The role of biopsychosocial factors in the rehabilitation process of individuals with a stroke

Purpose A large proportion of individuals with a stroke are unable to return to work, although figures vary greatly. Due to the very high cost of post-stroke care, both tangible and intangible, in the form of long-term social consequences, it seems extremely important to search for factors responsible for the low efficiency of the rehabilitation and recovery process, because this fact has direct influence on future employment. Such knowledge would enable physiotherapists to quickly identify those patients who are at risk of rehabilitation breakdown, in order to provide them with special care and include them in intensive therapeutic treatments. The aim of the study was to assess the efficacy of post-stroke rehabilitation, evaluated within the biopsychosocial aspect. Methods The study consisted of 120 patients after first stroke, including 48 women and 72 men aged 58.0 (±8.6). The measure of the effects of physiotherapy in the present study was not only the improvement of the functional state (simple and complex activities of daily life, locomotive activities), but also the improvement of the mental state (mood and the sense of well-being, level of acceptance of illness, perceived self-efficacy) and the reduction of pain. The Mini-Mental State Examination, the Geriatric Depression Scale, the Generalized Self-Efficacy Scale, the Acceptance of Illness Scale, the Visual Analogue Scale, the Barthel Index, the Instrumental Activity of Daily Living and the Rivermead Mobility Index were used. All parameters were measured twice: on admission to the ward and after three weeks of physiotherapy. The characteristics of the study group were presented using descriptive statistics. The analysis of interdependence of the efficacy of physiotherapy used two non-parametric tests: the Mann-Whitney U test to compare two groups, and the Kruskal-Wallis ANOVA test to compare a greater number of groups. Correlations between characteristics with continuous distributions were assessed using Spearman's rank correlation coefficient (ρ), and in case of categorical variables, Pearson's chi-squared (χ2) correlation coefficient. Linear regression was used to determine the hierarchy of the influence of particular characteristics on the efficacy of physiotherapy. Results Statistical analyzes show that patient's age, time since stroke, number of comorbidities, family care capacity, marital status of the patient and also a low level of acceptance of illness, depression symptoms and lack of a sense of self-efficacy were related with low efficacy of post-stroke rehabilitation. Conclusions Comprehensive neurological rehabilitation, taking into account mental challenges and socio-economic circumstances of individuals with a stroke is essential in order to achieve high efficacy of physiotherapy. Important external factors may play a pivotal role in returning to work as well and should be taken into account during rehabilitation. Of interest should be to assess more biopsychological factors, such as acceptance of illness and a sense of self-efficacy referred to as barriers to return to work.

Source: Kobylańska M, Kowalska J, Neustein J, Mazurek J, Wójcik B, Bełza M, Cichosz M, Szczepańska-Gieracha J, Work, 2018 Nov.

Reemployment of people with chronic stroke: A singlecentre retrospective study

Purpose 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). Conclusions 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.

Source: Fukuzawa I, Tokumaru O, Eshima N, Bacal K, Kitano T, Yokoi I, Australian Occupational Therapy Journal, Vol. 65 (6), p.598-605, 2018 Dec.

Operational Definitions and Estimates of Return-to-Work after Stroke: A Systematic Review and Meta-Analysis

Purpose To examine operational definitions of return-to-work (RTW) after stroke and provide more precise estimates of RTW through meta-analysis. Methods A systematic search was conducted using MEDLINE, CINAHL, PsycINFO, and SCOPUS (2005 to March 26, 2018). The search strategy involved expansion of medical subjective headings using terms related to 'stroke' and 'work'. The reference lists of review articles and included studies where checked for additional relevant studies. Studies were included if they 1) quantitatively analyzed RTW outcomes or factors associated with RTW, 2) reported RTW outcomes for participants employed prior to stroke, and 3) were written in English or French. Two reviewers independently screened titles and abstracts. Results Of 7265 articles initially identified, 55 studies were included. Data was extracted and study quality was assessed by one reviewer and verified by a second reviewer. Explicit and implicit operational definitions of RTW were determined and categorized. Ranges of RTW estimates were presented for study and participant characteristics. Pooled summary estimates were calculated for comparable studies by follow-up time post-stroke: 55.7% at one year (95% CI, 51.3% to 60.0%) and 67.4% at two years (95% CI, 60.4% to 74.4%). Similar summary estimates were noted when only population-based studies were considered: 56.7% at one year (95% CI, 48.3% to 65.1%) and 66.7% at two years (95% CI, 60.2% to 73.2%). Conclusions Operational definitions varied across studies and were often not explicitly reported. To promote comparability of RTW outcomes in future studies, we recommend working towards a universal operational definition and consistent follow-up times. The more precise estimates calculated in this review could be used as benchmarks for healthcare and social service providers.

Source: Duong P, Sauvé-Schenk K, Egan MY, Meyer MJ, Morrison T, Archives of Physical Medicine and Rehabilitation, 2018 Oct.

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

Purpose We aimed to investigate the proportion of young patients not returning to work (NRTW) at 1 year after ischemic stroke (IS) and during follow-up, and clinical factors associated with NRTW. Methods Patients from the Helsinki Young Stroke Registry with an IS occurring in the years 1994-2007, who were at paid employment within 1 year before IS, and with NIH Stroke Scale score ≤15 points at hospital discharge, were included. Data on periods of payment came from the Finnish Centre for Pensions, and death data from Statistics Finland. Multivariate logistic regression analyses assessed factors associated with NRTW 1 year after IS, and lasagna plots visualized the proportion of patients returning to work over time. Results We included a total of 769 patients, of whom 289 (37.6%) were not working at 1 year, 323 (42.0%) at 2 years, and 361 (46.9%) at 5 years from IS. When adjusted for age, sex, socioeconomic status, and NIH Stroke Scale score at admission, factors associated with NRTW at 1 year after IS were large anterior strokes, strokes caused by large artery atherosclerosis, high-risk sources of cardioembolism, and rare causes other than dissection compared with undetermined cause, moderate to severe aphasia vs no aphasia, mild and moderate to severe limb paresis vs no paresis, and moderate to severe visual field deficit vs no deficit. Conclusions NRTW is a frequent adverse outcome after IS in young adults with mild to moderate IS. Clinical variables available during acute hospitalization may allow prediction of NRTW.

Source: Aarnio K, Rodríguez-Pardo J, Siegerink B, Hardt J, Broman J, Tulkki L, Haapaniemi E, Kaste M, Tatlisumak T, Putaala J, Neurology, 2018 Oct

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

Purpose 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.

Source: Scott SL, Bondoc S, Occupational Therapy In Health Care, 2018 Jul.

Employment sustainability after return to work among Japanese stroke survivors

Purpose Few studies have investigated the work continuance rate among stroke survivors who return to work (RTW). The objective of this study was to investigate work sustainability after RTW and the causes of recurrent sickness absence (RSA) among Japanese stroke survivors. Methods Data on stroke survivors were collected from an occupational health register. The inclusion criteria were as follows: employees who were aged 15-60 years old and returned to work after an episode of sick leave due to a clinically certified stroke that was diagnosed during the period from 1 January 2000 through 31 December 2011.Results 284 employees returned to work after their first episode of stroke-induced sick leave. The work continuance rate for all subjects was 78.8 and 59.0% at one and 5 years after the subjects’ RTW, respectively. After returning to work, the subjects worked for a mean of 7.0 years. Of 284 employees who returned to work, 86 (30.3%) experienced RSA. The RSA were caused by recurrent strokes in 57.0% (49/86) of cases, mental disorders in 20.9% (18/86) of cases, and fractures (often due to accidents involving steps at train stations or the subject’s home) in 10.5% (9/86) of cases. 21 employees resigned after returning to work. The resignation rates at 1 and 5 years were 4.9 and 7.6%, respectively. According to the multivariate analysis including all variables, the subjects in the ≥ 50 year group were at greater risk of work discontinuation than the ≤ 49 year (reference) age group (HR: 2.26, 95% CI 1.39-3.68). Conclusions Occupational health professionals need to provide better RTW support to stroke survivors and should pay particularly close attention to preventing recurrent strokes, mental disorders, and fractures.

Source: Motoki E, Yasuo H, Go M, Kazuhito Y, Noriko K, Naohito Y, International Archives of Occupational & Environmental Health, Vol. 91 (6), p.717-724, 2018 Aug.

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

Purpose 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.

Source: Langhammer B, Sunnerhagen KS, Sällström S, Becker F, Stanghelle JK, Brain and Behavior, p.e01055, 2018 Jul.

Experiences of returning to work and maintaining work 7 to 8 years after a stroke: a qualitative interview study in Sweden

Purpose To explore how persons experienced return to work (RTW) and their work situation 7 to 8 years after a stroke. Methods An explorative qualitative design with individual interviews. The data analysis was inductive thematic and three researchers collaborated during the analysis process. The study population included five women and eight men who had a stroke during 2009-2010, received care at the Sahlgrenska University Hospital in Gothenburg, Sweden and RTW after stroke and it was a heterogenic sample based on age, occupation, stroke severity and time to RTW. Results The analysis led to four themes; motivated and RTW while struggling with impairments, mixed feelings in the RTW process, still at work though restricted and social support for a sustainable work situation. The themes revealed that participants were motivated to RTW while struggling with impairments. The RTW process evoked mixed feelings of worry and grief over lost functions but also acceptance and gratitude for being able to work. Although maintaining work 7 to 8 years after experiencing a stroke, most were restricted in some way. Fatigue and cognitive impairments meant having to set limits, omit work tasks and rest at work, but also rest during free time and refraining from social activities in order to manage work. Participants avoided work-related stress if they could because of aggravated symptoms and/or fear of a new stroke. Support from supervisors and colleagues was often crucial for a sustainable work situation. Conclusions Maintaining work can be a continuous struggle with invisible impairments many years after a stroke. Strategies for managing work are dependent on each individual work situation, where support and understanding at work seem to be crucial for a sustainable work situation.

Source: Palstam A, Törnbom M, Sunnerhagen KS, BMJ Open, Vol. 8 (7), p.e021182, 2018 Jul.

Employment sustainability after return to work among Japanese stroke survivors

Purpose Few studies have investigated the work continuance rate among stroke survivors who return to work (RTW). The objective of this study was to investigate work sustainability after RTW and the causes of recurrent sickness absence (RSA) among Japanese stroke survivors. Methods Data on stroke survivors were collected from an occupational health register. The inclusion criteria were as follows: employees who were aged 15-60 years old and returned to work after an episode of sick leave due to a clinically certified stroke that was diagnosed during the period from 1 January 2000 through 31 December 2011. Results 284 employees returned to work after their first episode of stroke-induced sick leave. The work continuance rate for all subjects was 78.8 and 59.0% at one and 5 years after the subjects' RTW, respectively. After returning to work, the subjects worked for a mean of 7.0 years. Of 284 employees who returned to work, 86 (30.3%) experienced RSA. The RSA were caused by recurrent strokes in 57.0% (49/86) of cases, mental disorders in 20.9% (18/86) of cases, and fractures (often due to accidents involving steps at train stations or the subject's home) in 10.5% (9/86) of cases. 21 employees resigned after returning to work. The resignation rates at 1 and 5 years were 4.9 and 7.6%, respectively. According to the multivariate analysis including all variables, the subjects in the ≥ 50 year group were at greater risk of work discontinuation than the ≤ 49 year (reference) age group (HR: 2.26, 95% CI 1.39-3.68). Conclusions Occupational health professionals need to provide better RTW support to stroke survivors and should pay particularly close attention to preventing recurrent strokes, mental disorders, and fractures.

Source: Endo M, Haruyama Y, Muto G, Yokoyama K, Kojimahara N, Yamaguchi N, International Archives of Occupational and Environmental Health, 2018 May. 

Return to work after young stroke: A systematic review

Purpose 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. 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. Methods 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. Results 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. Conclusions 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.

Source: Edwards JD, Kapoor A, Linkewich E, Swartz RH, International Journal of Stroke, Vol. 13 (3), p.243-256, 2018 Apr.

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.

Source: Schwarz B, Claros-Salinas D, Streibelt M, Journal of Occupational Rehabilitation, Vol. 28(1), p.28-44, 2018 Mar.

Interdisciplinary Approaches to Facilitate Return-to-Driving and Return-to-Work in Mild Stroke: A Position Paper

Purpose Adults with mild stroke face substantial challenges resuming valued roles in the community. The term "mild" provides false representation of the lived experience for many adults with mild stroke who may continue to experience persistent challenges and unmet needs. Rehabilitation practitioners can identify and consequently intervene to facilitate improved independence, participation, and quality of life by facilitating function and reducing the burden of lost abilities among adults with mild stroke. The [blind task force] identified two important, and often interdependent, goals that frequently arise among adults living with mild stroke that must be addressed to facilitate improved community reintegration: (1) return-to-driving and (2) return-to-work. Adults with mild stroke may not be receiving adequate rehabilitative services to facilitate community reintegration for several reasons but primarily because current practice models are not designed to meet such needs of this specific population. Methods Thus, the [blind task force] convened to review current literature and practice trends to 1) identify opportunities based on the evidence of assessment and interventions, for return-to-driving and return-to-work, and 2) identify gaps in the literature that must be addressed to take advantage of the opportunities. Conclusions Based on findings, the task force proposes a new interdisciplinary practice model for adults with mild stroke that are too often discharged from the hospital to the community without needed services to enable successful return to driving and work.

Source: Burns SP, Schwartz J, Scott S, Devos H, Kovic M, Hong I, Akinwuntan A, Archives Of Physical Medicine And Rehabilitation, 2018 Mar.

Experiences of the return to work process after stroke while participating in a person-centred rehabilitation programme

Purpose In Sweden, less than 50% of those getting stroke in working age return to work (RTW). Effective rehabilitation programmes need to be developed and therapeutic aspects understood. Aim To explore and describe how persons with stroke experience their RTW process while participating in a person-centred rehabilitation programme focusing on RTW. Methods Seven persons with mild or moderate stroke were interviewed twice during the intervention in the vocational training phase using semi-structured interviews. Data were analysed using grounded theory. Results Having a coordinator by their side gave support and guidance during the RTW process. Knowledge of stroke, strategies and a straightforward communication created a structure for the RTW process. Expressing one’s own wishes increased opportunities to influence and decide which path to follow in order to reach the goal. Conclusions Straightforward, open and recurring communication facilitated the possibility to adapt to the situation. These aspects increased insight and awareness which facilitated the RTW process. The findings indicate that a precondition for a fruitful RTW process was that suitable platforms at work were created in which the actors involved could cooperate. This knowledge might also be valuable in the RTW process for people with other diagnosis.

Source: Öst Nilsson A, Eriksson G, Johansson U, Hellman T, Scandinavian Journal of Occupational Therapy, Vol. 24 (5), 349-356, 2017 Sep.

Exploring the experiences of rehabilitated stroke survivors and stakeholders with regard to returning to work in South- West Nigeria

Purpose Stroke has been identified as a global cause of neurological disability with a resultant burden shared not only by the survivor but also by society. The resumption of an individual's role as a worker after having a stroke, is an important rehabilitation goal. South-West Nigeria has experienced a high incidence and prevalence of stroke, leaving a quarter of survivors with severe disabilities and difficulties in community integration after rehabilitation.The study was aimed at exploring and describing the experiences of rehabilitated stroke survivors and perceptions of stakeholders about stroke survivors returning to work in South-West Nigeria. Methods A qualitative research design was used to explore these experiences and perceptions from 19 participants, comprising nine stroke survivors, two key informants, who were rehabilitation specialists, and eight caregivers of the respective stroke survivors. The researcher made use of focus groups with the caregivers and semi-structured interviews with the stroke survivors and rehabilitation specialists. The data from the study were analysed using thematic analysis. Results Three themes emerged: Themes one and two described the barriers experienced by the stroke survivors on returning to work. Theme three described the factors that facilitated the resumption of the worker role. Conclusions The study findings clearly depicted the many barriers experienced by stroke survivors and how these negatively impact their worker roles. Limited facilitatory factors exist to assist stroke survivors in regard to adapting to their worker roles. Promoting participation of stroke survivors in work emanating from government policies was deemed to be a necessary recommendation for the study. These policies were seen to be achievable if rehabilitation resources were improved.

Source: Soeker MS, Ayoola Olaoye O, Work, 2017 Aug.

Returning to work after an acute coronary syndrome: When waiting is wasting

Purpose Return to work (RTW) after acute coronary syndrome (ACS) is an important issue for the patient's future.The study aim was to determine whether RTW practice complies with guidelines or is delayed by failure in patient management. We analysed the factors influencing RTW beyond the 90-day period recommended by guidelines. Methods We conducted a survey of 216 self-employed workers admitted to the hospital for ACS using self-report questionnaires and medical examination. Factors influencing RTW, occupational and cardiac features, and recall and source of medical information were investigated. Results Ninety-three of 216 patients did not return to work by 90 days, despite good cardiac performance in 30 cases (32 %). The mean sick leave duration was 93.3±103.7 days. Advice concerning return to work was completely missing for 44 % of patients. Cardiac performance was independent of sick leave duration, but was correlated with the likelihood of RTW (P<0.001). Patients assimilated about 70 % of the medical information they were provided, but only 53 % of work-related information. Recall of work-related information was better among patients admitted to a rehabilitation facility (65 %) compared to those who did not receive rehabilitation (P<0.05).Conclusions Cardiologists should assess the patient's cardiac performance within 2 months after ACS. Patient management should also include cardiac rehabilitation or therapeutic education toward improving information recall.

Source: Latil F, Iliou MC, Boileau C, Pietri JX, Lechien C, Ha-Vinh P, Guimond C, Annales De Cardiologie Et D'angeiologie, 2017 Mar.