Return to work for stroke survivors with aphasia: A quantitative scoping review

The international incidence of stroke in people of working age is rising. As such, meaningful work return is a major rehabilitation goal for many individuals, including those with aphasia. This scoping review aimed to outline the post-stroke aphasia evidence related to work outcomes, factors influencing employment along with contemporary vocational-language and communication rehabilitation practice. The review employed terms related to aphasia, stroke, rehabilitation, and return to work in publications preceding 25.6.2023. Data were descriptively analysed, and vocational outcomes were summarized at defined timepoints. Of the 908 articles reviewed, 31 papers were included. Individuals with post-stroke aphasia consistently have lower rates of return to work than those post-stroke without aphasia. Employment at one year was 34.29% for those with aphasia compared to 58.46% for people without aphasia. No literature reported vocational-language assessment practices and there were minimal work-focused aphasia interventions identified. There was insufficient evidence to clearly identify person-related, rehabilitation, workplace or other factors influencing work return. This scoping review has identified that there are gaps in knowledge about the factors that influence work return and targeted vocational rehabilitation for this group. Future research to optimize return to work for individuals with aphasia is recommended.

A framework to support early team-based provision of vocational rehabilitation for adults with acquired brain injury

PURPOSE

Specialised vocational rehabilitation (VR) following acquired brain injury (ABI) positively impacts return to work, however access to this is limited globally. Providing VR as a component of standard ABI rehabilitation may improve access to VR and influence vocational outcomes. This study aimed to develop an evidence-based framework for the delivery of ABI VR during early transitional community rehabilitation.

MATERIALS AND METHODS

The development of the ABI VR framework utilised an emergent multi-phase design and was informed by models of evidence-based practice, national rehabilitation standards, guidelines for complex intervention development, model of care and framework development, and the knowledge-to-action framework. Four study phases were undertaken to identify and generate the evidence base, with findings synthesised to develop the ABI VR framework in phase five.

RESULTS

The framework provides a structure for the systematic delivery of VR as a component of team-based ABI rehabilitation, through five phases of rehabilitation: assessment; goal setting and rehabilitation planning; intervention; monitoring and evaluation; and discharge. It details the activities to be undertaken across the phases using a hybrid model of ABI VR (involving program-based VR and case coordination) and contains service delivery features.

CONCLUSION

The framework has the potential to translate to other similar service contexts.

Risk factors and service gaps affecting a sustainable work: a qualitative multi-stakeholder analysis in the context of persons with acquired brain injury living in Switzerland

INTRODUCTION

Along with the social and economic challenges posed by an aging society, creating work conditions that allow persons to stay healthy and work into old age has become a major task of Western societies. Retaining employment after returning to work is particularly difficult for individuals with a disability, as evidenced by the high rate of premature labor market dropout. Individuals with acquired brain injury (ABI) exemplify this challenge, as it often impairs cognitive, technical, and interpersonal abilities that are crucial in today's labor market. To effectively support these individuals, vocational integration practitioners require comprehensive knowledge of risk factors for premature labor market dropout and effective strategies for sustainable work.

OBJECTIVE

This study aimed to identify perceived risk factors and related service gaps regarding sustainable work for people with ABI, as reported by affected individuals, employers, vocational integration professionals, and health professionals.

METHODS

Secondary data analysis. Data that was originally collected through seven focus groups and two interviews with persons with ABI, 15 interviews with employers, and 13 interviews with vocational integration and health professionals in the context of the project 'Sustainable employment' was re-analysed thematically.

RESULTS

Two major themes of risk factors were identified: (1) person-related factors (including the subthemes: post-ABI impairments; lack of understanding of post-ABI impairments; poor health management) and (2) environment-related factors (including the subthemes: challenges related to the service structure; insufficient knowledge and education about ABI; challenges at the workplace; difficulties in private life). While stakeholders noted the variety of the currently available services, they particularly pointed to the missing long-term monitoring and counseling services for persons with ABI following the initial return-to-work, reflecting a major challenge for sustainable work. An overarching gap related to the fragmentation of the service structure and the lack of case coordination along the working life.

CONCLUSIONS

Multiple stakeholders emphasized the importance of empowering individuals, ensuring easy access to professional support, and providing a suitable work environment to address key risk factors and facilitate sustainable work for individuals with ABI. Continuous coaching, long-term monitoring and counseling following return-to-work, were identified as potential strategies to achieve these goals.

What is the volume, quality and characteristics of evidence relating to the effectiveness and cost-effectiveness of multi-disciplinary occupational health interventions aiming to improve work-related outcomes for employed adults? An evidence and gap map of systematic reviews

Background

In the UK, tens of millions of working days are lost due to work-related ill health every year, costing billions of pounds. The role of Occupational Health (OH) services is vital in helping workers to maintain employment when they encounter injury or illness. OH providers traditionally rely on a clinical workforce to deliver these services, particularly doctors and nurses with OH qualifications. However, the increasing demand for OH services is unlikely to be met in the future using this traditional model, due to the declining number of OH-trained doctors and nurses in the UK. Multi-disciplinary models of OH delivery, including a more varied range of healthcare and non-healthcare professionals, could provide a way to meet this new demand for OH services. There is a need to identify collaborative models of OH service delivery and review their effectiveness on return-to work outcomes. There is an existing pool of systematic review evidence evaluating workplace based, multi-disciplinary OH interventions, but it is difficult to identify which aspects of the content and/or delivery of these interventions may be associated with improved work-related outcomes.

Objectives

The aim of this evidence and gap map (EGM) was to provide an overview of the systematic review evidence that evaluates the effectiveness and cost-effectiveness of multi-disciplinary OH interventions intending to improve work-related outcomes.

Search Methods

In June 2021 we searched a selection of bibliographic databases and other academic literature resources covering a range of relevant disciplines, including health care and business studies, to identify systematic review evidence from a variety of sectors of employment. We also searched Google Search and a selection of topically relevant websites and consulted with stakeholders to identify reports already known to them. Searches were updated in February 2023.

Selection Criteria

Systematic reviews needed to be about adults (16 years or over) in employment, who have had absence from work for any medical reason. Interventions needed to be multi-disciplinary (including professionals from different backgrounds in clinical and non-clinical professions) and designed to support employees and employers to manage health conditions in the workplace and/or to help employees with health conditions retain and/or return to work following medical absence. Effectiveness needed to be measured in terms of return to work, work retention or measures of absence, or economic evaluation outcomes. These criteria were applied to the title and abstract and full text of each systematic review independently by two reviewers, with disagreements resolved through discussion. We awarded each systematic review a rating of 'High', 'Medium' or 'Low' relevance to indicate the extent to which the populations, interventions and their contexts synthesised within the review were consistent with our research question. We also recorded the number of primary studies included within each of the 'High' and 'Medium' reviews that were relevant to research question using the same screening process applied at review level.

Data Collection and Analysis

Summary data for each eligible review was extracted. The quality of the systematic reviews, rated as 'High' or 'Medium' relevance following full text screening, was appraised using the AMSTAR-2 quality appraisal tool. All data were extracted by one reviewer and checked by a second, with disagreements being settled through discussion. Summary data for all eligible systematic reviews were tabulated and described narratively. The data extracted from reviews of 'High' and 'Medium' relevance was imported into EPPI-Mapper software to create an EGM.

Stakeholder Involvement

We worked alongside commissioners and policy makers from the Department of Health and Social Care (DHSC) and Department of Work and Pensions (DWP), OH personnel, and people with lived experience of accessing OH services themselves and/or supporting employees to access OH services. Individuals contributed to decision making at all stages of the project. This ensured our EGM reflects the needs of individuals who will use it.

Main Results

We identified 98 systematic reviews that contained relevant interventions, which involved a variety of professionals and workplaces, and which measured effectiveness in terms of return to work (RTW). Of these, we focused on the 30 reviews where the population and intervention characteristics within the systematic reviews were considered to be of high or medium relevance to our research questions. The 30 reviews were of varying quality, split evenly between High/Moderate quality and Low/Critically-Low quality ratings. We did not identify any relevant systematic review evidence on any other work-related outcome of interest. Interventions were heterogenous, both within and across included systematic reviews. The EGM is structured according to the health condition experienced by participants, and the effectiveness of the interventions being evaluated, as reported within the included systematic reviews. It is possible to view (i) the quality and quantity of systematic review evidence for a given health condition, (ii) how review authors assessed the effectiveness or cost-effectiveness of the interventions evaluated. The EGM also details the primary studies relevant to our research aim included within each review.

Authors’ Conclusions

This EGM map highlights the array of systematic review evidence that exists in relation to the effectiveness or cost-effectiveness of multi-disciplinary, workplace-based OH interventions in supporting RTW. This evidence will allow policy makers and commissioners of services to determine which OH interventions may be most useful for supporting different population groups in different contexts. OH professionals may find the content of the EGM useful in identifying systematic review evidence to support their practice. The EGM also identifies where systematic review evidence in this area is lacking, or where existing evidence is of poor quality. These may represent areas where it may be particularly useful to conduct further systematic reviews.

Experiences of participating in a vocational rehabilitation program in Singapore

PURPOSE

The purposes of this study were to (i) describe the lived experiences of participating in a Singaporean vocational rehabilitation (VR) program among individuals with stroke and spinal cord injury and (ii) identify salient features of the program that facilitated their return-to-work process.

MATERIALS AND METHODS

This was a qualitative phenomenological study. Participants were invited to complete an interview about their return-to-work process after acquiring a disability vis-à-vis their participation in a local VR program. The qualitative data were analyzed inductively.

RESULTS

Twenty-four middle-aged participants with a stroke or spinal cord injury completed the interviews. The participants' experiences with the local VR program were largely positive. Several key features of the VR program were identified. These were: (i) providing a multi-disciplinary and individualized program; (ii) building positive collaborations between service providers and participants; and (iii) supporting personal growth among participants.

CONCLUSION

The Singaporean VR program demonstrated internationally recommended best practices. These best practices were beneficial for the participants' return-to-work process, as reflected by their positive feedback about the program. Our study emphasizes the need for comprehensive and evidence-based VR programs to meet the complex needs of individuals with disabilities who want to return to work.Implications for rehabilitationMulti- or inter-disciplinary care services are needed in vocational rehabilitation (VR) programs to support the complex return-to-work process of clients.VR programs should have the capacity to provide client-centered care as their clients may experience diverse, yet unique challenges during their return-to-work processVR service providers play a crucial role in engaging and motivating their clients throughout the program to achieve their return-to-work goalsVR service providers should address concurrent or future concerns that could impact on their clients' ability to return to or remain at work.

Rate of return to work in patients with stroke under the health and employment support program of Rosai hospitals in Japan

To facilitate return to work (RTW) in patients with stroke, a health and employment support (HES) program was started at Rosai hospitals in Japan. This study aimed to determine the rate of RTW in patients with stroke under this support program. We collected demographic and clinical data of patients with stroke from the implementation reports of the HES program. The program provided coordinated dual support, such as acute medical treatments, and stroke and vocational rehabilitation on the medical side, and management and support on the workplace side. The primary endpoint was RTW. Successful and unsuccessful RTW were examined using the χ2 test. The RTW rate curves were analyzed using the Kaplan-Meier method. We enrolled 483 patients; 355 (73%) and 128 (27%) patients had successful and unsuccessful RTW, respectively. Stroke types, neurological findings, and activities of daily living were significant factors for RTW. The Kaplan-Meier method revealed that left hemiplegia, right hemiplegia, and neuropsychological deficits, except for combined disability (hemiplegia with neuropsychological deficits), had similar RTW curves with an RTW rate of > 70%.

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.

Addressing mood and fatigue in return-to-work programmes after stroke: a systematic review

Introduction

Return-to-work is a key rehabilitation goal for many working aged stroke survivors, promoting an overall improvement of quality of life, social integration, and emotional wellbeing. Conversely, the failure to return-to-work contributes to a loss of identity, lowered self-esteem, social isolation, poorer quality of life and health outcomes. Return-to-work programmes have largely focused on physical and vocational rehabilitation, while neglecting to include mood and fatigue management. This is despite the knowledge that stroke results in changes in physical, cognitive, and emotional functioning, which all impact one's ability to return to work. The purpose of this systematic review is to conduct a comprehensive and up-to-date search of randomised controlled trials (RCTs) of return-to-work programmes after stroke. The focus is especially on examining components of mood and fatigue if they were included, and to also report on the screening tools used to measure mood and fatigue.

Method

Searches were performed using 7 electronic databases for RCTs published in English from inception to 4 January 2023. A narrative synthesis of intervention design and outcomes was provided.

Results

The search yielded 5 RCTs that satisfied the selection criteria (n = 626). Three studies included components of mood and fatigue management in the intervention, of which 2 studies found a higher percentage of subjects in the intervention group returning to work compared to those in the control group. The remaining 2 studies which did not include components of mood and fatigue management did not find any significant differences in return-to-work rates between the intervention and control groups. Screening tools to assess mood or fatigue were included in 3 studies.

Conclusion

Overall, the findings demonstrated that mood and fatigue are poorly addressed in rehabilitation programmes aimed at improving return-to-work after stroke, despite being a significant predictor of return-to-work. There is limited and inconsistent use of mood and fatigue screening tools. The findings were generally able to provide guidance and recommendations in the development of a stroke rehabilitation programme for return-to-work, highlighting the need to include components addressing and measuring psychological support and fatigue management.

Sociodemographic and morbidity characteristics of people on long-term sick leave

BACKGROUND

Certifying long-term sick leave and coordinating complex rehabilitation programs are essential activities of social insurance doctors. These doctors have a role in preventing the decreased work capacity of employees that may lead to leaving the labour market and the transition of these employees to other social insurance benefits, such as a work disability pension.

OBJECTIVES

Analysis of long-term sick leaves (over 183 days) to identify risk factors and population groups with low potential for work capacity rehabilitation.

METHOD

We conducted a cross-sectional study between September 2019 and September 2020. The information was collected from the National Institute of Medical Assessment and Work Capacity Rehabilitation Bucharest registers and the EXPMED application. The data were statistically analysed using PSPP software.

RESULTS

The highest rehabilitation percentage was achieved in cases of traumatic injuries (73.17%), followed by musculoskeletal diseases (70.06%). We noticed lower recovery in cases of nervous system diseases (50.56%) and cardiovascular diseases (44.23%). In the group that summed up the other pathologies, the recovery percentage was 58.37%. People who regained their work capacity were significantly younger (mean age 47.87 y ± 8.93) than those who turned to other forms of social benefits, such as a disability pension or an old-age pension (mean age 53.16 y ± 8.43).

CONCLUSION

Most of the subjects (72%) regained their work capacity and did not need a disability pension. We identified the sociodemographic and morbidity characteristics of people on long-term sick leave along with target groups requiring intensive intervention measures.

Identifying models, processes, and components of vocational rehabilitation following acquired brain injury: a systematic scoping review

PURPOSE

Acquired brain injury (ABI) is a complex injury which impacts engagement with worker roles. Return to work (RTW) rates for individuals with brain injury are low and those who do RTW often report job instability. Vocational rehabilitation (VR) can improve RTW rates and job stability; however, service provision is varied, and no gold standard has been identified.

METHODS

A systematic scoping review of the literature was completed to explore research activity in VR for individuals with ABI to address the following three questions: what models have been identified to underpin VR in ABI? What clinical processes have been identified to guide provision of VR in ABI? What components of VR have been described and/or recommended in the ABI literature?

RESULTS

The number of included articles was 57. From these articles, 16 models, nine process steps, eight components, and four service delivery components were identified that were utilised in provision of ABI VR. Implications for practice are discussed.

CONCLUSIONS

Key processes and components of ABI VR have been identified across a range of models and apply to clients at all phases post-injury. Findings may be used to inform service provision across a range of time points and support clinicians in their delivery of VR to adults with brain injury.Implications for RehabilitationPeople with acquired brain injury (ABI), even severe injury, can be successful with return to work (RTW) when provided appropriate supports.A wide range of models, interventions, and service components have been identified in the literature which can be used to guide clinical and policy development in ABI vocational rehabilitation.Vocational rehabilitation for individuals with brain injury involves a complex interaction of factors, and consideration should be paid to not only the person and their abilities but also job demands and the environment (physical, social, cultural).Vocational rehabilitation services should be accessible and timed to maximise chances of a successful RTW, provided by a coordinated interdisciplinary team and should involve active stakeholder engagement.

Developing an implementation fidelity checklist for a vocational rehabilitation intervention

BACKGROUND

Despite growing numbers of studies reporting the efficacy of complex interventions and their implementation, many studies fail to report information on implementation fidelity or describe how fidelity measures used within the study were developed. This study aimed to develop a fidelity checklist for measuring the implementation fidelity of an early, stroke-specialist vocational rehabilitation intervention (ESSVR) in the RETAKE trial.

METHODS

To develop the fidelity measure, previous checklists were reviewed to inform the assessment structure, and core intervention components were extracted from intervention descriptions into a checklist, which was ratified by eight experts in fidelity measurement and complex interventions. Guidance notes were generated to assist with checklist completion. To test the measure, two researchers independently applied the checklist to fifteen stroke survivor intervention case notes using retrospective observational case review. The scoring was assessed for interrater reliability.

RESULTS

A fidelity checklist containing 21 core components and 6 desirable components across 4 stages of intervention delivery was developed with corresponding guidance notes. Interrater reliability of each checklist item ranged from moderate to perfect (Cohen's kappa 0.69-1).

CONCLUSIONS

The resulting checklist to assess implementation fidelity is fit for assessing the delivery of vocational rehabilitation for stroke survivors using retrospective observational case review. The checklist proved its utility as a measure of fidelity and may be used to inform the design of future implementation strategies.

TRIAL REGISTRATION

ISRCTN, ISRCTN12464275. Registered on 13 March 2018.

Priorities for returning to work after traumatic injury: A public and professional involvement study

Introduction

Following traumatic injury, occupational therapists (OTs) are pivotal in supporting people to return-to-work (RTW) and regain independence. Aim: to identify priorities for RTW after traumatic injury and highlight barriers hindering the process.

Method

We recruited 17 participants with direct (i.e. trauma survivor [ n = 11]; OT trauma survivor [ n = 2]) or indirect (i.e. OT [ n = 4]) experience of returning to work following traumatic injury. Online consultations, lasting 60 min, were guided by a semi-structured script ensuring relevant topics were covered. An inductive approach was used for coding themes using thematic analysis.

Findings

Sense of purpose, identity and social interaction were greater priorities for RTW, than financial stability. Major barriers were: pain and fatigue; adapting to physical changes; impacts on mental health; and lack of support (healthcare and the workplace). Participants (public and healthcare professionals) reported a lack of vocational rehabilitation in supporting trauma survivors RTW, but advocated occupational therapy for psychological recovery; purposeful engagement in occupations; and community support.

Conclusion

Restoring an individual’s self-identity and social connections, whilst helping control pain and fatigue, should be prioritised when planning occupational therapy for those returning to work after traumatic injury. This study was limited to ‘returners’, but can inform occupational therapy interventions for RTW.

Understanding the priorities in life beyond the first year after stroke: Qualitative findings and non-participant observations of stroke survivors and service providers

ABSTRACTLong-term unmet health needs are associated with a lower quality of life in stroke survivors. Survivors' priorities in living their lives and health professionals' recognition influence survivors' perceptions of their needs. From the perspectives of survivors and service providers, this study investigated survivors' long-term priorities for continuing their lives after stroke. A qualitative study was conducted with a convenience sample of 40 stroke survivors and a purposive sample of 11 providers who had worked with survivors for more than five years and were currently managers of community-based stroke care services or leaders of volunteer groups. Following the survivors' interviews, non-participant observations of a random day's activities were conducted. Data were transcribed verbatim. Survivors' and providers' data were analyzed separately and then together thematically. Five themes emerged: healing the mind in order to move forward, optimizing adaptations and maintaining physical function, living a safe and cost-effective life, returning to work, and giving back to society. Community-based services can be improved to offer more at-home, technology-supported psychological and self-management interventions, barrier-free and one-stop services, and opportunities for employment and volunteering. It would be worthwhile to invest in conducting public education to promote social inclusion and strengthening collaboration between academic and community organizations.

Interventions, barriers, and facilitators associated with return to work for adults following stroke: a scoping review protocol

OBJECTIVE

The purpose of this scoping review is to map what has been reported on interventions, barriers, and facilitators associated with return to work for adults with and without communication disorders following a stroke.

INTRODUCTION

Difficulties in returning to work following a stroke can have a significant impact on people's lives, not only in terms of the individual's finances (and the economy as a whole), but also in terms of the person's psychosocial adjustment, for example, their sense of role and purpose and their self-esteem. This scoping review aims to map the literature examining interventional approaches, barriers, and facilitators relevant to this topic.

INCLUSION CRITERIA

This review will include literature on the return to work for adults aged 16 years or older who have had a stroke. It will be restricted to research conducted in developed countries.

METHODS

Databases that will be searched include MEDLINE, CINAHL, Embase, AMED, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, PEDRo, and OTSeeker. Gray literature or unpublished studies will be searched in OpenGrey and ProQuest Dissertations and Theses, as well as professional bodies and organizations whose remit includes stroke and vocational rehabilitation. The search will be limited to studies written in English since 2010. Titles and abstracts will be screened by two independent reviewers and full-text articles assessed against the inclusion criteria by two independent reviewers. Data will be extracted and the findings will be presented in tabular and graphical format along with a narrative summary.

Predictors of return to work among stroke survivors in south-west Nigeria

INTRODUCTION

Stroke is acknowledged globally and among Nigerian rehabilitation researchers as a public health problem that leaves half of its survivors with significant neurological deficits and inability to re-establish pre-existing roles. Consequent to the dearth of country specific data on return to work and its determinants for stroke survivors in Nigeria, this study investigated the predictors of return to work among stroke survivors in south-west Nigeria.

METHOD

Two hundred and ten stroke survivors from five tertiary health facilities in Osun state, Nigeria responded to a validated three-section questionnaire assessing return to work rates and its determinants after stroke in this study. Collected data were analysed using descriptive statistics and inferential statistic of chi-square, t-test and multiple logistic regression.

RESULT

The mean age of the respondents was 52.90 ± 7.92 years. Over 60% of the respondents returned to work with about half of them in full time employment (32.9%). Majority of the respondents noted that travel to and from work (43.8%) and access at work (43.3%) had an impact on their ability to work. The symptoms of stroke (odds ratio (OR) = 0.87), the environment (OR = 0.83), body function impairments (OR = 0.86) as well as activity and participation problems (OR = 0.80) were the significant predictors of return to work. Hemiplegia or paresis of the non-dominant side of the body was associated with a higher chance of return to work (OR = 7.64).

CONCLUSION

Body function impairments, activity and participation problems were independent predictors of return to work after stroke. Similarly, side of hemiplegia plays a prominent role in resumption of the worker role of stroke survivors in south-west Nigeria.

Consumer perspectives of vocational rehabilitation and return to work following acquired brain injury

Introduction:

Following acquired brain injury, the goal of return to work is common. While return to work is supported through different rehabilitation models and services, access to vocational rehabilitation varies within and between countries, and global rates of employment post-injury remain low. The literature identifies outcomes from vocational programs and experiences with return to work, yet little is known about individuals’ perceptions and experiences regarding rehabilitation to support their vocational goals and experiences in attempting to return to work.

Method:

This qualitative study investigated the experiences of community-living adults with acquired brain injury (n = 8; mean age 45 years; mean time post-injury of 5.5 years) regarding their vocational rehabilitation and return to work. Focus groups and semi-structured interviews were conducted, with data analyzed via thematic analysis.

Results:

Participants identified negative and positive experiences with vocational rehabilitation and return to work. Five overarching themes were identified: addressing vocational rehabilitation in rehabilitation; facilitators of recovery and return to work; the importance and experience of working again; acquired brain injury and identity; and services, systems and policies. Participants also identified five key areas for early vocational rehabilitation services: education; service provision; employer liaison; workplace supports; and peer mentors. Study findings inform current and future practice and service delivery, at a clinical, service and system level.

An expert opinion: Vocational rehabilitation after stroke

Less than half of people return to work following a stroke. For those who do, their return is often complicated by residual 'invisible' symptoms. It is important to ask about work and to provide intervention early in the rehabilitation process. Specialist vocational rehabilitation services can support more complex and long-term interventions, but there is a paucity of service provision which needs to be addressed.

An individually randomised controlled multi-centre pragmatic trial with embedded economic and process evaluations of early vocational rehabilitation compared with usual care for stroke survivors: study protocol for the RETurn to work After stroKE (RETAKE) trial

BACKGROUND

Return to work (RTW) is achieved by less than 50% of stroke survivors. The rising incidence of stroke among younger people, the UK economic forecast, and clinical drivers highlight the need for stroke survivors to receive support with RTW. However, evidence for this type of support is lacking. This randomised controlled trial (RCT) will investigate whether Early Stroke Specialist Vocational Rehabilitation (ESSVR) plus usual care (UC) (i.e. usual NHS rehabilitation) is more clinically and cost-effective for supporting post-stroke RTW, than UC alone.

METHODS

Seven hundred sixty stroke survivors and their carers will be recruited from approximately 20 NHS stroke services. A 5:4 allocation ratio will be employed to randomise participants to receive ESSVR plus UC, or UC alone. The individually tailored ESSVR intervention will commence within 12 weeks of stroke onset and be delivered for up to 12 months as necessary by trained RETAKE occupational therapists in the community, participants' homes or workplaces, and outpatient/inpatient therapy settings, via telephone, email, or SMS text message. Outcome data will be collected via self-report questionnaires administered by post or online at 3, 6, and 12 months follow-up. The primary outcome will be self-reported RTW and job retention at 12 months (minimum 2 h/week). Secondary outcomes will include mood, function, participation, health-related quality of life, confidence, intervention compliance, health and social care resource use, and mortality. An embedded economic evaluation will estimate cost-effectiveness and cost-utility analyses from National Health Service (NHS) and Personal Social Services (PSS) perspectives. An embedded process evaluation will employ a mixed methods approach to explore ESSVR implementation, contextual factors linked to outcome variation, and factors affecting NHS roll-out.

DISCUSSION

This article describes the protocol for a multi-centre RCT evaluating the clinical- and cost-effectiveness of an early vocational rehabilitation intervention aimed at supporting adults to return to work following a stroke. Evidence favouring the ESSVR intervention would support its roll-out in NHS settings.

TRIAL REGISTRATION

ISRCTN, ISRCTN12464275 . Registered on 26 February 2018.

Supporting People With Stroke to Return to Work in Singapore: Findings From a Pilot Vocational Rehabilitation Program

IMPORTANCE

Return to work after stroke is an important rehabilitation outcome. Vocational rehabilitation may support people with stroke to return to work.

OBJECTIVE

To report the return-to-work rate of people with stroke who completed a local community-based vocational rehabilitation program and to describe the program's impact on their community reintegration.

DESIGN

Retrospective database study.

SETTING

Community-based voluntary welfare organization.

PARTICIPANTS

Fifty-eight men and women ages 21 to 55 yr, formally diagnosed with stroke, with no significant cognitive impairment, and fit to undergo rehabilitation.

INTERVENTION

A pilot community-based interdisciplinary vocational rehabilitation program implemented between 2014 and 2017. The program included physical rehabilitation, psychosocial support, employment support, and caregiver support services.

OUTCOMES AND MEASURES

Return-to-work rate and community reintegration as measured by the Community Integration Questionnaire (CIQ).

RESULTS

Fifty participants completed the program. Their median age was 44 yr, and most were male (n = 37; 74%). Forty-four participants (88%) returned to work after completing the program. Statistically significant differences (p < .001) were found between their CIQ scores at program enrollment and at completion.

CONCLUSIONS AND RELEVANCE

The program appeared to benefit people with stroke in their return-to-work process. Future studies are recommended to determine the effectiveness of such programs and identify features contributing to their success. Potential implications for occupational therapy practice are that vocational rehabilitation interventions can be initiated earlier, comprehensive return-to-work programs can better address the unique needs of people with stroke, and interdisciplinary evaluations are needed to assess suitability for return to work.

WHAT THIS ARTICLE ADDS

One of occupational therapy's unique goals is to facilitate performance and participation in valued activities such as work. Occupational therapists can play a pivotal role across the continuum of care to support their clients to explore and achieve their vocational goals after stroke.

The Influence of Gayatri Mantra and Emotional Freedom Technique on Quality of Life of Post-Stroke Patients

PURPOSE

The quality of life in stroke patients is vital for survival. Nowadays, studies that show a decrease in quality of life in post-stroke patients are increasing. Various non-pharmacological modalities were explored in the past to improve rehabilitation. However, the study about the effects of religious mantra and its combination with the modern technique was lacking. Therefore, this study aimed to analyse the effects of Gayatri Mantra and Emotional Freedom Technique (EFT) on quality of life (QOL) of post-stroke patients.

METHODS

A quasi-experimental with pretest and posttest with the control group design was conducted. Forty-six post-stroke subjects with reduced quality of life based on Stroke Specific Quality of Life were consecutively recruited and divided into controls and intervention groups. The intervention group received additional treatment with Gayatri Mantra and EFT. In contrast, the control group attends and adheres only to the standard hospital rehabilitation program.

RESULTS

All indicators and the overall score of QOL in the intervention group showed significant improvement after treatment (p<0.05) compared with no improvement in the control group. Overall, a higher QOL score was observed in the intervention group at the end of the study. Mann-Whitney test shows significant differences between the final QOL score in intervention and control groups (p<0.001).

CONCLUSION

Gayatri Mantra and EFT are significantly increasing the quality of life of post-stroke patients.

Exploring post acute rehabilitation service use and outcomes for working age stroke survivors (≤65 years) in Australia, UK and South East Asia: data from the international AVERT trial

OBJECTIVES

Information about younger people of working age (≤65 years), their post stroke outcomes and rehabilitation pathways can highlight areas for further research and service change. This paper describes: (1) baseline demographics; (2) post acute rehabilitation pathways; and (3) 12-month outcomes; disability, mobility, depression, quality of life, informal care and return to work of working age people across three geographic regions (Australasia (AUS), South East (SE) Asia and UK).

DESIGN

This post hoc descriptive exploration of data from the large international very early rehabilitation trial (A Very Early Rehabilitation Trial (AVERT)) examined the four common post acute rehabilitation pathways (inpatient rehabilitation, home with community rehabilitation, inpatient rehabilitation then community rehabilitation and home with no rehabilitation) experienced by participants in the 3 months post stroke and describes their 12-month outcomes.

SETTING

Hospital stroke units in AUS, UK and SE Asia.

PARTICIPANTS

Patients who had an acute stroke recruited within 24 hours who were ≤65 years.

RESULTS

668 participants were ≤65 years; 99% lived independently, and 88% no disability (modified Rankin Score (mRS)=0) prior to stroke. We had complete data for 12-month outcomes for n=631 (94%). The proportion receiving inpatient rehabilitation was higher in AUS than other regions (AUS 52%; UK 25%; SE Asia 23%), whereas the UK had higher community rehabilitation (UK 65%; AUS 61%; SE Asia 39%). At 12 months, 70% had no or little disability (mRS 0-2), 44% were depressed, 28% rated quality of life as poor or worse than death. For those working prior to stroke (n=228), only 57% had returned to work. A noteworthy number of working age survivors received no rehabilitation services within 3 months post stroke.

CONCLUSIONS

There was considerable variation in rehabilitation pathways and post acute service use across the three regions. At 12 months, there were high rates of depression, poor quality of life and low rates of return to work.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ACTRN12606000185561).

Association Between Walking Pace and Stroke Incidence: Findings From the UK Biobank Prospective Cohort Study

Background and Purpose- Stroke incidence in younger and middle-aged people is growing. Despite this, its associations in this subset of the stroke population are unknown, and prevention strategies are not tailored to meet their needs. This study examined the association between self-reported walking pace and incident stroke. Methods- Data from the UK Biobank were used in a prospective population-based study. Three hundred and sixty-three thousand, one hundred and thirty-seven participants aged 37 to 73 years (52% women) were recruited. The associations of self-reported walking pace with stroke incidence over follow-up were investigated using Cox proportional-hazard models. Results- Among 363,137 participants, 2705 (0.7%) participants developed a fatal or nonfatal stroke event over the mean follow-up period of 6.1 years (interquartile range, 5.4-6.7). Slow walking pace was associated with a higher hazard for stroke incidence (hazard ratio [HR], 1.45 [95% CI, 1.26-1.66]; P<0.0001). Stroke incidence was not associated with walking pace among people <65 years of age. However, slow walking pace was associated with a higher risk of stroke among participants aged ≥65 years (HR, 1.42 [95% CI, 1.17-1.72]; P<0.0001). A higher risk for stroke was observed on those with middle (HR, 1.28 [95% CI, 1.01-1.63]; P=0.039) and higher (HR, 1.29 [95% CI, 1.05-1.69]; P=0.012) deprivation levels but not in the least deprived individuals. Similarly, overweight (HR, 1.30 [95% CI, 1.04-1.63]; P=0.019) and obese (HR, 1.33 [95% CI, 1.09-1.63]; P=0.004) but not normal-weight individuals had a higher risk of stroke incidence. Conclusions- Slow walking pace was associated with a higher risk of stroke among participants over 64 years of age in this population-based cohort study. The addition of the measurement of self-reported walking pace to primary care or public health clinical consultations may be a useful screening tool for stroke risk.

Vocational rehabilitation and return to work: integrative review

Analysis of population growth trends and aging-which is associated with occurrence of chronic diseases, in addition to (work-related or not) diseases and accidents in general-points to an increasing need to implement rehabilitation services worldwide. Rehabilitation comprises three aspects: medical, vocational and social. The aim of the present study was to describe the state of the art in vocational rehabilitation approaches in several countries, as well as vocational rehabilitation-based return-to-work strategies for individuals with restrictions due to diseases and accidents in general developed in the past 30 years. We performed an integrative review of studies located in databases Virtual Health Library-Regional Library of Medicine (VHL-BIREME), PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, Web of Science, Sociological Abstracts, Education Resources Information Center (ERIC) and SCOPUS. A total of 1,109 studies were initially retrieved, of which 12 were considered eligible on methodological assessment and included for review. The selected studies analyzed new approaches and the implementation of existing programs, new programs/projects, and educational measures for workers on sick leave. Most programs had multidisciplinary nature and included complementary educational approaches, early intervention, and possibility of workplace adjustments. The studies on new projects consisted in job retention and return-to-work programs for unemployed or temporary workers. The number of studies which describe occupational rehabilitation programs is small and evaluating their efficacy is difficult. Scientific research on this subject is still scarce vis-à-vis the current demands.

The Impact of Vocational Interventions on Vocational Outcomes, Quality of Life, and Community Integration in Adults with Childhood Onset Disabilities: A Systematic Review

Purpose Despite the desire and ability to work, individuals with childhood onset disabilities are under-represented in employment. Vocational interventions alleviate some barriers to obtaining and maintaining employment for this population. The research question addressed is: What is the impact of vocational interventions on vocational outcomes, quality of life (QoL), and community integration (CI) in adults with childhood onset neurological disabilities including cerebral palsy (CP), spina bifida, and acquired brain injury (ABI)? Methods A literature search was conducted in multiple electronic databases. All experimental and observational studies with comparator group(s) were included. Two reviewers independently completed titles and abstracts screening, full text screening, data abstraction, and risk of bias assessment. Results Seventeen studies were eligible for final inclusion including three randomized-controlled trials, four non-randomized studies, and ten observational studies. Sixteen of seventeen studies included only individuals with ABI, while one study included individuals with CP. Vocational interventions from experimental studies were mainly components of multi-faceted interventions. Most observational studies were from the United States Vocational Rehabilitation Service. Conclusions Vocational interventions may be effective in improving vocational outcomes, QoL, and CI for individuals with ABI. There is limited experimental evidence on interventions that specifically target employment. Observational data suggest that receiving job placement assistance, on-the-job training and supports, counselling/guidance, maintenance, and supported employment successfully predicted employment outcomes.

Developing vocational rehabilitation services for people with long-term neurological conditions: Identifying facilitators and barriers to service provision

Introduction

This study aimed to understand existing vocational rehabilitation service provision in one locality in London (population 3.74 million), identify any gaps and explore reasons for this, to support service development.

Method

Using soft systems methodology to guide the research process, semi-structured interviews were completed with nine participants, who were clinicians and managers providing vocational rehabilitation within a National Health Service context. Data were analysed thematically to build a ‘rich picture’ and develop a conceptual model of vocational rehabilitation service delivery. Findings were then ratified with participants at an engagement event.

Results

The findings indicate a spectrum of vocational rehabilitation service provision for long-term neurological conditions with differing levels of funding in place. Vocational rehabilitation often takes place ‘under the radar’ and therefore the true vocational rehabilitation needs of this population, and the extent of service provision, is not known. There is inconsistency of understanding across the services as to what constitutes vocational rehabilitation and outcomes are not routinely measured.

Conclusion

For vocational rehabilitation services to develop they require appropriate funding, driven by government policy to commissioners. Clear definitions of vocational rehabilitation, collecting and sharing outcome data and effective communication across services are needed at a local level. This is expressed in a conceptual model of vocational rehabilitation service delivery.

Short-Term and Long-Term Outcomes of a Vocational Rehabilitation Program for Patients with Acquired Brain Injury in The Netherlands

Purpose To describe short-term and long-term work status after a vocational rehabilitation (VR) program in patients with acquired brain injury (ABI) in the Netherlands. Methods Patients with ABI who participated in a VR program between 2007 and 2010 were included in this study. The 4-month VR program included a multidisciplinary assessment, three meetings with all stakeholders and reintegration with coaching on the job. Short-term results at the end of the VR program were based on data extracted from medical records. Long-term results were determined at 3-6 years (mean 4.4 years) after the program based on patient-reported data. Outcome measures included return to work, hours at work and task adjustments. Results Fifty-eight patients were included [mean age 48 (SD 9.4) years; n = 33 male; all working before ABI]. After the intervention, 50 patients (86%) had returned to work, working on average 60% of their former hours. Working tasks were adjusted in 48 patients. At long-term follow-up 28 patients had paid work, working on average 5.3 h more than immediately after the VR program. Conclusions Directly after the intervention 86% of the patients had returned to work. After 3-6 years, 64% of these patients were still working in a paid job.

Return to work after stroke – Feasibility of 6-year follow-up

Introduction

Little is known about long-term work sustainability of stroke survivors. A feasibility trial of early stroke specialist vocational rehabilitation had 32/46 (69.5%) participants available for follow-up at 12 months post stroke. Of these, 19/32 (59.4%) were in work. This study aims to determine the feasibility of longer-term follow-up and explore work status 6 years post stroke.

Method

Forty-eight participants fitting criteria for the feasibility trial were sent postal questionnaires measuring employment, income, mood, functional ability and quality of life, and were invited for interview to explore working 6 years after stroke. Ethical approval was obtained.

Results

Of the 48 participants, five (10.4%) had died; 19/43 (44.2%) responded. Fourteen were men; mean age 62 (24–78) years. Fourteen (74%) reported working (paid work n = 10, voluntary work n = 3, full-time education n = 1). Five had retired. Most (11/13) remained with preinjury employers. Half (8/15, 53%) reported decreased income since stroke. Compared to one year, median functional ability was marginally higher (extended activities of daily living 63 (IQR 8, range 32–66) to 60 (IQR 9, range 17–66)), but health-related quality of life was lower (EuroQuol Visual Analogue Scale mean 77.4 [SD 11] to 70.7 [SD14]). Six interviewees felt returning to work was the correct decision but struggled with invisible impairments.

Conclusion

This study suggests that long-term follow-up is feasible and that those who made a good recovery were more likely to respond. Work remains important to stroke survivors 6 years post stroke.

Return to work after specialized rehabilitation-An explorative longitudinal study in a cohort of severely disabled persons with stroke in seven countries: The Sunnaas International Network stroke study

INTRODUCTION

Stroke may impose disabilities with severe consequences for the individual, with physical, psychological, social, and work-related consequences. The objective with the current study was to investigate to what extent persons with stroke were able to return to work, to maintain their financial situation, and to describe the follow-up services and participation in social networks and recreational activities.

METHODS

The design was a prospective, descriptive study of specialized stroke rehabilitation in nine rehabilitation centers in seven countries. Semistructured interviews, which focused on the return to work, the financial situation, follow-up services, the maintenance of recreational activities, and networks, were performed 6 and 12 months post discharge from rehabilitation.

RESULTS

The working rate before the onset of stroke ranged from 27% to 86%. At 12 months post stroke, the return to work varied from 11% to 43%. Consequently, many reported a reduced financial situation from 10% to 70% at 6 months and from 10% to 80% at 12 months. Access to postrehabilitation follow-up services varied in the different countries from 24% to 100% at 6 months and from 21% to 100% at 12 months. Physical therapy was the most common follow-up services reported. Persons with stroke were less active in recreational activities and experienced reduced social networks. Associations between results from the semistructured interviews and related themes in LiSat-11 were small to moderate. The study shows that education, age, and disability are predictors for return to work. Differences between countries were observed in the extent of unemployment.

CONCLUSIONS

In this international multicentre study, return to work after severe stroke and specialized/comprehensive rehabilitation was possible, depending on the extent of the disability, age, and education. Altered financial situation, reduced social networks, and reduced satisfaction with life were common psychosocial situations for these patients.

Return to Work After Stroke: A Survey of Occupational Therapy Practice Patterns

This descriptive study, consisting of a survey followed by semi-structured interviews, sought to describe the practice patterns and perceived competencies of occupational therapy practitioners in the provision of return to work (RTW) services for stroke survivors. Respondents (n = 119) were mostly occupational therapists (95%) working in outpatient settings (61%); 47% reported a caseload of mostly stroke survivors; and most addressing RTW (60%). Respondents focused predominantly on remediation of cognitive and physical skills and less on actual work performance and supports. Respondents assert occupational therapy's role in RTW for stroke survivors but generally reported limited competencies and low utilization of evidence-based approaches and theoretical models when addressing RTW. Systems, organizational support, and practitioner factors emerged as barriers and facilitators to RTW service provision. This study suggests there may be a critical gap in practitioners' RTW competencies with profound implications for entry-level education, professional development, advocacy, and research.

Meta-Synthesis of Qualitative Research on Facilitators and Barriers of Return to Work After Stroke

Purpose Despite existing rehabilitation services, return to work (RTW) rates among stroke survivors are quite low. An increased number of qualitative studies have been conducted to identify facilitators and barriers to RTW after stroke and to derive recommendations for future interventions. The aim of our study was to carry out a meta-synthesis of those studies and thus strengthen evidence in the field. Methods To identify relevant studies (qualitative studies focusing on RTW after stroke, published in English or German between 2000 and 2015), we conducted a systematic literature search in PubMed, OVID, and Web of Science. After assessing the quality of eligible studies, we synthesized their findings according to meta-ethnographic methodology. Results Fourteen out of 553 studies-three of very high, seven of high, three of medium, and one of low quality-met the inclusion criteria. After the extraction of all first-order concepts and their translation into 64 second-order interpretations, we synthesized the findings by developing a model of RTW factors after stroke. It contains factors related to the person (impairments, coping/adaptation, significance of work/RTW motivation), workplace (job demands/work adaptations, disability management, work climate/social support), and rehabilitation services (availability, accessibility, appropriateness), as well as relevant factors in the interaction of these three stakeholders (work capacity, performance and capability, and initial RTW experiences). Three basic principles-adaptiveness, purposefulness, and cooperativeness-complete the model and led us to its name: the APC model. Conclusions Successful RTW after stroke depends on diverse factors and stakeholders. Rehabilitation strategies have to consider this; otherwise they become RTW barriers themselves.

Return to work predictors of stroke survivors and their spousal caregivers

BACKGROUND

Return to work is an issue of concern for stroke survivors and their spouses. Ramifications may include loss of income and self-efficacy.

OBJECTIVE

This study describes the return to work patterns of stroke survivors and their spousal caregivers post stroke.

METHODS

One hundred fifty-nine dyads were examined for their return to work patterns at baseline (post hospital discharge) and then at 3 month intervals for one year. Relationships were determined between work and gender, age, ethnicity, education, type of insurance, type of stroke, location of stroke, motor and cognitive functional status, depression, mutuality, and life satisfaction.

RESULTS

Low levels of return to work by stroke survivors (7.5%) and a small decrease in the amount of working caregivers (from 45.3% to 40.35%) were found one year post baseline. Variables that predicted return to work changed over the five data points except for younger age for the caregiver, which was consistently significant across all data points. Three case scenarios representative of working patterns are offered.

CONCLUSIONS

Further research is needed regarding the return to work needs of stroke survivors and their spousal caregivers, particularly what role the occupational therapist may play in facilitating that process.

Factors affecting return to work after injury or illness: best evidence synthesis of systematic reviews

Background

Work disability is a major personal, financial and public health burden. Predicting future work success is a major focus of research.

Objectives

To identify common prognostic factors for return-to-work across different health and injury conditions and to describe their association with return-to-work outcomes.

Methods

Medline, Embase, PsychINFO, Cinahl, and Cochrane Database of Systematic Reviews and the grey literature were searched from January 1, 2004 to September 1, 2013. Systematic reviews addressing return-to-work in various conditions and injuries were selected. Eligible studies were critically appraised using the Scottish Intercollegiate Guidelines Network criteria to identify low risk of bias reviews.

Results

Of the 36,193 titles screened and the 94 eligible studies reviewed, 56 systematic reviews were accepted as low risk of bias. Over half of these focused on musculoskeletal disorders, which were primarily spine related (e.g., neck and low back pain). The other half of studies assessed workers with mental health or cardiovascular conditions, stroke, cancer, multiple sclerosis or other non-specified health conditions. Many factors have been assessed, but few consistently across conditions. Common factors associated with positive return-to-work outcomes were higher education and socioeconomic status, higher self-efficacy and optimistic expectations for recovery and return-to-work, lower severity of the injury/illness, return-to-work coordination, and multidisciplinary interventions that include the workplace and stakeholders. Common factors associated with negative return-to-work outcomes were older age, being female, higher pain or disability, depression, higher physical work demands, previous sick leave and unemployment, and activity limitations.

Conclusions

Expectations of recovery and return-to-work, pain and disability levels, depression, workplace factors, and access to multidisciplinary resources are important modifiable factors in progressing return-to-work across health and injury conditions. Employers, healthcare providers and other stakeholders can use this information to facilitate return-to-work for injured/ill workers regardless of the specific injury or illness. Future studies should investigate novel interventions, and other factors that may be common across health conditions.

Canadian Stroke Best Practice Recommendations: Managing transitions of care following Stroke, Guidelines Update 2016

Every year, approximately 62,000 people with stroke and transient ischemic attack are treated in Canadian hospitals. For patients, families and caregivers, this can be a difficult time of adjustment. The 2016 update of the Canadian Managing Transitions of Care following Stroke guideline is a comprehensive summary of current evidence-based and consensus-based recommendations appropriate for use by clinicians who provide care to patients following stroke across a broad range of settings. The focus of these recommendations is on support, education and skills training for patients, families and caregivers; effective discharge planning; interprofessional communication; adaptation in resuming activities of daily living; and transition to long-term care for patients who are unable to return to or remain at home. Unlike other modules contained in the Canadian Stroke Best Practice Recommendations (such as acute inpatient care), many of these recommendations are based on consensus opinion, or evidence level C, highlighting the absence of conventional evidence (i.e. randomized controlled trials) in this area of stroke care. The quality of care transitions between stages and settings may have a direct impact on patient and family outcomes such as coping, readmissions and functional recovery. While many qualitative and non-controlled studies were reviewed, this gap in evidence combined with the fact that mortality from stoke is decreasing and more people are living with the effects of stroke, underscores the need to channel a portion of available research funds to recovery and adaptation following the acute phase of stroke.

Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

PURPOSE

The aim of this guideline is to provide a synopsis of best clinical practices in the rehabilitative care of adults recovering from stroke.

METHODS

Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council's Scientific Statement Oversight Committee and the AHA's Manuscript Oversight Committee. The panel reviewed relevant articles on adults using computerized searches of the medical literature through 2014. The evidence is organized within the context of the AHA framework and is classified according to the joint AHA/American College of Cardiology and supplementary AHA methods of classifying the level of certainty and the class and level of evidence. The document underwent extensive AHA internal and external peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the AHA Science Advisory and Coordinating Committee.

RESULTS

Stroke rehabilitation requires a sustained and coordinated effort from a large team, including the patient and his or her goals, family and friends, other caregivers (eg, personal care attendants), physicians, nurses, physical and occupational therapists, speech-language pathologists, recreation therapists, psychologists, nutritionists, social workers, and others. Communication and coordination among these team members are paramount in maximizing the effectiveness and efficiency of rehabilitation and underlie this entire guideline. Without communication and coordination, isolated efforts to rehabilitate the stroke survivor are unlikely to achieve their full potential.

CONCLUSIONS

As systems of care evolve in response to healthcare reform efforts, postacute care and rehabilitation are often considered a costly area of care to be trimmed but without recognition of their clinical impact and ability to reduce the risk of downstream medical morbidity resulting from immobility, depression, loss of autonomy, and reduced functional independence. The provision of comprehensive rehabilitation programs with adequate resources, dose, and duration is an essential aspect of stroke care and should be a priority in these redesign efforts. (Stroke.2016;47:e98-e169. DOI: 10.1161/STR.0000000000000098.).

Barriers and facilitators associated with return to work after stroke: a qualitative meta-synthesis

PURPOSE

To enhance the employment outcomes of individuals who experience a stroke, it is essential to understand the factors that determine successful return to work. The aim of this systematic review was to examine barriers to and facilitators of return to work after stroke from the perspective of people with stroke through the process of a qualitative meta-synthesis.

METHODS

A systematic literature search was conducted. Studies that employed qualitative methods to explore the experiences of individuals with stroke around return to work after stroke were included. The methodological quality of the studies was assessed by two independent reviewers. Overarching themes, concepts and interpretations were extracted from each individual study, compared and meta-synthesized.

RESULTS

Fifteen studies were included and the overall methodological quality of the studies was good. Four broad themes emerged as factors associated with return to work after stroke. These included (i) the nature of the effects of stroke, (ii) the preparatory environment, (iii) personal coping strategies and internal challenges and (iv) the meaning of work.

CONCLUSION

Return to work after stroke is a complex process which can be facilitated or impeded by organizational, social or personal factors, as well as accessibility to appropriate services. Implications for Rehabilitation Following a period of dedicated inpatient rehabilitation, there is a need to integrate community-support services to optimize return to work among stroke survivors. A dedicated community stroke support liaison officer may help to facilitate the transition between the hospital and the community and workplace environment. Education provided by healthcare professionals is necessary in the community and the workplace to ensure that family, friends and employers are aware of the impairments, activity limitations and participation restrictions of the stroke survivor.

Outcomes of return-to-work after stroke rehabilitation: A systematic review

Introduction

The purpose of this systematic review was to identify the outcomes of return-to-work for stroke survivors of working age after conventional stroke rehabilitation or vocational rehabilitation.

Method

Searches were performed using three electronic databases for literature published in English in the 10-year period 2004–2014 which included a population of working age stroke survivors who had previously participated in conventional or vocational rehabilitation, and which presented the outcomes of return-to-work.

Findings

The literature search yielded 10 studies that satisfied our selection criteria. Three studies involved vocational rehabilitation. Studies illustrated and compared the vocational status at or among different stages of ‘pre-stroke’, ‘post-stroke and before rehabilitation discharge’, ‘rehabilitation discharge’ and ‘follow-up’. The employment rate at follow-up ranged from 7% to 81.1%.

Conclusion

Methodological variations accounted for the wide range of return-to-work rates. There was limited evidence to support the conclusion that rehabilitation increases return-to-work rates for stroke survivors of working age, but recent studies showed that improvements in fatigue and cognitive function after stroke rehabilitation were related to good return-to-work outcomes. Either specialised vocational rehabilitation, conventional stroke rehabilitation or their combination is needed to increase return-to-work rates and improve the quality of life for stroke survivors of working age.

Effective return-to-work interventions after acquired brain injury: A systematic review

OBJECTIVE

To gather knowledge about effective return-to-work (RTW) interventions for patients with acquired brain injury (ABI).

METHODS

A database search was performed in PubMed, EMBASE, PsycINFO, CINAHL and the Cochrane Library using keywords and Medical Subject Headings. Studies were included if they met inclusion criteria: adult patients with non-progressive ABI, working pre-injury and an intervention principally designed to improve RTW as an outcome. The methodological quality of included studies was determined and evidence was assessed qualitatively.

RESULTS

Twelve studies were included, of which five were randomized controlled trials and seven were cohort studies. Nine studies had sufficient methodological quality. There is strong evidence that work-directed interventions in combination with education/coaching are effective regarding RTW and there are indicative findings for the effectiveness of work-directed interventions in combination with skills training and education/coaching. Reported components of the most effective interventions were tailored approach, early intervention, involvement of patient and employer, work or workplace accommodations, work practice and training of social and work-related skills, including coping and emotional support.

CONCLUSION AND IMPLICATIONS

Effective RTW interventions for patients with ABI are a combination of work-directed interventions, coaching/education and/or skills training. These interventions have the potential to facilitate sustained RTW for patients with ABI.

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.

Return to Work after Stroke: Recording, Measuring, and Describing Occupational Therapy Intervention

Introduction:

Existing research on vocational rehabilitation following stroke has been criticised for not describing intervention in sufficient detail for replication or clinical implementation. The purpose of this study was to test the feasibility of recording and measuring the content of an early stroke-specific vocational rehabilitation intervention delivered to participants in a feasibility randomized controlled trial, using a proforma previously developed for a study of vocational rehabilitation following traumatic brain injury.

Method:

The proforma was adapted for use in stroke with input from an expert panel and was used to record intervention content, in 10-minute units, following each intervention session.

Findings:

Twenty-five people, working or in education at the time of stroke, participated in the study. Two thirds of the therapists' time was spent in face-to-face contact (43%) and liaison with the patient and others (20%). Intervention mainly focused on work preparation (21%) and the return to work process (24%). The remaining time was consumed by administration (19%) and travel (18%).

Conclusion:

The proforma was quick and easy to use and captured the main focus of intervention. This study suggests that it can be used to record stroke-specific vocational rehabilitation intervention content and has potential for wider use in research and clinical practice.

Young individuals with stroke: a cross sectional study of long-term disability associated with self-rated global health

Background

Perceived disability after stroke may persist long-term even among young individuals with mild stroke and may be related to age-related expectations of health and recovery. Thus, in order to appreciate the magnitude of perceived disability in a younger stroke population studies are needed to explore perceived health-related differences between young individuals with stroke and a matched general population. Further, to provide long-term measures by health care, relevant to the same young individuals with stroke, their perceived long-term functioning and disability associated with health need to be explored.

Methods

The generic questionnaire EQ-5D was used to compare ratings of global health and disability between young individuals living in the community up to 6 years after stroke (n = 150) and an age and geographically matched general population (n = 2661). Stroke related medical data were retrieved from medical records and the study specific questionnaire, the MYS-questionnaire, was used to assess self-rated disability associated with global health.

Results

Among the young individuals 79% had suffered a mild stroke, 45% rated a low global health compared to 15% of the matched general population and a higher proportion rated problems in mobility, self-care, usual activities and anxiety/depression. Among the young individuals with stroke, limitations and restrictions in leisure activities, work, reading as well as low level of physical activity, utilizing personal care provider or personal assistance and tiredness were negatively associated with self-rated global health (R square 0.60).

Conclusion

The negative effects of stroke, on self-rated global health among young individuals living in the community, appear to be substantial, multi factorial and long-standing which call for interdisciplinary research collaborations and team measures by health care long-term.

Participation in the chronic phase of stroke

BACKGROUND

Participation is a multidimensional concept, consisting of an objective and a subjective dimension. Many studies have focused on determinants of only 1 dimension of participation post stroke.

OBJECTIVE

To describe participation (both objective and subjective) and to determine how physical and cognitive independence and subjective complaints (pain, fatigue, and mood) influence participation in community-dwelling stroke survivors in the Netherlands.

METHODS

The Utrecht Scale for Evaluation of Rehabilitation (USER) measures physical and cognitive independence and subjective complaints. USER-Participation measures 3 dimensions of participation: frequency (objective perspective), restrictions (subjective perspective), and satisfaction (subjective perspective). Spearman correlations and backward linear regression analyses were used to analyze associations between the 3 USER-Participation scores with demographics, stroke characteristics, physical and cognitive independence, and subjective complaints.

RESULTS

Of the 111 participants, 48.5% returned to work post stroke, but mostly for only 1 to 16 hours a week. Experienced participation restrictions were most prevalent in physical exercise, chores in/around the house, housekeeping, and outdoor activities. On average, participants were relatively satisfied with their participation, but dissatisfaction occurred in cognition, activities outdoors, and work/housekeeping. Regression analysis revealed that objective participation was determined by physical and cognitive independence, age, and education, whereas subjective participation was determined by physical and cognitive independence, fatigue, and mood.

CONCLUSIONS

Most participants experienced participation problems, despite relatively good physical recovery. In addition to physical and cognitive factors, subjective complaints of persons with stroke should be addressed in the rehabilitation program.