can sometimes be necessary as well. Due to acute side effects (nausea, fatigue, infections, anaemia, neuropathia) sick leave is recommended for the entire period of oncologic treatment. A combination of paclitaxel and carboplatin can cause chronic problems (sensoric neuropathia, fatigue, anaemia), which can last for weeks or months. In these cases sick leave is recommended until the first follow-up examination, which usually takes place 3 months after completion of therapy. During this time rehabilitation can be carried out physiotherapy and balneotherapy in a spa. If adverse effects persist for several months, gradual return to work is recommended, with part-time work for a limited period of time. During the period of patient monitoring, several psychophysical problems, the consequence of a combination of adverse effects of treatment and the fear of cancer recurrence, can be observed. Therefore, rehabilitation (physical and/mental) once the treatment has been concluded, is of extreme importance. 49

50 Plenarna sekcija Sobota, Plenary Session - Saturday 13 th Psihoonkologija v izvedenstvu Avtor: Dr. Zvezdana Snoj, dr. med., specialistka psihiatrije, Zavod za pokojninsko in invalidsko zavarovanje Slovenije Ključne besede: psihoonkologija, onkološki pacienti, depresija, anksioznost, funkcionalnost Rak je težka bolezen, ki prizadene bolnika ne samo na telesnem področju temveč tudi na duševnem. Zahvaljujoč medicinskem napredku število preživelih z rakom stalno narašča. Mnoge od teh bolnikov, danes smatramo za ozdravljene, čeprav nikoli več ne bodo enaki. Njihovo preživetje je priznanje človeškem intelektu, njihova prilagodljivost pa priznanje človeškemu duhu. Kljub temu te delne zmage ne smejo zakriti osebne prizadetosti vsakega od njih in ne težav s katerimi se po bolezni sooča ta travmatizirana populacija. Kljub biomedicinskem napredku namreč, rak še vedno ostaja bolezen, ki je pogosto sinonim za bolečino, trpljenje in smrt. V zgodnjih obdobjih proučevanja preživelih z rakom se je pričakovalo, da ne bodo imeli večjih psihičnih posledic bolezni, vendar so poznejše študije pokazale, da je pri onkoloških bolnikih prisotnost psihiatrične simptomatike višja kot v splošni populaciji ali nekjer vmes med normalnimi kontrolami in psihiatričnimi bolniki. Depresivnost, anksioznost, pomanjkanje volje, občutja brezizhodnosti, opuščanje socialnih stikov, siromašenje komunikacije, spremenjena samopodoba ter subjektivno ali objektivno zmanjšana delazmožnost - vse to so spremljevalci telesne bolezni. Pogosto prav ti, še bolj kot telesna bolezen sama, povečujejo bolnikovo trpljenje, poslabšujejo izid bolezni in zmanjšujejo uspehe zdravljenja, ter posledično vplivajo na vključitev bolnikov v delovno in socialno okolje. Večina preživelih z rakom je motivirana vrniti se na delovno mesto čim prej, tiste, ki tega ne zmorejo, pa moramo obravnavati kot pomembno skupino pri ocenjevanju deleža preživelih, ki so resno prizadeti zaradi raka. Pri vrnitvi v delovno okolje se posamezniki srečujejo s številnim objektivnimi in subjektivnimi težavami, ki jih je v tem procesu potrebno upoštevati. Med drugim, poročajo tudi o diskriminaciji na delovnem mestu, ki je pogosto posledica prepričanja, da je produktivnost obolelih z rakom manjša zaradi telesnih posledic bolezni ali morebitne potrebe po nadaljnjem zdravljenju. Glede na stalno naraščanje števila obolelih za rakom ter resno in številno problematiko s katero se soočajo preživeli, ostaja še vedno odprto vprašanje, kakšne nadaljnje implikacije bo to imelo ne le na medicinskem in zdravstvenem področju temveč tudi na socialnem, delovnem in celotnem družbenem okolju. 50

51 Plenarna sekcija Sobota, Plenary Session - Saturday 13 th Psycho-Oncology in Medical Assessment Author: PhD. Zvezdana Snoj, MD., Pension and Disability Insurance Institute of Slovenia, Ljubljana, Slovenia Key words: psychooncology, oncological patients, depression, anxiety, functionality Cancer is a severe disease, affecting patients not only physically but also mentally. Owing to the progress in medical science, the number of survivors in cancer patients is constantly on the increase. Many of these patients are considered cured, though their health condition will never be the same as before the disease. Their survival is a tribute to human mind, their adaptability to human spirit. However, these partial victories should not conceal their personal distress nor the difficulties this traumatised population is faced with after the disease. Despite a biomedical progress, cancer still is a disease, which is often a synonym for pain, suffering and death. Although in the first periods under examination of cancer patient survivors it was expected they would not have significant mental health problems, later studies evidenced that psychiatric symptoms in oncologic patients were more common than in general population, or somewhere between those without any symptoms and psychiatric patients. Depression, anxiety, lack of will, feeling of impasse, avoiding social contacts, poorer communication, changed self-image and subjectively and objectively diminished work capacity accompany the physical disease. It is often the case, that these factors, more than the physical disease itself, increase a patient s suffering, deteriorate the disease s outcome and reduce successful treatment, thus affecting the reintegration of patients into work and social environment. Most of cancer patient survivors are motivated to return to their workplace as soon as possible; those who are not able to do that should be treated as an important group in assessing the share of survivors seriously affected by cancer. When returning to their work environment, they are faced with various objective and subjective issues, which have to be taken into consideration in this process. Cases of discrimination in the workplace have also been reported, which is often the result of a belief the productivity of cancer patients be lower due to physical health consequences or a possible need for further treatment. Regarding the fact that the number of cancer patients is steadily increasing and the various problems survivors are faced with, the question remains what implications this will have not only in the medical and health fields but also in welfare, work and entire social environment. 51

52 Paralelna sekcija I. Četrtek, Parallel Session I. - Thursday 11th

53 Paralelna sekcija I. Četrtek, Parallel Session I. - Thursday 11 th Utesnitvene in kompresijske nevropatije Avtor: Prof. Dr. Simon Podnar, dr. med., Nevrološka klinika, Univerzitetni klinični center Ljubljana, Slovenija Ključne besede: nevropatije, zdravljenje, funkcijske motnje Utesnitvene in kompresijske nevropatije so najpogostejše okvare perifernega živčevja. Povzročajo žariščne okvare živca s prizadetostjo distalno oživčenih struktur (predvsem mišic in kože). Utesnitvene nevropatije povzročajo telesu lastne (večinoma vezivne) strukture, kompresijske nevropatije pa so posledica zunanjega pritiska. Diagnosticiramo jih z anamnezo in usmerjenim nevrološkim pregledom. V primeru kompresijskih in blagih utesnitvenih nevropatij pričnemo s konzervativnim zdravljenjem: izogibanje škodljivim položajem udov, uporaba opornic, prilagoditve delovnega mesta... V primeru slabe odzivnosti na konzervativne ukrepe ali zmerne/ težje utesnitvene nevropatije potrdimo diagnozo z nevrofiziološko ali ultrasonografsko preiskavo. Za nekatere blage/zmerne utesnitvene nevropatije so na voljo infiltracije pod ultrasonografskim nadzorom, težje pa navadno zahtevajo operativno sprostitev živca. Najpogostejša je utesnitvena nevropatija medianega živca v zapestnem prehodu. Ta povzroča sindrom zapestnega prehoda: predvsem nočne bolečine in mravljinčenje v prvih treh prstih, ki jih ublaži otresanje roke. Pacienti s težjo okvaro imajo okrnjeno krčenje palca in moten občutek v konicah prstov. Recidivi po operativni sprostitvi so pogosto posledica nadaljevanja prekomernih delovnih obremenitev. Nevropatija ulnarnega živca v komolcu vključuje retrokondilarno kompresijo na nedominantni roki po delu z osebnim računalnikom (85%) ter utesnitveno nevropatijo v kubitalnem tunelu na dominantni roki pri težkih fizičnih delavcih (15%). Predvsem slednja se kaže predvsem z atrofijo in šibkostjo ulnarnih mišic dlani in zahteva čimprejšnjo kirurško sprostitev z 2-3 cm rezom distalno od komolca. Redkejši sta kompresijska nevropatija radialnega živca v žlebu nadlaktnice (pareza sobotne noči) ter utesnitvena nevropatija globoke veje radialnega živca ob prehodu skozi supinatorno mišico. Posledica obeh je šibkost ekstenzije zapestja in prstov. Na nogah je najpogostejša kompresijska nevropatija fibularnega živca ob glavici mečnice, zaradi sedenja s prekrižanimi nogami, dolgotrajnega čepenja ali večje izgube telesne teže. Med utesnitvenimi nevropatijami je na nogah najpogostejša meralgia parestetica, utesnitev zunanjega kožnega živca za stegno ob prehodu pod ingvinalnim ligamentom. Ta povzroča pekoče bolečine po zunanji površini stegna, predvsem stoje. 53

54 Paralelna sekcija I. Četrtek, Parallel Session I. - Thursday 11 th Compression and Entrapment Neuropathies Author: Prof. PhD Simon Podnar, MD, Neurology Clinic, University Medical Center Ljubljana, Slovenia Key words: neuropathy, healing, functional disorders Compression and entrapment neuropathies are one of the most frequent disorders of the peripheral nerves. They cause central disorders of nerves by harming the distal nervous structures (especially muscles and skin). Entrapment neuropathies are caused by the body s own (mostly connective) structures, while compression neuropathies are the consequence of external pressure. We diagnose them on the basis of the patient s anamnesis and directed neurological examination. Conservative treatment is used in compression and gentle entrapment neuropathies: avoidance of harmful positions of the body, usage of splints, adjustments made in the working environment, etc. In the event of a poor responsiveness to conservative measures or moderate/heavy entrapment neuropathy we confirm the diagnosis with a neurophysiological or ultrasound examination. Infiltrations under ultrasound supervision are available for certain mild/moderate entrapment neuropathies, while heavy neuropathies generally require surgery to release the nerve. The most common entrapment neuropathy is the neuropathy of the median nerve in the carpal tunnel. This causes the carpal tunnel syndrome: night pain and a tingling sensation in the first three fingers, alleviated by shaking one s hand. Patients with a severe disorder experience stunted contractions of the thumb and a dysfunctional feeling in fingertips. The return of such problems following a surgical release is usually the consequence of the continuation of excessive work loads. The ulnar nerve neuropathy in the elbow includes a retrocondylar compression on the non-dominant hand after working on a personal computer (85%) and an entrapment neuropathy in the cubital tunnel on the dominant hand in heavy labour workers (15%). The latter especially shows an atrophy and weakness of ulnary muscles in the palm and requires immediate surgical release with a 2-3 cm long cut distal from the elbow. Compression neuropathy of the radial nerve in the head of the bone (Saturday Night Paresis) and entrapment neuropathy of the deep branch of the radial nerve following the transition through the supination muscle. The consequence of both is weakness in extending one s wrist and fingers. The most common compression neuropathy in the legs is the fibular nerve neuropathy at the head of the fibula caused by sitting with legs crossed, prolonged crouching or severe body weight reduction. Among the entrapment neuropathies in the legs the most common one is the meralgia paresthetica, which is an entrapment of the external thigh nerve under the inguinal ligament. This causes burning pain on the outer surface of the thigh, especially when standing. 54

55 Paralelna sekcija I. Četrtek, Parallel Session I. - Thursday 11 th Rehabilitacijska obravnava bolnikov z utesnitvenimi nevropatijami Avtor: Prim. Asist. Mag. Lidija Plaskan, dr. med., Oddelek za medicinsko rehabilitacijo, Splošna bolnišnica Celje, Slovenija Ključne besede: Utesnitvene nevropatije, diagnostika, rehabilitacija smernice Povzetek: Utesnitvene nevropatije so najpogostejše okvare perifernih živcev in predstavljajo velik klinični problem. Povzroča jih utesnitev v ozkih prehodih med anatomskimi strukturami in so velikokrat povezane z določenimi obolenji ali poklici. Večinoma gre za mehanični dinamični pritisk na kratkem odseku posameznega živca. Klinična slika je zelo raznolika in obsega vse od blagega, občasnega mravljinčenja do motoričnih izpadov, včasih je vodilni simptom bolečina. Prizadeti so predvsem dolgi, periferni živci, utesnitev pa je lahko akutna ali kronična. Tipični predstavniki so sindrom zapestnega prehoda, utesnitev ulnarnega živca v komolcu in padajoče stopalo. Kljub veliki pojavnosti utesnitvenih nevropatij, imamo lahko težave pri postavljanju diagnoze, zdravljenju in rehabilitaciji. Pri potrjevanju in oceni stadija utesnitve, so nam poleg klinične ocene v največjo pomoč elektrofiziološke preiskave, v določenih primerih se poslužujemo tudi slikovnih metod, kot sta MR in UZ. Zdravljenje je v večini primerov konzervativno in vključuje omejevanje aktivnega gibanja prizadetih sklepov z uporabo ortoz, kortikosteroide, nesteroidne antirevmatike, različne oblike fizikalnega zdravljenja in ergonomske prilagoditve delovnega mesta. Kirurška sprostitev je indicirana, kadar je konzervativno zdravljenje neuspešno ali je potrebna takojšnja sprostitev živca. Najpogostejša utesnitvena nevropatija je sindrom zapestnega prehoda, ki se večinoma pojavlja pri odraslih ženskah, s prevalenco do 9%. V prispevku so predstavljeni tipični predstavniki utesnitvenih nevropatij, njihova obravnava in smernice ameriške akademije ortopedskih kirurgov (AAOS) za obravnavo sindroma zapestnega prehoda, ki so bile objavljene leta Literatura: American Academy of Orthopaedic Surgeons. Management of Carpal Tunnel Syndrome Evidence-Based Clinical Practice Guideline. Published February 29, Bayramoglu M. Entrapment neuropathies of the upper extremity. Neuroanatomy 2004; 3: Moharić M. Klinične smernice za rehabilitacijo bolnikov z utesnitvenimi nevropatijami. Rehabilitacija 2014: 1:

56 Paralelna sekcija I. Četrtek, Parallel Session I. - Thursday 11 th Rehabilitation of patients with entrapment neuropathies Author: Prim. asist. MsC. Lidija Plaskan, MD., General Hospital Celje, Slovenia, Key words: Entrapment neuropathies, diagnostics, rehabilitation, guidelines Summary Entrapment neuropathies are the commonest peripheral nerve lesions and represent an important clinical issue. They are due to compression of peripheral nerves within narrow passages of normal anatomical structures and often associated with certain diseases or professions. In most cases there is a mechanical dynamic compression of a short segment of a specific nerve. They give rise to paraesthesia, numbness, weakness, wasting and sometimes also to pain as a prominent symptom. Long peripheral nerves are mostly affected, entrapment can be either acute or chronic. Carpal tunnel syndrome, ulnar neuropathy at the elbow and drop foot are typical representatives. Despite of widespread pathology, there are problems in diagnostics and treatment of entrapment neuropathies. Clinical assessment is of great importance and for confirmation and stage of compression electrodiagnostic testing should be carried out. Imaging methods as MR and ultrasound are also used. The mode of treatment is in most cases conservative and includes avoidance of the use of the affected joint with splinting, corticosteroids, anti-inflammatory drugs, various modes of physical therapy and ergonomic modifications of working place. Surgical treatment is recommended when conservative treatment fails or the nerve needs to be decompressed immediately. Carpal tunnel syndrome is the most common entrapment neuropathy. It occurs most commonly in adult women with a prevalence rate as high as 9%. The most common representatives of entrapment neuropathies, their management and American Academy of Orthopaedic Surgeons Guidelines for carpal tunnel syndrome (published in 2016) are presented in this paper. References: American Academy of Orthopaedic Surgeons. Management of Carpal Tunnel Syndrome Evidence-Based Clinical Practice Guideline. Published February 29, Bayramoglu M. Entrapment neuropathies of the upper extremity. Neuroanatomy 2004; 3: Moharić M. Klinične smernice za rehabilitacijo bolnikov z utesnitvenimi nevropatijami. Rehabilitacija 2014: 1:

57 Paralelna sekcija I. Četrtek, Parallel Session I. - Thursday 11 th Piriformis sindrom in ocena delazmožnosti Avtor: Doc. Dr. Dušan Čelan dr. med., spec. fizikalne medicine in rehabilitacije. Ustanova Oddelek/referat: Univerzitetni klinični center Maribor Ključne besede: piriformis, ishialgija, razbremenitev, delazmožnost Opis problema: Ob prisotnosti ishialgije in pri negativnih slikovnih preiskavah spinalnih vzrokov je potrebno iskati zunajspinalne vzroke za pritisk na n. ishiadikus. V glutealnem predelu je zaradi posebnosti anatomskih odnosov m.piriformisa in n.ishiadikusa lahko prisoten piriformis sindrom (PS) pritisk na živec s strani m. piriformisa. Odgovoren je za 6% ishialgij, 6 krat pogostejši je pri ženskah, pogosto je vzrok poškodba. Diagnostika: Na PS posumimo ob glutealni bolečini in ishialgiji. Izvedemo teste natega (Freiberg) ali kontrakcije mišice (Pace, Beatty). Postavljeni so kriteriji za ( globoka glutealna bolečina z ishialgijo, izražena bolečina pri sedenju, boleč pritisk na m.piriformis, pozitivni provokativni testi, pozitiven CT ali NMR izvid, zmanjšanje bolečine pri lokalni infiltraciji) in proti diagnozi PS. Ishialgija je simptomatska, znakov nevroloških izpadov naj ne bi bilo. Delovno diagnozo PS preverimo s preiskavami NMR, eventuelno CT in diagnostični UZ Terapija: Priporočajo se razbremenitev, fizikalna terapija (ishemična kompresija, spray & stretch tehnika, rektalna masaža, elektroterapija, kinezioterapija, ESWT), lokalna infiltracija mišice; če po 3 mesecih konzervativnih metod ni izboljšanja je indicirana operacija konvencionalna ali endoskopska metoda. Delazmožnost: M. piriformis je funkcionalno anatomsko močan zunanji rotator in šibek abduktor ter fleksor kolka. Obremenjen je z daljšo močnejšo aktivno kontrakcijo in forsiranim raztegom. PS povzročajo tudi pritiski na m.piriformis in posredno n. ishiadikus. Aktivnosti, ki obremenjujejo m.piriformis, so: daljše sedenje počepi zasuki noge plezanje, vzpenjanje športi: daljši teki, kolesarjenje, jahanje Zaključki: PS je pogosto neodkrit vzrok ekstraspinalne ishialgije. Potrebna je natančna diagnostika, ustrezna konzervativna, v skrajnem primeru tudi operativna terapija. Uspešnost terapije je dobra, če je ustrezna in obsega vse možnosti. Prvi terapevtski ukrep je razbremenitev mišice. Pri oceni delazmožnosti je potrebno odsvetovati pozicije in aktivnosti, ki obremenjujejo m. piriformis. 57

58 Paralelna sekcija I. Četrtek, Parallel Session I. - Thursday 11 th Piriformis Syndrome and Work Capability Assessment Author: Assist. Prof. PhD Dušan Čelan MD, spec. of physical medicine and rehabilitation Establishment: Maribor University Medical Centre Key words: piriformis, ishialgia, relieving, working ability Problem description: At the presence of ischialgia in negative imaging diagnostics of spinal reasons we need to look for non-spinal related reasons for the pressure on n. ischiadicus. Due to the special anatomic relations between m. piriformis and n. ischiadicus, the piriformis syndrome (PS) may be present in the gluteal region - pressure on the nerve by m. piriformis. It is responsible for 6% of ischialgia, it is 6 times more common in women and the most frequent reason for it is an injury. Diagnostics: We think of PS at the presence of gluteal pain and ischialgia. We perform the tension (Freiberg) or muscle contraction test (Pace, Beatty). There are criteria in favour (deep gluteal pain with ischialgia, pain during sitting, painful pressure on m. piriformi, positive provocative tests, positive CT or NMR results, reduction of pain during local infiltration) and against the PS diagnosis. Ischialgia is symptomatic, there should be no signs of a neurological deficit. The working PS diagnosis is checked with NMR diagnostics, eventually CT and diagnostic US. Therapy: It is recommended that patients are relieved at work, undergo physical therapy (ischemic compression, spray & stretch technique, rectal massage, electrotherapy, kinesiotherapy, ESWT), local muscle infiltration; if no improvement is made after 3 months of conservative methods, then the next step is surgery - conventional or endoscopic method. Work capability: M. piriformis is functionally and anatomically a strong external rotator and weak abductor and flexor of the hip. It has a longer and stronger active contraction and forced stretching. PS is also caused by pressure onto m. piriformis and indirectly onto n. ischiadicus. Activities which put a burden onto m. piriformis are: prolonged sitting squats bending of legs climbing sports: longer runs, cycling, horseback riding Conclusions: PS is often an undiscovered reason of extraspinal ischialgia. An accurate diagnostic is necessary, as well as an appropriate conservative therapy, in severe cases also surgery. The therapy is successful if it is appropriate and comprises of all possibilities. The first therapeutic measure is the relief of muscle. When assessing one s work capability, it must be advised against positions and activities which pose a burden on m. piriformis. 58

59 Paralelna sekcija I. Četrtek, Parallel Session I. - Thursday 11 th Kronična bolečina Avtor: Dr. Aljoša Danieli, dr. med. Barsos MC Ljubljana Ključne besede: kronična bolečina, mehanizem nastanka, zdravljenje Izvleček: Fiziološka vloga bolečine je opozarjanje posameznika na poškodbo ali obolevnost tkiva in vplivanje na vedenje organizma na način, ki omogoča zdravljenje okvarjenega dela telesa. Občutek bolečine je subjektivna izkušnja in se je ne da objektivno izmeriti. Njena kvaliteta in intenzivnost je odvisna je od okoliščin nastanka, lokacije in prizadetosti tkiva ter psiholoških dejavnikov (pozornost, pričakovanje, prepričanje). Bolečino, ki traja več kot šest mesecev in nima fiziološkega pomena za organizem, imenujemo kronična bolečina. Patofiziološki mehanizem kronične bolečine ni povsem znan. Danes prevladuje mnenje, da dolgotrajna vzdraženost perifernih bolečinskih nevronov kot posledica različnih bolezenskih stanj, lahko povzroči nevroplastične spremembe in spremembe v povezavah nevronskega mrežja na nivoju perifernih nevronov, hrbtenjače in možganske skorje. Nastale spremembe posledično privedejo do hiperalgezije in alodinije. Zdravljenje je večplastno in vsebuje zdravljenje z zdravili, fizikalno terapijo (na primer TENS), kirurško zdravljenje (na primer blokade živcev, intratekalna infuzija analgetikov, stimulacija hrbtenjače) in različne psihološke pristope za izboljšanje prilagoditvenih sposobnosti bolnikov na kronično bolečino. 59

60 Paralelna sekcija I. Četrtek, Parallel Session I. - Thursday 11 th Chronic Pain Author: PhD Aljoša Danieli, MD, Barsos MC Ljubljana Key words: hronic pain, mechanism of formation, treatment Abstract: The physical role of pain is to warn the individual about an injury or morbidity of tissue and to change the behaviour of the organism in such a way that it shall allow healing of the defective part of the body. Pain is a subjective experience and cannot be measured objectively. Its quality and intensity depends on the circumstances of its occurrence, location and impairment of the tissue and psychological factors (attentiveness, expectation, belief). Pain lasting more than six months that has no physiological importance for the organism is called chronic pain. The pathophysical mechanism of chronic pain is not fully known. Today, it is strongly believed that long-term excitement of peripheral pain neurons as the consequence of various medical conditions may cause neuroplastic changes and changes connected to the neural network on the level of peripheral neurons, spine and cerebral cortex. The occurred changes consequently lead to hyperalgesia and allodynia. Treatment is multi-layered and includes treatment with drugs, physical therapy (e.g. TENS), surgery (e.g. blocking of the nerves, intrathecal infusion of painkillers, stimulation of the spine) and various psychological approaches in order to improve the adjustment capabilities of patients with chronic pain. 60

61 Paralelna sekcija I. Četrtek, Parallel Session I. - Thursday 11 th Poklicnea etiologija in vračanje na delo pri utesnitvenih sindromih roke Avtor: Metka Teržan, dr. med., Centar za poklicno rehabilitacijo, Univerzitetni rehabilitacijski Inštitut Republike Slovenije Soča Ljubljana, Slovenija Ključne besede: okvare zgornjega uda v zvezi z delovnim mestom, poklicne bolezni, vračanje na delo Namen prispevka je predstaviti fiziologijo dela z zgornjimi udi. Označuje jo izjemna zgradba zgornjega uda, ki je sijajno delovno orodje. Izpostavljamo kompleksnost posameznih gibov zgornjega uda. Utrujenost pri delu nastane, kadar je faza intenzivnega dela predolga, da se mišica ne more metabolično obnoviti. Način dela lahko bistveno zmanjša utrujanje, izbrati je treba kote in obsege gibov ter položaj telesa, ki pomenijo največjo možno razbremenitev. Ne smemo pozabiti na prijem, ki ima različne funkcije in omogoča razvoj različni sil. Veliko bolezni zgornjega uda nastane v povezavi z obremenitvami na delovnem mestu. Največ raziskav govori o sindromu zapestnega prehoda. Pravilneje je govoriti o aktivnosti na delovnem mestu, kot o poklicu, saj se aktivnosti znotraj posameznih poklicev lahko zelo razlikujejo. Pomembna je hitra diagnoza in iskanje povezave z dejavniki tveganja na delovnem mestu ter priporočila za ergonomsko ureditev delovnega mesta. Utesnitveni sindromi zgornjega uda imajo svoje mesto v Pravilniku o seznamu poklicnih bolezni, izdelani so tudi kriteriji za verifikacijo navedenih poklicnih bolezni. Izpostavljenih je nekaj dejavnikov tveganja in možnih rešitev pri prilagajanju delovnega mesta v procesu vračanja na delo. 61

62 Paralelna sekcija I. Četrtek, Parallel Session I. - Thursday 11 th Proffessional etiology and return to work process for persons with upper extremity disorders Author: Metka Teržan, MD., Vocational Rehabilitation Centre, University Rehabilitation Institute Republic of Slovenia SOČA, Ljubljana, Slovenia Key words: Work related upper extremity disorders, occupational diseases, return to work The aim of this article is to present physiology work with of upper extremity. Unique structure of upper extremity is described, which is brilliant instrument for work. Complexity of the separate movement is exposed. Too long phases of work are the reason for fatigue in muscles. Proper way of providing working tasks, angels and scales of movements and body postures with highest area of comfort can diminish fatigue. We must not forget on grip with its function and different power control. Illnesses of upper extremity are often associated with working tasks. It is better to discusse about activities at work than about profession, because they can differ among them. Quick diagnosis is important and searching for risk factors on workplace and proposing ergonomic arrangements is crucial. Diseases of upper extremity are present in legislation on the list of occupational diseases, we have our own criteria on verification of these diseases. We talk about some risk factors and possible workplace arrangements in returning to work programmes. 62

63 Paralelna sekcija II. Četrtek, Parallel Session II. - Thursday 11th

64 Paralelna sekcija II. Četrtek, Parallel Session II. - Thursday 11 th Vrtoglavica in druge motnje ravnotežja v izvedenski praksi Avtor: Mag. Branka Geczy Buljovčić, dr. med, specialistka otorinolaringologije Sektor za izvedenstvo ZPIZ Slovenije Ključne besede: vrtoglavica, motnje ravnotežja, funkcionalni testi, ocena delazmožnosti Namen prispevka je prikaz kompleksnosti diagnostične obravnave in ocene delazmožnosti zavarovancev z vrtoglavico in motnjami ravnotežja. Metode: predstavila bom multidisciplinarni pristop v diagnostiki motenj ravnotežja pri katerem sodeluje več specialistov kot so otorinolaringolog-avdiolog in nevrolog ter po potrebi še kardiolog, okulist, ortoped, fiziater, revmatolog, psihiater, psiholog in drugi. Prikazala bom občutljivost in zanesljivost posameznih testov za ugotovitev okvare periferne in centralne vestibularne proge ter navedla indikacije za dodatne teste v sklopu diagnostike omotice in motenj zavesti pri sinkopi in disfunkciji avtonomnega živčevja. Rezultati: navedla bom predlog za smernice, ki jih skupaj s specialisti medicine dela, prometa in športa uporabljamo pri oceni delazmožnosti in pri podajanju vsebinskih razbremenitev v primeru okvare ravnotežne proge, glede na zavarovančeve težave in rezultate funkcionalnih testov z ozirom na zahteve delovnega mesta in poklic. Prikazala bom tudi bolezni in stanja z motnjami ravnotežja pri katerih so rezultati funkcionalne diagnostike v nesorazmerju z zavarovančevimi težavami. Zaključek: V zaključku bom opozorila na zahtevnost in težave pri diagnostiki in oceni delazmožnosti pri obravnavanih bolezenskih stanjih. 64

65 Paralelna sekcija II. Četrtek, Parallel Session II. - Thursday 11 th Vertigo and other balance impairments in the medical assessment Author: Branka Geczy Buljovčić, MD., Pension and Disability Insurance Institute of Slovenia, Ljubljana, Slovenia Key words: vertigo, balance impairment, functional tests, working ability assessment The aim of the presentation is to emphasize the complexity of the diagnostic procedure and the working ability assessment of people with vertigo and balance impairment. Methods: the multidisciplinary approach for the assessment of balance disorders will be presented and the coordination of otorhinolaryngologist-audiologist and the neurologist will be emphasized, as well as the need for the cooperation with other specialists, such as the cardiologist, ophtalmologist, orthopedic, physiatrist, rheumatologist, psychiatrist and psychologist. The sensibility and the reliability of the functional tests for the diagnoses of the peripheral and central vestibular path impairment will be analyzed, as well as the indications for additional tests for the syncope and the autonomic neural system dysfunction. Results will suggest the guidelines for the assessment of the working ability of these patients, which are suggested in coordination with the specialist for the occupational medicine according to the patient s working place and their profession. In conclusion, the problems and the complexity of the assessment of the balance impaired patient, as well as their working ability assessment, will be summarized. 65

66 Paralelna sekcija II. Četrtek, Parallel Session II. - Thursday 11 th Motnje spanja in delazmožnost Avtor: Izr.Prof.Dr. Leja Dolenc Grošelj dr.med. Klinični inštitut za klinično nevrofiziologijo, Nevrološka klinika, UKC Ljubljana Strokovno sodelovanje: članica delovne skupine za enotno obravnavo bolnikov z motnjami spanja v Evropi pod okriljem Assembley of National sleep societies (ANNS) in European sleep research society (ESRS), avtorica evropskih smernic za obravnavo bolnikov z narkolepsijo (2008), avtorica evropskih smernic za obravnavo bolnikov z nespečnostjo (2017), članica delovne skupine za oblikovanje novih evropskih smernic pod okriljem European academy of neurology (EAN) in ESRS ( ), članica delovne skupine, ki je pripravila Pravilnik o zdravstvenih pogojih voznikov (Ministrstvo za zdravje) za bolezni, katerih posledica je prekomerna dnevna zaspanost, ter uskladila Pravilnik z Evropsko direktivo za bolnike z motnjami dihanja v spanju s prekomerno dnevno zaspanostjo (2011), specialistka konzultantka Agencije za civilno letalstvo Slovenije, Javne agencije za civilno letalstvo RS (od 2017). Ključne besede: motnje spanja, hipersomnije, narkolepsija, obstruktivna apneja v spanju, cirkadiane motnje spanja Povzetek: Motnje spanja so pogoste v splošni populaciji, a žal spregledane ter pozno diagnosticirane in zdravljene. Večina bolnikov z motnjami spanja v Sloveniji je napotena na specialistično obravnavo šele, ko zaradi bolezenske prekomerne dnevne zaspanosti povzročijo nesreče na delu ali med vožnjo motornih vozil. Bolezni, katerih posledica je prekomerna dnevna zaspanost (npr. narkolepsija), pomenijo resno nevarnost na delovnem mestu, zato je smiselna obravnava pri specialistu nevrologije/somnologu, ki na podlagi pregleda in diagnostičnih preiskav (celonočno polisomnografsko snemanje ter testi srednje latence uspavanja ali testi srednjega trajanja budnosti) postavi diagnozo motnje spanja, uvede zdravljenje ter predlaga delazmožnost, ki jo ugotovi pooblaščeni zdravnik specialist MDPŠ na podlagi usmerjenega izvida somnologa. Pogosta motnja spanja je sindrom obstruktivne apneje v spanju z pridruženo prekomerno dnevno zaspanostjo, kar predstavlja nevarnost na delovnem mestu. Potrebna je diagnostična obravnava pri zdravniku specialistu nevrologu/pulmologu z znanjem somnologije, ki uvede ustrezno zdravljenje in redno spremlja pacienta. Vedno več je bolnikov z motnjami cirkadianega ritma spanja, kot posledice nepravilnega vzorca budnosti in spanja zaradi izmenskega oziroma nočnega dela. Smiselna je specialistična obravnava pri nevrologu/somnologu, ki svetuje zdravljenje in delazmožnost. Zaradi možnosti hudih nesreč so v tujini v specialnih delovnih okoljih (npr. možnost nesreč v letalstvu, prometu, tovarnah, nuklearkah,... ) uvedeni zelo strogi delovni ukrepi. Dolgoletne motnje cirkadianih ritmov zaradi narave dela povečajo rizik za razvoj različnih oblik raka in s tem odgovornost delodajalca. Zaključek: Motnje spanja so pogoste v delovni populaciji, a žal pogosto spregledane in nezdravljene vodijo v hude nesreče na delovnem mestu in v prometu. Ustrezna zgodnja specialistična obravnava in timsko delo (sodelovanje osebnega zdravnika, specialista somnologa in specialista MDPŠ) pomembno izboljša klinično stanje bolnikov z motnjami spanja, ki so ob rednem zdravljenju z manjšimi omejitvami pogosto sposobni opravljati svoje delo. 66

67 Paralelna sekcija II. Četrtek, Parallel Session II. - Thursday 11 th Sleep Disorders and Work Capability Author: Assoc. Prof. PhD Leja Dolenc Grošelj MD, Clinical Institute for Clinical Neurophysiology, Neurology Clinic, UMC Ljubljana Professional cooperation: member of the working group for the treatment of patients with sleep disorders in Europe under the Assembly of National Sleep Societies (ANNS) in the European Sleep Research Society (ESRS), author of European guidelines for the treatment of patients with narcolepsy (2008), author of European guidelines for the treatment of patients with insomnia (2017), member of the working group for the formation of new European guidelines under the European Academy of Neurology (EAN) and ESRS ( ), member of the working group for the preparation of the Rules on health conditions for drivers (Ministry of Health) for diseases attributable to excessive daytime sleepiness, and harmonised the Rules with the European directive for patients with respiratory problems during sleeping with excessive sleepiness at day (2011), specialist consultant of the Civil Aviation Agency of Slovenia (as of 2017). Key words: sleep disorders, hypersomnia, narcolepsy, obstructive apnea in sleep, circadian sleep disorders Summary: Sleep disorders are common in the general population, but unfortunately ignored and diagnosed and treated too late. Most patients with sleep disorders in Slovenia are directed to specialist treatment only after an accident at work or traffic accident is caused due to the excessive daytime sleepiness. Diseases attributable to excessive daytime sleepiness (e.g. narcolepsy) are a serious risk at one s work place, therefore examination at a specialist of neurology/somnology is sensible, who may, on the basis of diagnostic treatment (polysomnography and multiple sleep latency tests or wakefulness tests), diagnose such patients with a sleep disorder, implement treatment and propose the patient s work capability determined by the authorised specialist of occupational medicine on the basis of a targeted examination performed by the somnologist. The obstructive sleep apnea syndrome with excessive daytime sleepiness is a common sleep disorder and poses a risk at the work place. A diagnostic treatment is necessary at a neurologist/ pulmonologist who has knowledge of somnology and who then implements the appropriate treatment and regularly monitors the patient. There is an increase in the number of patients with a circadian rhythm sleep disorder as the consequence of incorrect sleep and wake cycles due to shift work or night time work. A specialist examination at a neurologist/somnologist is sensible, who then implements the correct treatment and work capability. Due to the possibility of severe accidents, very strict working measures are implemented abroad in special work environments (e.g. the possibility of aviation accidents, traffic accidents, accidents in factories, nuclear power plants, etc). Long-term circadian rhythm sleep disorders due to the nature of one s work increase the risk for developing various forms of cancer and, consequently, the liability of the employer. Conclusion: Sleep disorders are common in the working population. Unfortunately, they are frequently ignored and if left untreated, they may lead to severe accidents at the work place or in traffic. An appropriate early specialist treatment and team work (which includes the personal physician of the patient, a somnologist and an occupational medicine specialist) can significantly improve the clinical condition of patients with sleep disorders, who are capable of performing their work with few restrictions after undergoing regular treatment. 67

68 Paralelna sekcija II. Četrtek, Parallel Session II. - Thursday 11 th Motnje spanja in vožnja motornih vozil Avtor: Vesna Pekarović Džakulin, dr. med., spec. družinske medicine in medicine dela, prometa in športa, Diagnostični center Šentjur, Slovenija Ključne besede: Motnje spanja, delazmožnost, stres, vožnja motornih vozil Motnje spanja so pogoste in lahko pomembno vplivajo na nastanek in potek različnih bolezni. Posledično vplivajo na zmožnost za delo in vožnjo motornih vozil ter s tem na kakovost življenja in varnost ljudi. Velja pa tudi obratno. Dolgotrajna izpostavljenost stresu spada med glavne vzroke primarne nespečnosti, kar vodi v nastanek začaranega kroga. Zaspanost za volanom je eden glavnih vzrokov prometnih nesreč s smrtnim izidom, še posebej na avtocestah, ki sicer spadajo med najbolj varne ceste. Ocenjujejo, da je zaspanost za volanom povzročitelj približno 20 % prometnih nesreč na cestah v Evropi. Med glavne vzroke zaspanosti za volanom spadajo pomanjkanje spanja, motnje spanja (apneja v spanju, narkolepsija, druge hipersomnije, nespečnost, depresija ) ter zdravila in snovi, ki povzročajo zaspanost. Motnje dihanja v spanju (predvsem obstruktivna apneja v spanju) spadajo med najpogostejše motnje spanja, ki se kažejo s prekomerno dnevno zaspanostjo. Ocenjujejo, da je v ZDA 14 milijonov poklicnih voznikov, med katerimi pričakujejo, da ima % (2,4-3,9 milijonov voznikov) obstruktivno apnejo v spanju. V vodilni teoriji stresa na delovnem mestu, ki jo je Karasek objavil leta 1979, igra pomembno vlogo predanost službi; gre za občutek,»da zvečer ne moreš nehati premišljevati o službi«ali pa»da začneš premišljevati o službi takoj, ko se zjutraj zbudiš«. V veliki študiji, opravljeni na oseb v Franciji, so ugotovili, da so specifični stresorji, ki vplivajo na motnje spanja, izmensko delo, podaljšan delovni teden, izpostavljenost vibracijam in»delo pod časovnim pritiskom«. Med delovnimi zahtevami je največ motenj spanja povzročal občutek, da je potrebno v delo»vlagati zelo veliko napora«in ne zgolj»prevelika količina dela«. Tveganje za motnje spanja je bilo še večje, če so osebe dodatno navajale,»da zvečer ne morejo prenehati premišljevati o službi«. 68

69 Paralelna sekcija II. Četrtek, Parallel Session II. - Thursday 11 th Sleep Disorders and Driving of Motor Vehicles Author: Vesna Pekarović Džakulin, MD, specialist in family medicine and occupational medicine, Šentjur Diagnostics Center, Slovenia Key words: Sleep disorders, work capability, stress, motor vehicle driving Sleep disorders are common and may have a significant impact on the occurrence and course of diseases. Consequently, they affect one s ability to work and drive motor vehicles and thus the quality of life and the safety of people. And vice versa. Long-term exposure to stress is one of the main reasons for primary insomnia, which leads to a vicious cycle. Sleepiness behind the wheel is one of the main reasons of traffic accidents resulting in death, especially on motorways which, in default, are one of the safest roads. It is assumed that sleepiness behind the wheel is the cause of approx. 20% of traffic accidents on roads in Europe. Among the main reasons for sleepiness behind the wheel are lack of sleep, sleep disorders (sleep apnea), narcolepsy, other hypersomnia, sleepiness, depression, etc) and drugs and substances which cause sleepiness. Breathing disorders during sleep (especially obstructive sleep apnea) are one of the most common sleep disorders, shown with excessive daytime sleepiness. It is assumed that there are 14 million professional drivers in the USA where 17-28% have an obstructive sleep apnea ( million drivers). The predominant theory of stress at the work place, which Karasek published in 1979, stats that commitment to one s job plays a significant role; it is a feeling that you cannot stop thinking about work in the evening or that you start thinking about work immediately after waking up. A major study in France involving 21,000 persons has determined that the specific stressors that have an impact on sleep disorders are shift work, extended work week, exposure to vibrations and working under time pressure. In terms of work demands, the most sleep disorders were caused by the feeling that much effort needs to be invested into work and not just too much work. The risk for developing sleep disorders was even greater if the persons additionally stated that they cannot stop thinking about work at night. 69

70 Paralelna sekcija II. Četrtek, Parallel Session II. - Thursday 11 th Glavobol onesposablja Avtor: Prof. Dr. Bojana Žvan, dr. med., višja svetnica, nevrologinja; Dr. Matija Zupan, dr. med., nevrolog, Univerzitetni klinični center Ljubljana, Nevrološka klinika, Ljubljana Ključne besede: glavobol, migrena, breme glavobola, absentizem, prezentizem, bolniški stalež. Uvod: Glavobol je eden najpogostejših simptomov v svetu, saj naj bi ga vsaj enkrat v svojem življenju izkusilo % ljudi. Najpogosteje se pojavlja med 20. in 45. letom. Incidenca se postopno zmanjšuje s starostjo. Svetovna zdravstvena organizacija (SZO) ga že več kot desetletje uvršča v sam vrh velikih javnozdravstvenih problemov in sicer kot tretje najpogostejše zdravstveno stanje in drugo najbolj onesposabljajočo nevrološko motnjo. Breme bolezni, ki ga v populacijah širom sveta predstavljajo različne vrste glavobolov, je predvsem povezano z onesposabljanjem ljudi, ki trpijo zaradi njih. Breme glavobola v svetu: Število izgubljenih delovnih dni zaradi migrenskega glavobola v splošni populaciji je okrog 270 dni na 1000 oseb, zaradi glavobola tenzijskega tipa pa 820 dni na 1000 oseb. Razlike med spoloma niso opazili. Steiner in sod. so pokazali, da so bili bolniki z migreno v Angliji v letu 2002 odsotni na delovnem mestu 5,7 delovnega dne na leto. Fiane in sod. so leta 2006 z analizo povezave med glavobolom in bolniškim staležem v določenem območju Norveške ugotovili, da je bila prevalenca bolniškega staleža pozitivno povezana s frekvenco migrenskih in drugih glavobolov, zlasti pri kroničnih glavobolih. Zaključili so, da boljše zdravljenje kroničnih glavobolov lahko privede do ugodnih ekonomskih implikacij. Evers je leta 2014 izpostavil visoke stroške, povezane z glavobolom. Poudaril je, da le manjšina bolnikov prejme terapijo, odrejeno po mednarodnih smernicah. Breme glvobola v Sloveniji: V Sloveniji nimamo dovolj ustrezno zbranih epidemioloških podatkov o glavobolu in migreni. V letu 2018 sta bili zato opravljeni dve krajši razsikavi. V prvi raziskavi, ki je potekala v dveh delih, smo Zaletel in soavtroji v prvem delu ocenili razširjenost glavobola in migrene v slovenski delovno aktivni populaciji ter njun vpliv na produktivnost, v drugem pa smo želeli pridobiti vpogled v proces zdravljenja bolnikov z migreno. Zbiranje podatkov je potekalo z računalniško podprtim spletnim anketiranjem, kjer smo v prvem delu vklljučili 1207 ponoletnih oseb z glavobolom, v drugem delu pa 102 zdravnika družinske medicine in 50 nevrologov. V prvem delu je 70 % anketirancev odgovorilo, da imajo glavobole, 8 % pa jih je imelo postavljeno diagnozo migrene. Približno 40 % anketirancev z diagnozo migrene in 16 % anketirancev brez diagnoze migrene je bilo v zadnjih treh mesecih zaradi glavobola odsotnih z dela vsaj en dan. Med anketiranci z diagnozo migrene je 30,1 % zaposlenih v zasebnem sektorju in 17,4 % zaposlenih v javnem sektorju ocenilo, da je migrena znatno vplivala na njihovo produktivnost na delovnem mestu. Drugi del raziskave je pokazal, da 97 % družinskih zdravnikov in 82 % nevrologov zdravi bolnike z migreno. V drugi slovenski raziskavi je avtor (Perko) analiziral podatke Nacionalnega inštituta za javno zdravje o bolniškem staležu zaradi glavobola v Sloveniji v letih 2015 in Raziskava je pokazala, da so glavoboli predstavljali ~1 % vseh primerov bolniških staležev in ~0,55 % vseh 70

71 Paralelna sekcija II. Četrtek, Parallel Session II. - Thursday 11 th izgubljenih koledarski dni. Večina zaposlenih v bolniškem staležu zaradi glavobola je bila stara pod 40 let. Ženske so predstavljale ~75 % vseh primerov bolniškega staleža, večji delež števila izgubljenih koledarskih dni pa so predstavljali zaposleni po 50. letu. Bolniški stalež je zaradi glavobola potreboval približno en zaposleni na 100 zaposlenih. Ženske so imele večje število izgubljenih koledarskih dni (leta ,8 %, leta ,7 %), moški pa so bili v povprečju dlje časa v bolniškem staležu (leta ,8 %, leta ,8 %). Glavoboli, po Mednarodni klasifikaciji bolezni uvrščeni med splošne simptome in znake, so privedli do največjega deleža primerov bolniškega staleža in števila izgubljenih koledarskih dni (leta %, leta %). Drugi glavobolni sindromi so privedli do dalj časa trajajočega bolniškega staleža (leta ,67 dne, leta ,40 dne). Zaključki: Prva raziskava je pokazala 70-odstotno prevalenco glavobola in 8-odstotno prevalenco migrene v slovenski delovno aktivni populaciji ter potrdila znaten vpliv migrene na odsotnost z dela (absentizem) ter zmanjšano produktivnost na delovnem mestu (prezentizem) in v zasebnem življenju. Analiza druge razsikave je pokazala, da glavobol z vidika Zavoda za zdravstveno zavarovanje Slovenije ni pomemben razlog odsotnosti na delovnem mestu, lahko pa je pomemben za delodajalca. 71

72 Paralelna sekcija II. Četrtek, Parallel Session II. - Thursday 11 th Headache Immobilises Author: Prim. Prof. PhD Bojana Žvan, MD, senior counsellor, neurologist; Matija Zupan, MD PhD, neurologist, University Medical Center Ljubljana, Neurology Clinic, Ljubljana Ključne besede: headache, migraine, absenteeism, presentism, sick leave. Introduction: Headache is one of the most common symptoms in the world, with 70-95% of people having experienced it at least once in their lifetime. It is most common in the ages between 20 and 45. The incidence is gradually decreased with age. The World Health Organisation (WHO) has been placing it at the very top of major public health issues for more than a decade as it is the third most common medical condition and second most disabling neurological disorder. The burden of the disease, which is represented by the various types of headaches around the world, is especially related to the disabling of people who suffer because of them. Burden of headache around the world: The number of lost work days due to migraines is about 270 days per 1,000 persons among the general population, and 820 days per 1,000 persons due to tension headache. No difference has been observed between the two genders. Steiner, et al, have shown that in 2002 migraine patients in England were absent from their job for 5.7 work days per year. Fiane, et al, performed an analysis in 2006, which showed a connection between a headache and sick leave in a certain area in Norway. They have found that the sick leave prevalence has been positively linked to the frequency of migraines and other headaches, especially in chronic types. They have concluded that better treatment of chronic headaches may lead to favourable economic implications. In 2014, Evers pointed out to high costs related to headaches. He stressed that a minority of patients receive treatment under international guidelines. Burden of headache in Slovenia: In Slovenia, we currently do not have enough adequate epidemiological data on headaches and migraines. Therefore, two short surveys were done in In the first survey, which was made in two parts, Zaletel, et al, assessed in the first part the prevalence of headache and migraine among the Slovenian working population and their impact on productivity, while the second part was aimed at getting an insight into the process of treating patients suffering from migraines. The collection of data was performed through an online survey, where 1,207 persons of age suffering from headaches were included in the first part and 102 family medicine specialists and 50 neurologists were included in the second part. In the first part, 70% of participants answered that they suffer from headaches, while 8% of participants had been diagnosed with a migraine. Approx. 40% of participants diagnosed with a migraine and 16% without the diagnosis were absent from work at least for one day due to headache in the last three months. Among those diagnosed with a migraine, 30.1% employed in private sector and 17.4% employed in public sector answered that migraine severely affected their productivity at the work place. The second part of the survey has shown that 97% of family medicine specialists and 82% of neurologists treat migraine patients. In the second survey in Slovenia, the author (Perko) analysed the data from the National Institute of Public Health on sick leave due to headaches in Slovenia between 2015 and The survey 72

73 Paralelna sekcija II. Četrtek, Parallel Session II. - Thursday 11 th has shown that headaches presented ~1% of all sick leaves and ~0.55% of all lost calendar days. Most employees on sick leave due to headaches were under 40 years of age. Women represented ~75% of all sick leave cases, while employees of 50+ years of age represented the majority of the lost calendar days. Approx. one per 100 employees needed sick leave due to a headache. Women had the most lost calendar days (73.8% in 2015, 66.7% in 2016) while men were absent longer on average (11.8% in 2015, 43.8% in 2016). Considering the International Classification of Diseases, headaches are one of the general symptoms and have led to the largest share of sick leave cases and the number of lost calendar days (62% in 2015, 63% in 2016). Other headache symptoms have led to longer sick leave absences (15.67 days in 2015, days in 2016). Conclusions: The first survey has shown a 70% prevalence of headaches and an 8% prevalence of migraines among the Slovenian working population and has confirmed a significant impact of migraines on the absenteeism of workers and a reduced productivity at the work place (presenteeism) in the private lives of patients. The analysis of the second survey has shown that headaches, from the viewpoint of the Health Insurance Institute of Slovenia, is not an important reason for the absence from one s work place, but it may be significant for the employer. 73

74 Paralelna sekcija I. Petek, Parallel Session I. - Friday 12th

75 Paralelna sekcija I. Petek, Parallel Session I. - Friday 12 th Vloga delodajalca pri ocenjevanju invalidnosti v Republiki Sloveniji Avtor: Boris Kramžar, dr.med., Zavod za pokojninsko in invalidsko zavarovanje Slovenije Ključne besede: delodajalec, invalidnost, poklicna rehabilitacija, zaposlitev invalida Zakonodajni in drugi predpisi s področja invalidskega zavarovanja v Republiki Sloveniji natančno opredeljujejo obveznosti in možnosti delodajalca v postopkih ocenjevanja invalidnosti delavcev. V primeru, ko so pri delavcu predvidene omejitve delovne zmožnosti, lahko delodajalec že pred oceno invalidnosti in izdajo odločbe aktivno sodeluje pri iskanju ustrezne oblike zaposlitve v okviru poklicne rehabilitacije. Pri tem mu strokovni delavci Zavoda za pokojninsko in invalidsko zavarovanje (ZPIZ) nudijo strokovno pomoč v zvezi s pripravo dokumentacije. Z vključitvijo strokovne institucije oziroma izvajalca zaposlitvene rehabilitacije v postopek pred oceno invalidnosti se delodajalcu omogoči najracionalnejša in najustreznejša oblika nadaljnje zaposlitve delavca, ki je usklajena z omejitvami delovne zmožnosti delavca. Tudi po nastanku invalidnosti ima delodajalec možnost sofinanciranja s strani ZPIZ v zvezi z ohranitvijo zaposlitve delovnega invalida. Delodajalci se, kljub vsem promocijskim aktivnostim v zvezi s poklicno rehabilitacijo in nedvoumno ugodnejši rešitvi zaposlitvenega statusa invalidnega delavca, le izjemoma aktivno vključujejo v postopke poklicne rehabilitacije. V prispevku so prikazane možnosti, ki so na voljo delodajalcu v zvezi s poklicno rehabilitacijo delavca z omejeno delovno zmožnostjo in usposobitvijo ter razporeditvijo delovnega invalida na ustrezno delovno mesto. Prikazani so tudi primeri uspešnega in neuspešnega sodelovanja delodajalcev in ZPIZ v zvezi s poklicno rehabilitacijo ter predlagani ukrepi za povečanje števila uspešno poklicno rehabilitiranih delovnih invalidov. 75

76 Paralelna sekcija I. Petek, Parallel Session I. - Friday 12 th Vocational Rehabilitation and the Role of the Employer in the Invalidity Assessment Process Author: Boris Kramžar, MD., Pension and Disability Insurance Institute of Slovenia, Celje Regional Unit, Slovenia Key words: employer, disability, vocational rehabilitation, employing disabled workers Legislative and other regulations in the field of disability insurance in the Republic of Slovenia accurately define employer obligation and activity in relation to procedures assessing worker disability. When workers are expected to be limited in terms of ability to work, employers may, prior to assessing disability and issuing a decision, actively cooperate in finding suitable employment in the framework of vocational rehabilitation, and when doing so, they are offered professional assistance in relation to documentation preparation by experts from the Pension and Disability Insurance Institute of Slovenia. The involvement of expert institutions and/or vocational rehabilitation providers in procedures prior to disability assessment enable employers to offer optimal employment in line with worker limitation; co-financing of such action by the Pension and Disability Insurance Institute of Slovenia is available, even after disability occurrence to enable continued the continued employment of such workers. Despite all of the promotional activities related to vocational rehabilitation and, undoubtedly, more favourable solutions in relation to the employment status of workers with disabilities, employers are still only exceptionally involved in vocational rehabilitation procedures. This paper presents the options available to employers in relation to the vocational rehabilitation of workers with limited work capacity and allocation of suitable employment. Case studies evidencing success and lack of success in terms of cooperation between employers and the Pension and Disability Insurance Institute of Slovenia relating to vocational rehabilitation are presented and measures to increase the number of workers with disabilities successfully rehabilitated in terms of vocation are proposed. 76

77 Paralelna sekcija I. Petek, Parallel Session I. - Friday 12 th Vključevanje delodajalcev v pripravljalni postopek priznajnja pravice do poklicne rehabilitacije Avtor: Peter Šalej, Zavod za pokojninsko in invalidsko zavarovanje Slovenije, Območna enota Celje, Slovenija Ključne besede: poklicna rehabilitacija, delodajalec, strokovni delavec ZPIZ-a Zavarovanci pri katerih je nastala sprememba v njihovem zdravstvenem stanju in imajo po končanem zdravljenju še vedno preostalo delovno zmožnost, lahko pridobijo ali ohranijo zaposlitev s pomočjo poklicne rehabilitacije. Potem, ko je na Zavod za pokojninsko in invalidsko zavarovanje Slovenije podan predlog za uvedbo postopka za uveljavljanje pravic iz invalidskega zavarovanja, lahko v sklopu pripravljalnega postopka za posameznega zavarovanca predsednik ali član izvedenskega organa I. stopnje s podajo preliminarnega mnenja priporoča postopek izvedbe poklicne rehabilitacije. Postopek se lahko prične tudi na zahtevo ali predlog samega zavarovanca. Interes zavoda je, da delodajalci aktivno sodelujejo v celotnem postopku priznanja pravice do poklicne rehabilitacije, kajti najbolje poznajo zavarovanca / delavca, njegovo delo in zdravstveno stanje. To je razlog, da sta na predstavitev vsebine in izvedbe postopka poklicne rehabilitacije vabljena zavarovanec in njegov delodajalec. Predstavitev poklicne rehabilitacije je sestavljena iz dveh delov. V prvem delu, se vsem, ki se odzovejo vabilu splošno predstavi vsebina poklicne rehabilitacije s slikovnim prikazom posamezno izvedenih dobrih praks. Sledi individualni motivacijski pogovor pri uradni osebi, ki vodi postopek. Pogovor je usmerjen v vsebino preliminarnega mnenja in dodatna konkretna vprašanja, ki jih zastavljata tako zavarovanec kot delodajalec. Individualni pogovor delodajalca pogosto močno motivira k iskanju najugodnejše oblike in načina izvedbe poklicne rehabilitacije, ki se v pripravljalnem postopku nadaljuje v sklopu obravnave na strokovni instituciji zaposlitvene rehabilitacije. 77

78 Paralelna sekcija I. Petek, Parallel Session I. - Friday 12 th Motivational Operation of ZPIZ in Terms of the Inclusion of Insured Persons and Employers in Vocational Rehabilitation Author: Peter Šalej, Pension and Disability Insurance Institute of Slovenia, Celje Regional Unit, Slovenia Key words: vocational rehabilitation, employer, ZPIZ expert worker The insured whose health condition has changed who are able to work after treatment can obtain and/or keep their employment by means of vocational rehabilitation. Pursuant to submitting a proposal for the initiation of a disability insurance rights enforcement proceeding to the Pension and Disability Insurance Institute of Slovenia, a president or member of a first level expert body can provide a preliminary opinion recommending vocational rehabilitation procedure implementation for an insured individual as part of their preparation procedure. The procedure can also be initiated on request or be proposed by the insured. The Institute wishes to ensure employers are actively involved in the entire procedure of granting said right to vocational rehabilitation because employers know the insured/worker, their work and health situation best. This is the reason why the insured and their employer are invited to the presentation of the vocational rehabilitation procedure s content and implementation. The aforementioned procedure consists of two parts: firstly, those who have responded to the invitation receive a general presentation of the vocational rehabilitation procedure s content with pictorial presentation of best practice; secondly, an individual motivational conversation with the official facilitating the procedure ensues, the conversation focused on preliminary opinion content, including additional concrete questions raised by the insured and employer. The individual conversation often strongly motivates employers to find the most favourable type and method of vocational rehabilitation implementation, and this is followed up in the preparation procedure in the context of discussion at an expert occupational rehabilitation institution. 78

79 Paralelna sekcija I. Petek, Parallel Session I. - Friday 12 th Izkušnje izvajalca zaposlitvene rehabilitacije s poklicno rehabilitacijo Avtor: Brstin Kavalar, univ. dipl. pedagog, CRI Celje, d.o.o. Ključne besede: delodajalec, motivacija, konkretni primeri Izvajalec zaposlitvene rehabilitacije (izvajalec) sodeluje z Zavodom za pokojninsko in invalidsko zavarovanje Slovenije (ZPIZ) na podlagi pogodbe, ki jasno opredeljuje končno poročilo izvajalca za potrebe poklicne rehabilitacije zavarovanca z omejeno delovno zmožnostjo. Izvajalec oblikuje poročilo na podlagi timske obravnave v sodelovanju z delodajalcem in zavarovancem. Posebno pozornost izvajalec usmerja v motivacijsko delovanje pri delodajalcu, da se že pred oblikovanjem mnenja o vrsti in načinu poklicne rehabilitacije oblikuje najustreznejši predlog za rešitev zaposlitve zavarovanca. Izvajalec pri tem upošteva vsa priporočila, ki so podana s strani naročnika (ZPIZ). V zahtevnejših primerih se pred oblikovanjem končnega poročila opravi tudi konzultacija s pristojnim izvedenskim organom naročnika ali strokovnim delavcem naročnika. Izvajalec pri oblikovanju predloga poklicne rehabilitacije večkrat naleti na nezainteresiranost delodajalca, ki posledično povzroči negativno stališče zavarovanca do poklicne rehabilitacije. V prispevku so prikazani primeri uspešnega sodelovanja med izvajalcem in delodajalcem ter zavarovancem in tudi primer neuspešnega postopka obravnave v zvezi s poklicno rehabilitacijo zaradi nerazumevanja oziroma nemotiviranosti delodajalca za aktivno rešitev zaposlitve zavarovanca z omejeno delovno zmožnostjo. V zaključku so navedeni predlogi motivacijskega delovanja izvajalca pri delodajalcu v zvezi s poklicno rehabilitacijo kot najprimernejšim načinom v okviru postopka vračanja delovnega invalida na delo. 79

80 Paralelna sekcija I. Petek, Parallel Session I. - Friday 12 th Occupational Rehabilitation Provider Experience in Terms of Vocational Rehabilitation Author: Brstin Kavalar, university graduate pedagogue, Employment Service of Slovenia Celje, Slovenia Key words: employer, motivation, concrete cases Occupational rehabilitation performers (performers) cooperate with the Pension and Disability Insurance Institute of Slovenia (ZPIZ) based on contracts that accurately define performers final reports for the vocational rehabilitation needs of insured people with limited ability to work. Performers prepare reports based on team discussion in collaboration with employers and the insured, and pay special attention to employer motivational work so the most suitable employment solution for the insured is prepared prior to creating an opinion about the type and method of vocational rehabilitation. In doing so, performers take into consideration all recommendations provided by the contracting entity (ZPIZ). In more complex cases, consultation with the contracting entity s competent expert body or provider s expert worker is conducted prior to preparing the final report. While drawing up the vocational rehabilitation proposal, providers often encounter employer lack of interest, which consequently has a negative impact on the insureds attitude to vocational rehabilitation. This paper presents cases of successful cooperation among performers, employer and the insured, and an example of an unsuccessful procedure relating to vocational rehabilitation pursuant to employer lack of understanding and/ or lack of motivation to find an active solution in relation to the employment of an insured person with a limited ability to work. This work proves that performers motivational work proposals for employers relating to vocational rehabilitation is the most suitable method in the context of disabled workers return to work. 80

81 Paralelna sekcija I. Petek, Parallel Session I. - Friday 12 th Delo z delovnimi invalidi Unior d.d. Avtor: Vili Močenik, dipl. org., inž. str. Zreče, Slovenija Ključne besede: Število zaposlenih invalidov, prilagoditev delovnih mest, ergonomija in osveščanje zaposlenih o ergonomiji Delovanje na področju vodenja postopkov pri uveljavljanju pravic iz invalidskega zavarovanja, vodenje postopkov in prilagoditev delovnih mest, vodenje službe Varnost, vodenje projekta Ergonomija in osveščanje zaposlenih o ergonomiji in član projektne skupine Obvladovanje bolniškega staleža v Unior d.d. Kratka predstavitev Unior d.d.: Naša družba je naravnana zlasti izvozno, saj 94,8 % prodaje kovinskih programov ustvarimo za tuje trge. V delovanje Skupine Unior je vključenih 26 povezanih družb, 18 odvisnih podjetij, 8 pridruženih podjetij, 19 držav in skoraj zaposlenih. V vseh vidikih stremimo k odličnosti, svojo kakovost pa želimo tudi učinkovito nadzorovati. Zato smo na različnih področjih delovanja uvedli ugledne certificirane sisteme. Prvi certifikat - Sistem vodenja kakovosti po zahtevah ISO 9001 leta 1994 za program Ročno orodje. Sistem vodenja kakovosti po zahtevah ISO 9001 za Unior d.d. leta 1999 Sistem ravnanja z okoljem po zahtevah IS od leta 2004 za Unior d.d. Sistemi vodenja kakovosti po zahtevah avtomobilske industrije: QS 9000 za program Odkovki v letu 2000 (zamenjan z ISO/TS16949 in kasneje z IATF16949) IATF 16949:2016 za program Odkovki od leta 2017 VDA 6.4 za program Strojegradnja od leta 2005 Sistem vodenja varnosti in zdravja pri delu OHSAS Pridobili smo pomembna potrdila o ustreznosti naših izdelkov in storitev: Certifikat za orodje za delo pod visoko napetostjo, IEC 60900, ki ga izdaja nemški inštitut VDE (pridobili smo ga že leta 1991), Potrdilo o ustreznosti za ročno orodje GOST PCT, Oznaka o skladnosti za stroje CE, Potrdilo o uvedenem sistemu po zahtevah HACCP. Program Odkovki: Program Odkovki je najstarejši proizvodni program in osnova, iz katere seje razvil današnji Unior, ki se s tem programom uvršča med pomembnejše dobavitelje avtomobilskih delov najuglednejših evropskih avtomobilskih proizvajalcev. Program Ročno orodje: Bogata tradicija orodnega kovaštva, upoštevanje novih tehnoloških dognanj in vrhunski materiali, kot je krom vanadijevo jeklo, zagotavljajo dolgo življenjsko dobo orodij UNIOR. Oblikovanje, razvoj in izdelava ročnega orodja Unior se nenehno prilagaja zahtevam novih strank. 81

82 Paralelna sekcija I. Petek, Parallel Session I. - Friday 12 th Working with Disabled Workers at Unior d.d. Author: Vili Močenik, Engineer, UNIOR d.d. Zreče, Slovenia Key words: number of disabled workers, workplace adaptation, ergonomics and raising awareness of ergonomics among employees Works in the field of process management vis-à-vis the enforcement of disability insurance rights, procedures and adapting work roles, manages the Safety Department and the Ergonomics Project to raise employee awareness about ergonomics, and is a member of the project group Sick Leave Management at Unior d.d. Brief presentation of Unior d.d.: Our company is particularly export-oriented: as much as 94.8% of our metal programme s revenue is generated in foreign markets. The Unior Group is present in 19 countries and includes 26 associated companies, 18 subsidiaries, and nearly 4,000 employees. We strive for excellence in all aspects of our work and effective quality control; therefore, we have achieved esteemed certification for various fields of our work. First Certificate Quality management system in line with ISO 9001 requirements in 1994 for our Hand Tools Programme. Quality management system in line with ISO 9001 requirements for Unior d.d. in Environmental management system in line with IS requirements since 2004 for Unior d.d. Quality management system in line with car industry requirements: QS 9000 for the Forge Programme in 2000 (first replaced by ISO/TS16949 then IATF16949); IATF in 2016 and Forge Programme since 2017; and VDA 6.4 for Special Machines Programme since Occupational health and safety management system OHSAS We have obtained important certificates in terms of the suitability of our products and services: Certificate for tools for work under high voltage, IEC 60900, issued by the German institute VDE (obtained in 1991); Certificate on suitability of hand tools GOST PCT; Compliance label for machinery CE; and Certificate on introduced system in line with the HACCP requirements. Forge Programme: The Forge Programme is the company s oldest production programme and the foundation on which today s Unior was built. This programme ranks the company amongst the most important suppliers of car parts for cars produced by the most esteemed European manufacturers. Hand Tools Programme: Our rich tradition of tool manufacture, our use of new technological findings and top-quality materials, such as chromium-vanadium steel, ensure the long life of UNIOR tools. The shaping, development and production of Unior hand tools is continuously adapted to new client needs. 82

83 Paralelna sekcija I. Petek, Parallel Session I. - Friday 12 th Pomen psihosocialne obravnave v okviru poklicne rehabilitacije Avtor: Barbara Zupančič, univ.dipl.psih.; Ksenija Bratuš Albreht, univ.dipl.soc.del. Šentprima - Zavod za rehabilitacijo in izobraževanje Ko-avtorji: Lea Jakič Hiti, univ.dipl.soc.del., Singha Monishankar, univ.dipl.psih., Samantha Eler, mag.psih., Erna Sarač, dipl.delovna terapevtka, Vanja Rodošek, dipl. delavna terapevtka; Ključne besede: poklicna rehabilitacija, zaposlitvena rehabilitacija, vračanje na delo, psihosocialna obravnava razširjena obravnava Ozadje/vprašanje/problem: Preko kvalitativne analize primerov ter fokusne skupine s strokovnimi delavci smo pripravili vpogled v psihološke in čustvene dejavnike zavarovanca in delodajalca ter uporabljene metode v psihosocialni obravnavi pri pripravi načrta poklicne rehabilitacije oz. vračanju na delo. Metode: Izvedli smo kvalitativno analizo psihosocialnih posledic pri napotenih zavarovancih ter dejavnikov na strani delodajalca. Za analizo uporabljenih metod v postopku priprave mnenja ter pripravo predlogov rešitev smo uporabili metodo fokusne skupine s strokovnimi delavci. Rezultati: Poleg fizičnih omejitev, ki jih v večini primerov pušča primarna diagnoza zavarovanca, se z daljšo odsotnostjo z delovnega mesta pojavijo dodatne psihosocialne posledice, kot npr.: strah pred bolečino, utrujenost in nizka vzdržljivost, težave s pozornostjo in osredotočanjem, težave s spominom, anksioznost in strah, občutki tesnobe, težave pri obvladovanju stresa, depresivno razpoloženje in nizka motivacija, strah pred realnimi težavami na delovnem mestu ali doma ter mnogi drugi dejavniki. Na strani delodajalca se kažejo dejavniki nezaupanja, strahu pred vračanjem zavarovanca v delovno okolje, administrativne ovire, slabše prilagajanje novim okoliščinam, pomanjkanje raznovrstnih delovnih mest, pomanjkljive informacije o zavarovancu ter druge objektivne in subjektivne okoliščine. Vse našteto vpliva na aktivno sodelovanje zavarovanca in delodajalca pri izdelavi načrta poklicne rehabilitacije ter kasnejši uspeh pri vračanju na delo. Strokovni delavci, ki sodelujejo pri pripravi načrta poklicne rehabilitacije, izvajajo dodatne psihosocialne storitve, ki so pomembne za dober načrt. Gre za socialno in psihološko intervencija v obliki metod podpornega svetovanja, motivacije, razbremenilnih pogovorov, opolnomočenja, spremljanje po zaključeni obravnavi v okviru priprave načrta. Storitve potrebujeta oba, tako zavarovanec kot tudi delodajalec. Zaključki/spoznanja: Psihološki in čustveni dejavniki so pomembni pri obravnavi zavarovanca, zato je psihosocialne storitve potrebno zagotoviti, če želimo pripraviti kvaliteten načrt poklicne rehabilitacije. Potrebne so tudi storitve spremljanja po zaključeni rehabilitaciji, ki so namenjene tako zavarovancem kot tudi delodajalcem. 83

84 Paralelna sekcija I. Petek, Parallel Session I. - Friday 12 th The Significance of Psycho-Social Treatment in the Framework of Vocational Rehabilitation Author: Barbara Zupančič, University graduate psychologist, and Ksenija Bratuš Albreht, BSc in Social Work, Šentprima Rehabilitation and Education Institute. Co-authors: Lea Jakič Hiti, BSc in Social Work, Singha Monishankar, University graduate psychologist, Samantha Eler, MSc in Psychology, Erna Sarač, BSc in Work Therapy, and Vanja Rodošek, BSc in Work Therapy; Key words: vocational rehabilitation, occupational rehabilitation, return to work, psychosocial treatment, extended treatment Background/issue/problem: An insight into the psychological and emotional aspects in relation to the insured and employers was prepared by means of a qualitative analysis of cases and a focus group, and its methods were used in relation to psycho-social treatment and the preparation of vocational rehabilitation plans and return to work. Methods: We conducted a qualitative analysis of psycho-social consequence in terms of the referred insured and employer factors. The focus group method with expert workers was used to analyse the methods used in the opinion preparation process and prepare solution proposals. Results: In addition to the physical limitations primarily diagnosed, longer absenteeism from work delivers additional psycho-social consequence, such as fear of pain, fatigue and low endurance, attention and focusing problems, memory problems, anxiety and fear, stress management problems, depression and low motivation, fear of real problems at the workplace and/or at home, and many other factors. In terms of employers, we see mistrust, fear of what may ensue pursuant to the insureds return to the working environment, administration obstacles, poorer adaptation to new circumstances, lack of varied work positions, insufficient information about the insured, and other objective and subjective concerns. This all affects the active cooperation of the insured and employers in preparing a vocational rehabilitation plan and subsequent success in terms of return to work. The expert workers who cooperate in the preparation of vocational rehabilitation plans facilitate additional psycho-social services, which are important when preparing good plans. This is a matter of social and psychological intervention in the form of support counselling methods, motivation, relieving conversations, empowerment, and follow-up after treatment in terms of plan preparation. This service is needed by both the insured and employers. Conclusion/findings: Psychological and emotional factors are important in the treatment of the insured; therefore, psycho-social services must be ensured in order to prepare good vocational rehabilitation plans. Rehabilitation follow-up services are also necessary for both the insured and employers. 84

85 Paralelna sekcija I. Petek, Parallel Session I. - Friday 12 th Od zdravstveno zaposlitvenega svetovanja do zaposlitve Avtor: Ksenija Šterman, dr. med., spec. medicine dela, prometa in športa, Univerzitetni rehabilitacijski inštitut RS-Soča, Ljubljana, Slovenija, Zavod za zaposlovanje RS, OE Murska Sobota, Slovenija Ključne besede: Svetovanje, zaposlovanje Izvleček: Zaposlovanje oseb z zdravstvenimi težavami zahteva dobro sodelovanje brezposelne osebe, strokovnih delavcev Zavoda za zaposlovanje (ZRSZ), predstavnikov delodajalcev, Zavoda za pokojninsko in invalidsko zavarovanje (ZPIZ) ter različnih institucij s področja zdravstva in zaposlitvene rehabilitacije. Brezposelna oseba ima svojega svetovalca zaposlitve, pri svetovanju invalidom in osebam z zdravstvenimi težavami pomaga tudi rehabilitacijski svetovalec. V zdravstveno zaposlitveno svetovanje se vključuje specialist medicine dela, prometa in športa, ki poda mnenje o zdravstvenih ovirah in omejitvah pri zaposlovanju. Osebe imajo lahko priznan status invalida po različnih predpisih. V zaposlitveno rehabilitacijo pa se vključujejo tiste brezposelne osebe, pri katerih so ugotovljene zmerne ali velike težave in ovire pri zaposlovanju in so to pravico pridobile ob oceni na Rehabilitacijski komisiji. Program zaposlitvene rehabilitacije se izvaja na podlagi individualnega rehabilitacijskega načrta in traja od nekaj mesecev do enega leta, izjemoma tudi do dveh let. Poteka v delovnih kabinetih izvajalca zaposlitvene rehabilitacije ter se nadaljuje z usposabljanjem na konkretnem delovnem mestu pri različnih delodajalcih. Usposabljanje se zaključi z oceno doseganja delovnih rezultatov, ko oseba doseže ustrezno delovno učinkovitost in stabilnost. V kolikor oseba ne doseže niti minimalne delovne učinkovitosti ji ZRSZ izda odločbo o nezaposljivosti. Tistim z znižano delovno učinkovitostjo pa izda odločbo o podporni ali zaščitni zaposlitvi. Velika težava na poti do zaposlitve je predvsem šibka motivacija, prav tako slabše prilagoditvene sposobnosti, pa tudi nemobilnost, pomanjkljiv javni prevoz, zdravstvene težave, nizka izobrazba, šibka znanja, ki niso v skladu z izobrazbo, slabša kritičnost do svojih zmožnosti, neustrezni zaposlitveni cilji, slabe predstave o zahtevah delovnega okolja. Tekom zaposlitvene rehabilitacije je poleg podpore strokovnih delavcev različnih institucij dobrodošla tudi podpora s strani družinskih zdravnikov ter ostalih zdravnikov specialistov. 85

86 Paralelna sekcija I. Petek, Parallel Session I. - Friday 12 th From Medical Vocational Counselling to Employment Author: Ksenija Šterman, MD, Specialist in Occupational, Traffic and Sports Medicine, University Rehabilitation Institute RS-Soča, Ljubljana, Slovenia, and Employment Service of Slovenia, RO Murska Sobota, Slovenia Key words: counselling, employment Abstract: Employing people with medical problems requires good cooperation among the unemployed, expert workers from the Employment Institute (ZRSZ), employer representatives, the Pension and Disability Insurance Institute of Slovenia (ZPIZ), and various institutions in the field of health and occupational rehabilitation. The unemployed have their own employment counsellor and rehabilitation counsellors also assist those with disabilities and medical problems. Specialist in occupational, traffic and sports medicine are also involved in medical vocational counselling by means of providing opinion on medical obstacles and limitations in terms of employment. People can be granted the status of disabled person in accordance with various regulations. The unemployed with moderate or significant employment problems and obstacles are eligible for vocational rehabilitation; such rights are based on assessment by the Rehabilitation Committee. Vocational rehabilitation programmes are performed in accordance with individual rehabilitation plans and last for a few months to one year, exceptionally two years. They are facilitated by vocational rehabilitation providers and continue with training in relation to concrete employment. Training is complete on assessment of achieved results and suitable work effectiveness and stability achievement. If people do not achieve minimum work effectiveness, ZRSZ issues an unemployability decision, and issues a support or protective employment decision for those with reduced work effectiveness. Substantial problems on the way back to work are especially faced in terms of motivation, adaptability, mobility, public transportation adequacy, medical problems, education, skills noncompliant with education, self-assessment, employment goals, and weak image in terms of employment requirements. During vocational rehabilitation, the support of family doctors and other medical specialists is a welcome addition to that provided by institutional expert workers. 86

87 Paralelna sekcija I. Petek, Parallel Session I. - Friday 12 th Delo z delodajalci pri zaposlitveni rehabilitaciji oseb z invalidnostjo Avtor: Mag. Stojan Zagorc, Zavod Papilot, Slovenija Ključne besede: Delodajalci, metodologije, rehabilitacija Delo z delodajalci je v okviru usposabljanja in zaposlovanja oseb z invalidnostjo ena od ključnih aktivnosti v procesu zaposlitvene/poklicne rehabilitacije. V prispevku bomo opisali razloge in načine sodelovanja z delodajalci, osvetlili pomen in način ter rezultate raziskave trga in potreb delodajalcev po kvalificirani delovni sili, ki jo permanentno izvajamo v poslovnem sistemu Papilot s posebnim poudarkom na osebnostnih in delovnih kompetencah. Opisali bomo lastno standardizirano metodologijo, ki smo jo razvili v sodelovanju s tujimi in domačimi partnerji ob s sofinanciranjem Avstrijske razvojne agencije ADA in Federalnega zavoda za zaposlovanje Federacije Bosne in Hercegovine. Metodologijo Aqui uporabljamo za optimizacijo delovnih rezultatov oseb z invalidnostjo v procesu procesu usposabljanja na delovnem mestu v realni ali simulirani delovni situaciji ter v procesu uvajanja na delo pri delodajalcih. Uporabljamo pa jo tudi za potrebe normiranja delovnih mest in ocenjevanje delazmožnosti (ocena N). Opisali bomo tudi elemente podpore delodajalcem, zaposlenim ter invalidom v procesu usposabljanja in zaposlovanja. Na koncu prispevka bomo prikazali primer dobre prakse, ki argumentira potrebo po ciljnem, kvalitetnem in intenzivnem sodelovanju z delodajalci v okviru zaposlitvene/poklicne rehabilitacije oseb z invalidnostjo. 87

88 Paralelna sekcija I. Petek, Parallel Session I. - Friday 12 th Working with Employers in the Vocational Rehabilitation of People with Disability Author: MsC Stojan Zagorc, Zavod Papilot, Slovenia Key words: employers, methodologies, rehabilitation In the context of training and employing people with disabilities, working with employers is one of the key activities in the occupational/vocational rehabilitation process. This paper will describe the reasons for and methods of cooperation with employers and evidence the importance, method and results of market research, and employer need for qualified workforce as permanently implanted in Papilot s business system, with a special emphasis on personality and competence. We will describe our standardised methodology as developed in cooperation with foreign and domestic partners, co-financed by the Austrian Development Agency (ADA) and the Federal Employment Institute of Bosnia and Herzegovina. We have utilised Aqui methodology to optimise the results of those with disability in terms of workplace training processes in real or simulated work situations, and in the process of introduction to employers. We also use it for the needs of workplace regulation and work ability assessment (Grade N). Furthermore, we will describe support elements for employers, employees and for those with disabilities in the training and employment process. At the end of the paper, we will present a good practice example which illustrates the need for quality, target-oriented intensive cooperation with employers in the context of the occupational/ vocational rehabilitation of those with disability. 88

89 Paralelna sekcija I. Petek, Parallel Session I. - Friday 12 th Krepitev notranje moči uporabnikov storitev zaposlitvene rehabilitacije Avtor: Črtomir Bitenc, Univerzitetni rehabilitacijski inštitut Soča, Ljubljana, Slovenija; Valentina Brecelj, Andreja Švajger, Bojana Fulder, Brigita Šinigoj Strokovno sodelovanje: Naloga je nastala po naročilu Direktorata za invalide Ministrstva za delo, družino, socialne zadeve in enake možnosti v letu Ključne besede: notranja moč, zaposlitvena rehabilitacija, Ozadje/vprašanje/problem: Pomembno področje, ki vpliva na pozitivne rezultate vključevanja v storitve zaposlitvene rehabilitacije in nadalje v zaposlovanje, je področje krepitve notranje moči (KNM) posameznika (ang. empowerment). KNM upošteva osebne, medosebne in družbene ravni moči ter temelji na samodeterminaciji, prenosu moči s strokovnih delavcev in suverenosti uporabnikov storitev. Je proces, v katerem posamezniki, organizacije in skupnost pridobijo nadzor nad odločitvami, ki vplivajo na njihova življenja. Ugotavljanje, kako posamezniki zaznavajo posamezne komponente, je pomembno (1) na individualni ravni za načrtovanja aktivnosti, ki bodo pripomogle k večji opolnomočenosti posameznika z namenom večje lastne aktivnosti, sodelovanja in izboljšanja upravljanja z lastnimi sposobnostmi ter določanja ciljev, ki naj bi jih posameznik dosegel v procesu zaposlitvene rehabilitacije ter (2) na skupinski ravni z vidika razvijanja področij ZR, kjer se ugotavlja primanjkljaje pri vseh uporabnikih storitev. Metode: Na podlagi pregledanih modelov krepitve notranje moči smo kot najprimernejši izbrali 6 komponentni model (vpliv, sodelovanje, samoodločanje, sposobnost, smisel, pozitiven občutek), ki je bil razvit v okviru projekta EQUAL: Request. Za merjenje KNM smo uporabili vprašalnik, ki smo ga razvili v RCZR. Rezultati: Sodelujoči uporabniki storitev v povprečju ocenjujejo svojo notranjo moč kot srednje visoko (povprečna ocena je 3,66). Izmed 6 merjenih komponent je v povprečju najvišje ocenjena komponenta vpliv, in sicer s povprečno oceno 3,99 udeleženci menijo, da njihove odločitve in izbire lahko vplivajo na njihova življenja. Ostale komponente si sledijo od najvišje ocenjene sodelovanje v skupini (3,70), do odločanje o samem sebi (3,66) in smisel/pomen (3,59). Kot najnižje ocenjeni, vendar še vedno nad srednjo vrednostjo, sta komponenti sposobnost/občutek lastne učinkovitosti (3,54) in pozitiven občutek o sebi (3,49). 89

90 Paralelna sekcija I. Petek, Parallel Session I. - Friday 12 th Empowerment and Quality of Life of Users of Vocational Rehabilitation Services Author: Črtomir Bitenc, University Rehabilitation Institute Republic of Slovenia - SOČA, Ljubljana, Slovenia; Valentina Brecelj, Andreja Švajger, Bojana Fulder, Brigita Šinigoj Expert cooperation: This paper was drawn up by order of the Directorate for People with Disabilities of the Ministry of Labour, Family, Social Affairs and Equal Opportunities in Key words: empowerment, vocational rehabilitation Background/issue/problem: Individual empowerment is an important field affecting positive results in terms of inclusion visà-vis vocational rehabilitation services and beyond whilst employed. Empowerment incorporates the personal, interpersonal and social levels of power, and is based on self-determination, the transfer of power from expert workers and service user sovereignty. It is a process in which individuals, organisations and the community gain control over the decisions that impact their lives. Establishing how people perceive the aforementioned individual components is important: (1) at the individual level to plan activities to enhance individual empowerment with the purpose of increasing activity, cooperation and improve management of own abilities and determining goals individuals need to achieve in the process of vocational rehabilitation; and (2) at the group level from the perspective of developing fields of vocational rehabilitation where deficits are established in all service users. Methods: Based on reviewed empowerment models, we selected a 6-component model (impact, cooperation, self-determination, ability, sense, positive feeling), developed in the context of EQUAL, as most suitable: Request project. Empowerment was measured using a questionnaire developed at RCZR. Results: On average, participating service users assess their empowerment as medium-high (Average Grade = 3.66). Of the six measured components, impact received the highest average grade of participants believe their decisions and choices affect their lives. In terms of the other components, the highest graded are cooperation in group (3.70), deciding about myself (3.66), and sense/meaning (3.59); the lowest graded components, yet still above the medium value, are ability/feeling of own effectiveness (3.54) and positive feeling about myself (3.49). 90

91 Paralelna sekcija I. Petek, Parallel Session I. - Friday 12 th Izhodi iz zaposlitvene rehabilitacije vključevanje v programe socialne vključenosti v Sloveniji Avtor: Dr. Aleksandra Tabaj, Univerzitetni rehabilitacijski inštitut Republike Slovenije So-avtorji: člani delovne skupine: mag. Valentina Brecelj, mag. Janez Vidmar, Lea Kovač, Suzana Bohorč, Sonja Bercko Eisenreich, Lea Jakič Hiti, Valerija Mikložič, Matjaž Lipovec, Jasmina Plavšič, Nataša Kraljič Černe, Darja Dovečar, Karmen Kočivnik Strokovno sodelovanje: Naloga je nastala po naročilu Direktorata za invalide Ministrstva za delo, družino, socialne zadeve in enake možnosti v letu Ključne besede: zaposlitvena rehabilitacija, program socialne vključenosti, invalidi, socialni prejemki Ozadje/vprašanje/problem: Prispevek se osredotoča na pomen programa socialne vključenosti za invalide, ki so ocenjeni kot nezaposljivi, na pomen denarnih nadomestil in vprašanje motivacije invalidov za aktivno vključevanje. Programi za socialno vključevanje potekajo v Sloveniji na podlagi Zakona o zaposlitveni rehabilitaciji in zaposlovanju invalidov od leta 2006 za nezaposljive invalide. Med leti 2006 in 2017 je bilo kot nezaposljivih ocenjeno invalidov. V letu 2017 je bilo v program socialne vključenosti vključeno 692 invalidov (25,37 %) populacije. V raziskavi so predstavljena stališča vključenih invalidov, stališča invalidov, ki niso vključeni v program in stališča strokovnih delavcev iz zaposlitvene rehabilitacije in centrov za socialno delo. Metode: Kvalitativna metoda raziskovanja: fokusne skupine in SWOT analiza. Rezultati: V raziskavi so predstavljena pozitivna kot tudi negativna stališča invalidov glede programa. Pozitivni učinki programa se nanašajo na številna področja življenja invalidov glede njihovega zdravja, življenja in socialnih aktivnosti. Večinoma vključeni invalidi v program socialne vključenosti prejemajo socialne prejemke denarno pomoč in varstveni dodatek, ki sta nižja zaradi prejemanja nagrade za socialno vključenost, kar negativno deluje na motivacijo za vključevanje v program po letu 2011, ko se je zakonodaja glede socialnih prejemkov spremenila. Ena od pomembnih možnosti vključenosti v program socialnega vključevanja je tudi ponovna ocena zaposljivosti za tiste invalide, ki se jim je v programu zaposljivost izboljšala, da jim lahko omogoča vstop na trg dela. 91

92 Paralelna sekcija I. Petek, Parallel Session I. - Friday 12 th Outcomes in Vocational Rehabilitation Social Inclusion Programmes in Slovenia Author: PhD. Aleksandra Tabaj, University Rehabilitation Institute Soča, Slovenia Co-authors: Working group members: Valentina Brecelj MSc, Janez Vidmar MSc, Lea Kovač, Suzana Bohorč, Sonja Bercko Eisenreich, Lea Jakič Hiti, Valerija Mikložič, Matjaž Lipovec, Jasmina Plavšič, Nataša Kraljič Černe, Darja Dovečar, and Karmen Kočivnik Expert cooperation: This paper was drawn up by order of the Directorate for People with Disabilities of the Ministry of Labour, Family, Social Affairs and Equal Opportunities in Key words: vocational rehabilitation, social inclusion programme, people with disabilities, social benefits Background/issue/problem: The paper is focused on the importance of the social inclusion programme for people with disabilities who have been assessed as unemployable, as well as on the importance of social benefits and the issue of the motivation of people with disabilities in terms of active inclusion. Social inclusion programmes since 2006 for the unemployable have been facilitated in Slovenia in terms of the Vocational Rehabilitation and Employment of Disabled People Act. Between 2006 and 2017, 2,728 disabled people were assessed as unemployable. In 2017, the social inclusion programme included 692 disabled people (25.37% of the population). The research presents the opinions of the included disabled, disabled people not included in the programme, and expert workers from vocational rehabilitation and social work centres. Methods: Qualitative research method: focus groups and SWOT analysis. Results: The research presents the positive and negative opinions of disabled people regarding the programme. Positive effects of the programme are seen in many aspects of disabled peoples lives, these being their health, life and social activities. The majority of the disabled people included in the social inclusion programme receive social benefits, that is, monetary aid and care benefits, which are at lower than usual rate pursuant to their receiving monetary awards for social inclusion, and this has negatively affected programme motivation and inclusion since 2011, when social benefits legislation was changed. One of the important aspects of participation in the social inclusion programme is its employability reassessment for those whose employability has improved whilst engaged in the programme, which enables said participants to enter the labour market. 92

93 Paralelna sekcija I. Petek, Parallel Session I. - Friday 12 th Uporaba Mednarodne klasifikacije funkcioniranja, invalidnosti in zdravja v postopkih ocenjevanja invalidnosti s poudarkom na nevroloških in onkoloških bolezenskih stanjih Avtor: Lea Kovač, Prof. defektolog, svetovalka generalne direktorice Zavoda Republike Slovenije za zaposlovanje; Sonja Kotnik, uni.dipl. sociolog, svetovalka generalne direktorice Zavoda Republike Slovenije za zaposlovanje; Suzana Butolen, uni.dipl. soc. del., rehabilitacijska svetovalka na Zavodu Republike Slovenije za zaposlovanje Ključne besede: Funkcioniranje, celostna obravnava, poklicna kariera, zaposljivost Ozadje: Temeljni zakon, ki ureja področje zaposlovanja in rehabilitacije invalidov v Sloveniji, vsebuje določitev, da je pri ocenjevanju invalidnosti poleg ugotovljenih trajnih posledic telesne ali duševne okvare ali bolezni, potrebno upoštevati težave pri dejavnostih, ki vplivajo na zaposljivost in ovire pri vključevanju v delovno okolje na način, kot ga opredeljuje Mednarodne klasifikacije funkcioniranja, invalidnosti in zdravja (v nadaljevanju: MKF). MKF v postopkih ocenjevanja invalidnosti na Zavodu za zaposlovanje zagotavlja celostno obravnavo potreb invalida in povezovanje strokovnjakov različnih profilov pri načrtovanju, izvajanju in spremljanju rehabilitacije. Osnova za razumevanje invalidnosti v kontekstu ocenjevanja zaposlitvenih možnosti je bio-psiho-socialni model, ki zajame oceno zdravstvenih, socialnih dejavnikov in dejavnikov okolja, psiholoških, izobrazbeno-poklicnih dejavnikov in dejavnikov pridobljenih delovnih izkušenj. Tako pripravljena celovita ocena posameznikovega delovnega funkcioniranja predstavlja prvo fazo priprave rehabilitacijskega načrta oz. vključitve v storitve zaposlitvene rehabilitacije. Namen vključevanja v storitve zaposlitvene rehabilitacije je krepitev in razvoj poklicne identitete oz poklicne kariere invalida, tako v običajnem delovnem okolju z ustrezno podporo, kot tudi v posebnih oblikah zaposlovanja invalidov, zato je v rehabilitacijskem procesu poleg poklicnega usposabljanja, poseben poudarek na opredelitvi vrste in obsega potrebne podpore. Metode: V prispevku bodo predstavljena teoretična in praktična izhodišča za uporabo MKF v postopkih ocenjevanja invalidnosti na Zavodu Republike Slovenije za zaposlovanje, vključno s kvantitativnim in kvalitativnim pregledom izdanih mnenj rehabilitacijskih komisij v obdobju s poudarkom na konkretni uporabi MKF na področju nevroloških in onkoloških bolezenskih stanj. 93

94 Paralelna sekcija I. Petek, Parallel Session I. - Friday 12 th Rezultati: Merila za priznanje pravice do zaposlitvene rehabilitacije so izoblikovana v smislu povzetka psiholoških, osebnih, družinskih in socialnih vidikov funkcioniranja osebe po MKF s poudarkom na ugotovljenih posebnostih nevroloških in onkoloških bolezenskih stanjih, predstavljajo pa osnovo za načrtovanje rehabilitacijskega procesa. Opredeljena vrsta in stopnja funkcijskih težav pomembno vpliva na izide zaposlitvene rehabilitacije. Zaključki: MKF v postopkih ocenjevanja invalidnosti na Zavodu za zaposlovanje zagotavlja celostno obravnavo potreb invalida in povezovanje strokovnjakov različnih profilov pri načrtovanju, izvajanju in spremljanju poteka in izidov rehabilitacijskega procesa. 94

95 Paralelna sekcija I. Petek, Parallel Session I. - Friday 12 th Using the International Classification of Functioning, Reduced Capability and Health at the Employment Service of Slovenia Avtor: Lea Kovač, Prof. Defectologist, Advisor to Director General of the Employment Service of Slovenia, Slovenia; Sonja Kotnik, BSc in Sociology, Advisor to Girector general of the Employment Service of Slovenia, Slovenia; Suzana Butolen, BSc in Social Work, Rehabilitation Counsel at the Employment Service of Slovenia Key words: functioning, holistic treatment, professional career, employability Background: The fundamental law regulating the field of employment and rehabilitation of disabled people in Slovenia includes a provision that in addition to the established permanent consequences of physical and mental damage in assessing disability, activity problems affecting employability and obstacles to working environment inclusion as determined by the International Classification of Functioning, Disability and Health (hereinafter: ICF) must be taken into consideration. In terms of disability assessment processes at the Employment Service, ICF assures the comprehensive treatment of disabled people and the connecting of experts with various profiles in relation to rehabilitation planning, implementing and monitoring. The basis for understanding disability in the context of assessing employment possibilities is a bio-psychosocial model including medical, social, environmental, psychological, education-professional and work experience assessment. A comprehensive assessment of an individual s work functioning prepared in this way represents the first phase of rehabilitation plan preparation and/or inclusion in vocational rehabilitation programmes. The purpose of said inclusion being to enhance and develop the vocational identity and careers of disabled people in both ordinary working environments with suitable support, as well as in special employment environments for disabled people; therefore, special emphasis is paid to the determination of type and scope of the necessary support in the rehabilitation process provided in addition to vocational training. Methods: The paper will present theoretical and practical starting points for the application of ICF in relation to disability assessment procedures at the Employment Service of Slovenia, including a quantitative and qualitative review of opinions made by rehabilitation committees between 2010 and 2018, with an emphasis on the concrete use of ICF in the field of neurological and oncological disease. 95

96 Paralelna sekcija I. Petek, Parallel Session I. - Friday 12 th Results: The criteria for vocational rehabilitation right recognition are related to the psychological, personal, family and social aspects of people s functioning according to ICF, with emphasis on the established special features of neurological and oncological disease, and represent the basis for rehabilitation process planning. The determined type and level of functional problems importantly affects employment rehabilitation results. Conclusions: In terms of disability assessment procedures at the Employment Service, ICF ensures a comprehensive meeting of disabled people s needs and the inclusion of experts with varying profiles in the planning, implementation and monitoring of rehabilitation process progress and results. 96

97 Paralelna sekcija II. Petek, Parallel Session II. - Friday 12th

98 Paralelna sekcija II. Petek, Parallel Session II. - Friday 12 th Delazmožnost in vrnitev na delo bolnikov z rakom: rak debelega črevesa, želodca in slinavke Avtor: Dr. Tadeja Pintar, dr. med., Univerzitetni klinični center Ljubljana, Oddelek za abdominalno kirurgijo, Medicinska fakulteta Ljubljana Ključne besede: zaposlitev, delazmožnost, vrnitev na delo, ocene delovne zmožnosti, kazalci, protokoli zdravljenja, kakovost življenja Izvleček: Pojavnost abdominalnega raka med zaposlenimi osebami srednjih let narašča. S samooceno delazmožnosti med zdravljenjem se lahko napove vrnitev na delo bolnikov z rakom, ki je močno odvisna od različnih dejavnikov in, kar je zelo pomembno, ima lahko negativen vpliv na zaposlitev in gmotno stanje bolnikov zaradi tesnobe in stiske kot posledice soočanja z boleznijo, ki ogroža življenje. Nove strategije zdravljenja in individualizirani protokoli zdravljenja raka želodca, slinavke in debelega črevesa so močno spremenili celotno prognozo in kakovost življenja. Kratkoročni in dolgoročni učinki načinov zdravljenja pomembno vplivajo na delazmožnost. Za določitev bolniškega staleža zaradi zdravljenja raka je obvezno treba prepoznati ključne dejavnike, ki vplivajo na čas do vrnitve na delo posameznikov po zdravljenju raka. Obvezno je treba določiti obseg telesnih in kognitivnih omejitev pri delu (delovna nezmožnost) posameznikov po primarni diagnozi raka in to mora biti del kakovostnega protokola zdravljenja, ki se ocenjuje v zvezi z načinom zdravljenja. Ocena delazmožnosti bolnikov z rakom temelji na standardnih testih (ocene delazmožnosti); v prvih mesecih po prvem dnevu bolniškega staleža je močno okrnjena, a se bistveno izboljša v obdobju po zdravljenju. Samoocena delazmožnosti šest mesecev po prvem dnevu bolniškega staleža je kazalec vrnitve na delo pri začetnih bolnikih z rakom. Najpomembnejši kazalci so: delazmožnost, zdravljenje (kemoterapija, radioterapija, operacija), starost, duševna delazmožnost in kognitivne motnje. 98

99 Paralelna sekcija II. Petek, Parallel Session II. - Friday 12 th Work ability and return-to-work in cancer patients: CRC, gastric and pancreatic cancer Author: Asist. Prof. PhD. Tadeja Pintar, MD, UMC Ljubljana Abdominal Surgery, Medical Faculty Ljubljana, Sloveni Keywords: employment, work ability, return-to-work, working ability scores, predictors, treatment protocols, QL Abstract: The incidence of middle-aged working individuals being diagnosed with abdominal cancer is increasing. Self-assessed work ability collected during treatment can predict return-to-work in cancer patients and is highly dependent to different factors and importantely, effect negatively to a person s employment and financial situation fuel the anxiety and distress created from facing a life-threatening illness. New treatment strategies and personalised treatment protocols in gastric, pancreatic and colorectal cancers significantely changed all over prognosis and QL. Short and long term effects of treatment modalities importantely influence to work abbility. Identification of key factors influencing time to work reentry after cancer treatment among individuals is mandatory for taking work leave for their cancer treatment. Quantication of the extent of physical and cognitive limitations at work (work disability) in individuals following a primary diagnosis of cancer is mandatory and should be the part of quality of treatment protocol beeing assesed at times related to treatment modality. Evaluation of the work ability of cancer patients is based on standard tests (working ability scores); it is severely impaired in the first months after the first day of sick leave, and improve significantly in time period after treatment. Self-assessed work ability 6 months after the first day of sick leave is a predictor of return-to-work in primary cancer patients. Among predictors the most important are: work ability, treatment (chemotherapy, radiotherapy, surgery), age, mental work ability and cognitive disfunction. 99

100 Paralelna sekcija II. Petek, Parallel Session II. - Friday 12 th Karcinom dojk vpliv dopolnilnega zdravljenja na delazmožnost Avtor: Doc. Dr. Erika Matos, dr. med., Onkološki Inštitut, Univerzitetni klinični center Ljubljana, Slovenija Ključne besede: specifično onkološko zdravljenje, neželeni učinki, rehabilitacija Zdravljenje raka dojk je multidisciplinarno, sestavljeno iz kirurškega, sistemskega in obsevalnega zdravljenja. Večina bolnic z zgodnjim (nerazsejanim) rakom dojk zdravljenje prične z operacijo. Približno tretjina bolnic po operaciji potrebuje dopolnilno kemoterapijo, ki traja tri do pet mesecev. Približno 15% bolnic je dodatno zdravljenih z antiher2 terapijo, ki traja eno leto. Kar 70% bolnic prejema hormonsko terapijo v trajanju 5 do 10 let. Približno polovica bolnic je tudi obsevanih. Vsaka od oblik zdravljenja je povezana z možnimi neželenimi učinki. Posledice kirurškega zdravljenja so bolečina in slabša razgibanost ramenskega sklepa in limfedem, ki se razvije pri približno 30% bolnic. Tveganje za pojav limfedema je večje pri bolnicah, ki so pooperativno tudi obsevane. Sistemsko zdravljenje je povezano z več različnimi neželenimi učinki. Glede na čas in trajanje pojava, jih delimo na akutne, subakutne ter kasne. Med akutne neželene učinke, ki so povezani predvsem s kemoterapijo, sodijo slabost, bruhanje, izpadanje las, okužbe, vnetje sluznic. V tem času so bolnice praviloma v bolniškem staležu. V bolniškem staležu so tudi v času obsevanja, ki sledi kemoterapiji. Večina kasnih in dolgotrajnih neželenih učinkov je povezanih s hormonsko terapijo, s katero bolnice pričnejo po zaključenem zdravljenju s kemoterapijo oziroma takoj po operaciji, če kemoterapija ni potrebna. S hormonsko terapijo povzročimo upad ravni ženskih spolnih hormonov, kar se kaže kot vročinski oblivi, nočno potenje, bolečine v mišicah in sklepih, znižanje mineralne kostne gostote, suha nožnica, motnje spolnosti, nespečnost, motnje razpoloženja in depresija, kognitivne težave in utrudljivost. Tem težavam se lahko pridružijo še kasni neželeni učinki kemoterapije, kot so srčno popuščanje in periferna nevropatija. V obvladovanje teh neželenih učinkov, ki pogosto zahtevajo tudi bolniški stalež, so poleg onkologov dodatno vključeni še psihoonkolog, ginekolog, specialist fizikalne medicine in rehabilitacije, po potrebi tudi nevrolog oziroma kardiolog. Vrnitev v delovni proces je za bolnice pogosto težka. Pogosto potrebujejo prilagoditev delovnega mesta, zato je smiselna napotitev k specialistu medicine dela, prometa in športa, ki poda mnenje o sposobnosti za vračanje na delo ali pa priporoči napotitev na kompleksno obravnavo v Center za poklicno rehabilitacijo. 100

101 Paralelna sekcija II. Petek, Parallel Session II. - Friday 12 th Gynaecologic Oncology and the Return to Work Author: Assist. prof. PhD. Erika Matos, MD., Institute of Oncology, University Medical Centre Ljubljana, Slovenia Key words: specific oncological treatment, adverse effects, rehabilitation Breast cancer treatment is a multidisciplinary composition of surgical, systemic and radiation therapy. The majority of early-stage, non-metastasised, breast cancer patients commence treatment with surgery; approximately one third require supplementary chemotherapy postsurgery, lasting three to five months; around 15% are additionally treated with the antiher2 therapy, which lasts one year; as many as 70% receive hormone therapy over a period of five to ten years; and around half receive radiation therapy. Each treatment entails possible adverse effects. Surgical treatment consequences are pain and poorer flexibility of the shoulder joint and lymphedema, this developing in approximately 30% of patients. Lymphedema risk is higher in patients who receive post-op radiation therapy. Systemic therapy delivers several possible adverse effects and, according to time and duration, are categorised as acute, subacute and late. Acute side effects, primarily connected with chemotherapy, include nausea, vomiting, hair loss, infection, and mucosa inflammation. During this time, patients are usually on sick leave; they are also on sick leave during the radiation therapy following chemotherapy. The majority of late and persistent side effects are connected with hormone therapy, which commences pursuant to chemotherapy, or immediately after surgery if chemotherapy is not necessary. Hormone therapy causes a drop in the level of female sex hormones, which is evidenced in terms of heat waves, night sweating, muscle pain, reduced mineral bone density, dry vaginas, sexual disorder, insomnia, mood swings and depression, cognitive problems and exhaustion. These problems may be accompanied by the late side effects of chemotherapy, such as heart failure and peripheral neuropathy. These side effects often require sick leave, and are managed by oncologists, psychooncologists, gynaecologists, specialists in physical medicine and rehabilitation, and, if necessary, neurologists and/or cardiologists. The return to work process is often difficult for patients; often requiring workplace adaptation, it is advised that specialists in occupational, traffic and sports medicine who will provide opinions on fitness to return to work and/or recommend referral for more complex treatment at the Vocational Rehabilitation Centre be referred to. 101

102 Paralelna sekcija II. Petek, Parallel Session II. - Friday 12 th Novotvorbe gibal in delazmožnost Avtor: Doc. Dr.Tomaž Tomažič, dr. med., specialist ortoped, ZPIZ IK Maribor Ključne besede: mehkotkivni tumorji, gibalni sistem, delazmožnost Novotvorbe gibal, ki sodijo v skupino tumorjev mehkih tkiv, hrustanca in kosti, se pojavljajo v tkivih gibalnega sistema kot primarna rašča ali se vanj zasejejo sekundarno. Večina je benignih (100 : 1), dobro ozdravljivih po kirurškem posegu in zavarovanci praviloma tudi nimajo večjih težav pri reintegraciji v delovni proces. Nasprotno je delazmožnost pri ljudeh z malignimi obolenji gibal pogosto spremenjena. Glede na retrogradno analizo podatkov na ZPIZ Slovenija, smo v obdobju med letoma 2008 do 2018, na invalidskih komisijah obravnavali skupaj 118 zavarovancev s primarnimi novotvorbami gibal. V povprečju je bilo 10,7 ocen letno s to patologijo, s trendom blage rasti od 10 na 11,3 letno v zadnji petletki. Od tega je bilo 78,8 % malignih in samo 21,2 % benignih tumorjev. Pri malignomih so očitno prevladovali plazmocitomi, ki so predstavljali 33,9 %, pri benignih tumorjih pa hemangiomi in limfangiomi s 7,6 % vseh novotvorb gibal. Med njim so bili le štirje primarni sarkomi kosti in tri primarne benigne neoplazme kosti in hrustanca. Zavarovanci z malignomi gibalnega sistema so bili v 66,6 % ocenjeni kot pridobitno nezmožni, v 22,5 % kot zmožni za delo v krajšem delovnem času z ali brez omejitev in v 4,4% zmožni za polni delovni čas, z ali brez poklicne rehabilitacije. Pri oceni delazmožnosti ima rehabilitacija prednost pred upokojitvijo. Zavarovančeva delovna zmogljivost in funkcioniranje nista odvisni le od diagnoze, ampak tudi od vpliva raka in posledic bolezni na njegovo telesno in duševno zdravje. Zato mora biti poklicna rehabilitacija aktivnih zavarovancev s tem obolenjem, sestavni del celostne obravnave. Ob»stabilni«klinični sliki, sprejemljivem funkcionalnem deficitu ter upoštevanju ustreznih fizičnih in časovnih omejitev, je smiselno zavarovanca čim prej vključiti nazaj v njegovo delovno okolje. S tem, poleg pozitivnega psihosocialnega učinka in ohranitve delovnega mesta, zavarovancu izboljšamo tudi gmotni položaj in kakovost preživetja. 102

103 Paralelna sekcija II. Petek, Parallel Session II. - Friday 12 th Tumours in Extremities and Work Ability Author: Assoc. Prof. PhD Tomaž Tomažič, MD., Specialist in Orthopaedics, Pension and Disability Insurance Institute of Slovenia, Slovenia Key words: soft tissue tumours, musculoskeletal system, work ability Tumours in the musculoskeletal system belonging to the group of tumours in soft tissue, cartilage and bone appear as primary growth or secondary metastasis. The majority of such tumours are benign (100:1), easily treatable after surgical procedure and the insured usually have no major problems with work process reintegration; in contrast, work ability for those with a malignant musculoskeletal system disease often changes. According to retrograde data analysis performed at the Pension and Disability Insurance Institute of Slovenia, disability committees discussed a total of 118 insured people with primary tumours in the musculoskeletal system between 2008 and 2018: on average, there were 10.7 assessments per year with this pathology, with a slight growth trend of between 10 and 11.3 per year in the last five years of the data. Of this, 78.8% of tumours being malignant and only 21.2% benign. In terms of malignant tumours, plasmacytoma prevailed, accounting for 33.9%, and in terms of benign tumours, hemangiomas and lymphangiomas accounted for 7.6% of all tumours in the musculoskeletal system. Only four of said cases concerned primary bone sarcomas and three primary benign bone and cartilage neoplasms. 66.6% of the insured with musculoskeletal system malignant tumours were assessed as unemployable, 22.5% as able to work part-time with or without limitations, and 4.4% as able to work full-time with or without occupational rehabilitation. In our assessment, rehabilitation is more advantageous than retirement in terms of ability to work. The insureds ability to work and function not only depend on diagnosis, but also on cancer impact and consequence in terms of physical and mental health. This is why the vocational rehabilitation of active insured people with this disease must be an integral part of holistic treatment regimes. With stable clinical assessment, acceptable functional deficit and observation of suitable physical and time limitation, the insured are able to be reintegrated into their working environment in a timely fashion. And this way, the insureds financial situation and quality of survival improve in addition to its delivery of positive psychosocial effect and employment maintenance. 103

104 Paralelna sekcija II. Petek, Parallel Session II. - Friday 12 th Delazmožnost pri obolelih za rakom Avtor: Vlasta Zajic Stojanović, dr. med., Hrvatski zavod za zdravstveno osiguranje Zagreb, R. Hrvaška; Nada Turčić, dr. med., Hrvatski zavod za zdravstveno osiguranje Zagreb, R. Hrvaška Obvladovanje raka se je v zadnjih tridesetih letih izboljšalo in posledično narašča število oseb, ki preživijo raka. Delavci, ki jih prizadene rak, poročajo o mnogih stranskih učinkih raka in njegovega zdravljenja na njihovo zdravje, vključno z duševnimi, kognitivnimi in fizičnimi simptomi. Najpogosteje navedeni simptom v literaturi je zmanjšana raven energije, ki je opisana kot utrujenost ali izčrpanost ter kot čustveni napor zaradi nenehnega boja z rakom. To velja za vse vrste raka. Druge posledice raka in njegovega zdravljenja, ki vplivajo na varnost in zdravje pri delu, so slabše duševno zdravje, vključno z depresijo in tesnobo, slabše telesno funkcioniranje in simptomi, ki vključujejo bolečino, ter zmanjšane kognitivne zmožnosti, vključno s težavami z osredotočanjem in spominom. Vrnitev na delo določajo dejavniki, povezani z boleznijo, in dejavniki, povezani z delovnim mestom, kot je težko fizično delo, ter posebna vrsta zdravljenja, kot je kemoterapija. Bolnikom, ki so preživeli raka, veliko pomeni to, da jim delodajalci omogočijo prilagoditev delovnega mesta in da jim zdravstveni delavci nudijo pomoč pri vrnitvi na delo. Diagnozo raka običajno spremljajo dolga obdobja bolniškega staleža zaradi zdravljenja. Hrvaška je ena izmed držav Evropske unije z zelo visoko pojavnostjo in smrtnostjo zaradi malignih bolezni. V prispevku bo prikazan delež malignih bolezni po kategorijah v skupnem številu dni bolniškega staleža ter pogostost in trajanje bolniškega staleža za različne vrste malignih bolezni in poklicev bolnikov v opazovanem obdobju. Trajanje bolniškega staleža se določi glede na trajanje diagnostičnih in terapevtskih postopkov in rehabilitacije ter glede na potrebe določenega delovnega mesta v zvezi z možnimi trajnimi posledicami bolezni za bolnikovo zdravje. V prispevku bo prikazano, da je ocenjevanje preostale delovne zmožnosti individualno in odvisno od izbire zdravljenja, stadija bolezni, stranskih učinkov zdravljenja in zahtev delovnega mesta. Motivirani bolniki v zgodnji fazi bolezni se lahko hitro vrnejo na delo z določenimi omejitvami (izogibanje naporom). Zato je v določenih primerih potrebna zaposlitvena rehabilitacija ali določitev delne invalidnosti. Pri pacientih v napredovani fazi bolezni lahko zdravljenje povzroči močne stranske učinke in funkcionalni status lahko vpliva na delovno zmožnost, zato je treba takšne bolnike oceniti kot splošne invalide. 104

105 Paralelna sekcija II. Petek, Parallel Session II. - Friday 12 th Work ability in cancer patients Author: Vlasta Zajic Stojanović, MD., Croatian Institute for Health Insurance Zagreb, R. Croatia; Nada Turčić, MD., Croatian Institute for Health Insurance Zagreb, R. Croatia, Cancer management has improved during the past three decades, and therefore the overall number of people who survive cancer is increasing. Workers affected by cancer report various effects of cancer and its treatment on their health, including mental, cognitive and physical symptoms. The symptom most frequently reported in the literature is a diminished level of energy, described as fatigue or exhaustion and as emotional strain due to the ongoing battle with cancer. This is consistent across cancer types. Other implications of cancer and its treatment that are reported to have an effect on occupational safety and health are diminished mental health, including depression and anxiety; diminished physical functioning and symptoms including pain; and diminished cognitive capacities, including problems with attention and memory RTW is considered to be predicted by disease-related factors, workplace-related factors, such as heavy physical work; and specific type of treatment, such as chemotherapy. Work accommodations provided by employers and support for RTW from healthcare professionals are appreciated by cancer survivors. The diagnosis of cancer is usually accompanied by long periods of sickness absence because of medical treatments and Croatia is one of the European Union countries that has a very high incidence and mortality from malignant diseases. This paper will show the share of malignant diseases by category in the total number of days for sick leave, as well as the frequency and duration of sick leave for various types of malignant diseases and occupations of the patients, during the observed period. The duration of sick leave is determined by the duration of diagnostic and therapeutic procedures and rehabilitation, but also by the requirements of a particular workplace in relation to the possible permanent consequences of the disease on the health of the patient. This paper will show that assessment of residual work capacitiy is individual and it depends upon treatement of choice,disease stage, side effects of treatement and job demands. Motivated patients in early stage can return quickly to work with ceratin limitations ( avoiding strains). Therefore, vocational rehabilitation or determination of partial diasability is needed in some case. In patients with advenced stages, treatement can cause significant side effects and functional status can affect work capacitiy and these patients should be assess as genaral disability. 105

106 Paralelna sekcija II. Petek, Parallel Session II. - Friday 12 th Medicinska rehabilitacija bolnikov po možganski kapi Avtor: Doc. Dr. Nika Goljar, dr.med., spec. fizikalne in rehab. med. Univerzitetni rehabilitacijski inštitut Republike Slovenije Soča, Ljubljana, Slovenija Ključne besede: možganska kap, zmanjšana zmožnost, rehabilitacija, rehabilitacijski tim Okrevanje po možganski kapi je večplastno, odvisno od okrevanja delovanja možganov in procesov učenja. Vključuje nevrološko restitucijo (obnova delovanja poškodovanega možganskega tkiva), substitucijo (reorganizacija delno okvarjenih nevronskih povezav) in kompenzacijo (nadomeščanje izgubljenih funkcij, ki jih človek potrebuje za obvladovanje okolja). Najpomembnejši dejavniki pri uvrščanju bolnikov po možganski kapi v rehabilitacijski program so vrsta in težavnost okvar, omejitev dejavnosti in sodelovanja, sposobnost učenja in telesna vzdržljivost. Dokazano najbolj učinkovita je celostna obravnava bolnikov v multidisciplinarnem rehabilitacijskem timu, ki ga sestavljajo zdravstveni strokovnjaki, posebej usposobljeni za delo z bolniki po možganski kapi (zdravnik specialist fizikalne in rehabilitacijske medicine, medicinska sestra, fizioterapevt, delovni terapevt, klinični logoped, klinični psiholog, socialni delavec in inženir ortotike in protetike). Bistvena za pripravo individualnega kratkoročnega in dolgoročnega načrta rehabilitacijske obravnave je celovita ocena bolnikovega funkcijskega stanja. Rehabilitacijski cilji so usmerjeni v izboljšanje funkcije na gibalnem, zaznavnem, spoznavnem področju (vključno s kognitivnimi in govorno-jezikovnimi sposobnostmi), predvsem pa v čim večjo samostojnost pri dejavnostih in sodelovanju v življenjskih situacijah. Pri tem je potrebno obvladovati in zmanjšati vplive spremljajočih bolezni na bolnikovo funkcioniranje, obvladovati njegove čustvene stiske, vedenjske spremembe, kronično bolečino in spastičnost. Sodobni pristopi v rehabilitaciji po možganski kapi temeljijo na spoznanjih nevroznanosti o tem, da je funkcionalno okrevanje večje, če so osebe prisiljene uporabljati okvarjene ude, če v terapevtskih programih vadijo intenzivno in ponovljivo, z veliko ponovitvami in če se zahtevnost nalog postopoma zvišuje. Poudarek je na intenzivnem ponavljanju določenih funkcijskih aktivnosti. Med dolgoročne rehabilitacijske cilje pri bolnikih, ki so še v aktivnem življenjskem obdobju in imajo po bolezni blago do zmerno zmanjšane zmožnosti, sodijo vožnja avtomobila in varno vračanje na delo ali šolanje, zato je za oboje potrebno izvesti presejalno ocenjevanje že med primarno rehabilitacijsko obravnavo 106

107 Paralelna sekcija II. Petek, Parallel Session II. - Friday 12 th Medical Rehabilitation of Patients After Brain Stroke Author: Assoc. Prof. PhD Nika Goljar, MD., Specialist in Physical and Rehabilitation Medicine, University Rehabilitation Institute Republic of Slovenia Ljubljana, Slovenia Key words: brain stroke, reduced ability, rehabilitation, rehabilitation team Brain stroke recovery consists of several layers dependent on brain activity recovery and learning processes. It includes neurologic restitution (recovery of damaged brain tissue functioning), substitution (reorganisation of partly damaged neuron connections), and compensation (replacing lost functions needed by people to manage the environment). The most important factors in terms of including patients in rehabilitation programmes after brain stroke are type and complexity of damage, limitation of activities and cooperation, ability to learn and physical endurance. Holistic treatment of patients by a multidisciplinary rehabilitation team consisting of medical experts specially trained for work with patients after brain stroke, that is, by specialists in physical and rehabilitation medicine, nurses, physical, work, clinical, speech and language therapists, clinical psychologists, social workers, and orthotic and prosthetic engineers, has been proven most effective. A comprehensive assessment of patient functional state is vital for the preparation of individual short- and long-term rehabilitation treatment plans. Rehabilitation goals are focused on improving function vis-à-vis the locomotor, perception and cognitive fields, including cognitive and speech-linguistic abilities, and especially on maximising independence in terms of activity and involvement in life situations; here, the impact of accompanying disease on patient functioning must be managed and mitigated, and patient emotional distress, behavioural change, chronic pain and spasticity must be managed. Modern post-brain stroke rehabilitation approaches are based on neuroscientific findings that functional recovery is better facilitated when people are encouraged to use damaged limbs, undergo intensive, repetitive, recurring practice as part of therapeutic programmes, including gradual task complexity increase. Emphasis is placed on the intensive repetition of certain functional activities. Long-term rehabilitation goals for patients still in the active period of their lives with only mild to moderately reduced ability post-disease are the drivers for the safe return to work or education, and this is why screening must take place during primary rehabilitation treatment. 107

108 Paralelna sekcija II. Petek, Parallel Session II. - Friday 12 th Vrnitev na delo oseb po možganski kapi Avtor: Metka Teržan, dr. med., Centar za poklicno rehabilitacijo, Univerzitetni rehabilitacijski Inštitut Republike Slovenije Soča Ljubljana, Slovenija Ključne besede: vračanje na delo, osebe po kapi, poklicna rehabilitacja Izhodišče: Slaba petina oseb po možganski kapi je še v aktivni dobi. Različne študije kažejo, da se jih vrne na delo od 1 do 90%, razlike so verjetno že v vhodnih parametrih. Metode: Proučevali smo literaturo na temo vračanja na delo po možganski kapi ter predstavili in analizirali naš primera vračanja na delo skozi proces poklicne rehabilitacije. Rezultati: Vračanje na delo je pomemben cilj oseb po možganski kapi v delovni dobi. Na njihovo zmožnost za aktivacijo notranjih zmogljivosti vplivajo številni dejavniki iz delovnega in socialnega okolja. Od osebnih okoliščin je v ospredju huda utrudljivost. Poudarjena je vloga delodajalca in intervencije na delovnem mestu. Delodajalci izpostavljajo pomen podpore ustrezno usposobljenih strokovnih delavcev. Sodelavci lahko spremenijo potek procesa. Vse trditve iz študij so bile potrjene v predstavljenem primeru. Zaključki: Vračanje na delo pri osebah po kapi je lahko bolj učinkovito ob podpori programov poklicne rehabilitacije na vseh nivojih zdravstvene dejavnosti. Ti programi morajo biti medresorski in multidisciplinarni in morajo zagotavljati podporo delavcu in delodajalcu v zgodnji, pa tudi v kasnejši fazi procesa prilagajanja na delo 108

109 Paralelna sekcija II. Petek, Parallel Session II. - Friday 12 th Return to Work after Brain Stroke Author: Metka Teržan, MD., Center for Vocational Rehabilitation, University Rehabilitation Institute Republic of Slovenia SOČA, Ljubljana, Slovenia Key words: return to work, persons after stroke, vocational rehabilitation Background: About 20% of persons after stroke is of working age. Different studies report from 1 to 90% persons will return to work after stroke. Methods: on the basis of literature study and on the basis of the presentation the case through the return to work process with vocational rehabilitation team support. Results: RTW is important goal for persons after stroke in working age. Their ability to activate their resources are influenced by many factors in their working and social environment. Among personal factors fatigue is most important. Main role of employer and work place interventions are emphasized. Employers report importance of professional support. Co-workers can change the process. All those statements from studies were proved by our case. Conclusions: RTW for persons after stroke can be more effective with the help of vocational rehabilitation personal in different programmes on all levels of health care system. This programmes should be cross-sector and multidisciplinary and they have to support RTW process in all phases. 109

110 Paralelna sekcija II. Petek, Parallel Session II. - Friday 12 th Pomoč nevropsihologa pri vračanju na delovno mesto po možganski kapi: ko zgolj ugoden motorični izid po bolezni ne zadostuje Avtor: Dr. Barbara Starovasnik Žagavec, univ.dipl.psih., specialistka klinične psihologije, Univerzitetni rehabilitacijski inštitut Republike Slovenije Soča, Oddelek za rehabilitacijo pacientov po možganski kapi Možganska kap povzroča žariščne ali več-žariščne okvare kognitivnih funkcij pri približno 65% vseh bolnikov. Čeprav je prevalenca kognitivnih motenj po cerebrovaskularnih dogodkih najvišja med starejšimi, pa ne smemo spregledati skupine mlajših in delovno aktivnih posameznikov (približno 10-20%) s t.i. ugodnim motoričnim izidom bolezni, kadar je motoričnih in govornojezikovnih posledic minimalno in ostaja zmožnost gibanja praktično skoraj enaka kot pred boleznijo. Pri teh posameznikih je izrazito povišano tveganje za: daljše bolniške odsotnosti z delovnega mesta, napake na delovnem mestu, razvoj duševnih in kroničnih telesnih obolenj ter psihofizično izgorelost. Klinični psihologi, nevropsihologi, ki se ukvarjamo s posledicami možganske kapi, ocenjujemo kognitivno in čustveno delovanje posameznika v prvih obdobjih po bolezni običajno za namene iskanja rehabilitacijskih potencialov in svetovanja multidisciplinarnemu timu, kasneje pa za spremljanje napredka, poučevanje bolnikov in njihovih svojcev ter usmeritve za vsakodnevno funkcioniranje ter eventualne prilagoditve na delovnem mestu. Spremembe pozornostnega sistema in kognitivne utrudljivosti so najbolj pogoste (pri % vseh bolnikov), a hkrati najbolj spregledane kognitivne spremembe pri bolnikih po možganski kapi. Ker je ta sistem vključen v skoraj vse ravni miselnega udejanjanja posameznika (pri pomnjenju, učenju, organizaciji v prostoru, izvajanju aktivnosti, jeziku...), takšne motnje pomembno zmanjšujejo ali omejujejo bolnikovo funkcioniranje na mnogih življenjskih področjih. V prvem letu po bolezni lahko najdemo kar 48,5% okvar na področju pozornostnega sistema, sledijo govorno-jezikovne motnje (27%), motnje kratkoročnega pomnenja (24,5%) in izvršilnih funkcij (18,5%). Po letu dni so motnje pozornosti še vedno dokaj izrazite, medtem ko izvršilne motnje, afazije in motnje dolgoročnega spomina (če so pred tem dosegale nivo blage okvare) s časom lahko izzvenijo. Poglobljena nevropsihološka ocena je zato ob pričetku vračanja na delo obvezna, saj tako bolniku kot delodajalcu pomaga razviti ustrezno in produktivno okolje, ki bo še vedno prilagojeno, a bo kljub temu pomembno zmanjševalo možnost zapletov na delovnem mestu. 110

111 Paralelna sekcija II. Petek, Parallel Session II. - Friday 12 th Aid of Neuropsychologist in Return to Work after Brain Stroke when Favourable Motor Results of the Disease are Insufficient Author: PhD. Barbara Starovasnik Žagavec, University graduate psychologist University Rehabilitation Institute Republic of Slovenia Soča, Department for rehabilitation of patients after stroke Brain stroke causes focal and multifocal damage of cognitive functions in around 65% of all patients. Despite the fact that the prevalence of cognitive disorders after a cerebrovascular event is the highest in elderly patients, younger persons of working-age (around 10-20%) with the so-called favourable motor outcome of the disease must not be overlooked, where motor and speech-language pathology is mild and mobility has practically remained the same as before the event. In these persons there is an extremely high risk of long-term sick leave, mistakes at work, development of mental and chronic physical health conditions and psychophysiological burnout. Clinical psychologists, neuropsychologists, who deal with brain stroke effects, assess cognitive and emotional functioning of a person in the period following the disease onset, primarily towards identifying rehabilitation potentials and advising a multidisciplinary team, as well as follow-up monitoring of the progress, educating patients and their family members and giving directions for day-to-day functioning and possible workplace adaptations. Changes in attention system and cognitive fatigue are most common (in 42 93% of all patients), the former being at the same time the most ignored cognitive changes in patients after brain stroke. Since this system is part of almost all levels of one s cognitive performance (memory, learning, spatial cognition, performing of activities, language...), such deficits significantly diminish or limit patient s functioning in numerous areas of life. In the first year after the disease 48.5% of deficits are in the field of attention system, followed by speech and language disorders (27%), working memory impairment (24.5%) and executive functions (18.5%). After one year attention disorders are still significantly pronounced, while executive functions, aphasias and long-term memory disorders (if a level of mild disorder was established before that) might eventually disappear. Thus a profound neuro-psychological assessment has to be made in the initial phase of returning a patient to work. It helps a patient as well as employer create an adequate and productive environment, which will, though adapted, significantly diminish the possibility of complications at workplace. 111

112 Paralelna sekcija II. Petek, Parallel Session II. - Friday 12 th Vožnja po možganski kapi Avtor: Marko Sremec, dr. med; mag. Franjo Velikanje, dr. med; doc. dr. Metka Moharić, dr. med., Univerzitetni rehabilitacijski Inštitut Republike Slovenije Soča, Subspecialistična ambulanta za voznike s posebnimi potrebami, Ključne besede: možganska kap, vožnja, mediatester Ozadje: možganska kap (MK) lahko različno vpliva na vozniške zmožnosti, odvisno od področja okvare možganov. Zaradi tega je pomembno, da so vsi vozniki po MK pregledani pri specialistu medicine dela, prometa in športa za oceno preostale vozniške zmožnosti. Metode: pregled voznika ali kandidata za voznika opravi specialist MDPŠ. Obseg pregleda sestavlja pregled zdravstvene dokumentacije, klinični pregled in testiranje na avtomobilskem simulatorju za merjenje psihofizičnih sposobnosti (Mediatester). Pregled je možno dodatno razširiti z nevropsihološkim testiranjem, ki je v primeru MK najpogostejša dodatna diagnostika in ga izvaja specialist klinične psihologije s posebnim naborom testov. Sledi lahko še pregled pri oftalmologu, nevrologu, psihiatru, internistu in fiziatru. Dodatno smo še opravili retrospektivno analizo prospektivno vodene datoteke. Rezultati: analiza je pokazala, da smo v ambulanti za voznike s posebnimi potrebami v obdobju od januarja 2013 do decembra 2017 obravnavali 387 voznikov po MK od tega 68 žensk (17,6 %) in 319 moških (82,4 %). Od tega je bilo 248 (64,1 %) prvih pregledov. Povprečna starost ob pregledu je bila 55 let (razpon 17-85). Nevropsihološko testiranje je imelo 228 (58,9 %) pacientov. V 55 primerih (14 %) smo napotili paciente na preizkus vožnje. Ugotovili smo, da je samo 27 (7 %) pacientov bilo zmožnih za varno vožnjo brez prilagoditev in omejitev. 276 (71 %) pacientov je bilo zmožnih za vožnjo s prilagoditvami in/ali omejitvami. 58 (15 %) jih je bilo začasno nezmožnih in 26 (7 %) trajno nezmožnih za vožnjo. Zaključek: v subspecialistični ambulanti za voznike s posebnimi potrebami na Univerzitetnem rehabilitacijskem inštitutu Republike Slovenije Soča se pri pregledih voznikov ali kandidatov za voznike poslužujemo testiranja na Mediatesterju za čim natančnejšo opredelitev njihovih zmožnosti. Glede na fizične in kognitivne okvare podajamo prilagoditve in omejitve, ki jim omogočajo varno vožnjo, tudi v sklopu varnega vračanja na delo in s tem pomembno vplivamo na kvaliteto življenja. 112

113 Paralelna sekcija II. Petek, Parallel Session II. - Friday 12 th Driving after Stroke Author: Marko Sremec, MD., University Rehabilitation Institute Republic of Slovenia SOČA, Ljubljana, Slovenia, MsC. Franjo Velikanje, MD., Assoc. Prof. PhD.. Metka Moharić, MD. University Rehabilitation Institute Republic of Slovenia SOČA, Ljubljana, Slovenia Subspecialist clinic for drivers with special needs Key words: stroke, driving, mediatester Background: Stroke can differently affect one s ability to drive, depending on the brain areas affected. Thus it is important that all drivers after stroke be examined by a specialist in occupational medicine, traffic and sports for driving ability. Methods: Examination of a driver or a learner driver is carried out by a specialist in occupational medicine, traffic and sports. The examination includes documentation examination, clinical inspection and a driving simulator test to measure psychophysical abilities (Mediatester). The examination can additionally be extended to neuropsychological testing, the latter being the most common additional diagnostics in strokes. It is carried out by a specialist in clinical psychology by means of special tests. The examination can be followed-up by one with ophthalmologist, neurologist, psychiatrist, internal specialist and physiatrist. A retrospective analysis of a prospectively led file was additionally carried out. Results: The analysis has shown that in the period January 2013 December 2017, the clinic for drivers with special needs treated 387 drivers after stroke 68 of them women (17.6%) and 319 men (82.4%); 248 (64.1%) thereof were first examinations. Average age at the examination was 55 years (from 17 to 85 years). 228 (58%) of the patients underwent neuropsychological testing. In 55 cases (14%) patients were referred to driving ability testing. It has been established that only 27 (7%) of patients were able to drive safely, without any adaptations or limitations required. 276 (71%) of patients were able to drive with required adaptations/limitations. 58 (15%) were temporary and 26 (7%) permanently unable to drive. Conclusion: Examinations of drivers and learner drivers in the subspecialist clinic for drivers with special needs at University Rehabilitation Institute Republic of Slovenia SOČA include testing by means of Mediatester, to define their driving ability as precisely as possible. As to their physical and cognitive impairments, adaptations and limitations for safe driving, also within safe return to work, are put forward, thus significantly contributing to the quality of life. 113

114 Poster sekcija Poster Section

115 Poster sekcija Poster Section Poklicna rehabilitacija s praktičnim delom na ustreznem delovnem mestu v kombinaciji s kratkotrajnim izobraževanjem Avtor: Darja Jamnik, psiholog, uni.dipl. psiholog, Želva, podjetje za usposabljanje in zaposlovanje d.o.o. Ključne besede: poklicna rehabilitacija, usposabljanje, ohranitev zaposlitve Na podlagi napotnice ZPIZ smo v letu 2018 obravnavali zavarovanca B.K.. Zavarovanec je star 46 let, ima 24 let rednih delovnih izkušenj na delovnem mestu obdelovalec kovin, v podjetju Litostroj Power, d.o.o.. Glavne delovne naloge so obdelovanje, mersko kontroliranje obdelovancev ter nastavljanje obdelovalnih strojev. Delo je fizično naporno, triizmensko, normirano, v hrupu in vročini. Zavarovanec je imel leta 2016 operacijo srca zaradi obsežnega akutnega miokardnega infarkta sprednje stene. Od takrat dalje je v bolniškem staležu. Pri zavarovancu je ugotovljeno, da ob upoštevanju obremenitev delovnega mesta obdelovalec kovin, tega dela ni več zmožen opravljati. Zmožen je le za lažje fizično delo pri katerem ročno premešča bremena do največ 10 kg in za delo v toplotno urejenem zaprtem prostoru. Preko intenzivnih pogovorov z delodajalcem in zavarovancem smo ugotovili, da v podjetju obstaja možnost premestitve na drugo ustreznejše delovno mesto - tehnolog tehnik, kjer so upoštevane vse predvidene omejitve. Zavarovanec je že imel ustrezno formalno izobrazbo za zasedbo tega delavnega mesta (strojni tehnik) in je tudi izkazoval izrazit tehnični interes. Želel si je ohraniti zaposlitev pri sedanjem delodajalcu in na področju, kjer delo opravlja že vso svojo kariero. Skupaj z delodajalcem smo natančno opredelili potrebna znanja, ki jih je zavarovanec potreboval za uspešno opravljanje tega dela. Predlagana je bila poklicna rehabilitacija s praktičnim delom na konkretnem delovnem mestu v kombinaciji s kratkotrajnim računalniškim izobraževanjem (znanja iz obdelovanja dokumentov in izdelave strojnih projektov v elektronski obliki). Po pridobitvi teh znaj se je zavarovanec še 6 mesecev usposabljal pri delodajalcu, na konkretnem delovnem mestu tehnolog tehnik, pod vodstvom mentorja, ki je usposobljen za to delo. Delodajalec je pripravil konkreten program usposabljanja, ki zajema tako teoretična in praktična znanja. Na podlagi predlagane poklicne rehabilitacije se je zavarovanec usposobil za delo na ustreznem delovnem mestu pri istem delodajalcu in tako ohranil zaposlitev kljub zdravstvenim omejitvam. 115

116 Poster sekcija Poster Section Vocational Rehabilitation with Practical Work at an Appropriate Workplace in Combination with Short-Term Education Author: Darja Jamnik, psiholog, univ. dipl. psiholog, Želva, Company for Training and Employment, Ljubljana, Slovenia Key words: vocational rehabilitation, training, preservation of employment In 2018, on referral from ZPIZ, we dealt with an insured person, B.K.. He was 46 years old, had been regularly employed in Litostroj Power d.o.o. for 24 years and worked as a metal worker. His main work tasks were metalwork, control measurements of workpieces and adjustment of machine tools. His work was physically strenuous, performed in three shifts, with quantified workload, in heat and noise. In 2016 the insured person had heart operation due to acute extensive anterior wall myocardial infarction. Since then he was on sick leave. He was assessed that, considering the demands of his workplace, he was no longer capable of performing this work anymore. He was capable of doing light physical work, handling of loads up to 10 kg, inside, in an environment with controlled temperature. Upon intensive discussions with the employer and the insured person it turned out that there was a possibility of reassigning him to another adequate workplace in the company technologisttechnician, where all restrictions proposed were observed. The insured had already had the required qualification for this post and showed strong interest in technology. His wish was to remain employed with his present employer, in the field he has been working his entire career. Along with his employer, a detailed definition of the knowledge required for this post was elaborated. A proposal for vocational rehabilitation, including on-the-job training in combination with a computer course (electronic documents management and elaboration of mechanical engineering projects on-line) was made. Once this know-how acquired, the insured person was being trained with the employer at the technologist-technician post, with the assistance of a mentor qualified for this job, for 6 months. Training programme was prepared by the employer, including theoretical as well as practical knowledge. Based on the vocational rehabilitation proposed, the insured person was qualified for the work at an appropriate workplace with the same employer and has kept his job despite health limitations. 116

117 Poster sekcija Poster Section Primer dobre prakse postopno vračanje na delovno mesto po daljši bolniški odsotnosti (podaljšanja poklicna rehabilitacija). Avtor: Aleksandra Denša, univ. dipl. socialna delavka, Univerzitetni rehabilitacijski inštitut Republike Slovenije Soča. Ključne besede: poklicna rehabilitacija, bolniška odsotnost, disociativna motorična motnja. Predstavitev primera: Predstavili bomo primer pacientke z nevrološkim obolenjem, pri kateri smo v procesu vračanja na delo uporabljali metode dela, ki so preverjene na področju zaposlitvene rehabilitacije in v tujini. Metode: Preverili smo naslednje metode dela v poklicni rehabilitaciji: individualno svetovanje aktivacija in krepitev notranjih virov moči in nudenje psihosocialne podpore pri vračanju nazaj na delovno mesto, informiranje, spremljanje, sodelovanje z delodajalcem, evalvacija delovnega funkcioniranja pacientke. Rezultati: Postopno vključevanje pacientke nazaj na delovno mesto je trajalo od meseca septembra 2017 do konca meseca marca Na podlagi preizkusov na različnih delovnih mestih (delo na področju rezervacij prodajni referent, delo v zdravstveni administraciji medicinski referent) in v okviru različnih časovnih obremenitev je strokovni tim ugotavljal, da bo rehabilitandka zmožna za: pretežno sedeče delo, s premeščanjem bremen do 3kg, brez izrazitih stalnih časovnih pritiskov, v skrajšanem 4-urnem delovnem času. Kot ustrezno delo se je za pacientko izkazalo delo na področju zdravstvene administracije medicinski receptor. V nadaljevanju je bila pacientka tudi obravnavana na invalidski komisiji in si pridobila pravice iz invalidskega zavarovanja. Zaključki / Spoznanja: Primer prikazuje pomembnost aktivnega povezovanja in sodelovanja različnih sistemov (delodajalec, imenovani zdravnik ZZZS, strokovni tim, ZPIZ) za uspešno ponovno vračanje delavca nazaj na delovno mesto po daljši bolniški odsotnosti. Pri tem se je kot zelo pomembno pokazalo zagotavljanje strokovne pomoči in podpore delodajalcu in delavcu. 117

118 Poster sekcija Poster Section An example of good practice Gradual Return to Work after a Long Absence (extended professional rehabilitation). Author: Aleksandra Denša, University graduate. soc, University Rehabilitation Institute Republic of Slovenia SOČA Key words: vocational rehabilitation, sick leave, dissociative motor disorder Case presentation: A case of a patient with a neurologic condition is presented, where, within the process of returning to work, working methods verified in vocational rehabilitation abroad were applied. Methods: The following methods have been tested: one-to one counselling activating and strengthening of internal sources of power and providing psychosocial support in one s return to work, providing information, monitoring and cooperation with the employer, evaluation of the patient s functioning at work. Results: Gradual returning to work of the patient lasted from September 2017 until the end of March Based on the tests performed in different workplaces (reservation clerk sales officer, a job in medical administration medical clerk) and in different time schedules, the expert team issued an opinion the reha patient was capable of: working in a sitting position, with handling of loads up to 3 kg, without significant and constant time pressure, working short-time (4 hours a day). Work in the field of medical administration medical receptionist proved to be the appropriate job for the patient. Later on the patient was also referred to the Board of Examiners, on the basis of their assessment she qualified for disability insurance entitlements. Conclusion: The case illustrates the importance of proactive collaboration of various systems (employer, physician authorized by the Health Insurance Institute, expert team, ZPIZ (the Pension and Disability Insurance Institute of the Republic of Slovenia) towards successful return of workers to their workplaces after a lengthy sick leave. Thereby the providing of assistance and support to the employer and worker proved to be of extreme importance. 118

119 Poster sekcija Poster Section Vloga zdravnika medicine dela pri vračanju na delo delavca z epilepsijo Avtor: Dr. Tihomir Ratkajec, dr.med., specialist medicine dela, prometa in športa, Medicina dela Rogaška d. o.o.o., Rogaška Slatina Ključne besede: epilepsija, vračanje na delo Opis problema: Delavce z epilepsijo je potrebno poklicno rehabilitirati in zaposliti na ustreznem delovnem mestu. Postavlja se vprašanje kdaj ga je potrebno predstaviti na Invalidsko komisijo in kakšna je vloga zdravnika medicine dela. Metode: Delavka, 46 let stara, zaposlena na stroju za pločevinasto-žične elemente, je bila pregledana pri zdravniku medicine dela na pregled podjetja, ker je v podjetju ob vročem dnevu 2016 leta doživela generalizirani epileptični napad. Za epilepsijo je redno jemala zdravila od 1994 leta in je zadnji napad od treh imela 2004 leta. Pri nevrološkem pregled ni bilo patoloških najdb. MR možganovine je pokazal hiperintenzivna žarišča demijelinizacije možganovine, rezultat lumbalne punkcija bil normalen, EEG je bil abnormen, enak izvidu od 2014 leta. Vrednosti karbomapezina so bile v referenčnih vrednosti. Zdravnik medicine dela je na delovnem mestu delavke ugotovil: prostorsko utesnjenost, močan hrup, fizično intenzivno delo s ponavljajočimi gibi, pogoste organizacijske spremembe, toplo mikroklimo po leti, glava in roki so pri delu oddaljeni od stroja okrog 60 cm. Rezultat in razprava: Zdravnik medicine dela je ocenil obremenitve na še dva druga delovna mesta, kjer ni bilo hrupa, norme, premakljivih delov strojev, klima je bila ugodna, delovne izmene so bilo dopoldan in popoldan. Smatral je, da je nevarnost za poškodbo telesa majhna. Predlagal je prestavitev na ta delovna mesta za dobo enega leta in po tem usmerjeni zdravstveni pregled. Odsvetoval je nočne izmene. Podjetje je podprlo predlog, izvedlo prestavitev na predlagana dela. Gospa je bila zadovoljna na novem delovnem mestu in ni bila odsotna z dela. Zdravljenje je nadaljevala pri nevrologu in osebnem zdravniku. Zaključek: Prikazana je vloga zdravnika medicine dela v vračanju na delo bolnice z epilepsijo. Postavlja se vprašanje ali je potrebna ocena delazmožnosti pred Invalidsko komisijo, ali bo mnenje zdravnika medicine dela vplivalo na odločitev komisije? Kateri so dejavniki, ki odločajo o predstavitvi na Invalidsko komisijo? 119

120 Poster sekcija Poster Section The Role of a Medical Doctor in Returning Epilepsy Patients to their Work Author: PhD. Tihomir Ratkajec, MD, Medicina dela Rogaška d. o.o.o., Rogaška Slatina, Slovenia Background: Epilepsy patients should be included in vocational rehabilitation and offered appropriate jobs. The question is at which point they should be referred to the Board of Examiners and what role an occupational medicine physician plays within this process. Methods: A female worker, 46 years of age, working at a sheet metal and wire fabrication machine, underwent, on the employer s proposal, a medical examination because she had a generalised epileptic seizure in the company on a hot summer day in She had had epilepsy medications on a regular basis since 1994 and had the last seizure out of three in No pathology findings were found in neurological examination. Brain tissue MRI showed hyperintense demyelinating foci of brain tissue; lumbar puncture results were within normal values; EEG results were abnormal, identical with the ones in Carbamazepine values were within reference values. As to the patient s workplace, the following was established by the occupational medicine specialist: too little space, heavy noise, physically intensive work with repetitive movements, frequent organisational changes, warm microclimate in summer, the distance of the head and hands at work 60 cm from the machine. Results and discussion: Occupational medicine specialist made an assessment regarding 2 other workplaces, where there was no noise, no quantified workload or moving machine parts, climate was favourable, work was performed in 2 shifts: in day and swing shifts. There, the possibility of injuries was low. A transfer of the worker to one of these posts was proposed for a period of 1 year, followed by a targeted medical examination. Work in the night shift was contraindicated. The proposal was supported by the company, which carried out the transfer of the worker to the post proposed. The patient was pleased with the new post, no absences from work could be established. The treatment was continued with a neurologist and her treating doctor. Conclusion: The role of the occupational medicine physician in returning an epilepsy patient to work is presented. The question is whether the assessment of her work capacity by the Board of Examiners is necessary and the occupational medicine specialist s opinion will influence their decision. Which are the factors which influence a decision whether a patient should be referred to the Board of Examiners? 120

121 Poster sekcija Poster Section PRIMER PODALJŠANE REHABILITACIJE IN POSTOPKA VRAČANJA NA DELO PRI PACIENTU S TUMORJEM Avtor: Bojana Fulder, univ. dipl. psih., Lidija DORA, mag. soc. dela, Ksenija Šterman, spec. MDPŠ, Uri SOČA, Center za poklicno rehabilitacijo, enota Murska Sobota Ključne besede: poklicna in zaposlitvena rehabilitacija, podaljšana rehabilitacija, vračanje na delo Pri 47 let starem elektrotehniku, ki je zaposlen kot monter II je bil ugotovljen švanom akustičnega živca levo. Po končanem zdravljenju z radioterapijo je ostala kombinirana izguba sluha levo, težje stopnje ter motnje ravnotežja. Tekom rehabilitacijske obravnave v Centru za poklicno rehabilitacijo URI-Soča smo ocenili, da bo za svoje delo monter II trajno nezmožen, saj je delo na višini, fizično težko, na prostem, v vseh vremenskih pogojih. Sprva je bil vključen v podaljšano rehabilitacijo v naši instituciji. Povezali smo se z delodajalcem, njihovim pooblaščenim specialistom MDPŠ ter skupaj poiskali novo delovno mesto skladiščnika, na katerem se je nato usposabljal in postopno vračal nazaj na delo. Na delovnem mestu je imel mentorja, spremljan pa je bil tudi s strani strokovnega delavca URI-Soča, ves čas mu je bila nudena psihosocialna podpora. Vse težave smo sproti reševali, v začetku je delal v skrajšanem delovnem času 4 ure, nato pa se je dnevna delovna obveznost postopno stopnjevala do dela v 8- urnem delavniku. Po koncu rehabilitacije, ki je v celoti trajala 1 leto, je bil za delo skladiščnika usposobljen. Zaradi naglušnosti je potrebno podajanje navodil ob očesnem kontaktu, občasno potrebuje ponovitve navodil, težave so pri telefoniranju. Podaljšana rehabilitacija oseb z zdravstvenimi težavami omogoča varno vračanje nazaj na delo, pomembno pa je tudi dobro sodelovanje delodajalca, varnostnega inženirja, kadrovske službe ter pooblaščenega spec. MDPŠ. Predstavitev primera: Na Centru za poklicno rehabilitacijo Uri SOČA smo na podlagi predhodne triaže gospoda najprej vključili v začetni ocenjevalno diagnostični program, ki traja 2 tedna. V timu sodelujejo dr. med., spec MDPŠ, psiholog, socialni delavec, delovni terapevt in tehnolog. Star je 47 let, po poklicu elektrotehnik. Ima okoli 24 let delovne dobe. Od leta 1998 je zaposlen v podjetju Elektro Maribor d.d. na delovnem mestu - monter II. Delo obsega vzdrževanja omrežja in daljnovodov, opravlja priklope električne napeljave v hiše, dela na transformatorskih postajah, vključen je v dežurstva in opravlja prevoze v službene namene. Zaradi bolezni je v bolniškem staležu 10 mesecev. Oktobra 2015 je bil hospitaliziran zaradi levostranske kombinirane naglušnosti, defekta inkusa in stapesa s perforacijo in retrakcijo v predelu zadnjih kvadrantov, narejena je bila osikuloplastika s totalno Goldenberg protezo in timpanoplastika s hrustancem in perihondrijem 121

122 Poster sekcija Poster Section skozi transkanalni pristop. V letu 2016 so se začele težave s slabšanjem sluha, vrtoglavicami, glavoboli. Bil je diagnostično obdelan, preiskave so pokazale švanom na akustičnem živcu na levi strani, ki je bil 3,2x2,8 cm velik in sicer je segal v predel notranjega sluhovoda in levega pontocerebelarnega kota. Zdravljen je bil z lokalno radioterapijo visoke natančnosti 54 Gy v 30 frakcijah v 6 tednih. Ostala je obojestransko kombinirana izguba sluha, levo težje stopnje ter motnje ravnotežja. Ostaja pod kontrolo onkologa, kjer ob zadnji kontroli ugotavlja delni regres akustičnega nevrinoma levostransko, sicer pa je v dobrem splošnem stanju. Za svoje delo monter II trajno ni zmožen. Na podlagi ugotovitev je bila predlagana podaljšana rehabilitacija, sprva v naši inštituciji, predvidoma 2x mesečno oziroma po potrebi, nato pa so se aktivnosti razširile na postopno vračanje na delo pri delodajalcu. Celotna podaljšana rehabilitacija je trajala 1 leto. Prve štiri mesece je bil vključen predvsem v individualne obravnave v naši inštituciji, predvsem v smislu podpore pri ponovnem delovnem vključevanju in varnem vračanju na delo. V tem času smo navezali kontakt z delodajalcem, ki je bil pripravljen na sodelovanje v procesu podaljšane rehabilitacije in varnega vračanja na delo. Ker za svoje delo trajno ni zmožen, mu je bil delodajalec pripravljen prilagoditi delovno mesto in ga za to delo tudi usposobiti. Povezali smo se tudi s pooblaščenim spec. MDPŠ, ki je s prilagoditvijo delovnega mesta soglašal. S postopnim vračanjem na prilagojeno delo v skladu z omejitvami (DM skladiščnik) je pričel v skrajšanem delovnem času 4 ure. V delovni proces se je vključeval postopoma. Bil je ustrezno motiviran in delovno naravnan. Pri izvedbi delovnih nalog je bil natančen, odgovoren in vztrajen. Ves čas je tudi sam vršil kontrolo nad opravljenim delom. Napake je večinoma zaznal sam in jih tudi popravil. V začetku je bilo prisotno nekoliko več utrudljivosti in mu je mestoma upadla koncentracija. Postopoma je napredoval. Tako je začel opravljati tudi nekoliko zahtevnejša delovna opravila. Tudi pri večjem obsegu del si je zmožen sam postaviti prioritete. Nekoliko več podpore je potreboval v delovnih situacijah, ko je dobil več navodil hkrati ter ko se je zahtevalo, da se naloge izvedejo v hitrejšem tempu. Ugotavljalo se je, da mu je zaradi težav s sluhom, posamezna navodila potrebno ponoviti. Nekoliko težja je komunikacija tudi po telefonu, predvsem ko je v okolici prisoten večji ropot ali šum. Aktivnosti smo stopnjevali v naslednjih dveh mesecih na 6 ur dnevno in nato na polni delovni čas. Ob koncu rehabilitacije ugotavljamo stabilno delovno funkcioniranje na delovnem mestu, na katerem je potekala podaljšana rehabilitacijska obravnava in menimo, da je za delo sposoben v okviru zdravstvenih omejitev. Sposoben je za lažja fizična dela z dvigovanjem bremen do 10 kg, redko do 15 kg, ne v prekomernem ropotu, ne na višini, ne na lestvi, brez vožnje tovornih vozil ali delovne mehanizacije v poklicne namene, ne ponoči. Predlagana je bila ocena na IK. 122

123 Poster sekcija Poster Section EXTENDED REHABILITATION AND A PROCESS OF RETURNING TO WORK WITH A PATIENT WITH TUMOR (CASE STUDY) Author: Bojana Fulder, University graduate psychologist, University Rehabilitation Institute Republic of Slovenia SOČA, Murska Sobota; MsC Lidija Dora; Ksenija Šterman, MD. MDPŠ, URI SOČA, Vocational Rehabilitation Centre Murska Sobota Key words: vocational rehabilitation, extended rehabilitation, return to work A 47 year old electrical engineer, employed as installer II was diagnosed with an acoustic neuroma (left side). After the treatment with radiotherapy balance disorders and hearing loss remained. During the rehabilitation treatment at the Vocational Rehabilitation Centre URI-Soča, we assessed that he would permanently be incapable of doing his previous work (work was at height, physically difficult, outdoors in all weather conditions). At the beginning we started extended rehabilitation programmes in our institution. We also contacted his employer, his authorized specialist for occupational, traffic and sports medicine and together we searched for his new work place in their company. Together we decided that working in a warehouse would be the most appropriate for him. Rehabilitation continued with the training on the workplace. There he had a mentor and was accompanied by an expertl worker from our institution with all psychosocial support he needed. At the beginning he worked short-time, 4 hours per day, and after a few months we increased his daily workload to 8 hours. The extended rehabilitation lasted for 1 year. At the end he was qualified for working in a warehouse. Because of health problems he still needs some adjustments (instructions should be given by eye contact, occasionally he needs instructions to be re-explained, it is difficult for him to make phone calls). Attending the extended rehabilitation programmes makes it easier for persons with health problems to return to their work safely. It is also very important to have good cooperation with the employer, security engineer, human resources and authorized specialists for occupational, traffic and sports medicine. Background: At the Vocational Rehabilitation Centre URI-Soča, based on preliminary triage, the patient was first included into the initial assessment diagnostic programme, lasting 2 years. The team consists of a physician, specialist in occupational medicine, traffic and sports, psychologist, social worker, occupational therapist and technologist. The patient was 47 years old, electrotechnician by profession, with 24 years of service. He had been employed with Elektro Maribor d.d. company since 1998, as installer II. The job included maintenance of networks and power lines, power supply connections in houses, work at transmission substations, including standby duty and transportation for business purposes. Due to his condition he was on sick leave for 10 months. 123

124 Poster sekcija Poster Section In October 2015 he was hospitalized due to combined hearing loss in left ear, incus and stapes with perforation and retraction in the rear quadrant area; ossiculoplasty with a total Goldenberg prosthesis and tympanoplasty with cartilage and perihondrium via transcanal approach were performed. Health problems started in 2016, with a drop in hearing capacity, vertigo, headaches. He was diagnosed with an acoustic neuroma (left side), 3.2x2.8cm in size, reaching in the internal acoustic duct and left pontocerebellar angle. He was treated with local high precision radiotherapy (54 Gy) in 30 fractions during 6 weeks. Bilateral combined hearing loss, more severe in left side, and balance disorders have persisted. He has had regular control examinations with oncologist, a partial regression of acoustic neuroma (left-side) could be established at the recent examination. His health condition is good. He is not capable of performing his work as installer II. Based on the findings, extended rehabilitation was proposed, in the initial stage at our institution, twice a month or more, if necessary. Later on activities were extended to gradual returning to work with the employer. The entire extended rehabilitation lasted 1 year. In the first 4 months he was included in one-to-one treatment in our institution, primarily regarding the support in work reintegration and safe return to work. During this time contacts have been established with the employer, who was willing to cooperate in the process of extended rehabilitation and safe return to work. Due to the fact that the patient is incapable of his work on a permanent basis, his employer was ready to offer him an adapted post and train him on the job. We also contacted the authorized specialist in occupational medicine, traffic and sports, who agreed with the adaptation of the workplace. By way of gradual returning to the adapted post, in accordance with the limitations (storekeeper), he started working short-time, 4 hours a day. He gradually engaged in the working process. He was properly motivated and had positive attitude toward work. When performing his work, he proved to be very precise, responsible and persistent. He himself constantly checked on his work he had performed, noticed the mistakes and corrected them. At first some fatigue could be observed with subsequent decreased concentration. He gradually made progress and started to engage in more demanding jobs. When faced with more extensive work, he was able to set priorities. A little more support was required in situations where several instructions were given simultaneously and it was demanded that the tasks be carried out faster. It turned out that, due to hearing problems, instructions sometimes had to be repeated. Another problem might be communication on phone, especially when there is much noise. Activities were increased during the following 2 months, resulting in work 6 hours a day and later full-time. At the end of rehabilitation, stable working functioning could be established in the workplace in which extended rehabilitation took place. We consider he is able to perform work within the health restrictions. He is capable of performing light physical work, with handling of loads up to 10 kg, seldom 15 kg, not in heavy noise, at height, on the ladder, driving freight vehicles or heavy machines for business purposes, and at night. Assessment by the Board of Examiners was put forward. 124

125 Poster sekcija Poster Section Prva zaposlitev rehabilitandke z nevrološkim obolenjem, prikaz primera dobre prakse Avtor: Korošec Tanja, Centar za poklicno rehabilitacijo, Univerzitetni rehabilitacijski Inštitut Republike Slovenije Soča Ljubljana, Slovenija Ključne besede: zakonodaja ZPIZ, proces poklicne rehabilitacije Izhodišče: Prispevek je namenjen sistematični predstavitvi procesa zaposlitvene rehabilitacije in povezave z zakonodajo ZPIZ skozi konkreten primer. Metode: Sistematičen pregled in analiza celotnega spisa obravnave in predstavitev ključnih faz procesa zaposlovanja rehabilitandke z nevrološkim obolenjem (Tourettov sindrom), skozi proces zaposlitvene rehabilitacije. Rezultati: Prikazana je pot zaposlovanja mlade ženske od zaključka šolanja do zaposlitve in ob tem vloge posameznih institucij in strokovnih delavcev. Primer je zanimiv, ker vključuje tudi postopek na Invalidski komisiji ZPIZ. Pomembno je, da se mlade ljudi z nevrološkimi obolenji, po zaključku šolanja, čim hitreje usmerja na trg dela. Z ustrezno podporo, pomočjo in vodenjem je pot zaposlovanja za te osebe lažja in prinaša ugodne možnosti in rešitve tudi po zaposlitvi. Poudarjena je vloga strokovnega tima URI Soča in delodajalca ter pomembne intervencije za ohranitev zaposlitve konkretne osebe. Zaključki: Zaposlitvena rehabilitacija je za osebe z nevrološkimi obolenji ob prvi zaposlitvi nujno potrebna in prinaša razbremenitev tako za delodajalca kot tudi osebo samo. Pomembne so možnosti navezovanja na zakonodajo ZPIZ. 125

126 Poster sekcija Poster Section First Job of a Female Rehabilitant with a Neurological Condition, an Example of Good Practice Author: Korošec Tanja, Vocational Rehabilitation Centre, University Rehabilitation Institute Republic of Slovenia SOČA, Ljubljana, Slovenia Key words: Pension and Disability Insurance Act, vocational rehabilitation process Background: The aim of this article is to give a systematic presentation of the vocational rehabilitation process, in relation to pension and disability insurance legislation, using a concrete case example. Methods: A systematic study and analysis of the whole case-file regarding the treatment and the presentation of the key phases in the process of finding a job for the rehabilitant with a neurological condition (Tourette syndrome) through a vocational rehabilitation process. Results: The process of finding a job for a young female is presented, from the completion of her studies until finding a job, and the role of individual institutions and experts involved. The case description also includes the procedures led by the ZPIZ Board of Examiners. It is of great importance that young patients with neurological disorders be offered professional guidance regarding the integration into the labor market as soon as they finish school. Appropriate support, assistance and guidance make finding a job for these persons easier, offering favourable options and solutions also once they get employed. Emphasis is laid on the role of the URI-SOČA expert team and the employer, as well as essential interventions towards keeping their jobs. Conclusion: Vocational rehabilitation for persons with neurological conditions in finding their first job is quite a necessity, thus making it easier for the employer and the patient as well. The possibilities of the application of pension and disability regulations should be underlined as well. 126

127 Poster sekcija Poster Section Primer podporne zaposlitve pri uporabnici po transplantaciji jeter Avtor: Ana Kapel, dipl. delovna terapevtka, univ. dipl. sociologinja, Centerkontura d.o.o.; Romana Božič, univ.dipl. socialna delavka, Centerkontura d.o.o. Ključne besede: zaposlitvena rehabilitacija, prilagoditev delovnega mesta, na uporabnika usmerjen pristop, timsko delo, sodelovanje. Poklicno sodelovanje: Proces zaposlitvene rehabilitacije je izvajal strokovni tim pri koncesionarju Centerkontura d.o.o., v sodelovanju z Zavodom za zaposlovanje Republike Slovenije (ZRSZ). V proces so bil vključeni še delodajalec, Javni štipendijski, razvojni, invalidski in preživninski sklad Republike Slovenije in Zavod za pokojninsko in invalidsko zavarovanje. Ozadje: V prispevku je predstavljen primer podporne zaposlitve in prilagoditve delovnega mesta za uporabnico po transplantaciji jeter. Metode: Strokovni tim zaposlitvene rehabilitacije je v procesu rehabilitacije uporabil bio-psiho-socialni model in na uporabnika usmerjen pristop. V ocenjevalni fazi smo zbrali podatke o izobrazbi, delovnih izkušnjah, zaposlitvenih ciljih, delovnih navadah, življenjskih vlogah, delazmožnosti, delovnem funkcioniranju, kognitivnih zmožnostih in osebnostnih lastnostih uporabnice. Uporabnica je imela stalne bolečine pod desnim rebernim lokom, oslabljen imunski sistem in pogosto je bila utrujena. Imela je dokončano visokošolsko izobrazbo in dve leti delovnih izkušenj na področju vrtnarstva in slaščičarstva. Zaposlitvenih ciljev ni imela jasno oblikovanih. Želela si je delo, ki bi bilo skladno z njenimi zdravstvenimi omejitvami, dopoldan, ne preveč enolično delo in blizu doma. Rezultati: Skupaj z ZRSZ smo našli delodajalca, ki je bil pripravljen usposabljati uporabnico na področju administracije. V individualnem rehabilitacijskem načrtu smo se usmerili na naslednje cilje: ugotavljanje zaposlitvenega ujemanja (analiza delovnega mesta), postopno povečanje vzdržljivosti, edukacija delodajalca o ravnanju z invalidnostjo na delovnem mestu in učenje strategij za zmanjšanje bolečinske simptomatike. Delodajalec je po 4 mesecih usposabljanja uporabnico zaposlil. Skupaj smo oblikovali individualni načrt podpore in načrt prilagoditve delovnega mesta (ergonomski delavni stol, ki omogoča dinamično sedenje in spreminjanje kota v kolku). Zaključki / ugotovitve: Glede na kompleksnost procesa zaposlitvene rehabilitacije in velikega števila deležnikov je bistveno, da se vsi deležniki zavedajo svojih vlog, odgovornosti in možnosti. Za uspešno sodelovanje je bistveno, da deležniki razumejo skupen cilj in sicer zagotavljati invalidom enakopravno vključevanje na trg dela ob ustrezni podpori in prilagoditvah. 127

128 Poster sekcija Poster Section An Example of Supported Employment for a Patient after Liver Transplantation Author: Ana Kapel, University graduate. soc, Centerkontura d.o.o.; Romana Božič, University graduate. soc, Centerkontura d.o.o.; Key words: occupationonal rehabilitation, workplace adjustments, user-oriented approach, team work, cooperation Professional cooperation: The process of occupational rehabilitation was carried out by an expert team at Centerkontura d.o.o., concession holder, in cooperation with the Employment Service of Slovenia. The process also included the employer, the Public Scholarship, Development, Disability and Maintenance Fund of the Republic of Slovenia and the Pension and Disability Insurance Institute of the Republic of Slovenia. Background: The article presents an example of supported employment and workplace adaptations for a patient after liver transplantation. Methods: A psychosocial model and user-oriented approach was used in the process of occupational rehabilitation by an expert occupational rehabilitation team. During the assessment period, information regarding qualifications, work experience, employment objective, work habits, life roles, work capacity, work functioning, cognitive abilities, character traits of the patient was collected. The patient reported persistent pain under the right rib arc, poor immune system and fatigue. She had higher education qualifications and 2 years of work experience in horticulture and confectionery. Her employment objectives were not clearly shaped. Her wish was to perform work which would meet the requirements regarding her health limitations, it should be performed during the day shift, not be monotonous and in the vicinity of her home. Results: With the help of Employment Service of Slovenia we found an employer who was willing to train the patient for administrative work. The goals of the individual rehabilitation plan were: employment adequacy (workplace analysis), gradual increasing of resilience at work, education of the employer how to treat a disabled person at workplace and tutoring in strategies for pain management. After a 4-month education period, the client was employed by the employer. Together with the employer an individual plan for support and workplace adaptations (ergonomic chair, enabling dynamic sitting and changing of hip angle) was elaborated. Conclusion: Due to the fact that occupational rehabilitation process is complex, including many participants, it is very important that all who take part in the process be well aware of their role, responsibilities and possibilities. The idea of a common goal shared by all participants is crucial for successful cooperation, which is to enable disabled persons to be integrated into the labor market on equal terms, including adequate support and required adaptations. 128

129 Poster sekcija Poster Section Predstavitev projekta S4H Signs for handshakes Avtor: Simona Korez,. spec. managementa, Racio d.o.o.; mag. Karmen Vodenik, univ. dipl. sociolog, Racio d.o.o. Ključne besede: gluhi, zaposlitvena rehabilitacija, zaposlovanje, delodajalci, komunikacijska orodja Ozadje: Racio d. o. o. je od leta 2006 koncesionar Ministrstva za delo, družino, socialne zadeve in enake možnosti na področju zaposlitvene rehabilitacije in zaposlovanja invalidov. Storitve zaposlitvene rehabilitacije izvajamo za osebe z različnimi invalidnostmi na področju Območne službe Celje Zavoda Republike Slovenije za zaposlovanje. Za gluhe in naglušne osebe pa na področju celotne Slovenije. V preteklih letih smo bili partner v pomembnih projektih, s katerimi smo gluhim in naglušnimi ter drugim invalidom pomagali do kvalitetnejšega življenja in dela ter ustreznejšega prehoda na trg dela. Zelo prepoznaven je projekt SIGNS FOR HANDSHAKES S4H, ki je bil sofinanciran s strani Erasmus + in je trajal od oktobra 2015 do decembra Izvajali smo ga v partnerstvu z vodilnim partnerjem, podjetjem Equalizent iz Avstrije ter s partnerjema Assist Net iz Bolgarije in Kindersite iz Združenega Kraljestva. Metode: V projektu smo uporabljali metodo akcijskega raziskovanja. V celotnem obdobju smo vključevali mlade gluhe in naglušne, ki so odgovorno in z velikim zanosom prevzemali vlogo pri soustvarjanju prispevkov in razvoju komunikacijskih orodij. Skozi usposabljanje so pridobivali dodatna znanja in kompetence za boljšo zaposljivost na področju multimedijske tehnologije. Delovali smo po načelu»nič o gluhih brez gluhih«. Rezultati: V projektu so nastali številni produkti oziroma komunikacijska orodja za delo z gluhimi. Za delodajalce so to odlični pripomočki pri vsakodnevni komunikaciji z gluhimi, pa tudi za učenje znakovnega jezika. Za dvigovanje ozaveščenosti in premagovanje komunikacijskih ovir smo izvedli delavnice za delodajalce kot dodatno podporo razvoju»gluhim prijaznih delovnih mest«ter še bolj trdno povezali sodelovanje delodajalcev in gluhih. Zaključki/Spoznanja: Rezultate praktičnega raziskovanja permanentno uporabljamo pri delu z gluhimi in naglušnimi v procesu zaposlitvene rehabilitacije in zaposlovanja. 129

130 Poster sekcija Poster Section S4H Project Presentation Signs for Handshakes Author: Simona Korez, spec. managementa, Racio d.o.o., Slovenija MsC. Karmen Vodenik, University graduate. soc, Racio d.o.o. Key words: the deaf, occupational rehabilitation, employment, employers, communication tools Background: Racio d.o.o., has been holding a concession granted by the Ministry of Labour, Family, Social Affairs and Equal Opportunities in the field of occupational rehabilitation and employment of disabled workers since We have been carrying out occupational rehabilitation services for persons with various disabilities in the territory of the Regional Office of the Employment Service of Slovenia and for the deaf and hard of hearing persons for the entire Slovenian territory. In recent years we have been partners in relevant projects, thereby helping the deaf and hard of hearing persons as well as other disabled persons to improve their life quality and obtain work as well as facilitate their transition to the labour market. A project SIGNS FOR HANDSHAKES S4H is a notable project, co-funded by Erasmus+, which lasted from October 2015 to December It was carried out in partnership with a chief partner, Equalizent from Austria, and Assist Net from Bulgaria and Kindersite from the UK. The aim of the project was to describe to employers the possibilities to employ young deaf persons, enhance communication between employers, deaf employees and their colleagues at work with no hearing impairment, thus raising awareness of the culture and sign language of the deaf in the work environment. Methods: The method used in the project was the action research method. During the entire period, young deaf and hard of hearing persons were taking part in the project. They took on their part in contributing to the products and development of communication tools with a high sense of responsibility and great enthusiasm. Through training they acquired additional knowledge and skills for better possibilities in obtaining a job in the field of multimedia technology. The moto we followed was Nothing about the deaf without the deaf. Results: The result of the project was numerous products, i.e. communication tools for work with the deaf. They represent valuable help for employers in their everyday communication with the deaf, as well as learning sign language. In order to raise awareness and overcome communication barriers, we organised workshops for employers as an additional support in the development of deaf-friendly workplaces, and enhanced the cooperation between employers and deaf persons. Conclusion: The results of practical research have continuously been applied in practical work with the deaf and hard of hearing in occupational rehabilitation and employment processes. 130

131 Poster sekcija Poster Section Multipla skleroza in delazmožnost, analiza ocenjevanja v Federaciji Bosne in Hercegovine v obdobju od 2013 do 2018 Avtor: Fehma Kovač, dr. med.; Ivo Šandrk, dr. med.; Goran Grabovac, dr. med.; Marica Arambasic, dr. med.; Miroslav Šišić, dr. med.; Ivanka Alomerović, dr. med.; Dzavid Habibović, dr. med. Inštitut za medicinsko izvedenstvo BIH, BIH Ozadje: Multipla skleroza (MS) je najpogostejša demielinizacijska bolezen. Bolezen najpogosteje nastane med 18 in 50 letom starosti. Glede na starost, pri kateri nastane, vpliva tudi na delovno zmožnost. Cilj: Osnovni namen študije je bila analiza razmerja med MS in delovno zmožnostjo. Prav tako smo želeli izračunati gibanja pri pacientih z multiplo sklerozo v naslednjih 5 letih. Metode: Študija je bila opisna in presečna v obdobju med in Študija je vključevala paciente obeh spolov z MS starimi med 18 in 65 let, ki so zaprosili za invalidnino. Uporabljeni podatki izvirajo iz Inštituta za medicinsko presojo zdravstvenega stanja v Federaciji Bosne in Hercegovine Vsi pacienti z diagnozo MS so bili opazovani glede na določeno stopnjo invalidnosti. Gibanje je bilo izračunano s pomočjo regresijske analize. Rezultati: V opazovanem obdobju je bilo ocenjenih 389 oseb, med njimi 118 moških in 271 žensk. 6-letna kumulativna stopnja je znašala 52,4 % (n=204) tistih upokojenih zaradi MS in je bila nekoliko višja pri ženskah kot pri moških, trend se zmanjšuje. Izjava o drugi stopnji invalidnosti se zmerno povečuje. Trend je linearen. Ocenjuje se, da se bo število prosilcev ocene delazmožnosti v naslednjih 5 letih zvišalo za 20 %. Zaključek: Dodatne raziskave so potrebne za določitev, kateri dejavniki so tisti, ki ljudem z MS preprečujejo opravljanje dela, kot tudi kateri dejavniki so tisti, ki bi ljudem omogočali ohranitev zaposlitve. 131

132 Poster sekcija Poster Section Multiple sclerosis and work capability, analysis of assessments in the Federation of Bosnia and Herzegovina in the period Author: Fehma Kovač, MD; Ivo Šandrk, MD; Goran Grabovac, MD; Marica Arambasic,MD; Miroslav Šišić, MD; Ivanka Alomerović, MD; Dzavid Habibović, MD, Institute for medical expertise of health condition Federation of Bosnia and Herzegovina, BIH Background: Multiple sclerosis (MS) is the most frequently seen demyelinating disease. The illness occurs most often between 18 and 50 years. Considering the age in which it occurs, it affects the working capability. Objective: The primary purpose of the present study was to analyze the relationships between MS and work capability. Also, we wanted to calculate trends in patients with multiple sclerosis in the next 5 years. Methods: This study was descriptive cross-sectional, in the period between The study included patients with MS, age 18 65, of both gender, applied for a work disability benefit. Data of the Institute for medical expertise of health condition Federation of Bosnia and Herzegovina were used. All patients with diagnose of MS, were observed according to the determined disability level.the trend was calculated using Joinpoint Regression Analysis. Results: In the observed period, 389 persons were assessed for work capability, 118 men and 271 women. The 6-year cumulative incidence was 52,4% (n = 204) for disability retirement from MS, and was somewhat higher in women than in men, and trend is decreasing. Declaration of second degree of disability moderately increasing. Sumary, the trend is linear, and the projected increase in the number of people who report to the assessment of working capacity by 20% the next 5 years. Conclusion: Additional research should be conducted to determine what factors are preventing people with MS from working, and factors that would enable people to stay in employment. 132

133 Poster sekcija Poster Section 133

134 KAZALO Table of Contents ORGANIZATORJI 4 Organizers ČASTNA POKROVITELJA 4 Honorary sponsors PREDGOVOR 5 Foreword 6 Plenarna sekcija Četrtek, Plenary Session Thursday 11 th Razvoj in primerjava ocene delazmožosti v Evropi in nekaj več 8 Development and Comparison of Workability Assessment in Europe and some more 9 Avtor: Gert Lindenger, dr. med., Predsednik Švedske zbornice zdravnikov v zavarovalniški medicini in podpredsednik Evropskega združenja zdravnikov v zavarovalniški in socialni medicine, Švedska Zaposlitvena rehabilitacija v Sloveniji 10 Employment Rehabilitation in Slovenia 11 Avtor: Lea Kovač, prof. defektologije, svetovalka generalne direktorice Zavoda Republike Slovenije za zaposlovanje; Karl Destovnik, predsednik skupščine Združenja izvajalcev zaposlitvene rehabilitacije v Republiki Sloveniji Novi izzivi medicinskega izvedenstva in zavarovalniške medicine v Sloveniji 12 New Challenges in Medical Assessment and Insurance Medicine in Slovenia 13 Avtor: prof. Mag. Jana Mrak, vodja Oddelka za nadzor, Zavod za zdravstvno zavarovanje Slovenije; Dr. Ticijana Prijon, dr. med., višji specialist, Nacionalni inštitut z a javno zdravje (NIJZ), Slovenija Verifikacija usposobljenosti izvedencev za izvedensko delo v Republiki Sloveniji 14 Qualification Verification of Medical Assessors for Medical Assessment in the Republic of Slovenia 15 Avtor: Dr. Zdenka Čebašek-Travnik, dr. med., spec. psihiatrije, Zdravniška zbornica Slovenije Multidisciplinarno sodelovanje pri ocenjevanju na področju zavarovalniške medicinekomparativna študija nadomeščanja nalog v Evropi 16 Multidisciplinary participation in social insurance assessments.a comparative study on task substitution in Europe 17 Avtor: Dr. Brage Søren, dr. med., Predsednik delovne grupe ICF EUMASS, Član Strokovnega odbora EUMASS, Norveška; de Wind A, Latil F, Williams N. Finski sistem ocene začasne in trajne nezmožnosti za delo 18 The Finnish System for assessing Temporary and Permanent Inability to Work 19 Avtor: Krisi Vainiemi,dr. med., zdravnica svetovalka pri finskem inštitutu za poklicno zdravje in splošno medicino, Finska 134

135 Plenarna sekcija Petek, Plenary Session Friday 12 th Epilepsija: klasifikacija, zdravljenje in zmožnost za delo 21 Epilepsy: classification, treatment and ability to work 22 Avtor: Izrd. Prof. Dr. Dušan Butinar, dr. med.; Univerzitetni klinični center Ljubljana, Slovenija Multipla skleroza in pridobitno delo 23 Multiple Sclerosis and Gainful Employment 24 Avtor: Izrd. Prof. Dr. Uroš Rot, dr. med.; Klinični oddelek za bolezni živčevja, Nevrološka klinika, UKC Ljubljana in Medicinska fakulteta, Univerza v Ljubljani, Slovenija Možganska kap nekoč in danes 25 Brain Stroke in the Past and Today 26 Avtor: Igor Rigler, dr. med., Nevrološka klinika, Univerzitetni klinični center Ljubljana, Slovenija Poklicna rehabilitacija hitro vračanje zaposlenih na delo, mesto in vloga medicine dela 27 Vocational Rehabilitation Rapid Return to Work, Occupational Medicine s Place and Role 28 Avtor: Prim. Bojan Pelhan, dr. med., Univerzitetnim rehabilitacijskim inštitutom RS-Soča Ljubljana, Slovenija Analiza epidemiologije možganske kapi in njenih posledic pri osebah mlajših od 45 let v Sloveniji 29 Analysis of Epidemiology of Brain Stroke and its Consequences for Slovenia s Under 45s 30 Avtor: Dr. Ticijana Prijon, dr. med., višji specialist, Nacionalni inštitut z a javno zdravje (NIJZ), Slovenija Zdravljenje in vodenje bolnikov v protibolečinski ambulanti, možnosti in pričakovanja 31 Patient Treatment and Management at a Pain Clinic, Possibilities and Expectations 32 Avtor: Gorazd Požlep, dr.med, UKC Ljubljana Pomagati ljudem s kronično ne-rakavo bolečino kaj učinkuje, kaj ne in odprta vprašanja 33 Helping People with Chronic Non-Cancerous Pain: What Works, What Doesn t, Open Issues 34 Avtor: Helena Jamnik, dr. med. URI Soča, Linhartova 51, 1000 Ljubljana, Slovenija Kronična bolečina pri bolnikih z rakom 35 Chronic Pain in Cancer Patients 36 Avtor: Prim. mag. Slavica Lahajnar Čavlovič, dr. med. Onkološki inštitut Ljubljana Psihiatrično vodenje bolnikov s kronično bolečinsko simptomatiko in ocena trajne nezmožnosti za delo Trajna somatoformna bolečinska motnja 37 The Psychiatric Management of Patients with Chronic Pain Symptomatology and Assessment of Permanent Inability to Work: Permanent Somatoform Pain Disorder 38 Avtor: Prof. Dr. Peter Pregelj, dr. med., spec. psih., Univerza v Ljubljani, Medicinska fakulteta; Univerzitetna psihiatrična klinika Ljubljana 135

136 Plenarna sekcija Sobota, Plenary Session Saturday 13 th Zakaj mora biti načrt vračanja na delo sestavni del uspešne rehabilitacije bolnika z rakom? 40 Why should Return to Work Plan be a Part of Successful Rehabilitation of the Patient with Cancer 41 Avtor: Mag. Olivera Masten Cuznar, dr.med., spec.spl.med., vodja oddelka nadzornih zdravnikov OE Ljubljana, Zavod za zdravstveno zavarovanje Slovenije, Poklicni rak 42 Occupational cancer 43 Avtor: Izr. Prof. Dr. Alenka Franko, dr. med.; Klinični inštitut za medicino dela, prometa in športa, Univerzitetni klinični center Ljubljana, Emilija Pirc Ćurić, dr. med., Zavod za pokojninsko in invalidsko zavarovanje Slovenije Izzivi in problemi onkološke rehabilitacije 44 Challenges and Problems of Oncological Rehabilitation 45 Avtor: Prim. Izr. Prof. Dr. Breda Jesenšek Papež, dr. med., Predstojnica Inštituta za FRM UKC Maribor, Slovenija Onkološko zdravljenje in rehabilitacija bolnic z rakom dojke in potrebne razbremenitve pri delu 46 Oncological Treatment and Rehabilitation of Patients with Breast Cancer and the Required Unburdening at Work 47 Avtor: Prof. Dr.Nikola Bešić, dr. med., Vodja oddelka za kirurgijo naonkološkem inštitutu,univerzitetni klinični center Ljubljana, Slovenija Ginekološka onkologija in vračanje na delo 48 Gynecologic Oncology and Return to Work 49 Avtor: Izred. Prof. Dr. Erik Škof, dr. med., Onkološki Inštitut, Univerzitetni klinični center Ljubljana, Slovenija Psihoonkologija v izvedenstvu 50 Psycho-Oncology in Medical Assessment 51 Avtor: Dr. Zvezdana Snoj, dr. med., specialistka psihiatrije, Zavod za pokojninsko in invalidsko zavarovanje Slovenije Paralelna sekcija I. Četrtek, Parallel Session I. Thursday 11 th Utesnitvene in kompresijske nevropatije 53 Compression and Entrapment Neuropathies 54 Avtor: Prof. Dr. Simon Podnar, dr. med., Nevrološka klinika, Univerzitetni klinični center Ljubljana, Slovenija Rehabilitacijska obravnava bolnikov z utesnitvenimi nevropatijami 55 Rehabilitation of patients with entrapment neuropathies 56 Avtor: Prim. Asist. Mag. Lidija Plaskan, dr. med., Oddelek za medicinsko rehabilitacijo, Splošna bolnišnica Celje, Slovenija 136

137 Piriformis sindrom in ocena delazmožnosti 57 Piriformis Syndrome and Work Capability Assessment 58 Avtor: Doc. Dr. Dušan Čelan dr. med., spec. fizikalne medicine in rehabilitacije. Ustanova Oddelek/referat: Univerzitetni klinični center Maribor Kronična bolečina 59 Chronic Pain 60 Avtor: Dr. Aljoša Danieli, dr. med. Barsos MC Ljubljana Poklicnea etiologija in vračanje na delo pri utesnitvenih sindromih roke 61 Proffessional etiology and return to work process for persons with upper extremity disorders 62 Avtor: Metka Teržan, dr. med., Centar za poklicno rehabilitacijo, Univerzitetni rehabilitacijski Inštitut Republike Slovenije Soča Ljubljana, Slovenija Paralelna sekcija II. Četrtek, Parallel Session II. Thursday 11 th Vrtoglavica in druge motnje ravnotežja v izvedenski praksi 64 Vertigo and other balance impairments in the medical assessment 65 Avtor: Mag. Branka Geczy Buljovčić, dr. med, specialistka otorinolaringologije Sektor za izvedenstvo ZPIZ Slovenije Motnje spanja in delazmožnost 66 Sleep Disorders and Work Capability 67 Avtor: Izr.Prof.Dr. Leja Dolenc Grošelj dr.med. Klinični inštitut za klinično nevrofiziologijo, Nevrološka klinika, UKC Ljubljana Motnje spanja in vožnja motornih vozil 68 Sleep Disorders and Driving of Motor Vehicles 69 Avtor: Vesna Pekarović Džakulin, dr. med., spec. družinske medicine in medicine dela, prometa in športa, Diagnostični center Šentjur, Slovenija Glavobol onesposablja 70 Headache Immobilises 72 Avtor: Prof. Dr. Bojana Žvan, dr. med., višja svetnica, nevrologinja; Dr. Matija Zupan, dr. med., nevrolog, Univerzitetni klinični center Ljubljana, Nevrološka klinika, Ljubljana Paralelna sekcija I. Petek, Parallel Session I. Friday 12 th Vloga delodajalca pri ocenjevanju invalidnosti v Republiki Sloveniji 75 Vocational Rehabilitation and the Role of the Employer in the Invalidity Assessment Process 76 Avtor: Boris Kramžar, dr.med., Zavod za pokojninsko in invalidsko zavarovanje Slovenije Vključevanje delodajalcev vpripravljalni postopek priznajnja pravice do poklicne rehabilitacije 77 Motivational Operation of ZPIZ in Terms of the Inclusion of Insured Persons and Employers in Vocational Rehabilitation

138 Avtor: Peter Šalej, Zavod za pokojninsko in invalidsko zavarovanje Slovenije, Območna enota Celje, Slovenija Izkušnje izvajalca zaposlitvene rehabilitacije s poklicno rehabilitacijo 79 Occupational Rehabilitation Provider Experience in Terms of Vocational Rehabilitation 80 Avtor: Brstin Kavalar, univ. dipl. pedagog, CRI Celje, d.o.o. Delo z delovnimi invalidi Unior d.d. 81 Working with Disabled Workers at Unior d.d. 82 Avtor: Vili Močenik, dipl. org., inž. str. Zreče, Slovenija Pomen psihosocialne obravnave v okviru poklicne rehabilitacije 83 The Significance of Psycho-Social Treatment in the Framework of Vocational Rehabilitation 84 Avtor: Barbara Zupančič, univ.dipl.psih.; Ksenija Bratuš Albreht, univ.dipl.soc.del. Šentprima - Zavod za rehabilitacijo in izobraževanje Od zdravstveno zaposlitvenega svetovanja do zaposlitve 85 From Medical Vocational Counselling to Employment 86 Avtor: Ksenija Šterman, dr. med., spec. medicine dela, prometa in športa, Univerzitetni rehabilitacijski inštitut RS-Soča, Ljubljana, Slovenija, Zavod za zaposlovanje RS, OE Murska Sobota, Slovenija Delo z delodajalci pri zaposlitveni rehabilitaciji oseb z invalidnostjo 87 Working with Employers in the Vocational Rehabilitation of People with Disability 88 Avtor: Mag. Stojan Zagorc, Zavod Papilot, Slovenija Krepitev notranje moči uporabnikov storitev zaposlitvene rehabilitacije 89 Empowerment and Quality of Life of Users of Vocational Rehabilitation Services 90 Avtor: Črtomir Bitenc, Univerzitetni rehabilitacijski inštitut Soča,Ljubljana, Slovenija; Valentina Brecelj, Andreja Švajger, Bojana Fulder, Brigita Šinigoj Izhodi iz zaposlitvene rehabilitacije vključevanje v programe socialne vključenosti v Sloveniji 91 Outcomes in Vocational Rehabilitation Social Inclusion Programmes in Slovenia 92 Avtor: Dr. Aleksandra Tabaj, Univerzitetni rehabilitacijski inštitut Republike Slovenije Uporaba Mednarodne klasifikacije funkcioniranja, invalidnosti in zdravja v postopkih ocenjevanja invalidnosti spoudarkom na nevroloških in onkoloških bolezenskih stanjih 93 Using the International Classification of Functioning, Reduced Capability and Health at the Employment Service of Slovenia 95 Avtor: Lea Kovač, Prof. defektolog, svetovalka generalne direktorice Zavoda Republike Slovenije za zaposlovanje; Sonja Kotnik, uni.dipl. sociolog, svetovalka generalne direktorice Zavoda Republike Slovenije za zaposlovanje; Suzana Butolen, uni.dipl. soc. del., rehabilitacijska svetovalka na Zavodu Republike Slovenije za zaposlovanje 138

139 Paralelna sekcija II. Petek, Parallel Session II. Friday 12 th Delazmožnost in vrnitev na delo bolnikov z rakom: rak debelega črevesa, želodca in slinavke 98 Work ability and return-to-work in cancer patients: CRC, gastric and pancreatic cancer 99 Avtor: Dr. Tadeja Pintar, dr. med., Univerzitetni klinični center Ljubljana, Oddelek za abdominalno kirurgijo, Medicinska fakulteta Ljubljana Karcinom dojk vpliv dopolnilnega zdravljenja na delazmožnost 100 Gynaecologic Oncology and the Return to Work 101 Avtor: Doc. Dr. Erika Matos, dr. med., Onkološki Inštitut, Univerzitetni klinični center Ljubljana, Slovenija Novotvorbe gibal in delazmožnost 102 Tumours in Extremities and Work Ability 103 Avtor: Doc. Dr.Tomaž Tomažič, dr. med., specialist ortoped, ZPIZ IK Maribor Delazmožnost pri obolelih za rakom 104 Work ability in cancer patients 105 Avtor: Vlasta Zajic Stojanović, dr. med., Hrvatski zavod za zdravstveno osiguranje Zagreb, R. Hrvaška; Nada Turčić, dr. med., Hrvatski zavod za zdravstveno osiguranje Zagreb, R. Hrvaška Medicinska rehabilitacija bolnikov po možganski kapi 106 Medical Rehabilitation of Patients After Brain Stroke 107 Avtor: Doc. Dr. Nika Goljar, dr.med., spec. fizikalne in rehab. med. Univerzitetni rehabilitacijski inštitut Republike Slovenije Soča, Ljubljana, Slovenija Vrnitev na delo oseb po možganski kapi 108 Return to Work after Brain Stroke 109 Avtor: Metka Teržan, dr. med., Centar za poklicno rehabilitacijo, Univerzitetni rehabilitacijski Inštitut Republike Slovenije Soča Ljubljana, Slovenija Pomoč nevropsihologa pri vračanju na delovno mesto po možganski kapi: ko zgolj ugoden motorični izid po bolezni ne zadostuje 110 Aid of Neuropsychologist in Return to Work after Brain Stroke when Favourable Motor Results of the Disease are Insufficient 111 Avtor: Dr. Barbara Starovasnik Žagavec, univ.dipl.psih., specialistka klinične psihologije, Univerzitetni rehabilitacijski inštitut Republike Slovenije Soča, Oddelek za rehabilitacijo pacientov po možganski kapi Vožnja po možganski kapi 112 Driving after Stroke 113 Avtor: Marko Sremec, dr. med;mag. Franjo Velikanje, dr. med;doc. dr. Metka Moharić, dr. med., Univerzitetni rehabilitacijski Inštitut Republike Slovenije Soča, Subspecialistična ambulanta za voznike s posebnimi potrebami, 139

140 Paralelna sekcija II. Petek, Parallel Session II. Friday 12 th Poklicna rehabilitacija s praktičnim delom na ustreznem delovnem mestu v kombinaciji s kratkotrajnim izobraževanjem 115 Vocational Rehabilitation with Practical Work at an Appropriate Workplace in Combination with Short-Term Education 116 Avtor: Darja Jamnik, psiholog, uni.dipl. psiholog, Želva, podjetje za usposabljanje in zaposlovanje d.o.o. Primer dobre prakse postopno vračanje na delovno mesto po daljši bolniški odsotnosti (podaljšanja poklicna rehabilitacija). 117 An example of good practice Gradual Return to Work after a Long Absence (extended professional rehabilitation). 118 Avtor: Aleksandra Denša, univ. dipl. socialna delavka, Univerzitetni rehabilitacijski inštitut Republike Slovenije Soča. Vloga zdravnika medicine dela pri vračanju na delo delavca z epilepsijo 119 The Role of a Medical Doctor in Returning Epilepsy Patients to their Work 120 Avtor: Dr. Tihomir Ratkajec, dr.med., specialist medicine dela, prometa in športa, Medicina dela Rogaška d. o.o.o., Rogaška Slatina Primer podaljšane rehabilitacije in postopka vračanja na delo pri pacientu s tumorjem 121 Extended rehabilitation and process of returning to work with patient with tumor (case study) 123 Avtor: Bojana Fulder, univ. dipl. psih., Lidija DORA, mag. soc. dela, Ksenija Šterman, spec. MDPŠ, Uri SOČA, Center za poklicno rehabilitacijo, enota Murska Sobota Prva zaposlitev rehabilitandke z nevrološkim obolenjem, prikaz primera dobre prakse 125 First Job of a Female Rehabilitant with a Neurological Condition, an Example of Good Practice 126 Avtor: Korošec Tanja, Centar za poklicno rehabilitacijo,univerzitetni rehabilitacijski Inštitut Republike Slovenije Soča Ljubljana, Slovenija Primer podporne zaposlitve pri uporabnici po transplantaciji jeter 127 An Example of Supported Employment for a Patient after Liver Transplantation 128 Avtor: Ana Kapel, dipl. delovna terapevtka, univ. dipl. sociologinja, Centerkontura d.o.o.; Romana Božič, univ.dipl. socialna delavka, Centerkontura d.o.o. Predstavitev projekta S4H Signs for handshakes 129 S4H Project Presentation Signs for Handshakes 130 Avtor: Simona Korez,. spec. managementa, Racio d.o.o.; mag. Karmen Vodenik, univ. dipl. sociolog, Racio d.o.o. Multipla skleroza in delazmožnost, analiza ocenjevanja v Federaciji Bosne in Hercegovine v obdobju od 2013 do Multiple sclerosis and work capability, analysis of assessments in the Federation of Bosnia and Herzegovina in the period Avtor: Fehma Kovač, dr. med.; Ivo Šandrk, dr. med.; Goran Grabovac, dr. med.; Marica Arambasic, dr. med.; Miroslav Šišić, dr. med.; Ivanka Alomerović, dr. med.;dzavid Habibović, dr. med. Inštitut za medicinsko izvedenstvo BIH, BIH 140

141 KAZALO 134 Table of contents ABECEDNO KAZALO AVTORJEV 142 Index of Authors SPONZORJI 143 Sponsors 141

142 ABECEDNO KAZALO AVTORJEV Index of Authors A Aleksandra Denša, Aleksandra Tabaj, Alenka Franko, Aljoša Danieli, Ana Kapel, B Barbara Starovasnik Žagavec, Barbara Zupančič, Bojan Pelhan, Bojana Fulder, Bojana Žvan, Boris Kramžar, Brage Søren, Branka Geczy Buljovčić, Breda Jesenšek Papež, Brstin Kavalar, Č Črtomir Bitenc, D Darja Jamnik, Dean Premik, 5-6 Dušan Butinar, Dušan Čelan, E Erik Škof, Erika Matos, F Fehma Kovač, G Gert Lindenger, 8-9 Gorazd Požlep, H Helena Jamnik, I Igor Rigler, J Jana Mrak, K Karl Destovnik, Kirsi Vainiemi, Ksenija Šterman, L Lea Kovač, Leja Dolenc Grošelj,66-67 Lidija Plaskan, M Marko Sremec, Metka Teržan, Metka Teržan, N Nika Goljar, Nikola Bešić, O Olivera Masten Cuznar, P Peter Pregelj, Peter Šalej, R PhD, Tihomir Ratkajec, S Simon Podnar, Simona Korez, Slavica Lajhnar Čavlovič, Stojan Zagorc, T Tadeja Pintar, Tanja Korošec, Ticijana Prijon, 12-13; Tomaž Tomažič, U Uroš Rot, V Vesna Pekarović Džakulin, Vili Močnik, Vlasta Zajic Stojanović, Z Zdenka Čebašek-Travnik, Zvezdana Snoj,

143 SPONZORJI Sponsors