Factors influencing return-to-work after cerebrovascular disease: the importance of previous cardiovascular risk

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.

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.

Understanding Return to Work After Stroke Internationally: A Scoping Review

ABSTRACT

BACKGROUND: Internationally, the changing landscape of diagnosis, treatment, and follow-up post stroke is resulting in a concomitant rise in the number of survivors still in the workforce. Return to work (RTW) is a common goal for adults after stroke; however, poststroke disabilities may limit occupational opportunities. This scoping review was undertaken to gain an understanding of the concept of RTW, how it is defined in the literature, types of research conducted on RTW after stroke, and characteristics of patients who do and do not RTW. We also wanted to gain an understanding of the interventions that were successful for RTW, their efficacy, and which healthcare professionals conducted such interventions. METHODS: Two authors reviewed articles using a customized data extraction tool. Adhering to current scoping review guidelines, data were collated and described using narrative and tables. RESULTS: A total of 48 studies were included in this scoping review: 34 quantitative, 11 qualitative, and 3 mixed method studies. The studies were conducted between the years 1998 and 2018, with more than half undertaken within the past decade and primarily in economically developed countries. DISCUSSION: Few interventions specifically targeted RTW as a primary outcome; most interventions were conducted by rehabilitation professionals with RTW measured by self-report. The nursing contribution was noticeably absent in the literature. CONCLUSIONS: Return to work has not been consistently operationalized in the literature. Although nurses are in a unique position to assist stroke survivors in their goal of RTW, how to do so remains elusive.

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.

Potential Role of Tocotrienols on Non-Communicable Diseases: A Review of Current Evidence

Tocotrienol (T3) is a subfamily of vitamin E known for its wide array of medicinal properties. This review aimed to summarize the health benefits of T3, particularly in prevention or treatment of non-communicable diseases (NCDs), including cardiovascular, musculoskeletal, metabolic, gastric, and skin disorders, as well as cancers. Studies showed that T3 could prevent various NCDs, by suppressing 3-hydroxy-3-methylglutaryl-coenzyme A reductase (HMGCR) in the mevalonate pathway, inflammatory response, oxidative stress, and alternating hormones. The efficacy of T3 in preventing/treating these NCDs is similar or greater compared to tocopherol (TF). TF may lower the efficacy of T3 because the efficacy of the combination of TF and T3 was lower than T3 alone in some studies. Data investigating the effects of T3 on osteoporosis, arthritis, and peptic ulcers in human are limited. The positive outcomes of T3 treatment obtained from the preclinical studies warrant further validation from clinical trials.

Cross-Cultural Adaptation of the Work Rehabilitation Questionnaire (WORQ) to French: A Valid and Reliable Instrument to Assess Work Functioning

Purpose The Work Rehabilitation Questionnaire (WORQ) is a patient-reported instrument to assess work related functioning in vocational rehabilitation (VR) and work, based on the International Classification of Functioning, Disability and Health (ICF) core set for VR. The objective of this study was to cross-culturally adapt WORQ to French and to evaluate its psychometric properties. Methods The cross-cultural adaptation followed a dual-panel approach. Psychometrics was examined in one VR-centre in the French speaking part of Switzerland. Test-retest reliability was analyzed with intraclass correlation coefficient (ICC), internal consistency was assessed with Cronbach's alpha. Construct validity was determined by convergence to the self-reported general functioning scale and the Hospital Anxiety and Depression Scales (HADS). The association of patient's return-to-work expectation within 6-months and having a case manager was examined. The usability of WORQ-French was tested in 10 VR patients. Results Eighty-nine patients with musculoskeletal injuries were included. WORQ-French showed excellent internal consistency (0.968) and a high test-retest reliability (0.935). WORQ-French was positively associated with self-reported general functioning (r = 0.662) and both HADS scales (r = 0.56-0.57). Neither the patient's return-to-work expectation nor having a case manager were significantly correlated with WORQ-French. Usability in terms of understandability of questions and response options was found to be good. Seven patients rated the length of WORQ-French as good, while two found the instrument a little too long and one found it too long. Conclusions WORQ French is a valid, reliable, and easy to administer instrument to assess self-reported work functioning given our study setting and sample characteristics.

Return to work after ischemic stroke in young adults: A registry-based follow-up study

OBJECTIVE

We aimed to investigate the proportion of young patients not returning to work (NRTW) at 1 year after ischemic stroke (IS) and during follow-up, and clinical factors associated with NRTW.

METHODS

Patients from the Helsinki Young Stroke Registry with an IS occurring in the years 1994-2007, who were at paid employment within 1 year before IS, and with NIH Stroke Scale score ≤15 points at hospital discharge, were included. Data on periods of payment came from the Finnish Centre for Pensions, and death data from Statistics Finland. Multivariate logistic regression analyses assessed factors associated with NRTW 1 year after IS, and lasagna plots visualized the proportion of patients returning to work over time.

RESULTS

We included a total of 769 patients, of whom 289 (37.6%) were not working at 1 year, 323 (42.0%) at 2 years, and 361 (46.9%) at 5 years from IS. When adjusted for age, sex, socioeconomic status, and NIH Stroke Scale score at admission, factors associated with NRTW at 1 year after IS were large anterior strokes, strokes caused by large artery atherosclerosis, high-risk sources of cardioembolism, and rare causes other than dissection compared with undetermined cause, moderate to severe aphasia vs no aphasia, mild and moderate to severe limb paresis vs no paresis, and moderate to severe visual field deficit vs no deficit.

CONCLUSIONS

NRTW is a frequent adverse outcome after IS in young adults with mild to moderate IS. Clinical variables available during acute hospitalization may allow prediction of NRTW.

Examination of the relevance of the ICF cores set for stroke by comparing with the Stroke Impact Scale

PURPOSE

To examine if the International Classification of Functioning (ICF) core set for stoke contains problems that are relevant for the persons living with stroke as expressed in the Stroke Impact Scale (SIS).

METHODS

Cross-sectional study of 242 persons with previous stroke. The agreement between the perceived problems in the SIS items and problems in the categories of Comprehensive ICF Core Set for stroke were analyzed using percent of agreement and Kappa statistic.

RESULTS

The analyses between 57 items of the SIS and 31 second-level categories of the ICF were conducted. The problems in domains of "Mobility", "Activities of daily living", "Hand function", "Strength" in the SIS had moderate agreement when compared to ICF categories. The SIS domains of "Emotion" and "Communication", as well as some aspects of the "Memory" had slight or fair agreement with corresponding ICF categories. The results of the study suggest that there is acceptable agreement between persons after stroke and health professionals in the physical aspects, but rather poor agreement in the cognitive and emotional aspects of functioning.

CONCLUSIONS

Health professionals do not fully capture the magnitude of emotional or social problems experienced by persons after stroke when using the ICF Core Set as a framework for evaluation. Implications for Rehabilitation The ICF Core Set for Stroke provides comprehensive list of possible health and health related outcomes for persons after stroke. Problems reported in condition-specific patient-reported outcome scales can be important in decision making in rehabilitation. Patients and health professionals tend to agree more on physical than cognitive problems. Examination of the relevance of the ICF cores set for stroke by comparing with the Stroke Impact Scale.

Trends in Diagnosis-Specific Work Disability Before and After Stroke: A Longitudinal Population-Based Study in Sweden

Background

Although a stroke event often leads to work disability, diagnoses behind work disability before and after stroke are largely unknown. We examined the pre‐event and postevent trends in diagnosis‐specific work disability among patients of working age.

Methods and Results

We included all new nonfatal stroke events in 2006–2008 from population‐based hospital registers in Sweden among women and men aged 25 to 60 years (n=12 972). Annual days of diagnosis‐specific work disability were followed for 4 years before and after stroke. Repeated measures negative binomial regression models using the generalized estimating equations method were fitted to examine trends in diagnosis‐specific work disability before and after the event. Already during the 4 pre‐event years, work disability attributed to circulatory diseases increased among women (rate ratio, 1.99; 95% confidence interval, 1.68–2.36) and men (rate ratio, 2.20; 95% confidence interval, 1.88–2.57). Increasing trends before stroke were also found for work disability attributed to mental disorders, musculoskeletal diseases, neoplasms, diseases of the nervous, respiratory, and digestive systems, injuries, and diabetes mellitus. As expected, a sharp increase in work disability days attributed to circulatory diseases was found during the first year after the event among both sexes. Overall, during 4 years after the stroke, there was a decreasing trend for circulatory diseases and injuries, whereas the trend was increasing for nervous diseases and diabetes mellitus.

Conclusions

Work disability attributed to several mental and somatic diagnoses is higher already before a stroke event.

Permanent work disability before and after ischaemic heart disease or stroke event: a nationwide population-based cohort study in Sweden

OBJECTIVES

We examined the risk of disability pension before and after ischaemic heart disease (IHD) or stroke event, the burden of stroke compared with IHD and which factors predicted disability pension after either event.

DESIGN

A population-based cohort study with follow-up 5 years before and after the event. Register data were analysed with general linear modelling with binary and Poisson distributions including interaction tests for event type (IHD/stroke).

SETTING AND PARTICIPANTS

All people living in Sweden, aged 25‒60 years at the first event year, who had been living in Sweden for 5 years before the event and had no indication of IHD or stroke prior to the index event in 2006‒2008 were included, except for cases in which death occurred within 30 days of the event. People with both IHD and stroke were excluded, resulting in 18 480 cases of IHD (65%) and 9750 stroke cases (35%).

PRIMARY OUTCOME MEASURES

Disability pension.

RESULTS

Of those going to suffer IHD or stroke event, 25% were already on disability pension a year before the event. The adjusted OR for disability pension at first postevent year was 2.64-fold (95% CI 2.25 to 3.11) for people with stroke compared with IHD. Economic inactivity predicted disability pension regardless of event type (OR=3.40; 95% CI 2.85 to 4.04). Comorbid mental disorder was associated with the greatest risk (OR=3.60; 95% CI 2.69 to 4.83) after an IHD event. Regarding stroke, medical procedure, a proxy for event severity, was the largest contributor (OR=2.27, 95% CI 1.43 to 3.60).

CONCLUSIONS

While IHD event was more common, stroke involved more permanent work disability. Demographic, socioeconomic and comorbidity-related factors were associated with disability pension both before and after the event. The results help occupational and other healthcare professionals to identify vulnerable groups at risk for permanent labour market exclusion after such an event.