Returning to Work After Stroke: Predictors and a Paradox

Damian McNamara

May 31, 2018

GOTHENBURG, Sweden — Factors such as intravenous thrombolysis and occupational therapy at 3 months independently and significantly predicted which patients would be employed 1 year after a first stroke, in a new registry study.

Overall, 34% of patients who were working at the time of their stroke were re-employed at 3 months. However, this proportion decreased to 27% at 1 year, to 25% at 5 years, and to 10% at 10 years.

"Another trend we saw is that patients who returned to work within 1 year were more likely to still be employed at 10 years," said Arup Sen, MRCP, from the NIHR Biomedical Research Centre at Guy's and St. Thomas' NHS Foundation Trust of Ageing and Health at King's College London, United Kingdom. "This suggests, in terms of planning post-stroke rehab, the time to get patients back to work would be as soon as possible — and ideally within the first year."

In addition, a large proportion of the independent patients are not returning to work initially, Sen told Medscape Medical News. Only 39% of the functionally independent patients were back to work at 1 year, although this increased to 47% at 5 years and 69% at 10 years.

"We wanted to look at this in more detail because little is known about the long-term factors affecting return to work at different time points post-stroke," he said during an ePoster presentation here at the 4th European Stroke Organisation Conference (ESOC) 2018. The researchers defined functional independence as a Barthel Index score greater than 90.

Sen and colleagues reviewed data for 5609 multiethnic urban patients from 2005 to 2014 from the South London Stroke Registry maintained by the Royal College of London. They further evaluated the 940 patients, or 17%, who were employed at the time the stroke occurred.

Emotional Toll of Returning to Work

The investigators also assessed anxiety and depression by using scores on the Hospital Anxiety and Depression Scale and 12-Item Short-Form survey at 1, 5, and 10 years. Potential long-term negative emotional consequences associated with a return to work emerged.

People who returned to work after stroke were statistically significantly more likely to experience anxiety and depression at 1 year (P < .01) and 5 years (P < .05) than those who did not.

"It's paradoxical," Sen said. "Previous studies have shown that return to work is seen as a recovery milestone."

"Although patients are physically ready to go back to work, there may be other reasons for increased stress levels around going back to work," he said, "such as lack of coping or adaption, social factors or workplace factors such as the work climate."

Returning to work is a dynamic, multifaceted process that is difficult to explain by measures such as the Barthel Index alone, Sen said. "There may be other factors like fatigue, cognition, and personal factors."

Quality-of-life concerns, including emotional issues, can persist even after successful treatment of acute ischemic stroke, suggested a study of 75 patients presented at the World Congress of Stroke in 2016.

In addition, other research in 279 people employed at the time of a stroke demonstrated that post-stroke depression predicted not returning to work almost to the same extent as physical disability.

Manual vs Nonmanual Labor

A meeting attendee asked Sen if he stratified patients by the type of employment before their stroke. Because it was a registry study, the data only indicated if a person was involved in manual labor or not, he replied.

"Interestingly, we did do a subanalysis," he noted. "The nonmanual labor patients were less likely to return to work." He speculated that more people in manual labor might have been physically able to go back to work, whereas people in office jobs may have been limited because of deficits in cognition.

However, session moderator Kenneth Butcher, MD, PhD, professor of neurology at the University of Alberta, Edmonton, Canada, speculated it may be more a matter of means. "In my experience, the white collar workers have the financial means to retire after they've had a stroke," he said. "I think in the future you need to ask people if they want to return to work."

"I think motivation is an important factor as well," Sen said. "There also could be financial pressures and family pressures."

"I think the biggest predictor of return to work is your age," Butcher told Medscape Medical News when asked to comment. "The point estimate [for patient age] is very close to unity here, which means most stroke patients are close to the retirement age already."

But the findings are still "quite significant," he added. "He did show, in terms of occupation, that white collar workers were less likely to return to work. It's plausible and requires more research, but it could also be possible that those people don't need to return to work."

Stroke is a life-changing event, "and if you're in an occupation where you're just working because you can — you might say, 'That's enough. I'm going to go retire now,'" he said.

The findings are interesting, but more prospective research looking at possible confounders is needed, Butcher added.

"Our database is limited, but I think we definitely will try to take the research forward," Sen said.

Sen and Butcher have disclosed no relevant financial relationships.

4th European Stroke Organisation Conference (ESOC) 2018. Presented May 17, 2018.

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