Multivariable Prediction of Return to Work at 6-Month Follow-Up in Patients With Mild to Moderate Acute Stroke

Determinants of Return to Work After a Stroke: A Systematic Review and Meta-analysis

OBJECTIVE

To identify prognostic factors for return to work (RTW) after stroke.

DATA SOURCES

PubMed, MEDLINE, Cochrane, and Embase were systematically searched.

STUDY SELECTION

Studies had to include people of working age (<65 years old) at the time of stroke (ischemic, hemorrhagic, or subarachnoid hemorrhage). The evaluation of RTW and rate of RTW had to be mentioned. Study selection was done by 2 independent authors. In total, 1241 articles were screened, 39 met all inclusion criteria.

DATA EXTRACTION

Characteristics of included studies were recorded independently by 2 authors. Differences were resolved through discussion or with a third author. Quality was assessed using the Scottish Intercollegiate Guidelines Network quality assessment tool.

DATA SYNTHESIS

Among the 39 studies, prognostic factors for RTW were hemorrhagic stroke (odds ratio 0.53 [95% confidence interval 0.45-0.60], n=18 studies), sex (men) (1.26 [1.14-1.40], n=31), aphasia (0.37 [0.20-0.69], n=7), occupation (white collar worker) (1.84 [1.64-2.06], n=17), independence in activities of daily living (3.99 [1.73-9.23], n=7), and stroke severity (NIHSS) (1.23 [1.08-1.39], n=6).

CONCLUSIONS

This meta-analysis highlighted positive and negative prognostic factors associated with RTW after stroke. Two categories were distinguished: modifiable and non-modifiable prognostic factors. This study provides information to help understand the issues, set appropriate objectives and implement appropriate strategies to guide people to RTW after stroke. Randomized controlled studies are needed to better evaluate work-place intervention programs as well as the effects of intravenous thrombolysis, and cognitive and neuropsychological rehabilitation on return-to-work rates after stroke.

Stroke survivors' long-term participation in paid employment

BACKGROUND

Knowledge on long-term participation is scarce for patients with paid employment at the time of stroke.

OBJECTIVE

Describe the characteristics and the course of participation (paid employment and overall participation) in patients who did and did not remain in paid employment.

METHODS

Patients with paid employment at the time of stroke completed questions on work up to 30 months after starting rehabilitation, and the Utrecht Scale for Evaluation of Rehabilitation-Participation (USER-P, Frequency, Restrictions and Satisfaction scales) up to 24 months. Baseline characteristics of patients with and without paid employment at 30 months were compared using Fisher's Exact Tests and Mann-Whitney U Tests. USER-P scores over time were analysed using Linear Mixed Models.

RESULTS

Of the 170 included patients (median age 54.2 interquartile range 11.2 years; 40% women) 50.6% reported paid employment at 30 months. Those returning to work reported at baseline more working hours, better quality of life and communication, were more often self-employed and in an office job. The USER-P scores did not change statistically significantly over time.

CONCLUSION

About half of the stroke patients remained in paid employment. Optimizing interventions for returning to work and achieving meaningful participation outside of employment seem desirable.

Return to work for adults following stroke: a scoping review of interventions, factors, barriers, and facilitators

OBJECTIVE

This scoping review aimed to map the literature on interventions, factors, barriers, and facilitators for return to work for adults post-stroke with or without communication disorders.

INTRODUCTION

Difficulties in returning to work can significantly impact individuals following a stroke (eg, their sense of purpose and self-esteem), not only financially, but also as they adjust to the change in their situation. Such difficulties may arise from communication disorders as well as physical impairments. Previous reviews on return to work post-stroke have focused on specific aspects, such as interventions, or barriers and facilitators, but have not provided a comprehensive map of the field. Further, no systematic or scoping reviews to date have focused on literature addressing return to work for people with communication disorders post-stroke.

INCLUSION CRITERIA

This review considered literature that reported on interventions, barriers, and facilitators for return to work for adults (aged 16 years or older) following an ischemic or hemorrhagic stroke. Records focusing on transient ischemic attacks or acquired brain injury were excluded, as were those in which a comorbidity or disability (eg, learning disability, dementia, respiratory disorder) had a significant impact on the individual's ability to work.

METHODS

This review followed the JBI scoping review methodology. Primary research of any type, systematic and non-systematic reviews, and gray literature from developed countries written in English from 2010 to the present day were identified from 7 databases, 2 gray literature repositories, JBI Evidence Synthesis , and an internet search. Records were screened for relevance to the review topic by 2 independent reviewers, and data relevant to the review questions were extracted. Findings were presented as narrative supported by tables.

RESULTS

Of the 106 sources included, 61 addressed demographic-based, socioeconomic-based, impairment-based, or recovery-based factors related to return to work. One of these 61 sources, a narrative review, focused on communication disorders. Thirty-eight sources explored barriers and facilitators for return to work from different stakeholders' perspectives; 3 of these 38 sources, including 2 qualitative studies and 1 narrative review, focused on post-stroke communication disorders. Eleven sources focused on interventions, including 7 studies (reported across 9 sources) that developed or tested return-to-work interventions. Of these primary studies, 1 randomized controlled trial and 1 retrospective cohort study were identified. The remaining intervention studies were case studies or case series. None of these intervention studies addressed communication disorders.

CONCLUSIONS

While there has been extensive research on factors, barriers, and facilitators for return to work post-stroke, there is a lack of research on interventions supporting return to work. There is also a significant gap in the evidence base on returning to work with a post-stroke communication disorder, highlighting the need for further research in this important area.

[Work Participation after Multimodal Rehabilitation due to Neurological Diseases - Representative Analyses Using Routine Data of the German Pension Insurance]

PURPOSE

There is little representative evidence for the German rehabilitation system on occupational reintegration after medical rehabilitation. For persons who have undergone rehabilitation on behalf of the German Pension Insurance (GPI) due to a neurological disease, it is therefore important to determine (a) what socio-medical risks exist prior to rehabilitation, (b) how well persons were able to participate in working life after rehabilitation, and (c) what conditions determine the work participation.

METHODS

The study is conducted on the basis of the GPI's database of rehabilitation statistics. Included were all persons, who completed medical rehabilitation in 2016 due to a neurological disease. The analyses were carried out for the entire group and also in a differentiated manner for the 2 main diseases, cerebrovascular diseases (CD) and multiple sclerosis (MS). Work participation was operationalized both via a monthly status variable until 24 months after rehabilitation and as a rate of all persons who were employed at the 12 and 24 months follow up and in the 3 months before, respectively. To analyse the factors influencing stable work participation, multiple logistic regression models with stepwise inclusion were calculated separately for the rates after 12 and 24 months.

RESULTS

A total of 42,230 data sets were included in the analysis (CD: n=18,368, 44%; MS: n=6,343, 15%). Patients with neurological diseases were 50 years old on average, 43% were female. We found that approximately15% of patients reported no absenteeism, whereas 17% stated an absence leave of six months or more in the year prior to rehabilitation. Mental and cardiovascular comorbidity was documented in 31 and 44% of the cases respectively. Nearly 48% of patients with CD returned to work two years after rehabilitation. For MS patients, the percentage was slightly higher at 54%. The amount of sick leave of the rehabilitated individual, their gross/net income prior to rehabilitation as well their work capacity prior to admission were the three strongest influencing factors on their return to the labour market.

CONCLUSION

About half of all persons with neurological diseases return to sustainable work after medical rehabilitation in Germany. The amount of sick leave and the income before rehabilitation are determining factors as to whether the person will return to work. The analysis provides representative data on occupational reintegration after medical rehabilitation due to a neurological disease for the first time.

The reasons for not returning to work and health-related quality of life among young and middle-aged patients with stroke: A cross-sectional study

Objectives

This study aimed to explore the reasons and influencing factors for non-return to work (non-RTW) within 1 year among young and middle-aged patients with stroke and to assess their health-related quality of life (HRQoL) at 1 year across different reasons.

Methods

The study was conducted as a telephone-based cross-sectional survey. Seven hundred eighty-nine young and middle-aged patients with stroke aged between 18 and 54 years for men and 18 and 49 years for women in the electronic medical system were included. Data collection included demographic characteristics, socioeconomic status, behavioral habits, history of chronic diseases, work status, reasons for non-RTW, and HRQoL.

Results

Of 789 patients, 435 (55.1%) (mean [SD] age, 47.7 [7.8] years) did not return to work within 1 year after stroke. Among the patients who did not RTW, 58.9% were unable to work, 9.7% retired early, 11.03% became full-time homemakers or were unemployed, and 20.5% were reluctant to work. The disordered multiclass logistic regression model showed that the factors influencing the reasons for non-RTW included age, gender, education, income, health insurance, diabetes comorbidity, ability to perform activities of daily living, and mobility of the right upper extremity. Furthermore, patients who were unable to work had significantly lower HRQoL compared to those who had RTW, followed by those who retired early.

Conclusions

More than half did not RTW within 1 year in our study. The results will help inform future research to identify interventions to promote RTW and improve HRQoL for young and middle-aged patients with stroke.

Factors associated with paid employment 12 months after stroke in A Very Early Rehabilitation Trial (AVERT)

BACKGROUND

Returning to work is an important outcome for stroke survivors.

OBJECTIVES

This sub-study of a randomised controlled trial aimed to provide characteristics of working-age stroke participants and identify factors associated with return to work at 12 months.

METHODS

We used paid employment data collected as part of A Very Early Rehabilitation Trial (AVERT, n=2104), an international randomised controlled trial studying the effects of very early mobilisation after stroke at 56 acute stroke units across Australia, New Zealand, the United Kingdom, Malaysia and Singapore. For the present analysis, data for trial participants < 65 years old were included if they were working at the time of stroke and had complete 12-month return-to-work data. The primary outcome was 12-month return to paid work. Univariable and multivariable logistic regression analyses were conducted to determine the association of multiple factors with return to work.

RESULTS

In total, 376 AVERT participants met the inclusion criteria for this sub-study. By 12 months, 221 (59%) participants had returned to work at a median of 38 hr per week. Similar rates were found across geographic regions. On univariable analysis, the odds of returning to paid employment were increased with younger age (OR per year 0.95, 95%CI 0.92-0.97), no previous diabetes (0.4, 0.24-0.67), lower stroke severity (OR per National Institutes of Health Stroke Scale point 0.82, 0.78-0.86), less 3-month depressive traits (Irritability Depression Anxiety [IDA] scale) (OR per IDA point 0.87, 0.80-0.93), less 3-month disability (modified Rankin Scale), and prior full-time work (2.04, 1.23-3.38). On multivariable analysis, return to work remained associated with younger age (OR 0.94, 95%CI 0.91-0.98), lower stroke severity (0.92, 0.86-0.99), prior full-time work (2.33, 1.24-4.40), and less 3-month disability.

CONCLUSIONS

Return to work at 12 months after stroke was associated with young age, acute stroke severity, 3-month disability and full-time employment before stroke. Greater understanding of this topic could help in developing programs to support successful resumption of work post-stroke.

Cognitive function is an important determinant of employment amongst young ischaemic stroke survivors with good physical recovery

BACKGROUND AND PURPOSE

This cross-sectional cohort study aims at investigating young ischaemic stroke survivors with good physical recovery 7 years post-stroke in order to analyze the relation between late cognitive ability and employment.

METHODS

Consecutive ischaemic stroke survivors participating in the Sahlgrenska Academy Study on Ischemic Stroke, <55 years of age at stroke onset, and with no or minimal persisting neurological deficits corresponding to a score ≤2 on the National Institutes of Health Stroke Scale at long-term follow-up 7 years post-stroke were included. At this follow-up, the participants were assessed with respect to general cognitive function, processing speed, executive functions, cardiovascular risk factors, self-reported employment, cognitive difficulties, fatigue, depressive symptoms, anxiety and physical function.

RESULTS

Seven years post-stroke 112/142 (79%) had part-time or full-time work and 30/142 (21%) had full-time disability pension or sick leave. Compared to those with full-time disability pension or sick leave, participants with current employment demonstrated significantly better performance with respect to general cognitive function and processing speed, and significantly lower self-ratings for cognitive difficulties, physical limitations, fatigue and depressed mood. Multivariable logistic regression selected self-rated memory (odds ratio [OR] 2.61, 95% confidence interval [CI] 1.61-4.21), processing speed (OR 3.50, 95% CI 1.67-7.33) and self-rated communication skills (OR 3.46, 95% CI 1.75-6.85) as most important correlates (area under the curve 0.83-0.87) of having current employment.

CONCLUSION

This study indicates that cognitive dysfunction is an important contributor to long-term work disability amongst young stroke survivors with good physical recovery.

Psychosocial Sequelae of Stroke in Working-Age Adults: A Pilot Study

OBJECTIVE

Few prospective studies have examined psychosocial symptoms in young adult stroke survivors. The purpose of this pilot study was to examine the feasibility of methods to assess and describe the presence of symptoms and their characteristics in young adult stroke survivors.

METHODS

A prospective descriptive design using PROMIS and NeuroQoL patient-reported outcomes was used. Stroke survivors aged 18 to 65 years admitted for acute ischemic stroke completed baseline measures before hospital discharge; the same measures were collected by telephone interview 6 months later.

RESULTS

Thirty patients were recruited, and 18 (60%) completed follow-up measures. There was wide variability in scores across patients for each patient-reported outcome that persisted at 6 months. NeuroQoL cognitive function was the only patient-reported outcome to have a statistically significant change from baseline to 6 months (P = .045).

CONCLUSIONS

It is feasible to recruit and retain young adult stroke survivors in a prospective study. Wide variability in scores across patients suggests different trajectories of recovery in the first 6 months after stroke. Neuroscience nurses can assess for these symptoms and provide individualized interventions to aid in self-management of burdensome symptoms.

Return to Work Among Stroke Survivors

Despite improvements in the treatment of stroke, many individuals still face cognitive, emotional, and physical impairments. Stroke is a leading cause of serious long-term disability and subsequent failure to return to work (RTW). The purpose of this literature review was to synthesize and discuss the literature relevant to factors affecting RTW for stroke survivors, summarize the identified gaps, and discuss steps occupational health nurses can take to facilitate RTW among stroke survivors. A literature search was conducted using the keywords: “stroke,” “cerebrovascular disease,” “return to work,” and “employment.” After excluding articles based on inclusion/exclusion criteria, 19 quantitative research articles were reviewed. Consistent themes found in the literature affecting RTW following stroke included physical, social, and cognitive factors. One of the most consistent predictors of RTW found was stroke severity. Individuals who experienced a mild to moderate stroke, those of Caucasian ethnicity, and higher socioeconomic levels were more likely to RTW. Findings suggest the importance of future studies to examine factors among African American stroke survivors that predict RTW and the role of occupational health nurses.