The effect of professional reintegration of stroke survivors on their quality of life: a scoping review: Professional Integration and QoL after stroke

BACKGROUND

Professional reintegration is an indicator of recovery and a common goal for many stroke survivors. However, data on the effect of professional reintegration on the quality of life (QoL) of stroke survivors is scarce.

AIMS

To assess and synthesize the available evidence, and identify the gaps on the effect of professional reintegration on the QoL of stroke survivors.

METHODS

A scoping review was performed, following PRISMA-ScR guidelines. The electronic databases PubMed, ISI Web of Science, PsycINFO, and SciELO were searched for empirical, peer-reviewed, original, and full-length studies on the effect of professional reintegration on QoL of stroke survivors. The main quantitative findings were synthesized and qualitative data was explored by thematic content analysis.

RESULTS

The included studies, 7 quantitative, 1 qualitative, and 1 mixed-methods, were published between 2009 and 2021. The assessment of QoL was highly heterogenic but globally most studies reported a significant and positive association between return to work (RTW) and QoL, 3 to 36 months post-stroke. For some stroke survivors, being able to focus on their rehabilitation was more important for their QoL than RTW.

CONCLUSIONS

The results highlight the importance of investing in professional reintegration after stroke to improve survivors' QoL. Further mixed-methods longitudinal research, performed in different countries and settings, with higher, homogeneous, and comparable samples, providing a broader approach to professional reintegration and the use of specific and standardized instruments to assess subjective domains of stroke survivors' QoL, is needed.

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.

Early Opportunities to Explore Occupational Identity Change: Qualitative Study of Return-To-Work Experiences After Stroke

BACKGROUND

Rates of return-to-work after stroke are low, yet work is known to positively impact people's wellbeing and overall health outcomes.

OBJECTIVE

To understand return-to-work trajectories, barriers encountered, and resources that may be used to better support participants during early recovery and rehabilitation.

PARTICIPANTS

The experiences of 31 participants (aged 25-76 years) who had or had not returned to work after stroke were explored.

METHODS

Interview data were analysed using reflexive thematic analysis methods within a broader realist research approach.

RESULTS

Participants identified an early need to explore a changed and changing occupational identity within a range of affirming environments, thereby ascertaining their return-to-work options early after stroke. The results articulate resources participants identified as most important for their occupational explorations. Theme 1 provides an overview of opportunities participants found helpful when exploring work options, while theme 2 explores fundamental principles for ensuring the provided opportunities were perceived as beneficial. Finally, theme 3 provides an overview of prioritized return-to-work service characteristics.

CONCLUSION

The range and severity of impairments experienced by people following stroke are broad, and therefore their return-to-work needs are diverse. However, all participants, irrespective of impairment, highlighted the need for early opportunities to explore their changed and changing occupational identity.

The centrality of work in everyday life after stroke: A qualitative study of long-term stroke survivors

BACKGROUND

Work is an occupation of great concern for younger stroke survivors. Given the high rate of people not working after stroke, there is a need to explore work after stroke from a long-term perspective, including not just an initial return to work, but also the ability to retain employment and how this may affect everyday life after stroke. Therefore, the objective of this study was to explore experiences relating to work and to work incapacity among long-term stroke survivors.

METHOD

This study used thematic analysis on data gathered through individual semi-structured interviews with long-term stroke survivors.

RESULTS

The analysis resulted in four themes that together comprised the main theme 'The centrality of work in everyday life', containing descriptions of how everyday life was affected by aspects of work both for those who did work and those who did not return to work after stroke.

CONCLUSION AND SIGNIFICANCE

The results highlight the importance of addressing return to work not just as an isolated outcome but as part of everyday life after stroke. The results indicate a need for a more flexible approach to supporting return to work that continues past the initial return.

Labour market participation and retirement after stroke in Denmark: registry based cohort study

OBJECTIVE

To examine labour market participation and retirement among patients with stroke and matched people in the general population according to stroke subtype.

DESIGN

Nationwide, population based, matched cohort study.

SETTING

Danish Stroke Registry, covering all Danish hospitals, and other nationwide registries (2005-18).

PARTICIPANTS

Patients (aged 18-60 years and active in the labour market) with a first time diagnosis of ischaemic stroke (n=16 577), intracerebral haemorrhage (n=2025), or subarachnoid haemorrhage (n=4305), and individuals from the general population, matched on age, sex, and calendar year (n=134 428). The median Scandinavian stroke scale score was 55.

MAIN OUTCOME MEASURES

Unweighted prevalences of labour market participation, receipt of sick leave benefits, receipt of disability pension, voluntary early retirement, state pension, and death were computed for each week and up to five years after stroke diagnosis. A log-linear Poisson model was used to obtain exact prevalence estimates as well as propensity score weighted prevalence differences and prevalence ratios at six months, one year, two years, and five years after stroke diagnosis.

RESULTS

Most patients (62% of those with ischaemic stroke, 69% of those with intracerebral haemorrhage, and 52% of those with subarachnoid haemorrhage) went on sick leave within three weeks of diagnosis. Prevalence of labour market participation among patients with ischaemic stroke compared with matched individuals from the general population was 56.6% versus 96.6% at six months, and 63.9% versus 91.6% at two years. Prevalence of sick leave was 39.8% versus 2.6% at six months, and 15.8% versus 3.8% at two years. Prevalence of receipt of a disability pension was 0.9% versus 0.2% at six months, and 12.2% versus 0.6% at two years. Adjusting for socioeconomic and comorbidity differences between patients and matched individuals from the general population using propensity score weighting methods had little impact on contrasts. Patients with intracerebral haemorrhage had higher prevalences of sick leave and receipt of a disability pension and thus a lower prevalence of labour market participation, while prevalences for patients with subarachnoid haemorrhage were similar in magnitude to those for patients with ischaemic stroke.

CONCLUSIONS

In a highly resourced country, about two thirds of working age adults with ischaemic stroke of primarily mild severity participated in the labour market two years after diagnosis. Sick leave and receipt of a disability pension were the most common reasons for non-participation. Patients with intracerebral haemorrhage were less likely to return to the labour market than patients with ischaemic stroke and subarachnoid haemorrhage.

Work situation of patients with stroke who have returned to work: a scoping review protocol

INTRODUCTION

The incidence of stroke in working-age adults is increasing. Many patients face cognitive, emotional and physical impairments and their subsequent influences on returning to work. An increasing number of studies have been conducted on the transformation from unemployment to returning to work. The criteria for returning to work only used the 'working yes/no' as the primary outcome. Although some researchers have investigated the characteristics of patients with stroke who have returned to work, there is a paucity of evidence regarding the work situation. This scoping review aimed to examine and map the work situation of patients with stroke who have returned to work.

METHODS AND ANALYSIS

This study will be based on the Joanna Briggs Institute Reviewers' Manual for scoping reviews. A systematic literature search will be conducted using related medical subject headings and keywords on the work situation of patients with stroke who have returned to work. Relevant publications will be searched using 17 data sources, including grey literature sources, published in English or Chinese between 1957 and 2022. None of the articles will have restrictions on the data sources or study designs. The study selection and search results will be reported and presented according to the Preferred Reporting Items for Systematic Review and Meta-Analyses extension for scoping reviews flow diagram. The results will be presented in a table format based on the data extraction tool.

ETHICS AND DISSEMINATION

This study is exempted from a medical ethical review. This scoping review addresses the knowledge gap by identifying and synthesising the work situation of patients with stroke who have returned to work, which will provide helpful information for various stakeholders. This scoping review will be submitted and published in a peer-reviewed scientific journal.

Predictors for Returning to Paid Work after Transient Ischemic Attack and Minor Ischemic Stroke

This study aims to determine which factors within the first week after a first-ever transient ischemic attack (TIA) or minor ischemic stroke (MIS) are associated with stroke survivors’ ability to return to either partial or full time paid external work (RTpW). In this single-center prospective cohort study, we recruited 88 patients with first-ever TIA or MIS (NIHSS ≤ 5). Bivariate analyses were conducted between patients that did (RTpW) or did not return to paid work (noRTpW) within 7 days after stroke onset and at 3-months follow-up. Then, we conducted multivariate logistic and negative binomial regression analyses assessing (i) which factors are associated with RTpW at 3 months (ii) the likelihood that patients would RTpW at 3 months and (iii) the number of months necessary to RTpW. Overall, 43.2% of the patients did not RTpW at 3 months. At 3-months follow-up, higher anxiety/depression and fatigue-related disabilities were associated with noRTpW. Multivariate analysis showed that higher NIHSS scores at onset and hyperlipidemia (LDL cholesterol > 2.6 mmol/L or statins at stroke onset) were associated with noRTpW at 3 months. Stroke severity and/or newly diagnosed hypercholesterolemia at stroke onset in TIA or MIS patients were associated with not returning to paid work at 3 months.

Trends in Prevalence of Serious Psychological Distress and Depression Among Adults with Stroke in the United States

OBJECTIVES

To examine national trends in prevalence of serious psychological distress and depression among adults with stroke in the United States (US) from 2004 to 2017, and variations across sociodemographic subgroups.

METHODS

Data were obtained from the household components of the 2004-2017 Medical Expenditure Panel Survey, a nationally representative survey in the US. History of stroke or transient ischemic attack was based on self-report. Psychological distress was measured by the Kessler-6 scale, and depressive symptoms were measured by the 2-item Patient Health Questionnaire. Logistic regression models were used to examine the trends in prevalence of serious psychological distress and depression overall and by age, sex, and race/ethnicity.

RESULTS

Among 10889 participants with stroke or transient ischemic attack, 60.0% were aged ≥ 65, 54.4% were female, and 72.2% were non-Hispanic white. The prevalence of serious psychological distress decreased from 14.9% in 2004-2005 to 11.3% in 2016-2017, corresponding to 7% lower odds every 2 years (adjusted odds ratio [aOR0.93, 95% confidence interval [CI]=0.89-0.97); and the prevalence of depression decreased from 23.1% in 2004-2005 to 18.3% in 2016-2017, corresponding to 5% lower odds every 2 years (aOR=0.95, 95% CI=0.92-0.98), after adjustment for sociodemographic characteristics, functional limitations, and antidepressant use. The trends varied significantly by age, but not sex and race/ethnicity. The overall decline was mainly driven by older adults above age 64.

CONCLUSIONS

Prevalence of serious psychological distress and depression among US adults with stroke decreased from 2004 to 2017, but the burden of mental health problems remained high.

Assessing the psychometric properties of the Chinese return-to-work self-efficacy questionnaire using Rasch model analysis

Background

Self-efficacy is a significant predictor of return to work and affects the confidence of survivors to return to work after illness. The Return-to-work self-efficacy (RTW-SE) questionnaire is a self-report questionnaire to assess confidence in returning to work with good reliability and validity. The aim of this study was to translate and cross-culturally adapt the RTW-SE questionnaire into Chinese and examine the psychometric properties among young and middle-aged stroke survivors using Rasch model analysis.

Methods

The cross-cultural adaptation and translation procedures followed a dual-translation approach. The psychometric properties of the RTW-SE questionnaire were examined using Rasch model analysis by Winsteps software. The unidimensionality and local independence were analyzed by principal component analysis of the residuals (PCAR) and standardized residual correlations.Category diagnostics were performed for scale function, and the item fit, reliability, and separation were also validated. Item-person maps were used to examine the distribution and matching of item’s location and person ability. Finally, the differential item functioning (DIF) was used to measure gender-related group equivalence.

Results

A total of 366 participants aged 23–59 years were recruited from three communities in Zhengzhou. The RTW-SE questionnaire demonstrated unidimensionality and a 5-point Likert rating scale was more appropriate to investigate young and middle-aged stroke survivors’self-efficacy. There was a good fit for the items with both person and item reliabilities greater than 0.8 and separation indices of 3.75 and 3.94, respectively. The item location was identified from the item-person map as not covering person ability, but the scale did not have an age-related DIF.

Conclusions

The results confirm evidence of appropriate psychometric properties of the RTW-SE questionnaire and can be used as a reliable and validated instrument for measuring self-efficacy to return to work in young and middle-aged Chinese patients with stroke.

Factors associated with sustaining work after an acquired brain injury: a scoping review

PURPOSE

Maintaining work in the long term represents a major challenge for people with acquired brain injury (ABI) as evidenced by a high rate of premature labour market dropouts. The present study aimed to compile factors associated with working in the long term after sustaining an ABI.

MATERIALS AND METHODS

We carried out a scoping review synthesizing quantitative and qualitative research conducted between 2000 and 2021. Databases searched comprised PubMed, CINAHL Complete, PsycINFO, Scopus, and Web of Science.

RESULTS

Ten quantitative and nine qualitative studies were included, all but one from high-resource countries. Quantitative research predominantly comprised longitudinal follow-ups on individuals' work status several years post ABI onset, showing an effect of injury-related and sociodemographic factors. Qualitative studies mostly dealt with work maintenance and revealed a key role of cognitive difficulties, psychological personal factors (e.g., adequate coping strategies) and environmental factors (e.g., flexible work schedules, supportive colleagues).

CONCLUSIONS

The factors identified in our review should receive particular attention in vocational integration and job retention programs to support work participation of people with ABI in the long term. There is a need for measures that regularly monitor and promote a good match between individuals and their work environment.Implications for RehabilitationPeople with acquired brain injury (ABI) often have long-lasting and invisible injury-related difficulties that hamper their labour market participation.Factors identified as positively associated with working in the long term, such as coping strategies and self-awareness, should be strengthened.Future interventions should educate affected persons, employers and health care professionals about long-lasting injury-related difficulties and promote a supportive work environment for people with ABI.Prolonged availability of vocational services could be beneficial for supporting work maintenance of people with ABI.

Neuropsychiatric Complications after Stroke

Neuropsychiatric disturbances represent a common and uniquely challenging consequence of stroke. These disorders arise at the intersection of lesion-related brain dysfunction and psychological distress related to the event and its aftermath, making it difficult to identify what symptom is a direct physiological consequence of the stroke. Depression, anxiety, fatigue, apathy, emotionalism, and anger are the most common of these syndromes, and posttraumatic stress disorder related to the stroke event has become increasingly recognized as a relevant entity. Mania, obsessive-compulsive disorder, and psychosis are less commonly encountered but potentially highly debilitating conditions that may be underrecognized. Early identification and treatment may mitigate functional impairment and improve quality of life. Evidence-based guidelines from the general population are often relied upon to guide treatment. Further research is needed to understand and tailor treatment of these disorders in the poststroke population.

Cross-Cultural Adaptation and Validation of the Chinese Version of the Work-Ability Support Scale (WSS) in Young and Middle-Aged Stroke Survivors

Purpose To translate and cross-culturally adapt the Work-Ability Support Scale (WSS) into Chinese and evaluate the reliability and validity of the measure among young and middle-aged stroke survivors. Methods A total of 210 participants aged 28-60 years were recruited from two communities in Zhengzhou. Item analysis, internal consistency, inter-rater reliability, and construct validity were tested. Results A moderate level of correlation between the items and the domains (r > 0.60), and the significant differences in items between the high group and the low group were tested by independent sample t-tests (P < 0.001). For Part A, Cronbach's α of the domains "physical", "thinking and communication", and "social/behavioural" was 0.865, 0.857 and 0.912, respectively. The Cronbach's α coefficient of Part A of the WSS was calculated as 0.931. The Cronbach's α of Part B was 0.761, with Cronbach's α values of 0.795, 0.649 and 0.643 for "personal factors", "environmental factors (within the workplace)", and "barriers to return to work", respectively. The split-half coefficients of Parts A and B were assessed as 0.804 and 0.559, respectively. The kappa coefficient of the other items all exceeded 0.60 (P < 0.001), except for a few items. The scale-level content validity index (S-CVI) was 0.94 and 0.90 for Parts A and B, respectively. The original construct of the scale was examined by confirmatory factor analysis (CFA), and model fit indices were mostly satisfactory. Conclusion The WSS is a reliable and valid tool for measuring young and middle-aged Chinese stroke survivors' work ability and support needs during their return to work.

Socioeconomic Factors Predicting Depression Differ in the Acute Stage and at 1 year After Ischemic Stroke or TIA

INTRODUCTION

Considerable depressive symptoms follow stroke in about one third of patients. Initial depressive symptoms may wane after the acute phase of stroke, but persisting depressive symptoms adversely affect rehabilitation and quality of life. We set forth to evaluate predictors of depressive symptoms with a focus on socioeconomic factors.

METHODS

We evaluated clinical features and socioeconomic characteristics in 233 consecutive patients with acute ischemic stroke or TIA. Depressive symptoms could be evaluated in 168 subjects in the acute phase with a repeated testing after a mean of 14.7 months via telephone interview in 116 patients. Survival status, scores on the Center for Epidemiologic Studies-Depression Scale (CES-D), Beck Depression Inventory (BDI) and disability (modified Rankin scale, mRS) were recorded.

RESULTS

In the acute phase, employment status (p = 0.037) and level of education (p = 0.048) whereas one year later dependency (mRS≥3, p = 0.002) and income (p = 0.012) were the significant predictors of the severity of depressive symptoms. A change from independent (mRS≤2) to dependent living predicted worsening depressive symptoms (p = 0.008), whereas improving to functional independence from an initially dependent condition was associated with diminishing depressive symptoms (p = 0.077 for CES-D and p = 0.044 for BDI) in the first year after an acute ischemic cerebrovascular event.

CONCLUSIONS

Predictors of the severity of depressive symptoms differed in the acute phase and at follow-up. In addition to disability, education and employment status in the acute phase and income in the late phase predict the severity of depressive symptoms after ischemic stroke or TIA.

Evaluating a Novel Multifactorial Falls Prevention Activity Programme for Community-Dwelling Older People After Stroke: A Mixed-Method Feasibility Study

Purpose

The overall purpose of this study was to explore participants’ and physiotherapists’ experiences regarding the acceptability, implementation, and practicality of a novel group-based multifactorial falls prevention activity programme for community-dwelling older people after stroke. Specifically, the purpose was to explore if and how participating could impact on the participants’ health-related quality of life (HRQoL) in terms of their daily lived experience regarding physical, mental, emotional and social well-being. A secondary purpose was to explore whether participating in the programme could positively influence participants’ balance, strength, falls efficacy, mobility and motor impairment of the trunk.

Materials and Methods

This was an exploratory mixed-method Phase I feasibility study. A convenience sample of five older community-dwelling people after stroke participated in a novel eight-week multifactorial activity programme which included falls education, a mix of individually tailored and group-based strength and balance exercises, exploring limits of stability and safe landing techniques and a social element. Qualitative data from post-intervention interview transcripts with the participants and the physiotherapists who delivered the programme were thematically analysed using both deductive and inductive approaches to explore the participants’ and therapists’ experiences with the programme. Quantitative outcomes included balance, strength, falls efficacy, mobility and motor impairment of the trunk.

Results

The programme was deemed feasible in terms of acceptability, implementation and practicality by the participants as well as the physiotherapists delivering the programme. The overarching theme regarding HRQoL identified that participating in the programme was perceived to empower the participants living with stroke and positively influenced their daily physical, mental, emotional and social well-being. Participant outcomes showed a change in the direction of improvements in balance, strength, mobility, motor impairment of the trunk and reduced concerns about falling. Subjectively, participants only reported perceived improvements in balance and strength.

Conclusion

Running a novel multifactorial falls prevention activity programme for older community-dwelling people after stroke was feasible. Participating in the programme helped participants to perceive improved balance, strength and empower them to make meaningful changes, improving their daily lived experiences. A future fully powered study could build on these results to investigate physical improvements, prevention of falls and improvements to domains of HRQoOL.

[Differential expression of miR-30a-5p in post stroke depression and bioinformatics analysis of the possible mechanism]

OBJECTIVE

To investigate the differential expression of miR-30a-5p in patients with poststroke depression and explore the possible mechanism.

METHODS

We obtained the target microRNAs through searching PubMed using the online software VENNY2.1. We collected the baseline demographic, clinical and radiographic data from consecutive patients with first-ever acute ischemic stroke on admission in our department from October, 2018 to March, 2019. From each patient, 5 mL peripheral venous blood was collected upon admission. Hamilton Depression Scale (HAMD-17) was used to evaluate the degree of depression at the end of the 3-month follow-up. The patients with a HAMD-17 score≥7 were diagnosed to have depression according to the diagnostic criteria of the Fourth Edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association (DSM-IV). The patients were divided into post-stroke depression group (PSD group, n=11) and non-post-stroke depression group (non-PSD group, n=25), and their plasma levels of miR-30a-5p were detected using qPCR. The STARBASE Database ENCORI miRNA-mRNA module and Comparative Toxicogenomics Database were used to predict and screen the possible target genes related to miR-30a-5p, and the possible mechanism of the target genes was further analyzed through bioinformatics.

RESULTS

miR-30a-5p was identified by cross-screening as the target miRNA associated with stroke and depression and showed obvious differential expression between PSD and non-PSD patients (2.462±0.326 vs 1±0.126, P &lt; 0.0001). ROC curve analysis showed that the AUC of miR-30a-5p for predicting PSD was 0.869 (95%CI: 0.745-0.993, P=0.0005) at the cutoff value of 1.597, with a sensitivity and specificity of 0.727 and 0.840, respectively. The target proteins of miR-30a-5p involved a wide range of biological processes, including signal transduction, intercellular communication, regulation of nucleobase, nucleoside, nucleotide and nucleic acid metabolism. KEGG pathway enrichment analysis showed that the target proteins affected mainly the neural nutrient signaling pathway, axon guidance signaling pathway and insulin signaling system. We also identified the top 20 HUB genes that might be associated with post-stroke depression.

CONCLUSIONS

Plasma miR-30a-5p is differentially expressed in PSD and can serve as a new blood marker for diagnosis and also a therapeutic target of PSD.

Intention to Return to Work after Stroke Following Rehabilitation in Ontario

Background.

Returning to work is important for many people following stroke. An estimate of the prevalence of people intending to return to work post-stroke would be helpful in planning services supporting work reintegration.

Purpose.

This study examined the prevalence of intention to return to work after discharge among stroke rehabilitation inpatients.

Methods.

We performed secondary analysis of National Rehabilitation Reporting System data for all stroke rehabilitation inpatients across Ontario (2012–2017). Intention to return to work was examined by gender, age, and level of disability.

Findings.

Among 25,691 stroke rehabilitation inpatients, 4,668 (18.2%) were employed pre-stroke and 2,039 (43.7%) of them intended to return to work. Intention to return to work was somewhat higher among younger and middle-aged stroke survivors and those with mild disability.

Implications.

Providers and planners should be aware that almost half of previously employed stroke-rehabilitation inpatients may be seeking services to assist with return to work.