Return to work after stroke. A follow-up study

Body representation in people with apraxia post Stroke- an observational study

Objective: To investigate how two types of body representation (body schema and body image) were affected in people with and without apraxia following a supratentorial stroke.Design: Observational cross-sectional studySetting: Level 1 Specialist Neurological Rehabilitation UnitParticipants: 30 participants post-stroke diagnosed with (n = 10) and without apraxia (n = 20) according to a modified version of the short Ideomotor Apraxia Test.Interventions: Not applicableMain Outcome Measures: Body schema assessed using the hand laterality recognition test and body part knowledge test; Implicit body image assessed using the sidedness test.Results: Left-sided lesions were more common in the apraxic group. Compared to people without apraxia post-stroke, those with apraxia showed significantly reduced accuracy and longer reaction times on the hand laterality test and fewer correct responses on the body part knowledge test. There was no between-groups difference in the sidedness test.Conclusions: People with apraxia showed deficits in online body representations (body schema) that are used to plan and execute actions. Future research studies could target body schema deficits as an adjunct in the rehabilitation of apraxia.

What characterises work and workplaces that retain their employees following acquired brain injury? Systematic review

OBJECTIVES

The objective of this study was to conduct a systematic review assessing workplace factors related to work retention (or return to work) in employees with acquired brain injury (ABI). Additionally, we aimed to synthesise the evidence and state of knowledge on this subject.

METHODS

A database search was performed in nine relevant electronic databases. Inclusion criteria were quantitative peer-reviewed publications empirically investigating the relationship between work/workplace factors and work retention in employees following ABI. The methodological quality was determined by Effective Public Health Practice Project scoring, and evidence was synthesised narratively.

RESULTS

Thirteen studies were included. We found moderate evidence for a negative relationship between manual work and work retention. We also found limited evidence for a U-shaped relationship between workload and complete work retention at 6 months and no relationship at 12 months; a positive relationship between managers, compared with non-managers, and faster work retention; a positive relationship between large enterprise size defined as ≥250 employees, and no relationship between large enterprise size, defined as ≥1000 employees, and work retention.

CONCLUSION

Relative to individual factors, there is little evidence on specific workplace factors' relationship to work retention among employees with ABI. For most workplace factors, there were too few high-quality studies to designate evidence as more than limited or insufficient. Future studies should replicate rigorous studies of well-defined modifiable workplace factors related to work retention.

PROSPERO REGISTRATION NUMBER

CRD42018082201.

Impact of Upper Limb Function and Employment Status on Return to Work of Blue-Collar Workers after Stroke

BACKGROUND AND PURPOSE

Return to work (RTW) after stroke is the ultimate goal of the working population to achieve economic independence and well-being. Previous studies have reported lower RTW rates of blue-collar workers versus white-collar workers. Thus, investigating predictive factors for RTW of blue-collar workers is meaningful to improve RTW after stroke. Here, we investigate the physical, cognitive, and social factors associated with the RTW of blue-collar workers after stroke.

METHODS

Poststroke rehabilitation data for 71 patients aged 15-64 years who had been active blue-collar workers at stroke onset were analyzed from a single-center observational cohort database. Baseline characteristics, social background factors, and quantitative assessments of the upper limb, lower limb, and cognitive functions at discharge were analyzed to identify any association with RTW. Receiver operating characteristic curve analysis was performed to determine the optimal cutoff value of continuous valuables with significant associations.

RESULTS

Functional upper limb represented by an increasing Simple Test for Evaluating hand Function (STEF) score was independently associated with RTW of blue-collar workers by multivariable logistic regression analysis (odds ratio [OR], 1.08; 95% confidence interval [CI], 1.01-1.14; p = .017). Correlation with self-employment status was also significant compared to that with employee status (OR, 185; 95% CI, 1.05-32400; p = .048). The cutoff value of the 100-point scale STEF to discriminate between RTW and non-RTW was 82.

CONCLUSIONS

Functional upper limb and self-employment status were independent predictors for the RTW of blue-collar workers after stroke.

Factors, trends, and long-term outcomes for stroke patients returning to work: The South London Stroke Register

Background and purpose

There is limited information on factors, trends, and outcomes in return to work at different time-points post-stroke; this study aims to identify these in a multi-ethnic urban population.

Methods

Patterns of return to work were identified in individuals in paid work prior to first-ever stroke in the population-based South London Stroke Register (SLSR) between 1995 and 2014. Multivariable logistic regression examined associations between patient characteristics and return to work at 1 year (1 y), 5 years (5 y) and 10 years (10 y) post-stroke.

Results

Among 5609 patients, 940 (17%) were working prior to their stroke, of whom 177 (19%) were working 3 months post-stroke, declining to 172 (18%) at 1 y, 113 (12%) at 5 y, and 27 (3%) at 10 y. Factors associated with return to work within 1 y, after logistic regression, included functional independence (BI ≥ 19; p < 0.01) and shorter length of stay ( p < 0.05). Younger age ( p < 0.01) was associated with return to work at 5 y and 10 y post-stroke. Non-manual occupation ( p < 0.05) was associated with return to work at 10 y post-stroke. Return to work within 1 y increased the likelihood of working at 5 y (OR: 13.68; 95% CI 5.03–37.24) and 10 y (9.07; 2.07–39.8). Of those who were independent at follow-up (BI ≥ 19), 48% were working at 1 y, 42% at 5 y, and 28% at 10 y. Lower rates of anxiety and depression and higher self-rated health were associated with return to work at 1 y ( p < 0.01).

Conclusion

Although functionally independent stroke survivors are more likely to return to work long-term, a large proportion do not return to work despite functional independence. Return to work post-stroke is associated with improved long-term psychological outcomes and quality of life.

Re-employment of people with chronic stroke: A single-centre retrospective study

BACKGROUND/AIM

Re-employment is the goal of rehabilitation for many patients after stroke. This study retrospectively examined previously employed stroke survivors who were unable to return to work at time of discharge from hospital and identified factors which were correlated with successful re-employment following a rehabilitation programme involving occupational therapy at a support facility. Factors correlated with reactivation of drivers' licence after stroke were also investigated.

METHODS

Participants were 150 post-stroke patients who were discharged from a support facility for persons with disabilities from April 2011 to March 2016. Data on patients' sociodemographic information, activities of daily living, and physical functions had been recorded at the time of admission into the facility. Employment status was recorded at discharge. Data were collected retrospectively in July 2017 from the medical records. Logistic regression models were prepared to examine factors correlated with successful re-employment and reactivation of drivers' licence after occupational therapy.

RESULTS

A stepwise logistic regression model revealed that the following four factors were significantly correlated with successful re-employment: (i) the dressing-lower body item in the Functional Independence Measure (P < 0.001), (ii) the grooming item in the Functional Independence Measure (P = 0.002), (iii) marital status (P = 0.007), and (iv) the problem-solving item in the Functional Independence Measure (P = 0.028). Another stepwise logistic regression model revealed that the factors were significantly correlated with successful reactivation of drivers' licence: (i) the problem-solving item in the Functional Independence Measure (P = 0.002), (ii) the dressing-lower body item in the Functional Independence Measure (P = 0.011) and (iii) the residence area (P = 0.038).

CONCLUSION

A single-centre retrospective study demonstrated several significant correlates of successful re-employment and reactivation of drivers' licence after stroke following rehabilitation training which employs occupational therapy to target skills critical for employment.

Documenting the impact of stroke in a middle-income country: a Malaysian case study

Purpose: Stroke is an abrupt event that often leaves survivors with long term disabilities, causing role changes, and financial strains on households. The profound impact of stroke on survivors may lead to a decline in quality of life due to the physical, psychological, and social difficulties they experience. Taking Malaysia as an example, this study aimed to explore the impact of stroke on survivors and how health services influence their recovery in low and middle-income countries (LMIC).Method: An ethnographic approach with data obtained primarily through in-depth interviews was used. Twenty-seven participants identified as having suffered a stroke were drawn from a health and demographic surveillance system in Malaysia.Results: The physical and social disruption of the lives of stroke survivors was intensified by the resultant financial constraints placed upon individuals, families and households, compounded by inadequate support from the health, and welfare systems. Despite the disruption to their lives, most participants were, at least in part, able to reestablish their lives through various factors that include a strong family support and active coping strategies.Conclusion: In LMIC, recovery can be shaped by the family unit and through active coping strategies especially those in relation to spirituality.Implications for rehabilitationThe impact of stroke on survivors and lack of specialized stroke care compromise the recovery process and quality of life for stroke survivors in low and middle-income countries.Support from the family and reinforcement of religious coping were judged to successfully aid recovery.Physical and emotional impairments as well as psychosocial wellbeing of survivors in the context of environmental factors need to be addressed.

Comparison of the Time Course of Return to Work After Stroke Between Two Cohort Studies in Japan

The conditions for stroke rehabilitation such as individual therapeutic procedure and medical treatment system in Japan have drastically changed over the past decade: increasing incidence of ischemic stroke, the use of intravenous recombinant tissue plasminogen activator, hospital specialization, introduction of convalescent rehabilitation wards, and public long-term care insurance. However, it is not known whether these changes have influenced the time course of return to work (RTW) after stroke. In this study we compared the time course of RTW after stroke in Japan that was reported in two cohort studies performed 20 years apart. The cumulative rate of RTW after first stroke was similar in the two studies, even though they were separated by an interval of two decades. This shows that advances in stroke rehabilitation have not impacted RTW, and we suggest that the social security system, particularly sickness benefit, has a strong influence on RTW.

Cost-Effectiveness of a National Opportunistic Screening Program for Atrial Fibrillation in Ireland

OBJECTIVES

To evaluate the cost-effectiveness of a national atrial fibrillation screening program in Ireland involving annual opportunistic pulse palpation of all those older than 65 years during general practitioner consultations, with an electrocardiogram being performed if an irregular pulse is detected.

METHODS

A probabilistic Markov model was used to simulate costs and clinical outcomes in a hypothetical cohort of men and women with and without screening over the course of 25 years, using a societal perspective.

RESULTS

Screening was associated with an incremental cost-effectiveness ratio of €23,004/quality-adjusted life-year compared with routine care. Nevertheless, if the relative risk of stroke and systematic embolism in screen-detected patients is more than 12% lower than that in patients with atrial fibrillation identified through routine practice, then screening would not be considered cost-effective at a willingness-to-pay threshold of €45,000/quality-adjusted life-year. An analysis comparing alternative combinations of start age and screening interval found that less frequent screening with a later start age may be more cost-effective than an annual screening from age 65 years.

CONCLUSIONS

Annual opportunistic screening of men and women aged 65 years and older in primary care in Ireland is likely to be cost-effective using conventional willingness-to-pay thresholds, assuming that those detected through screening have a comparable stroke risk profile as those detected through routine practice. Raising the start age of screening or increasing the screening interval may improve the cost-effectiveness of a prospective screening program.

Integrating Palliative Care Into the Care of Neurocritically Ill Patients: A Report From the Improving Palliative Care in the ICU Project Advisory Board and the Center to Advance Palliative Care

OBJECTIVES

To describe unique features of neurocritical illness that are relevant to provision of high-quality palliative care; to discuss key prognostic aids and their limitations for neurocritical illnesses; to review challenges and strategies for establishing realistic goals of care for patients in the neuro-ICU; and to describe elements of best practice concerning symptom management, limitation of life support, and organ donation for the neurocritically ill.

DATA SOURCES

A search of PubMed and MEDLINE was conducted from inception through January 2015 for all English-language articles using the term "palliative care," "supportive care," "end-of-life care," "withdrawal of life-sustaining therapy," "limitation of life support," "prognosis," or "goals of care" together with "neurocritical care," "neurointensive care," "neurological," "stroke," "subarachnoid hemorrhage," "intracerebral hemorrhage," or "brain injury."

DATA EXTRACTION AND SYNTHESIS

We reviewed the existing literature on delivery of palliative care in the neurointensive care unit setting, focusing on challenges and strategies for establishing realistic and appropriate goals of care, symptom management, organ donation, and other considerations related to use and limitation of life-sustaining therapies for neurocritically ill patients. Based on review of these articles and the experiences of our interdisciplinary/interprofessional expert advisory board, this report was prepared to guide critical care staff, palliative care specialists, and others who practice in this setting.

CONCLUSIONS

Most neurocritically ill patients and their families face the sudden onset of devastating cognitive and functional changes that challenge clinicians to provide patient-centered palliative care within a complex and often uncertain prognostic environment. Application of palliative care principles concerning symptom relief, goal setting, and family emotional support will provide clinicians a framework to address decision making at a time of crisis that enhances patient/family autonomy and clinician professionalism.

The effect of a severe health shock on work behavior: Evidence from different health care regimes

In this paper, we use the policy variation of two different types of health insurance in the US and in Denmark - employer-provided and universal insurance combined with substantial differences in expected and actual medical out-of-pocket expenditures - to explore the effect of new severe health shocks on the labor force participation of older workers. Our results not only provide insight into how relative disease risk affects labor force participation at older ages, but also into how different types of health care and health insurance systems affect individual decisions of labor force participation. Although employer-tied health insurance and greater out-of-pocket medical expenditures give US Americans greater incentives to continue to work, we find only small differences in the work response between the two countries. We provide compelling evidence that our somewhat counterintuitive finding is the result of differential mortality and baseline health differences coupled with distinct treatment regimes under the respective health care systems.

Survey of survivors' perspective on return to work after stroke

PURPOSE

To describe the development and results of a detailed survey on return to work (RTW) after stroke completed by survivors at various stages of recovery.

METHOD

This study used a multi-method qualitative and quantitative research strategy to design and implement a 39-item survey for stroke survivors. Individual interviews, focus groups, and working committees were used to conceptualize the issues and translate them into a survey format. Surveys were distributed in regular and electronic mail. Groups of rehabilitation professionals, employers, and stroke survivors were assembled to review findings and obtain feedback to aide in interpretation.

RESULTS

Overall 715 surveys were completed. The respondents were on average 54 years of age, mostly white, well-educated, urban dwelling, and in skilled occupations. Results are described in seven areas: financial, stroke impairments, organizational, work and psychological issues, interpersonal support, and therapy. Several salient findings are described including the role of fatigue, under utilization of vocational rehabilitation (VR) services, and motivational factors related to finances, self-esteem, work, and workplace relationships.

CONCLUSION

Although earning an income is a strong motivation to RTW, salary decreases in importance when compared with other psychological benefits. Fatigue was rated as the second highest impairment barrier to RTW and persisted as a relevant impediment over time. Attitudes of co-workers and flexibility in work schedule were viewed as most helpful to the RTW process, whereas work stress was viewed as the greatest impediment to return. Only 24% of the sample received VR counseling with more respondents receiving counseling if they returned 6 months or longer after their stroke. Other trends and clinical and research implications are discussed.

Developing stroke-specific vocational rehabilitation: a soft systems analysis of current service provision

Purpose:

This study aimed to clarify the existing service provision of stroke-specific vocational rehabilitation (VR) in one English county, in order to facilitate future service development.

Method:

Using soft systems methodology, services in Health, Social Care, Department of Work and Pensions, the voluntary and private sectors, which were identified as supporting return to work after stroke, were mapped using a mixed-methodology approach.

Results:

A lack of a sanctioned VR pathway meant access to support relied on brokered provision and tacit knowledge. The timing of an intervention was complex and there was a substantial degree of unmet need for mild stroke patients. VR was seen as “non-essential” due to competing commissioning priorities. Service providers from all sectors lacked training and cross-sector partnerships were tenuous and provider roles unclear.

Conclusions:

Stroke-specific VR should be delivered by an integrated, cross-sector multi-disciplinary team and integrated commissioning between health and other sectors is necessary. Although early intervention is important, support later on in the recovery process is also necessary. Service providers need adequate training to meet the needs of stroke survivors wishing to return to work and better awareness of best practice guidelines. Business cases which demonstrate the efficacy and cost-effectiveness of VR are vital.

Implications for Rehabilitation

Determinants of return to work among Nigerian stroke survivors

PURPOSE

Employment, an important aspect of life, could be adversely affected by a disabling condition like stroke. This study explores the frequency and determinants of return to work (RTW) among Nigerian stroke survivors.

METHOD

One-hundred and one stroke patients attending Physiotherapy clinics at seven teaching and specialist hospital centers in north-eastern Nigeria participated in the study. Socio-demographic, clinical and RTW data were obtained from participants while the modified Rankin Scale was used to assess functional ability. Chi-square statistics and multivariable logistic regression analysis was used to identify the determinants of RTW among the participants.

RESULTS

About half of the participants (55%) had returned to work. Absence of disability [Odds Ratio (OR) = 57.7; 95% CI = 12.0-276.8) and mild disability (OR = 15.1; 95% CI = 3.9-58.3) were the significant determinants of RTW, while post-stroke duration of a year or less was associated with lower chance of returning to work (OR = 0.2; 95% CI = 0.0-0.8).

CONCLUSIONS

The prominence of functional independence among the determinants of RTW implies that rehabilitation efforts and support programmes to optimize functional ability, especially within the first year after stroke, will greatly enhance RTW among Nigerian stroke survivors.

The Relationship Between Physical Fitness and Work Integration Following Stroke

Objective:To investigate the relationship between physical fitness and work integration following stroke.Design:Single-group study, measurement of physical fitness pre and post physical training, measurement of employment status in a follow-up assessment 2 to 36 months after rehabilitation.Setting:Interdisciplinary outpatient rehabilitation program.Participants:58 stroke survivors (62% male, mean age at program start 46.7 years, mean time since stroke 1.1 years) who were consecutively referred to the program.Intervention:1½ hours of intensive training of cardiorespiratory fitness and muscle strength 1–3 times weekly as part of the 3-month program.Measures:Physical fitness was measured with a modified Harvard Step Test, the Åstrand Cycling Test, and walking/running speed. The type of participants' employment as well as the amount of working hours was registered.Results:Good physical fitness as measured by the Harvard Step test, but not the Åstrand Cycling Test and walking/running speed, was related to return to competitive, full-time employment. Test results from training tended to predict work reintegration better than test results from training start. Improvement of physical fitness as measured by the Harvard Step Test was also related to follow-up employment.Conclusions:The results imply a relationship between physical fitness and work integration following stroke and should be confirmed with a randomised controlled study design.

Barriers to rehabilitation and return to work for unemployed chronic pain patients: A qualitative study

This paper explores the perceived barriers to return to work presented by unemployed patients with chronic musculoskeletal pain. The findings are based on one to one in depth semi-structured interviews conducted with patients from four sites in the UK. Interview data were recorded from 38 patients (15 male, 23 female) aged between 29 and 62 years the sample included patients who had participated in a vocational rehabilitation scheme, those who had refused to participate and a nai ve group. Patients were in receipt of long-term social welfare benefits (incapacity benefits) and recruited via local Job Centres. The mean duration of work absence was over 5 years. The data was transcribed and analysed by means of thematic analysis. Several themes were identified as barriers to return to work from the data including pain related issues, uncertainty (both financial and physical), the healthcare system, interaction with benefits providers, perceptions of employers and personal limitations. The uncertainty and the pain condition itself were the overarching barriers from which other obstacles stemmed. This is the first qualitative study of long term unemployed benefit recipients with chronic pain. Others authors have reported psychosocial factors as barriers to work among disabled populations however, this qualitative study has identified barriers specific to unemployed chronic pain patients. The themes identified will help with the planning and development of future initiatives for returning chronic pain patients to employment.

Diagnosis and treatment of upper limb apraxia

Upper limb apraxia, a disorder of higher motor cognition, is a common consequence of left-hemispheric stroke. Contrary to common assumption, apraxic deficits not only manifest themselves during clinical testing but also have delirious effects on the patients' everyday life and rehabilitation. Thus, a reliable diagnosis and efficient treatment of upper limb apraxia is important to improve the patients' prognosis after stroke. Nevertheless, to date, upper limb apraxia is still an underdiagnosed and ill-treated entity. Based on a systematic literature search, this review summarizes the current tools of diagnosis and treatment strategies for upper limb apraxia. It furthermore provides clinicians with graded recommendations. In particular, a short screening test for apraxia, and a more comprehensive diagnostic apraxia test for clinical use are recommended. Although currently only a few randomized controlled studies investigate the efficacy of different apraxia treatments, the gesture training suggested by Smania and colleagues can be recommended for the therapy of apraxia, the effects of which were shown to extend to activities of daily living and to persist for at least 2 months after completion of the training. This review aims at directing the reader's attention to the ecological relevance of apraxia. Moreover, it provides clinicians with appropriate tools for the reliable diagnosis and effective treatment of apraxia. Nevertheless, this review also highlights the need for further research into how to improve diagnosis of apraxia based on neuropsychological models and to develop new therapeutic strategies.

Barriers and facilitators of return to work for individuals with strokes: perspectives of the stroke survivor, vocational specialist, and employer

The purpose of this study was to identify factors that facilitated or acted as a barrier to return to work (RTW) for stroke survivors. We applied 3 approaches to identify the factors. First, we conducted qualitative interviews with 10 stroke survivors about their RTW experience post stroke. Second, we surveyed 21 vocational specialists about barriers and facilitators of RTW based on their clinical practice. Last, we interviewed 7 employers who had experience in interviewing individuals with disabilities or had the authority to make hiring decisions. Descriptions of barriers and facilitators to RTW from these 3 perspectives were illustrated. Identified components were mapped based on the ICF framework. From stroke survivors' perspectives, factors affecting employment after stroke include neurological (motor, cognition, communication), social, personal, and environmental factors. Vocational specialists described similar barriers and facilitators of RTW as the stroke survivors but emphasized personal factors such as flexibility and being realistic in vocational goals. The employers explained that the candidate's disability plays no role in the hiring process and indicated that all applicants must meet the essential job requirements. Some employers described the benefits of having the support of vocational rehabilitation staff and being able to interact with the vocational rehabilitation specialists during the hiring process. The interaction allows the employer to gather initial information (consented to by the job applicant) about the applicants from the vocational rehabilitation service and to be educated about any specific needs related to the applicant's medical issues.

Income and education as predictors of return to working life among younger stroke patients

BACKGROUND

Socioeconomic conditions are not only related to poor health outcomes, they also contribute to the chances of recovery from stroke. This study examines whether income and education were predictors of return to work after a first stroke among persons aged 40-59.

METHODS

All first-stroke survivors aged 40-59 who were discharged from a hospital in 1996-2000 and who had received income from work during the year prior to the stroke were sampled from the Swedish national register of in-patient care (n = 7,081). Income and education variables were included in hazard regressions, modelling the probability of returning to work from one to four years after discharge. Adjustments for age, sex, stroke subtype, and length of in-patient care were included in the models.

RESULTS

Both higher income and higher education were associated with higher probability of returning to work. While the association between education and return to work was attenuated by income, individuals with university education were 13 percent more likely to return than those who had completed only compulsory education, and individuals in the highest income quartile were about twice as likely to return as those in the lowest. The association between socioeconomic position and return to work was similar for different stroke subtypes. Income differences between men and women also accounted for women's lower probability of returning to work.

CONCLUSIONS

The study demonstrates that education and income were independent predictors of returning to work among stroke patients during the first post-stroke years. Taking the relative risk of return to work among those in the higher socioeconomic positions as the benchmark, there may be considerable room for improvement among patients in lower socioeconomic strata.

The psychology of stroke in young adults: the roles of service provision and return to work

Literature about the psychological consequences of stroke in those under 65 is reviewed focussing on services and work. Despite similarities, young and old survivors have different experiences and needs. These are attributable to the effects of stroke on age-normative roles and activities, self-image, and the young person's stage in the life-cycle, especially family and work. "Hidden" cognitive impairments, a disrupted sense of self, and the incongruity of suffering an "older person's" disease are salient. Young survivors benefit from services, but experience lack of congruence between their needs and service philosophy, methods, and aims, and consequently have unmet needs. Employment is psychologically salient, and the evidence about return rates, factors that affect return, and the adequacy of employment-related service provision is reviewed. Specific and general recommendations are made for increasing congruence between young survivors' needs and service provision and also for facilitating their return to work.

A nationwide prospective cohort study on return to gainful occupation after stroke in Denmark 1996-2006

BACKGROUND

Return to work is an important outcome factor for working-age patients poststroke. Previous epidemiological studies on this topic have been small (on average 125 patients per study). Their estimated effects are therefore associated with a tremendous statistical uncertainty. The present study estimates the effect of various predictors on the odds of returning to work after stroke in the total population of 20-57-year-old previously employed hospital treated patients with stroke in Denmark 1996-2006 (N=19,985).

METHODS AND RESULTS

The patients were followed through national registers; 62% were gainfully occupied 2 years after stroke. The odds of returning to work were higher among people with intracerebral infarction, OR 1.0 (the reference group), than they were among people with subarachnoid haemorrhage, OR 0.79 (95% CI 0.71 to 0.88), and intracerebral haemorrhage, OR 0.39 (0.35 to 0.43). The odds of returning to work were lower among workers in elementary occupations OR 1.0 (reference group) than they were among workers in occupations that require skills at a basic level, OR 1.50 (1.38 to 1.64), technicians and associate professionals, OR 2.33 (2.05 to 2.65) and professionals, OR 3.04 (2.70 to 3.43). Patients in municipalities with a brain-injury rehabilitation centre did not have a better prognosis than patients in other municipalities, OR 0.91 (0.78 to 1.06). Being a woman, OR 0.79 (0.74 to 0.84), self-employed, OR 0.87 (0.78 to 0.96), or ≥ 50 years, OR 0.61 (0.57 to 0.65), was associated with an adverse prognosis.

CONCLUSION

Further research is needed to explain the gender inequality, which suggests either a potential to improve return-to-work rates among the females or a tendency among the males to return too early.

Study protocol to a nationwide prospective cohort study on return to gainful occupation after stroke in Denmark 1996 - 2006

Background

Successful return to work is regarded as one of the most important outcome factors for working-age post stroke patients. The present study will estimate the effect of various predictors on the odds of returning to work after stroke. Nearly twenty thousand 20-57 year-old stroke patients in Denmark who were gainfully occupied prior to the stroke will be included in the study.

Methods/design

Stroke patients will be followed prospectively through national registers. Multi-level logistic regression will be used to model the odds of being gainfully occupied ca. two years after the stroke as a function of the following predictors: Age (20-49 years, 50-57 years) gender, occupational class, self-employment (yes; no), onset calendar year (1996, 1997, ..., 2006), diagnosis (subarachnoid haemorrhage; intracerebral haemorrhage; cerebral infarction; stroke, not specified as haemorrhage or infarction) and 'type of municipality' (the variable is set to 1 if the person lived in a municipality which had a brain injury rehabilitation centre at the time of the stroke. Otherwise it is set to 0).

Municipalities will be treated as the subjects while individual observations within municipalities are treated as correlated repeated measurements.

Discussion

Since our follow-up is done through registers and all people in the target population are included, the study is free from sampling bias, recall bias and non-response bias. The study is also strengthened by its size. The major weakness of the study is that it does not contain any stroke severity measures. Thus, it cannot accurately predict whether a particular stroke patient will in fact return to work. The study is, however, quite useful from a public health perspective. It can be used to estimate the proportion of patients in a certain group that is expected to return to work, and thereby provide a comparison material, which e.g. municipalities can use to evaluate their success in returning their stroke patients to work.

How many people return to work after acquired brain injury?: a systematic review

PRIMARY OBJECTIVE

To investigate how many people return to work (RTW) after acquiring brain injury (ABI) due to traumatic or non-traumatic causes. Secondary objectives were to investigate the differences in outcome between traumatic and non-traumatic causes, the development of RTW over time and whether or not people return to their former job.

METHODS

A systematic literature search (1992-2008) was performed using terms of ABI and RTW. The methodological quality of the studies was determined. An overall estimation of percentage RTW 1 and 2 years post-injury was calculated by data pooling.

MAIN OUTCOMES AND RESULTS

Finally, 49 studies were included. Within 2 years post-injury, 39.3% of the subjects with non-traumatic ABI returned to work. Among people with traumatic ABI, 40.7% returned to work after 1 year and 40.8% after 2 years. No effect of cause or time since injury was found. Some people with traumatic ABI who returned to work were not able to sustain their job over time. Changes of occupation and job demands are common among people with ABI.

CONCLUSIONS

About 40% of the people with traumatic or non-traumatic ABI are able to return to work after 1 or 2 years. Among those with acquired traumatic brain injury a substantial proportion of the subjects were either not able to return to their former work or unable to return permanently.

Working after a stroke: Survivors' experiences and perceptions of barriers to and facilitators of the return to paid employment

PURPOSE

This paper examines respondents' relationship with work following a stroke and explores their experiences including the perceived barriers to and facilitators of a return to employment.

METHOD

Our qualitative study explored the experiences and recovery of 43 individuals under 60 years who had survived a stroke. Participants, who had experienced a first stroke less than three months before and who could engage in in-depth interviews, were recruited through three stroke services in South East England. Each participant was invited to take part in four interviews over an 18-month period and to complete a diary for one week each month during this period.

RESULTS

At the time of their stroke a minority of our sample (12, 28% of the original sample) were not actively involved in the labour market and did not return to the work during the period that they were involved in the study. Of the 31 participants working at the time of the stroke, 13 had not returned to work during the period that they were involved in the study, six returned to work after three months and nine returned in under three months and in some cases virtually immediately after their stroke. The participants in our study all valued work and felt that working, especially in paid employment, was more desirable than not working. The participants who were not working at the time of their stroke or who had not returned to work during the period of the study also endorsed these views. However they felt that there were a variety of barriers and practical problems that prevented them working and in some cases had adjusted to a life without paid employment. Participants' relationship with work was influenced by barriers and facilitators. The positive valuations of work were modified by the specific context of stroke, for some participants work was a cause of stress and therefore potentially risky, for others it was a way of demonstrating recovery from stroke. The value and meaning varied between participants and this variation was related to past experience and biography. Participants who wanted to work indicated that their ability to work was influenced by the nature and extent of their residual disabilities. A small group of participants had such severe residual disabilities that managing everyday life was a challenge and that working was not a realistic prospect unless their situation changed radically. The remaining participants all reported residual disabilities. The extent to which these disabilities formed a barrier to work depended on an additional range of factors that acted as either barriers or facilitator to return to work. A flexible working environment and supportive social networks were cited as facilitators of return to paid employment.

CONCLUSION

Participants in our study viewed return to work as an important indicator of recovery following a stroke. Individuals who had not returned to work felt that paid employment was desirable but they could not overcome the barriers. Individuals who returned to work recognized the barriers but had found ways of managing them.

Return to work in stroke patients

PURPOSE

To present the current state of knowledge regarding return to work (RTW) following stroke.

METHOD

A comprehensive review of the current stroke rehabilitation literature pertaining to prognostic and treatment factors for RTW following stroke.

RESULTS

Stroke is a major healthcare problem and one of the most expensive diseases in modern society. Stroke results not only in impairment and limitation in basic daily activities; it also impacts on participation in community activities, such as returning to work. Return to work in post-stroke patients has been reported to range between 19% and 73%. Various studies report on return to work in diverse populations, using different follow-up periods, while utilizing variable definitions of stroke and successful work outcomes. The factors positively related to RTW in stroke patients, as found in the literature, are age less then 65 years, high education level and white-collar employment. The significant negative predictor is the severity of stroke. This is indicated by neurological parameters including functional measures of the presence and extent of motor and cognitive impairment. Significantly, the side of the brain damaged and stroke location were not found to be correlated with RTW. Social and financial factors also significantly influence RTW.

CONCLUSIONS

RTW in stroke patients should be considered one of the indicators of a successful rehabilitation as it influences self-image, well-being and life satisfaction. There is still a considerable lack of knowledge regarding effective assessments and interventions in vocational rehabilitation in stroke patients.

Predictors of return to work following carotid endarterectomy

BACKGROUND

Carotid endarterectomy (CEA) is an important part of secondary prevention in selected patients following a transient ischaemic attack or stroke. A key marker of success, return to work following surgery, was assessed in a retrospective cohort study.

METHODS

Patients from the UK aged less than 65 years at operation were sent a questionnaire concerning return to work after CEA. Data were analysed using univariable tests and logistic regression.

RESULTS

Some 174 (64.4 per cent) of 270 patients responded; their median age was 60 (range 35-64) years and 124 were men. Seventy-five per cent of respondents employed preoperatively returned to work following CEA. Newly retiring patients were older (62 versus 58 years; P < 0.001). Univariable analysis confirmed that age and preoperative stroke influenced return to work. The adjusted odds ratio for patients with versus without a preoperative stroke was 0.46 (95 per cent confidence interval 0.22 to 0.97) (P = 0.040). Median convalescence was 4 weeks, but was shorter in the self-employed (P = 0.039) and prolonged in patients with symptomatic cardiovascular disease (P = 0.023) and those who required postoperative critical care (P = 0.039).

CONCLUSION

Return to work following CEA was influenced by age and preoperative stroke.

The association between stroke location and return to work after first stroke

Although various factors, including age, race, job category, disability, and cortical function, have been associated with return to work (RTW) after stroke, few studies have examined the influence of stroke location on RTW. We conducted a retrospective cohort study on the association between stroke location and RTW after first stroke. The patients were all younger than age 65 years and were working at the time of their stroke (n = 126). A follow-up questionnaire evaluated RTW. Data were analyzed using the Cox proportional hazards model for hazard ratios (HRs) of successful RTW, taking potential confounding factors into consideration. The Cox model revealed that maximum weakness (HR 3.74, normal vs severe), apraxia (10.7, no vs yes), and occupation (2.11, white collar vs blue collar) were significant predictors, but stroke location was not a significant predictor. We conclude that stroke location is less important than other easily measured factors in predicting RTW.

Health shocks and retirement: the role of welfare state institutions

We investigate the effect of an acute health shock on retirement among elderly male workers in Denmark, 1991-1999, and in particular whether various welfare state programs and institutions impinge on the retirement effect. The results show that an acute health event increases the retirement chances of elderly male workers by 8%, and that this increase in the baseline retirement probability is not affected by eligibility to early exit programs and persists even after accounting for selection due to take-up of disability pension. Neither is it affected by the relatively long duration of sickness benefits in Denmark nor by the promotion of corporate social responsibility initiatives since the mid-1990s. In the late 1990s, however, the retirement rate following a health shock is reduced to 3% with the introduction of the subsidized employment program (fleksjob) but this effect is on the margin of being significant. For the most part, the retirement effect following a health shock seems to be immune to the availability of a multitude of government programs for older workers in Denmark.

Long-term survival and vascular event risk after transient ischaemic attack or minor ischaemic stroke: a cohort study

BACKGROUND

Determinants of survival and of risk of vascular events after transient ischaemic attack (TIA) or minor ischaemic stroke are not well defined in the long term. We aimed to restudy these risks in a prospective cohort of patients after TIA or minor ischaemic stroke (Rankin grade< or =3), after 10 years or more.

METHODS

We assessed the survival status and occurrence of vascular events in 2473 participants of the Dutch TIA Trial (recruitment in 1986-89; arterial cause of cerebral ischaemia). We included 24 hospitals in the Netherlands that recruited at least 50 patients. Primary outcomes were all-cause mortality and the composite event of death from all vascular causes, non-fatal stroke, and non-fatal myocardial infarction. We assessed cumulative risks by Kaplan-Meier analysis and prognostic factors with Cox univariate and multivariate analysis.

FINDINGS

Follow-up was complete in 2447 (99%) patients. After a mean follow-up of 10.1 years, 1489 (60%) patients had died and 1336 (54%) had had at least one vascular event. 10-year risk of death was 42.7% (95% CI 40.8-44.7). Age and sex-adjusted hazard ratios were 3.33 (2.97-3.73) for age over 65 years, 2.10 (1.79-2.48) for diabetes, 1.77 (1.45-2.15) for claudication, 1.94 (1.42-2.65) for previous peripheral vascular surgery, and 1.50 (1.31-1.71) for pathological Q waves on baseline electrocardiogram. 10-year risk of a vascular event was 44.1% (42.0-46.1). After falling in the first 3 years, yearly risk of a vascular event increased over time. Predictive factors for risk of vascular events were similar to those for risk of death.

INTERPRETATION

Long-term secondary prevention in patients with cerebral ischaemia still has room for further improvement.

Functional implications of ipsilesional motor deficits after unilateral stroke

OBJECTIVE

To investigate the functional impact of ipsilesional motor deficits after unilateral stroke and the best predictors of those deficits.

DESIGN

Observational cohort.

SETTING

Primary care Veterans Affairs and private medical center.

PARTICIPANTS

Volunteer right-handed sample; stroke patients with left (LHD) or right hemisphere damage (RHD) a mean of 3.9 to 5.2 years poststroke and able-bodied participants who were tested using their left (LAB) or right hand.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

The Jebsen-Taylor Hand Function Test (JHFT).

RESULTS

Ipsilesional JHFT performance was impaired to the same extent in the LHD and RHD groups. LHD patients with apraxia had poorer scores on the JHFT than LHD patients without apraxia and the LAB group. Regression analyses showed that severity of apraxia was the best predictor of JHFT performance for the LHD group and that right (ipsilesional) motor performance (grip strength, finger tapping) was the best predictor of JHFT performance for the RHD group.

CONCLUSIONS

Ipsilesional deficits are present on simulated activities of daily living after LHD or RHD, suggesting that rehabilitation after stroke should include the ipsilesional arm and that ipsilesional limb apraxia is a better predictor of ipsilesional functional motor skills after LHD than aphasia or simple motor skills (grip strength, finger tapping). These findings suggest that limb apraxia should be assessed more routinely after stroke of the left hemisphere.

Deconstructing apraxia: understanding disorders of intentional movement after stroke

Impairments in praxic functioning are common after stroke, most frequently when the left hemisphere is affected. Several recent studies of apraxia after stroke have made advances in understanding the right hemisphere contribution to praxis, particularly for the performance of novel actions. Moreover, quantitative lesion analysis in stroke patients indicates the importance of cortical regions such as the intraparietal sulcus and the middle frontal gyrus for subserving praxic function. Complex neuropsychological models have been developed to account for the many dissociations observed in the types of errors observed in stroke patients. Relatively lacking, however, are models that attempt to relate the neurological data to what is known about praxis from functional neuroimaging in normal subjects and from physiological studies in the monkey. Moreover, a coherent interpretation of the results of apraxia studies remains hampered by the lack of a standard testing instrument to assess the nature and severity of apraxic impairments in the groups tested.

Struck by stroke: a pilot study exploring quality of life and coping patterns in younger patients and spouses

So far, research on quality of life after stroke has focused mainly on elderly patients. This study is targeted at younger stroke patients and their partners, aiming to evaluate stroke impact, as related to coping strategy. For our pilot study, eight patients who had suffered a stroke and four partners completed the Impact of Event Scale questionnaire. The mean age was 47.6 years in patients and 44.5 years in partners. The patients' level of activities of daily life was assessed using the Barthel Index. They were then interviewed to obtain information with respect to stroke impact and coping. The Schedule for the Evaluation of Individual Quality of Life procedure was carried out to measure quality of life, and stroke impact was quantified using Visual Analogue Scales. On average, patients scored 19.25 on the Barthel Index. Quality of life had deteriorated by 20.1% in patients, whereas partners did not show a decline in quality of life. However, well-being was inversely correlated among patients and partners. Accommodative coping was positively correlated with quality of life in both patients and partners. Conversely, assimilation was negatively related to quality of life in patients.

Survival analysis in public health research

This paper reviews the common statistical techniques employed to analyze survival data in public health research. Due to the presence of censoring, the data are not amenable to the usual method of analysis. The improvement in statistical computing and wide accessibility of personal computers led to the rapid development and popularity of nonparametric over parametric procedures. The former required less stringent conditions. But, if the assumptions for parametric methods hold, the resulting estimates have smaller standard errors and are easier to interpret. Nonparametric techniques include the Kaplan-Meier method for estimating the survival function and the Cox proportional hazards model to identify risk factors and to obtain adjusted risk ratios. In cases where the assumption of proportional hazards is not tenable, the data can be stratified and a model fitted with different baseline functions in each stratum. Parametric modeling such as the accelerated failure time model also may be used. Hazard functions for the exponential, Weibull, gamma, Gompertz, lognormal, and log-logistic distributions are described. Examples from published literature are given to illustrate the various methods. The paper is intended for public health professionals who are interested in survival data analysis.