Returning to paid employment after stroke: the Psychosocial Outcomes In StrokE (POISE) cohort study

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

BACKGROUND

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Professional reintegration among professionally active Portuguese stroke survivors: a multicentric study

PURPOSE

To assess professional reintegration, the perceived impact of stroke on work, and the main determinants of return to work (RTW) among stroke survivors.

MATERIALS AND METHODS

A cross-sectional study was performed, based on a cohort of stroke survivors. A structured questionnaire was administered to previously working stroke survivors, 18-24 months post-stroke. Data on sociodemographic characteristics, stroke features and their impact on work, access to rehabilitation services during hospital admission and after discharge, social support, and professional reintegration were reported by 553 stroke survivors.

RESULTS

On average, 56.6% (95% CI 52.4-60.8) of stroke survivors resumed professional activity, 20 months after stroke. Approximately 90% of survivors who RTW, returned to the same job and same function they performed before stroke. The majority did not receive reintegration support. The main determinants of RTW were lower age, higher socioeconomic status, and better functional status.

CONCLUSIONS

Professional reintegration and vocational support after stroke, remained below the international goals for community reintegration of stroke survivors. Future studies should explore the impact of professional and social reintegration on the psychological health and quality of life of stroke survivors and the barriers, challenges, and strategies used to overcome them, to allow for effective professional reintegration policies.

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.

Perceived vocational support needs and return-to-work outcomes in the first 12-months post-discharge in individuals with acquired brain injury and spinal cord injury: A retrospective cohort study

BACKGROUND

Return-to-work (RTW) is often viewed as an important outcome following acquired brain injury (ABI) and spinal cord injury (SCI), although not all individuals have vocational goals and many experience barriers to RTW.

OBJECTIVE

This study investigated the relationship between RTW and psychosocial functioning at 12-months post-discharge after ABI and SCI and examined patterns of RTW according to perceived need for and receipt of vocational support.

METHODS

A file audit was conducted for 69 participants with ABI (n = 44) and SCI (n = 25). Data on employment status and perceived vocational support at 3- and 12-months post-discharge, home and community participation, psychological distress, and health-related quality of life were extracted.

RESULTS

Individuals in paid employment at 12-months post-discharge (22%, n = 15) reported significantly better psychosocial functioning at this timepoint compared to those not employed (78%; n = 54). For those not employed, three subgroups were identified: 1) Did not perceive the need for or receive vocational support (50%; n = 27); 2) Perceived vocational support needs were unmet (19%; n = 10); and 3) Perceived and received vocational support (31%; n = 17). Psychological distress was highest for those who perceived and received vocational support but were not employed.

CONCLUSION

RTW was associated with better psychosocial functioning after acquired neurological injury. The findings highlight the need for clinicians to explore and revisit individuals' perceived need for and preferences for vocational support and monitor the psychological well-being of those with RTW goals that are not yet successful.

Impact of depression on stroke outcomes among stroke survivors: Systematic review and meta-analysis

BACKGROUND

Depression may negatively affect stroke outcomes and the progress of recovery. However, there is a lack of updated comprehensive evidence to inform clinical practice and directions of future studies. In this review, we report the multidimensional impact of depression on stroke outcomes.

METHODS

Data sources. PubMed, PsycINFO, EMBASE, and Global Index Medicus were searched from the date of inception. Eligibility criteria. Prospective studies which investigated the impact of depression on stroke outcomes (cognition, returning to work, quality of life, functioning, and survival) were included. Data extraction. Two authors extracted data independently and solved the difference with a third reviewer using an extraction tool developed prior. The extraction tool included sample size, measurement, duration of follow-up, stroke outcomes, statistical analysis, and predictors outcomes. Risk of bias. We used Effective Public Health Practice Project (EPHPP) to assess the quality of the included studies.

RESULTS

Eighty prospective studies were included in the review. These studies investigated the impact of depression on the ability to return to work (n = 4), quality of life (n = 12), cognitive impairment (n = 5), functioning (n = 43), and mortality (n = 24) where a study may report on more than one outcome. Though there were inconsistencies, the evidence reported that depression had negative consequences on returning to work, functioning, quality of life, and mortality rate. However, the impact on cognition was not conclusive. In the meta-analysis, depression was associated with premature mortality (HR: 1.61 (95% CI; 1.33, 1.96)), and worse functioning (OR: 1.64 (95% CI; 1.36, 1.99)).

CONCLUSION

Depression affects many aspects of stroke outcomes including survival The evidence is not conclusive on cognition and there was a lack of evidence in low-income settings. The results showed the need for early diagnosis and intervention of depression after stroke. The protocol was pre-registered on the International Prospective Register of Systematic Review (PROSPERO) (CRD42021230579).

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.

Long term employment following heart transplantation in the United States

BACKGROUND

Employment is an important metric of post-transplant functional status and the quality of life yet remains poorly described after heart transplant. We sought to characterize the prevalence of employment following heart transplantation and identify patients at risk for post-transplant unemployment.

METHODS

Adults undergoing single-organ heart transplantation (2007-2016) were evaluated using the UNOS database. Univariable analysis was performed after stratifying by employment status at 1-year post-transplant. Fine-Gray competing risk regression was used for risk adjustment. Cox regression evaluated employment status at 1 year with mortality.

RESULTS

Of 10,132 heart transplant recipients who survived to 1 year and had follow-up, 22.0% were employed 1-year post-transplant. Employment rate of survivors increased to 32.9% by year 2. Employed individuals were more likely white (70.8% vs 60.4%, p < 0.01), male (79.6% vs 70.7% p < 0.01), held a job at listing/transplant (37.6% vs 7.6%, p < 0.01), and had private insurance (79.1% vs 49.5%, p < 0.01). Several characteristics were independently associated with employment including age, employment status at time of listing or transplant, race and ethnicity, gender, insurance status, education, and postoperative complications. Of 1,657 (14.0%) patients employed pretransplant, 58% were working at 1-year. Employment at 1year was independently associated with mortality with employed individuals having a 26% decreased risk of mortality.

CONCLUSION

Over 20% of heart transplant patients were employed at 1 year and over 30% at 2 years, while 58% of those working pretransplant had returned to work by 1-year. While the major predictor of post-transplant employment is preoperative employment status, our study highlights the impact of social determinants of health.

Return to work and depressive symptoms in young stroke survivors after six and twelve months: cross-sectional and longitudinal analyses

BACKGROUND

While depression after stroke is common and stroke prevalence globally increases in working age populations, the role of return-to-work (RTW) in the pathogenesis of post-stroke depression (PSD) remains unclear. This study examined if RTW is linked to PSD within the first year after ischemic stroke, independently from established risk factors.

METHOD

Stroke survivors (n = 176) in their working age (<65 years) recruited from two rehabilitation clinics were assessed for established risk factors: pre-stroke depression, activities of daily living, stroke severity, cognitive impairment, and social support. RTW and depressive symptoms (Geriatric Depression Scale: GDS-15) were assessed six- and twelve-months post-stroke. Multivariate regression analyses were used to assess the cross-sectional and longitudinal relationship between RTW and GDS-15, while controlling for established PSD risk factors.

RESULTS

Successful RTW was independently associated with lower GDS-15 at both measurement occasions (p < .05), next to the absence of pre-stroke depression and higher social support. Stroke severity predicted GDS-15 at twelve months. The predictive value of six-months RTW for subsequent depressive symptoms beyond the influence of established risk factors was ß = -1.73 (p = .09).

DISCUSSION

RTW was independently associated with PSD in young stroke survivors within the first-year post-stroke, and exerted a (marginally significant) effect on subsequent depression. Our study highlights the relevance of RTW for young stroke survivors' PSD, beyond the influence of established risk factors. Further assessments examining to what extent fostering RTW contributes to mental well-being after stroke might be promising for PSD prevention, next to evident beneficial economic effects.

Depression symptoms reducing return to work: a meta-analysis of prospective studies

Objectives. This study was conducted to estimate the risk of return to work for people who experience symptoms of depression based on the pool of prospective data. Methods. All online articles in PubMed and Scopus which were accessible before November 2019 were searched. The odds ratios of each of the studies were pooled together to obtain an overall odds ratio. The pool of studies was with random effects. The analysis was performed based on the depression symptoms scale, type of disease and duration of follow-up. Two other aspects were examined in the analysis, one being the bias in the publication of studies and the other being the level of heterogeneity that was examined. Results. Thirty-five studies were selected for the meta-analysis. The pooled odds ratio indicates that the odds of return to work in people with depressive symptoms is 31% lower than in those without depressive symptoms. The funnel plot shows that there is asymmetry. The Egger test result was significant (p < 0.001) and there is publication bias. Conclusion. Depression symptoms after sick leave due to physical illness is a risk factor for not returning to work.

Returning to Work after Stroke: Associations with Cognitive Performance, Motivation, Perceived Working Ability and Barriers

OBJECTIVE

To investigate post-stroke return-to-work and its associations with cognitive performance, motivation, perceived working ability, and self-perceived barriers to returning to work.

DESIGN

Prospective cohort study of a clinical sample.

SUBJECTS AND METHODS

Participants were 77 stroke patients younger than age 69 years. Assessment included a cognitive screening method for stroke patients (CoMet), a questionnaire regarding work-related matters, and a question regarding motivation to return to work. A predictive model of return-to-work was built, and how participants managed in their working life was examined.

RESULTS

Cognitive performance was significantly connected with returning to work. Three of the 5 individuals who dropped out of working life had cognitive dysfunction. Cognitive performance predicted 80% of those who had not returned and 37% of those who had returned by 6 months after the initial assessment. Self-perceived working ability and barriers predicted 64% of those who had not returned and 78% of those who had returned at the 12-month follow-up.

CONCLUSION

Cognitive performance seems to be a crucial predictor of return-to-work post-stroke, but individuals' own evaluations of their working capabilities are also important.

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

OBJECTIVE

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

DESIGN

Nationwide, population based, matched cohort study.

SETTING

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

PARTICIPANTS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

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

Objectives

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

Methods

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

Results

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

Conclusions

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

Feasibility of the community-based Stay at Work Intervention (SAWI) for stroke survivors

BACKGROUND: Rates of stroke in people of working age are increasing. Returning to work (RTW) after stroke is a key rehabilitation aspiration for younger stroke survivors. A pilot community-based Stay at Work Initiative (SAWI) was developed and delivered from March 2017 to December 2019. SAWI used a co-ordination based approach, covering rehabilitation and vocational recovery to support RTW in younger stroke survivors. OBJECTIVE: The aim of the study was to conduct a feasibility evaluation of SAWI. METHODS: A mixed methods approach was taken considering quantitative and qualitative data. Quantitative data included employment, mood, anxiety and fatigue outcomes at time of engagement with the service and at 6-months post-stroke. Qualitative data was collected on a sub-sample of SAWI clients who volunteered to participate in a semi-structured interview. RESULTS: Overall, there were 93 referrals to SAWI, with 42 clients completing an initial service meeting. Average working hours pre-stroke were high (mean 46.9, SD 22.0, range 5–100 hours/week). By 6 months post stroke, 71% (n = 29 of 41) of SAWI clients were working. For those with 6-month questionnaire information (n = 19), there was a significant reduction in cognitive fatigue, overall fatigue levels, and perceived impact of stroke on employment (medium effect sizes of r = 0.36, 0.34 and 0.40 respectively). No significant difference was seen on measures of mood or anxiety from pre- to post-intervention. Qualitative interviews with six SAWI participants highlighted the importance of personalised support that addresses individual needs during the RTW journey. CONCLUSIONS: A significant number of eligible participants referred to SAWI can engage with the service. RTW is able to be assessed as are potential predictor variables. Seventy one percent of participants had RTW at 6 months post-stroke. Mood, self-efficacy, adjustment, and fatigue likely impact RTW. Qualitative interviews identified that SAWI’s personalised support, tailored to individual need, was valued.

Sex Disparities in Re-Employment in Stroke Patients With Large Vessel Occlusion Undergoing Mechanical Thrombectomy

BACKGROUND

Strokes in the working-age population represent a relevant share of ischemic strokes and re-employment is a major factor for well-being in these patients. Income differences by sex have been suspected a barrier for women in returning to paid work following ischemic stroke. We aim to identify predictors of (not) returning to paid work in patients with large vessel occlusion treated with mechanical thrombectomy (MT) to identify potential areas of targeted vocational rehabilitation.

METHODS

From 6635 patients enrolled in the German Stroke Registry Endovascular Treatment between 2015 and 2019, data of 606 patients of the working population who survived large vessel occlusion at least 90 days past MT were compared based on employment status at day 90 follow-up. Univariate analysis, multiple logistic regression and analyses of area under the curve were performed to identify predictors of re-employment.

RESULTS

We report 35.6% of patients being re-employed 3 months following MT (median age 54.0 years; 36.1% of men, 34.5% of women [P=0.722]). We identified independent negative predictors against re-employment being female sex (odds ratio [OR], 0.427 [95% CI, 0.229-0.794]; P=0.007), higher National Institutes of Health Stroke Scale (NIHSS) score 24 hours after MT (OR, 0.775 [95% CI, 0.705-0.852]; P<0.001), large vessel occlusion due to large-artery atherosclerosis (OR, 0.558 [95% CI, 0.312-0.997]; P=0.049) and longer hospital stay (OR, 0.930 [95% CI, 0.868-0.998]; P=0.043). Positive predictors favoring re-employment were excellent functional outcome (modified Rankin Scale score of 0-1) at 90 day follow-up (OR, 11.335 [95% CI, 4.864-26.415]; P<0.001) and combined treatment with intravenous thrombolysis (OR, 1.904 [95% CI, 1.046-3.466]; P=0.035). Multiple regression modeling increased predictive power of re-employment status significantly over prediction by best single functional outcome parameter (National Institutes of Health Stroke Scale 24 hours after MT ≤5; R²: 0.582 versus 0.432; area under the receiver operating characteristic curve: 0.887 versus 0.835, P<0.001).

CONCLUSIONS

There is more to re-employment after MT than functional outcome alone. In particular, attention should be paid to possible systemic barriers deterring women from resuming paid work.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT03356392.

Cognitive Testing During Mild Acute Ischemic Stroke Predicts Long-Term Return to Work

OBJECTIVES

Many survivors of a mild ischemic stroke do not return to work or driving. Cognitive testing is commonly done to assess long-term cognitive impairment after stroke. Inpatient cognitive testing during the acute period of ischemic stroke may also be a predictor for workforce reengagement and functional outcome.

MATERIALS AND METHODS

At our comprehensive stroke center, we prospectively enrolled previously working adults < 65 years old who were diagnosed with first-ever ischemic stroke, had a prestroke modified Rankin Scale (mRS) ≤ 1 and NIHSS ≤ 3. Testing performed within 1 week of stroke included the Montreal Cognitive Assessment (MOCA), Clock Drawing Test (CDT), Trail Making Tests A and B, Backward Digit Span Test, and Hospital Anxiety and Depression Scale (HADS). Other data obtained included age, gender, years of education, occupation, stroke location, stroke laterality, and presence of white matter disease on imaging. Outcome measures assessed at 3 months, 6 months, and 12 months post-stroke included return to work, return to driving, and mRS. In a logistic regression analysis, we performed both univariate and multivariate analyses. Multivariate analysis was completed on variables with p-value ≤ 0.05 in the univariate analysis.

RESULTS

Of 39 total stroke patients enrolled and tested (median [IQR] age 55 [46-60] years; 77.5% male; 22.5% female), 36 completed 3-month follow up, of which 58% returned to work, 78% returned to driving, and 72% had mRS of 0-1. In multivariate analysis, a single point increase in the clock drawing task score increased the odds of return to work by 3.79 (95% CI, 1.10-14.14) and return to driving by 6.74 (95% CI, 1.22-37.23) at 3 months. MOCA and HADS were both associated with mRS ≤ 1. MOCA was associated with return to work at 6 months and CDT was associated with return to work at 12 months.

CONCLUSION

Cognitive testing with CDT and MOCA in the acute period after ischemic stroke may predict common patient goals post stroke, including return to work, driving, and independence. These tools can potentially be used for prognosis and identifying those who may benefit from further interventions.

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.

Post-stroke fatigue: A factor associated with inability to return to work in patients <60 years-A 1-year follow-up

This study investigated the association between post-stroke fatigue and inability to return to work/drive in young patients aged <60 years with first stroke who were employed prior to infarct while controlling for stroke severity, age, extent of disability, cognitive function, and depression. The Fatigue Severity Scale (FSS) was used to evaluate post-stroke fatigue in this 1-year prospective cohort study. Follow-ups were completed at 3, 6, and 12 months post rehabilitation discharge. A total of 112 patients were recruited, 7 were excluded, due to loss to follow-up (n = 6) and being palliative (n = 1), resulting in 105 participants (71% male, average age 49 ±10.63 years). Stroke patients receiving both inpatient and outpatient rehabilitation were consecutively recruited. Persistent fatigue remained associated with inability to return to work when controlling for other factors at 3 months (adjusted OR = 18, 95% CI: 2.9, 110.3, p = 0.002), 6 months (adjusted OR = 29.81, 95% CI: 1.7, 532.8, p = 0.021), and 12 months (adjusted OR = 31.6, 95% CI: 1.8, 545.0, p = 0.018). No association was found between persistent fatigue and return to driving. Fatigue at admission was associated with inability to return to work at 3 months but not return to drive. Persistent fatigue was found to be associated with inability to resume work but not driving. It may be beneficial to routinely screen post-stroke fatigue in rehabilitation and educate stroke survivors and employers on the impacts of post-stroke fatigue on return to work.

From Three-Months to Five-Years: Sustaining Long-Term Benefits of Endovascular Therapy for Ischemic Stroke

Background and Purpose: During the months and years post-stroke, treatment benefits from endovascular therapy (EVT) may be magnified by disability-related differences in morbidity/mortality or may be eroded by recurrent strokes and non-stroke-related disability/mortality. Understanding the extent to which EVT benefits may be sustained at 5 years, and the factors influencing this outcome, may help us better promote the sustenance of EVT benefits until 5 years post-stroke and beyond.

Methods: In this review, undertaken 5 years after EVT became the standard of care, we searched PubMed and EMBASE to examine the current state of the literature on 5-year post-stroke outcomes, with particular attention to modifiable factors that influence outcomes between 3 months and 5 years post-EVT.

Results: Prospective cohorts and follow-up data from EVT trials indicate that 3-month EVT benefits will likely translate into lower 5-year disability, mortality, institutionalization, and care costs and higher quality of life. However, these group-level data by no means guarantee maintenance of 3-month benefits for individual patients. We identify factors and associated “action items” for stroke teams/systems at three specific levels (medical care, individual psychosocioeconomic, and larger societal/environmental levels) that influence the long-term EVT outcome of a patient. Medical action items include optimizing stroke rehabilitation, clinical follow-up, secondary stroke prevention, infection prevention/control, and post-stroke depression care. Psychosocioeconomic aspects include addressing access to primary care, specialist clinics, and rehabilitation; affordability of healthy lifestyle choices and preventative therapies; and optimization of family/social support and return-to-work options. High-level societal efforts include improving accessibility of public/private spaces and transportation, empowering/engaging persons with disability in society, and investing in treatments/technologies to mitigate consequences of post-stroke disability.

Conclusions: In the longtime horizon from 3 months to 5 years, several factors in the medical and societal spheres could negate EVT benefits. However, many factors can be leveraged to preserve or magnify treatment benefits, with opportunities to share responsibility with widening circles of care around the patient.

Prevalence and predictors of return to work among stroke survivors in Jordan

BACKGROUND

Returning to work (RTW) is an essential goal for many stroke survivors. Currently, the prevalence of RTW post stroke in developing countries such as Jordan is unknown. Additionally, more research is required to identify factors that contribute to RTW post stroke.

OBJECTIVES

This study aims to (1) determine the prevalence of RTW among stroke survivors in Jordan, and (2) determine the predictors of RTW from a holistic perspective using the Occupational Therapy Practice Framework (OTPF) 3rd edition.

METHODS

Recruitment was carried out from different Jordanian hospitals and rehabilitation centers. A complete battery of outcome measures was used to reflect OTPF domains. These included outcome measures of occupations, client factors, performance skills, and context and environment. Logistic regression was used to determine factors that predicted RTW.

RESULTS

69 participants were enrolled; 45 Males, 24 females; mean age±SD, 52.2±11.07 years. Only 29% succeeded in RTW during the first year after stroke onset. The highest percentage of RTW was among craft workers (40% ), and those who were self-employed (60% ). Of those who resumed work, 35% returned to their previous work, while 65% needed to make work modifications, or change positions or jobs. Factors that predicted higher rates of RTW were walking speed (Odds ratio (OR)=0.004, 95% confidence interval (CI)=0.00-0.55, P < 0.02), as well as absence of environmental restrictions (OR = 21.16, 95% CI = 1.91-233.5, P < 0.013).

CONCLUSIONS

The alarming low prevalence of RTW among stroke survivors in Jordan emphasizes the essential need to develop vocational rehabilitation programs. Clinicians should pay attention to enhancing walking abilities and reducing environmental restrictions post stroke, in order to improve the occurrence of RTW.

The cost-of-illness due to rheumatic heart disease: national estimates for Fiji

BACKGROUND

Rheumatic heart disease (RHD) is a chronic valvular heart disease that is responsible for a heavy burden of premature mortality in low- and middle-income countries. The total costs of RHD are important to health policy and research investment decisions. We estimate for the first time the total cost of RHD for Fiji (2008-2012) using a cost-of-illness approach and novel primary data on RHD disease burden and costs.

METHODS

RHD cases were identified using probabilistic record linkage across four routine data sources: (1) the Fiji RHD Control Program, (2) national hospital admissions records, (3) the Ministry of Health database of cause-specific deaths and (4) hospital ECG clinic registers. For each individual with RHD, we obtained information on RHD hospital admissions, treatment and death. We conducted a prevalence-based cost-of-illness analysis, including bottom-up assessment of indirect and direct (healthcare) costs.

RESULTS

The estimated cost of RHD in Fiji for 2008-2012 was year-2010 $FJ91.6 million (approximately US$47.7 million). Productivity losses from premature mortality constituted the majority of costs (71.4%). Indirect costs were 27-fold larger than the direct costs.

CONCLUSIONS

RHD leads to a heavy economic burden in Fiji. Improved prevention strategies for RHD will likely confer substantial economic benefits to the country.

The effects of sudden health reductions on labor market outcomes: Evidence from incidence of stroke

While increasing attention is given to how health reductions affect workers, estimating their effects is usually challenging. This paper aims to identify the causal effect of health deterioration on labor market outcomes by exploiting the incidence of stroke. Stroke, which often reduces health suddenly and unexpectedly, allows us to exploit the within-person random variation of the timing and isolate the effects of health reduction. By applying the fixed-effects method to a sample of stroke survivors in the University of Michigan Health and Retirement Study data, I find that stroke immediately halves the employment probability as well as hours and weeks worked 1 year after the occurrence and its effects persist for at least 3 years, while earnings reduction is relatively moderate and gradual. I also find the negative effects of stroke are larger among men with severe stroke and women with longer pre-stroke job tenure, while the effects are mitigated for younger women. These results make a stark contrast with the studies on other health events such as cancer diagnosis, which generally find much smaller effects and significant heterogeneity by education and occupation. This analysis shows that the labor market effects largely differ by types of diseases and calls for disease-specific studies in order to understand the social gradient in health and how workers adjust to work limitations.

Effect of mood on long-term disability in younger stroke survivors: results from the Psychosocial Outcomes In StrokE (POISE) study

Background & Purpose: Anxiety and depression are common among stroke survivors, and their effect on long-term outcome remains unknown in those under 65 years of age. We investigated the association between early anxiety/depression after stroke and 12-month disability, and whether this is modified by sex.Methods: The Psychosocial Outcomes In StrokE (POISE) study was a prospective observational cohort study that recruited 441 younger (< 65 years) stroke survivors ≤28 days of acute stroke. Anxiety and depression were assessed using the Hospital Anxiety and Depression Scale, and disability using the World Health Organization Disability Assessment Scale version II (WHODAS-II). Associations between baseline anxiety/depression, and disability at 12-months was tested using analysis of covariance. Subgroup analysis was conducted using interaction term.Results: 92 (25%) had anxiety and 53 (14%) depression at baseline. Multivariable models showed significant association between baseline anxiety and 12-month disability (WHODAS-II score 15.24 vs. 11.49, p < .05). Those with anxiety had more impairment in 'cognition' (WHODAS-II score 18.26 vs. 8.71, p < .001), 'getting along' (WHODAS-II score 11.87 vs. 7.42, p < .05) and 'participation' (WHODAS-II score 22.37 vs. 15.92, p < .005) WHODAS-II. No significant relationship was found between baseline depression and long-term disability. There was no differential effect of anxiety by sex found in this study.Conclusions: Post-stroke anxiety has an adverse effect on disability at one year among young stroke survivors.

Exploring the lived return-to-work experience of individuals with acquired brain injury: use of vocational services and environmental, personal and injury-related influences

PURPOSE

To explore work outcomes, vocational services, barriers and facilitators for returning to work in individuals with acquired brain injury (ABI) in Queensland, Australia and to identify areas for improvement.

DESIGN AND METHODS

Ten semi-structured interviews were conducted with individuals with ABI (stroke, traumatic brain injury, tumour). Interviews were analysed using a realist thematic analysis approach.

RESULTS

Participants either returned to the same work, different work, did not maintain work or did not have any work since their injury. Use of vocational services depended on participants' needs and insurance. Facilitators for return to work (RTW) were a supportive workplace and family, vocational rehabilitation that met the individual's needs, insurance coverage and self-motivation. Workplaces that were not understanding of brain injury, employment service providers who were unable to find work for participants, and physical and cognitive deficits were barriers to RTW. Workplaces, employment service providers and individuals require more information about the deficits associated with brain injury.

CONCLUSIONS

The use and effectiveness of vocational services were variable across participants and depended on insurance coverage and needs. Barriers and facilitators for RTW were affected by both the environment and the individual. Implications for vocational rehabilitation were identified.Implications for RehabilitationA supportive workplace and family, and access to appropriate vocational rehabilitation are important environmental facilitators for RTW in individuals with ABI.Workplaces with a poor understanding of ABI and employment service providers unable to find work for individuals with ABI are environmental barriers to RTW.Workplaces, employment service providers and individuals with ABI require more information about the physical and cognitive deficits associated with ABI.Employment service providers need more training to develop comprehensive strategies to help individuals with ABI find new employment.

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.

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).

Factors which Influence Risk Taking and the Evolution of Social-Identity in Stroke Narratives: A Thematic Synthesis

Background: The disruption of a stroke can impact an individual’s sense of social identity. A comprehensive review is required to understand the factors and processes that influence changes in social identity following a stroke. Aims: To undertake a review of literature to discover a process of social identity evolution for people with stroke and identify the factors which influence it. Methods: A meta-ethnographic approach to review was undertaken and a subtle realist viewpoint was assumed. Studies were included if they documented experiences and perceptions relating to stroke. Eight electronic databases were searched from January 2009 until January 2019. Quality assessment and synthesis techniques were applied. Findings: Out of the 18 papers included, a total of 251 (141/251, 56% male, 109/251, 43% female, 1/251, 0.4% undisclosed) individuals were included within the synthesis. The evolution of social-identity model was developed and identified with five key stages to represent a process that individuals with stroke can experience. Factors which influence the process were identified and direct implications for clinical practice are given. Conclusion: This review has highlighted the major themes within the evolution of social identity and management strategies for risk taking to achieve a desired future. Further research is required to consider how these findings may be tested in clinical practice.

Return to work after stroke: A Swedish nationwide registry-based study

OBJECTIVES

A substantial proportion of individuals with stroke are of working age. After stroke, it is important to return to work (RTW), both for the individual's satisfaction with life and economically for society. The current comprehensive, long-term study aimed at investigating in what time period the RTW continues after stroke and what factors could predict RTW.

MATERIALS AND METHODS

All individuals registered in the registry Riksstroke with stroke in Sweden at ages 18-58 years during 2011 were eligible for participation. RTW was based on sickness absence data from the Social Insurance Agency covering 1 year prestroke to 5 years post-stroke. Time to RTW was analyzed with Kaplan-Meier curves. Potential predictors of RTW were analyzed with Cox regression and logistic regression.

RESULTS

For RTW analyses, 1695 participants were included. Almost 50% RTW within 3 months, 70% within 1 year, and 80% within 2 years post-stroke. However, the RTW continued for several years, with a total of 85% RTW. Predictors of favorable time to RTW were male sex, ischemic stroke, and long university education compared with primary school education. Predictors of unfavorable times to RTW were higher stroke severity, defined by the level of consciousness, and older ages. Participants with self-expectations of RTW 1 year post-stroke had higher odds of RTW within 5 years.

CONCLUSIONS

The RTW continues for a longer time after stroke than previously known. Both self-expectations and demographical, socioeconomic, stroke-related factors were important predictors of RTW. This knowledge could assist healthcare professionals to individualize the rehabilitation post-stroke.

Young ischaemic stroke incidence and demographic characteristics - The Norwegian stroke in the young study - A three-generation research program

INTRODUCTION

Norwegian Stroke in the Young Study (NOR-SYS) is a three-generation research program of young ischaemic stroke. In this study, we assessed ischaemic stroke incidence, education and work status among young stroke patients. Furthermore, we evaluated the participation of family members for future validated information on hereditary cardiovascular events.

PATIENTS AND METHODS

Patients aged 15-60 years with radiologically verified acute ischaemic stroke, admitted to Haukeland University Hospital in Bergen, Norway from 2010 to 2015, were included. Patients' partners, common offspring ≥ 18 years and biological parents of patients and partners were invited to participate. Ischaemic stroke incidence was analysed with respect to year, age and sex using multiple logistic regression.

RESULTS

A total of 385 patients, 260 partners (80.0%) and 414 offspring (74.6%) were clinically examined. The mean annual ischaemic stroke incidence rate was 30.2 per 100,000. Incidence was higher in men, and the difference was accentuated with increasing age (p = 0.008). There was no sex difference in educational status (p = 0.104) in contrast to work status (p < 0.001) for patients. In all, 84.1% of men worked, and of these, 80.3% are fulltime. In all, 74.4% of women worked, and of these, 52.9% are fulltime. Parents participated by returning a questionnaire. For patients, 91 fathers (55.2%) and 142 mothers (57.3%) participated. For partners, 48 fathers (38.4%) and 68 mothers (40.2%) participated.

CONCLUSION

The mean annual incidence rate of young stroke was 30.2 per 100,000, and the incidence rate was higher in men. Work status was high among both sexes. Active participation rates were high for patients, partners and offspring.

Cognitive, Emotional, and Physical Functioning as Predictors of Paid Employment in People With Stroke, Traumatic Brain Injury, and Spinal Cord Injury

OBJECTIVE

Our objective was to examine demographic, cognitive, emotional, and physical factors that predict return to paid employment for people after neurological injury.

METHOD

Four hundred eighty adults with stroke (n = 149), traumatic brain injury (n = 155), and spinal cord injury (n = 176) completed an occupational outcome questionnaire and physical, emotional, and cognitive assessments at three rehabilitation facilities.

RESULTS

Odds of employment were predicted by being married or partnered, having more education, requiring fewer prompts for task sequencing, and having higher inhibitory control (but were not predicted by specific type of injury). Participants who returned to work within 3 mo were more likely to work with the same employer and to take a full-time position than those who returned later.

CONCLUSION

Executive functioning, in particular sequencing and inhibitory control, strongly predicts employment and highlights the importance of cognitive strategy training during occupational therapy with people who have sustained neurological injuries.

Work-related predictors for return to work after stroke

Objectives

Disability due to stroke imposes a large burden on individuals, and on society, in terms of impaired work ability and sick leave. The reported return to work (RTW) rate after stroke varies globally and is influenced by a range of different aspects. The aim of this study was to investigate the influence of work‐related factors on time to RTW after stroke, and possible differences between the sexes.

Materials & Methods

Data from 204 persons with first‐time stroke in the years 2009‐2010 in Gothenburg, Sweden, who were of working age and had worked prior to their stroke, were analysed. Disease‐related characteristics were retrieved from medical records, and work‐related‐ and socio‐economic data were collected up to 6 years post‐stroke from Statistics Sweden and the Swedish Social Insurance Agency. Cox regression was used to analyse predictors for time to RTW.

Results

We identified qualified occupation and large organizational size as work‐related predictors for shorter time to RTW after stroke. Being male predicted a faster and higher frequency of RTW. Qualified occupation predicted shorter time to RTW in men but not in women. For women, the only predictor for RTW was physical dependency at discharge.

Conclusion

Type of work and organizational size are work‐related factors of importance for RTW after stroke. Work‐related factors were important for RTW in men, but not in women. Reasons for differences between men and women in work‐related factors that influence RTW need to be further investigated to better understand how to support women in the RTW process.

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

Background and purpose

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

Methods

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

Results

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

Conclusion

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

Return to Work Among Stroke Survivors

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

Association Between Anxiety, Depression, and Post-traumatic Stress Disorder and Outcomes After Ischemic Stroke

Background: Stroke patients are known to be at risk of developing anxiety, depression, and post-traumatic stress disorder (PTSD). Objective: To determine the overlap between anxiety, depression, and PTSD in patients after stroke and to determine the association between these disorders and quality of life, functional status, healthcare utilization, and return to work. Methods: A cross-sectional telephone survey was conducted to assess for depression, anxiety, PTSD, and health-related outcomes 6-12 months after first ischemic stroke in patients without prior psychiatric disease at a single stroke center. Results: Of 352 eligible subjects, 55 (16%) completed surveys. Seven subjects (13%) met criteria for probable anxiety, 6 (11%) for PTSD, and 11 for depression (20%). Of the 13 subjects (24%) who met criteria for any of these disorders, 6 (46%) met criteria for more than one, and 5 (39%) met criteria for all three. There were no significant differences in baseline characteristics, including stroke severity or neurologic symptoms, between those with or without any of these disorders. Those who had any of these disorders were less likely to be independent in their activities of daily living (ADLs) (54 vs. 95%, p < 0.001) and reported significantly worse quality of life (score of 0-100, median score of 50 vs. 80, p < 0.001) compared to those with none of these disorders. Conclusions: Anxiety, depression, and PTSD are common after stroke, have a high degree of co-occurrence, and are associated with worse outcomes, including quality of life and functional status.

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

BACKGROUND/AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Pulmonary embolism in Europe - Burden of illness in relationship to healthcare resource utilization and return to work

OBJECTIVES

Pulmonary embolism (PE) is associated with a substantial economic burden. However evidence from patients in Europe is scarce. The aim of this study was to report the impacts of PE on healthcare resource utilization (HCRU) and return to work using the PREFER in VTE registry.

METHODS

The PREFER in VTE registry was a prospective, observational, multicenter study in seven European countries, aiming to provide data concerning treatment patterns, HCRU, mortality, quality of life and work-loss. Patients with a first-time or recurrent PE were included and followed up at 1, 3, 6 and 12 months. Treatment patterns, re-hospitalization rates, length of hospital stays (LOS), and ambulatory/office visits, as well as proportion of patients returning to work, were assessed. Subgroups by country and with/without active cancer were examined separately. Zero-inflated negative binomial and Cox regression were applied to investigate the relationship between baseline characteristics and LOS and return to work, respectively.

RESULTS

Amongst 1399 patients with PE, 53.2% were male and the average age was 62.3 ± 17.1 years old. Overall, patients were treated with combinations of heparin, vitamin K antagonists (VKA) and the non-VKA oral anticoagulants (NOACs) (50.0% treated with the combination of heparin with VKA). Patients with active cancer were primarily treated with heparin (84.9%). NOACs were used more frequently in DACH (Germany, Austria and Switzerland) and France (55.2% and 32.6%) compared to Italy and Spain (4.5% and 6.1%). The VTE-related re-hospitalization rate within 12 months and the average LOS varied substantially between countries, from 26.2% in UK to 12.3% in France, and from 12.9 days in Italy to 3.9 days in France. PE patients were often co-managed by general practitioners in France and DACH (>84%), and less frequently in other countries (<47%). The regression results confirmed the country variation of HCRU. Of the employed patients (n = 385), 60% returned to work at 1 month but 27.8% had not after one year. PE patients with DVT were more likely to return to work. Active cancer was a significant predictor for not returning to work, as well as smoking history.

CONCLUSIONS

Medical treatment of PE differed between patients with active cancer and patients without active cancer. VTE-related resource utilization differed markedly between countries. While the reported 'not return to work' was high for patients with PE, this may at least in part reflect the presence of co-morbidities such as cancer.

Deep-vein thrombosis in Europe - Burden of illness in relationship to healthcare resource utilization and return to work

OBJECTIVES

Deep-vein thrombosis (DVT) forms a major healthcare burden in Europe, but exact estimates concerning the economic burden on society are lacking. This study reports results from the PREFER in VTE study concerning resource utilization and absence from work in DVT patients.

METHODS

The PREFER in VTE registry was a prospective, observational, multicenter study carried out in Europe (France, Italy, Spain, the UK, and DACH [Germany, Switzerland and Austria]), designed to provide data concerning treatment patterns, resource utilization, mortality and quality of life. Patients with a first-time and/or recurrent DVT, were recruited and followed for 12 months. Data about resource utilization concerns resource utilization related to DVT. Specifically, treatment pattern, re-hospitalization rate, length of hospital stay, ambulatory/office visit, and proportion of patients returning to work, were analyzed and presented. Subgroup analysis by country and active cancer were also conducted. The length of hospital stay was analyzed as a function of demographics, previous events and co-morbidities using zero-inflated binomial negative regression. Similarly, time until return to work was analyzed using Cox regression.

RESULTS

A total of 2056 patients with DVT were recruited, with an average age of 60 years. Patients with active cancer were mostly treated with heparin (83.9%), while patients without active cancer were treated with combinations of heparin, VKA and DOACs. DOACs were less often used in Spain and Italy (<7.0%). Following the management of their initial DVT 20.5% of the patients with and 12.2% of patients without active cancer (n = 88; n = 1462) were hospitalized for on average 8.2 and 10.1 days, respectively. The hospitalization-rate was highest in Italy (16.7%) and lowest in France (7.7%). Furthermore, the average length of stay was highest in Italy (16.6 days) and lowest in DACH (5.2 days). Physician visits were highest in DACH (9.3), lowest in the UK (2.6). Of those working, 50% returned to work at 1 month; >30% did not return to work within the year.

CONCLUSIONS

Medical treatment of DVT differed between patients with active cancer and those without. Post-VTE or VTE-related resource utilization differs remarkably between countries. Work-loss seems high, but questions may be raised concerning the causality due to the presence of co-morbidities.

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.

Impact of balance on functional independence after stroke: A cross-sectional study at rehabilitation settings in Nigeria

BACKGROUND

Functional independence is often compromised after stroke and its restoration is one of the goals of stroke rehabilitation.

OBJECTIVE

This study assessed the impact of balance on functional independence after stroke.

METHODS

Ninety-five stroke patients undergoing physical rehabilitation at two health institutions in Nigeria participated in the study. Balance and functional independence were respectively assessed with the Berg Balance Scale and the Barthel Index. Binary logistic regression analysis was conducted to examine the independent impact of balance on functional independence while controlling for participants' age, sex, side of hemiparesis and post-stroke duration.

RESULTS

Mean±SD age of the participants was 58.4±13.1 years and females were more (f = 48; %  = 50.5). The regression model from the binary regression analysis explained 73.2% (Nagelkerke R2 = 0.732) of the variance in functional independence. Good balance function was found to independently and significantly (P <  0.01) increase the likelihood of being functionally independent after stroke (Odds ratio = 1.33; 95% CI = 1.11 to 1.58).

CONCLUSION

The goal of attaining functional independence after stroke may depend to a significant extent on good balance function irrespective of the stroke survivor's age, sex and post-stroke duration.

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.

Return to work after young stroke: A systematic review

Background The incidence of stroke in young adults is increasing. While many young survivors are able to achieve a good physical recovery, subtle dysfunction in other domains, such as cognition, often persists, and could affect return to work. However, reported estimates of return to work and factors affecting vocational outcome post-stroke vary greatly. Aims The aims of this systematic review were to determine the frequency of return to work at different time points after stroke and identify predictors of return to work. Summary of review Two electronic databases (Medline and Embase) were systematically searched for articles according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A total of 6473 records were screened, 68 were assessed for eligibility, and 29 met all inclusion criteria (working-age adults with stroke, return to work evaluated as an outcome, follow-up duration reported, and publication within the past 20 years). Return to work increased with time, with median frequency increasing from 41% between 0 and 6 months, 53% at 1 year, 56% at 1.5 years to 66% between 2 and 4 years post-stroke. Greater independence in activities of daily living, fewer neurological deficits, and better cognitive ability were the most common predictors of return to work. Conclusion This review highlights the need to examine return to work in relation to time from stroke and assess cognition in working age and young stroke survivors. The full range of factors affecting return to work has not yet been explored and further evaluations of return to work interventions are warranted.

Stroke in women - from evidence to inequalities

Stroke is the second largest cause of disability-adjusted life-years lost worldwide. The prevalence of stroke in women is predicted to rise rapidly, owing to the increasing average age of the global female population. Vascular risk factors differ between women and men in terms of prevalence, and evidence increasingly supports the clinical importance of sex differences in stroke. The influence of some risk factors for stroke - including diabetes mellitus and atrial fibrillation - are stronger in women, and hypertensive disorders of pregnancy also affect the risk of stroke decades after pregnancy. However, in an era of evidence-based medicine, women are notably under-represented in clinical trials - despite governmental actions highlighting the need to include both men and women in clinical trials - resulting in a reduced generalizability of study results to women. The aim of this Review is to highlight new insights into specificities of stroke in women, to plan future research priorities, and to influence public health policies to decrease the worldwide burden of stroke in women.

Marriage after the transition to stroke: a systematic review

In health and chronic illness, satisfying marriages promote wellbeing and life satisfaction, yet stroke research has focused on either the stroke survivor as the patient or the spouse as a care-giver. Using Pope, Mays and Popay's framework for synthesising qualitative and quantitative methods, we conducted a systematic review and synthesis of 39 peer-reviewed studies to determine what happens to marital relationships after one partner has suffered a stroke. All the articles examined the impact of stroke. Three overarching themes characterise the evolution of marriage after stroke: chaos in the marriage, work to re-establish the marriage and evolution of the marriages. While both the stroke condition itself and the survivors’ need for care undermined the emotional qualities of the relationship for some couples, about two-thirds were able to retain or regain the relationship closeness. As in other chronic illnesses, the relationship closeness and a couple's ability to collaborate contributed to the survivor's recovery and to the satisfaction with life of the stroke survivor and the spouse. Our results underscore the need to consider the quality of, and the qualities of, the relationship between stroke survivors and their spouses. Future research could include a greater focus on qualitative or mixed-methods approaches to explore the interactions between stroke survivors and spouses that impact the wellbeing of both partners.

Return to Work 2-5 Years After Stroke: A Cross Sectional Study in a Hospital-Based Population

Purpose To describe factors associated with RTW in patients 2-5 years after stroke. Methods Cross sectional study, including patients 2-5 years after hospitalization for a first-ever stroke, who were <65 years and had been gainfully employed before stroke. Patients completed a set of questionnaires on working status and educational level, physical functioning (Frenchay Activities Index, FAI), mental functioning (Hospital Anxiety and Depression Scale, HADS), Coping Orientations to Problems Experienced, (COPE easy) and quality of life (Short-Form(SF)-36 and EQ(Euroqol)-5D). Caregivers completed the Caregiver Strain Index (CSI). Baseline stroke characteristics were gathered retrospectively. Baseline characteristics and current health status were compared between patients who did and did not RTW by means of logistic regression analysis with odds ratios (OR) and 95 % confidence intervals (CI), adjusted for age and gender. Results Forty-six patients were included, mean age of 47.7 years (SD 9.7), mean time since stroke of 36 months (SD 11.4); 18 (39 %) had RTW. After adjusting for age and gender a shorter length of hospitalization was associated with RTW (OR 0.87; CI 0.77-0.99). Of the current health status, a lower HADS depression score (0.76; 0.63-0.92), a less avoidant coping style (1.99; 0.80-5.00), better scores on the FAI (1.13; 1.03-1.25), the mental component summary score of the SF36 (1.07; 1.01-1.13), the EQ5D (349; 3.33-36687) and the CSI (0.68; 0.50-0.92) were associated with the chance of RTW. Conclusions A minority of working patients RTW after stroke; a shorter duration of the initial hospitalization was associated with a favorable work outcome. The significant association between work status and activities, mental aspects and quality of life underlines the need to develop effective interventions supporting RTW.