Topics in Stroke Rehabilitation

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Vocational outcome after stroke

Randie M. Black-Schaffer & Lori Lemieux

To cite this article: Randie M. Black-Schaffer & Lori Lemieux (1994) Vocational outcome after
stroke, Topics in Stroke Rehabilitation, 1:1, 74-86, DOI: 10.1080/10749357.1994.11754008

To link to this article: https://doi.org/10.1080/10749357.1994.11754008

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 This article reviews the literature on vocationai outcome after strolte and discusses ireasons for the minimal
use of vocational outcome ineasures in stroke rehabiiitation research. A \iocaiionai function measuremerit
tcoi is proposed. The vocational rehabilitation process and experience of the Young Stroke Program i t New
England Rehabilitation Hospital are descr~bed,and determitiants of success or failiire in vocatioi?al
rehabilitation after stroke as described in the medical literatiire are rev~e~ved.
The iiiipact oithe Americans
with Disabilities Act of 1990 and of changes in health care funding on vocational outcomes aiter stroke are
discussed. Key words: cerebroi/ascular accideni, young adult, outconle i~easurement,vocations! I-ehabili-
ration, stroke

Randie Ad, Black-SchaAfe~~ MD RETURN TO WORK AS AN

Medical D I M (to<,Your~gStroke Piogi-am OUTCOME OF WEW,%BILPTATPON
Departme~zfof Rehabill fatiota Med~czne
The successfujnl performance of valued
Lori Lemieux9 iWS, CRC work is central to (he well-being and psycho-
Vocatdonai Keizabilitatknn CounseZoi., logical health of adults in mosq if nsr all,
Young Stroke Program societies. In rehabilitation bhesry and prac-
Depar.rment of \F/cicarioi?al
RelzaJi7iiiiulkol.e tice, return to work is considered among the
New Engiand Rehabilifarion HospI1'aI highest functional goals, typically requiring
Woburx. Ma~~dassachusetts motor, cognitive, communication, and per-
ceptual abilities beyond those needed for the
performance of seif-care and basic mobility
tasias. Moreover, return to vocational fkri.c-
tion, and therefore to a. prodiactkde societal
role and an active taxpayer status, has histori-
cally been tou.ted by the rehabilirzti.oc corn-
munity as a major reason why rehabilitation
efforts are worthwhile and deserve pknblic
and private support (Gresham, 199%).
Bes~iaethis, the rehabilitation community
has devoied 011191limited effort to the task s f
defining what is meant by the phrase resum
to w'oi.k, to developing measures of voca-
tional '.~r?ctioa,to applying these measures to
;;iatient popdations, and to tracking rerun ;is

Top Sti-!;kcRrhuhii !994; 1(1):73-86

O 1994 Aspen Publishers. Tnc.
i~d0l.kas a ineasure of rehabilitation outcome.
Quantitative indices for n~easuringactivities
of daily living (ADLs) and basic mobility
performance a.bound; the Barthe?, the Katz,
the Functional Independence Measure
(FIM), the Patient Evaluation and Confer-
ence System (PEGS),and those of Menny and
of Rankin are several that have enjoyed
widespread ilse. Vscarlsnal fi~nctios?,how-
ever, if measured at all. is typically done as a
nominal variable: L6Yes91 the patient returned
ao i~iork,or the patient did not. It is not
difficult to appreciate that a ""yes" response
can mean different rhilrrgs f u ~different pa-
tients, The young s t r ~ k patient
e who, with a
greas deal of assista~zceirom ~ehabil~tatlon
personriel, is able after many months to re-
turn part time to a modified: closely super-
vised position with reduced salary and hours
is a "yes," as is the patient who rettims to his
or her unanodified forrnes job after. minimal
rehabilitation intervention and with the same
hours and salary as before the stroke. Signifi-
cant information is clearly lost by lumping
these two levels of outcome together as "re-
im to v~ork."We are unaware, however, of
more detailed measures of vocational out-
come in regular use in rehabiliclatian practice
or research.
A number of studies over The past several
decades have addressed serum to work as xi
outcome after stroke in young adults in this
binary kshion (Tabje I j.The wide spread of
percentages of patients returned to work in
these studies suggests, as is borne out by
c a r e f ~reading
~l of the studies (summarized in
column 5 of Table I), that the investigators
do not all mean the same thing by "work"; for
example, some include homemaking and
study "ot others only competitive ernploy-
men$, and some restrict it to fomer employ-
ment but others do not specify at all. Also, the
age ranges of the groups srbadied differ
widely, with some studies including persons
65 years old and older and others considerkg
only patients younger than 30 or 45 years
sf age. Additionally, sample sizes differ
greatly, and few involve Large cohorts, Fi-
b
nally, the end point for deciding whether a
patient has been able to return to wofk is
-miable and cccasionally unstaied: Remn io
wor1c is measured atthe f me sfrehabihalation
discharge, at 3 months after discharge, a.t 12
months after cerebrovascular accident (CVA),
or at a specific point of zlme with a variable
relationship to the individual patient9s course.
T3us the average percentage of patients re-
tunrsbd to worlc (43%) il-,b a s csn~pilarioncf 17
& -A-
studies, rather than being a helpful measure of
vocational rehabilitation performance against
which clinicians can evaluate their own expe-
rience, is of limited use.
at is note~lorthyin reviewing the data in
Table 1 that the same s i m p l i s r ? ~and
nonstandardized handling of vocational out-
come that was the norm in studies in the early
2960s renains the norm in the 1390s. There
has keen little movementtoward develop-
ment of more informative or better standard-
ized t3~1esfor looking at vocational outcome.
Why has the rehabilitation community.
which professes helief in the importance of
vocadona; rehabilitarion as a xil G ~ b r I 1
aiA2
to work as a desirable outcome, used this
outcome so little and with such an absence of
sophistication? A number of cogent reasons
are ready to hand. First, there is no obvious
end point in time to assess vocational out-
come after a stroke, h contrast to ABLs and
mobility skills, vsscationai status is usually
not appropriate to consider at the point sf
$ischarge from inpatient rehabilitaeron. Pa-
tients who are severely enough affected by
their strokes ro qualify for inpatient rehakili-
Table 1.Return to work after stroke: Review of studies

Number of Return to Definition of

Investigators patients work (%) Ages (years) worka

Adunsky, Herskikowitz, Rabbi,

Asher-Sivron, $r Ohry (1992) 20-45 FE, other
Black-Schaffer & Osberg (1990) 2 1-65 FT, PT,HM US
Bogoussiavsky & Regli (1987) 130 FT
Cuughlan & Biimphrey (i982) 165 FT, PT
David & Heynan (1 960) 2 6 7 6 or older FE
Feidman, Lee, U~terecker,Lloyd,
Rusk, & Toole (1962)
Fugl-Meyer, JXiskii, & Norlin (4975)
Heinemana, Roth, Cichowski,
& Berts (1987) Unspecified
Bindfelt & Wilsson (1977) FT.PT
Howard, Stanwood, Toole, Mairhews,
%i Truscoi! (1985) :55-oldel than 66
Kotila, Waltirno, Neimi, Laaksonen.
& Lernpinen (1984) 155 CE, HM, US
Mackay & Nias (1979) 165 Picspecified
Marquarclse~~ (1969) 170 FT, HM, PT
Srnolltin & Cohen (1974) Mean. 44 CE
Mialtimo, Maste, Aho, & igobila (1980) :55 hinspecifned
Weisbroth, Esibill, & Zuger (1971) 4 5 CE

T E Ecompetitive
, employment; FE, former employmenr; FT, full-time competitive employment; PT,pna-time competitive
employrne~lt:EIM, homemaking: US, fuli-time university level study.

tarion in 1993 a-re not likely to be ready to
return to work zit the time of discharge.
When, then, is the right time to say that the
end point for voca%ion2?reha$kli;a"lion has
been reached? Six months after rehabilita-
tion discharge is pla~usibie;she average time
from CVA to return to work in I992 to 1993
in the Young Stroke Program at New En-
gland Rehabilitation Hospital (NEWA) was 6
months. A 12-month post-rehzbiiitation dis-
charge end point would give more positive
results because it is not uncommon for a
srroke parlent to need that many months of
recovery and rehabilitation time before being
able to return to vocational %ceivity.Another
source sf difficulty in setting a vocational
rehabilitation end point is the issue of the
equilibfiun~(as opposed to the initial) voca-
tionad level. The majority of patients in our
program who get back to work do so in
graded fashion, heginning with part-time
modified work and gradkaa%Byover severad
months increasing hours as stamina im-
proves and level of duties as cognitive and
physical performance improves. How to
gauge when the maximum level of employ-
ment has been reached is unclear.
Axather reason for the lack of emphasis on
vo~aViona1outcome assessment relates to the
pressures on providers that lead to the gatb-
ering of outcome data. Vocational rehabilita-
tion after stroke is usually initiated and often
carried out in the context of rehabilitative
medical care. The medical care system in
general, however, and health insurers in par-
ticular have little intrinsic interest in the
vocational outcomes of patients (and limited
willingness to pay for vocalional rehabilita-
tion seawices). Payors are interested in track-
ing variables that affect timing of discharge
from resource-consuming entities (e.g.,
acute and rehabifitation hospitals) and con-
sumption of aftercare resources (e.g., visit-
ing nurse and outpatient services). The level
of independence that a patienhachieves in
self-care>honaen~aking,bed rnobiilty, rrans-
fers, and either ambralatien or wheelchair
mobility has obvious relevance to the timing
sf discharge to home and the need for home
services, whereas return to work does not.
Long-term disability (LTD) insurers, should,
an theory, care deeply about getting their
insureds back on the job after a stroke be-
cause this would end their financial liability
for that patient for that illness. To date in the
Yaung Stroke Program at NERH, however,
remap-kably little interest has been shown by
LTD caniers regarding the course and ouk-
come of our vocational rehabilitation efforts
on behalf of their insureds.
A fhird reason for failhag to look in a murk:
sophisticated fashion at vocational function
as an outcome a f e r stroke relates to the
understandable fear of appearing to have
poor outcomes. The reader of the hypotheti-
cal phrase ""2 of our 40 patients were able to
return to work after discharge9'comes away
with the vague sense that all those patients
returned to full-time competitive employ-
ment at the same level as before, a much more
positive impression than the same reader gets
if the report then notes that, of those 20, 2
work full time with modified duties, HO have
returned part time to full duties, and 8 have
returned part time to suppofied work place-
ments. Neurosurgeons have been faulted for
believing that their subarachnoid hemor-
rhage patients have excellent outcomes on
the basis of a normal standard neurologic
examinatisn when a more detailed Look at
memory and cognition may show substantial
residual impairment and the patient may be
having difficulty functioning well in the
community (Ljunggren, Sonesson, SBve-
land, & Brandt, 1985). Similarly, rehabilita-
tion prokssionals may not wish to look too
closely at what "return to work" really means
fur patients 'Pestit become clear that it is often
far from the premorbid Bevel of work and
limited in terms sf work duties, schedule, and
pay. Getting a residually impaired stroke
patient back to vocational activity is a com-
plex and delicate process that is easily de-
railed. Tne Comer plumber way not recover
quite enough dexterity in his right a m , al-
though his speech is adequate, to resume his
job; another worker may do better, finan-
ciallgi, by remaining disabled from his former
position with 180% disability papi than he
would by accepting the lesser job thathe can
perform; the motorically high-level patient
who is unable to acknowledge cognitive
deficits may refuse outpatient therapy and
vocational counseling, go back to his former
job, and fail; another patient with good neu-
rologic potential to return to his former job
may be offered an attractive early retirement
Getting a residually impaired stroke
patieat back to vocational activib is a
complex a ~ delicate
d process ihas u
easily derailed
package by his downsizing empioyer, All
these obstacles, and the many medical and
psychiatric compfications thatpreclude or
intenupt vocational rehabilitation efforts,
have yet to be mentioned! It is perhaps nore
appropriate to be impressed that anyone is
able to return to emp3oymen'u after a stroke
Clan to be disappointed that many do GOT. As
rehabilitation teams (\vl-lich in many settlags
do not include anyone with expertise in voca-
tional rehabilitation) become more i~xo~~/jZil-
edgeable regarding these issues, one can an-
-
ilLipaeethat the degree of sophistication with
+;
which thls outcome is assessed will BT.~ ,prove.
TvIEASURES OF VQGATHONAL
FUNCTION
Return to work measures that csanpare the
level sf premorbid vocaf onal f u ~ ~ c t i i s n i ~ gof recovery and residual impairment; modi-
whhthat achieved after stroke would provide
~ l far assessing the extent of w c a -
h e l p f ~data
tional reha.bilrtatlon achieved. Percentage of
premorbid income attained after stroke is a
simple measure that could give quantitative
data regarding the relative value to society of
the work perfomed by the individual after
the stroke^ A ~ ~ f happro~ch
er is to develop an
ordinal scale of vocational n'unctisning with
fiefined levels, to score patients before end
aftei CXJA,dlrd ,--. - - -
aG eajrirpare the ~ W Ovaiues.
The inpatient Young Stroke Program at
NERM is in the process of develh;pirag such an
index; a prototype of which is presented in
the box as a-n example of a, genre of measure
that may be found to have clinicaI utility.
This index seeks to rank-order vocational
functioning along several dimensions con-
currently: paat time versus full timel often
related to intellectual and physical stamina;
volunteer versus competitive work- a acom-
pfex issue that may or may not relate to level
Vscationa%Functisnai Index
0. No work
1. dls-time
D.
1 +. volunteer work, with sup-
ports
2. Part.-time modified competitive work9
siiilr?.supports
3~ Part-rime modified cornpetithe work
. -:ajunieer walk
4~ 1 ati e-tune
5, Part-time cornpetitfive work
6" Full-time vohateei~wsrk, wit11 su-p-
ports
7. FuY1-tine modified competitive work,
with supports
8 Full-time modified competitive work
9. FULI-.I:IITIPvolunteer \i/ork
10. Firil-rime comperiak~ework
fied ( i s . , reduced in number and/or scope)
versus regrrlar job duties; and need for extra
support, such as mentoring or coaching, typi-
cally an issue for patients with residual cog-
nitive GT a.ttes?tion problems. The regular use
of vocalisna%function scales ef this type in
studies seeking to predict functional sut-
come aAer stroke wzi-3uldhelp establish PT~O-e
realistic expectatior-nsregarding likely voca-
tional outcomes and standardize the termi-
nology regarding return to work, thus render-
ing different studies more comparable and
more helpful to cli~:,.;
.i~ians.
EXPERIENCE OF THE YOUNG
STROKE PROGRAM AT NERH
The inpatient young stroke unit at NEWH
was begun in 1984. The inpatient unit seeks
to pmv~deworking-age stroke patients with
the benefits of peer support gained horn
living and receiving treatment together on
the same nursing unit, neuropsychological
testing and vocational rehabilitation coun-
seling, and a core inpatient rehabilitation
program including physical, occupational,
and speech therapy, rehabilitation nursing,
and physiatric and internal medicine medical
care. The unit admits patients with ischemic
or hemomhagic stroke who are younger than
60 years and those older than 60who appear
to have potential to resume vocational func-
tioning. Between 1985,the unit's first full
year, and 1992, the most recent full year, the
unit admitted 8 1%. patients, an average of 101
Der year (range, 88 to 188 patients per year).
The average length of stay (EOS) on the unit
over t"ne same time period was 40 days,
although review of yearly data demonstretes
that LOS was stable at 40 to 44 days through
1990 and decreased to 35 days in 1992. This
is consistent with a national trend toward
reduction in inpatient rehabilitation EOS
conditioned by payor constraints that has
developed over the same time period. Fortu-
nately, in response to this pressure on inpa-
tient LOS the hospital has been able to de-
velop a cosrdinaked and comprehensive
outpatient Young Stroke Program, which has
become the IGCUSfor most of the =iacational
rehabilitation effort for these patients.
In the United States, just 3% of strokes
occur to people younger ihan 45 years, al-
though 25% occur to persons between the
ages of 45 and 65 years (Weinfeld, 1981).
Consistent ~ " k this
h age distribution of the
disease, the inpatient Young Stroke Program
admits mainly patients in their 4-0s and 50s.
Average age over the 4985 to 1992 period
was 53.7years, with little variation from year
to yeas. Hence these patients are mostly
middle-aged, not young aduiis, and their vo-
cational issues reflect this. The31 are in
midcareer, often at the peak of their voca-
tional attainments, typically with stable work
histories and moderate seniority and with the
job flexibility and employer goodwill that
develop in a stable career. There is no pre-
dominance of any one category of employ-
ment among blue collar, white collar, and
professionalltechnical employees. During
the recent recession the young stroke unit
experienced, not suvfisiagly, an increase is,
the number of padents who were betureen
jobs or underemployed at the time of their
stroke,
As the yomg stroke unit patient popula-
tion has become better defined over the
years, experienced rehabilitation team mem-
hers have come to recogrize a partiwia~
constellation of attributes in some of these
patients, refemed to as the young stroke per-
sonality. The profile is sf someone, usually a
man, in his late 40s or early 50s with a type A
personality who was working more than full
time bedksre the stroke 460 to 80 hoursiweek
is not unusual), who smokes, who consumes
two to six drinks per day, and who may have
experienced a recent major stress such as
divsrce, change sf job, layoff, or death sf a
loved one. The individual is often first found
Rc be hypertensive at the time of the stroke
and may not have been to a physician for
many years. In medical terns, this profile fits
LheyaGieni eaily onset uf a ~ h e r ~ ~ ~ ~ e T O ~ i C
cerebrovascular disease promoted by smok-
ing and unrecognized hypa-tension and. with
a contribution to his orher risk of stroke from
alcohol consumption (Donahue, Abbott,
Reed, & Uano, 4986; Gill, Zezulka, Shipley,
Gill, $s Beevers, 4986) and stress (Franks,
Adamson, Bulpitt, & Bulpitt, 1991). This
profile is actually quite similar to the picture
of the stroke-prone man that emerges froxi
the recent work oof CJchiyarna, Kurasawa,
Sekizawa, and Nakaesul<a (199%).In their
$0 Torres IN STROKE
REF~AB~LIT$-TO~/SPS?I~G
1994
cohort of 899 treated hypertensive men ages
50 to 59 years, those who worked more than
B B horns per day had 4.1 times the risk of
stroke compared with those who worked
fewer hours; those in managerial positions
had 2'7times the risk of nonmanagefial em-
ployees. Risk was elevated [or smokers and
those with inadequately controlled systolic
blood pressure. Alcchol conscmption was
not studied. The young stroke unit at NERH
has, since 1984, also had patients with many
of the unusual etiologies of stroke detailed
elsewhere in this issue who do not fit this
pattern, although this constellation of medi-
cal md life-style attributes has occurred fie-
qnenkly enough in our patient populalior; to
prompt its recognition as a stereotype.
THE VOCATIONAL
REHABILITATION PROCESS
For most worlaing-age survivors of stroke,
the loss of identity as a worker is one of the
most devastating consequences of the event.
With the option of retirement usually years
away, Social Security benefits meager, and
other disability benefits uncertain, survivors
often need to return to productjvc, competi-
tive work to support themselves and their
families. Return to work for these patients is
ac important gaal that often requires exten-
sive effort from a multidisciplinary treatment
team focused on vsca";ona8 issues.
Inpatient phase
The incoqoration of vocational rehabili-
tation services early on in the patient's treat-
ment program is cmcial in establishing ap-
propriate vocational goals with the patient
and in arding team treatment placning and
goal setting. Shortly after admission to the
NERH inpatient young stroke unit, the pa-
tient is seen by the vocational rehabiiitalion
counselor 8 0 identify his or her vocational
options and goals and to discuss concerns
about being out of work. Pnfonnation is ob-
tained about educational and work history
with emphasis on the vmrk situation just
before the CVA.Job description infoma-
tion, employer infomation, and disability
benefits are discussed, Mosqasienles are anx-
ious about finances while out of work and
need assistance from the vocational rehabili-
tation counselor to clarify disability benefits
avaihble from the employer. Many patients
and their families also need assistance from
the counselor in applying for Social Security
disability benefits,
To obtaln additional job infomation and
to identify future options for returning to
work?the vocational rehabilitation coua?selor
(with the patient's written permission) next
initiates contact with the employer. In acting
as a liaison between the employer and the
rehabilitation team, the counselor facilitates
planning for the patient's eventual return to
work. The punpose of initial contact with the
employer is to obtain a derailed job descrip-
tion, to determine the employer's flexibility
in providing accommodations for the patient
if needed, a.nd to begin to educate the em-
ployer about CVA recovery and the process
of returning the patient to work.
The treatment team concumently is work-
ing together to identify physical, language,
cognitive, and visual perceptual barriers that
may affect the patient's ability to return to
work. Evaluations by phy sicai therapy, occu-
pational therapy, speech therapy, and
neuropsychology identify the physical and
cognitive areas that need to be focused on in
therapy $0 prepare the patient to return to
work Once a. treatment plan is established,
cotreatments among the therapists are ar-

ranged as needed to address pa~-ticulardeficit
areas.
The treatment team and the vocational
rehabilitation counselor provide recommen-
dations about services needed to address the
patient's vocational goals in the outpatient
Young Stroke Program. Often, because of
lack of knowledge about the recovery pro-
cess from C$'A or decreased insight, patients
with substantial deficits assume that they
wii"le ready to return to work upon dis-
charge from the inpatient young stroke unit.
Counseling and education are necessary for
the paf ent to understacd thathe or she must
continue the process of rehabilitation in the
outpatient program to prepare adequately for
returning to the job.
Outpatient phase
In the outpatient Young Stroke Program a
major emphasis is incoa-porating a vocational
component into treatment planring. Patients
are involved inwork simulation and situational
assessments to evaluate thek vocational poten-
tial md readiness to go back to the job.
Additional jo"s:information may be ob-
tained during this phase via a work site job
analysis conducted by the vocational reha-
bilitation counselor, Visiting the work site
allows the counselor to observe employees
performing the job tasks, to obtain work
projects and work samples (e.g., forms, re-
ports, procedures, and tools) to be used in
therapies, to evaluate the conditions of the
work environment, and to build rapport WY th
the employer. The following aspects of the
job should be evaluated during the work site
job analysis:
Physical demands: requirements for
lifting and carrying, standing and walk-
ing tolerances, upper extremity fine and
gross motor skills required, and other
Voratlonu/ Butt on?e 81
physical demands such as climbing,
stooping, and squatting.
Communiccrrio~~ demar?d..;: degree of
verbal fluency required, reading and
writing skills, and level of auditory
comprehension.
Gng~zitil*edenmnds: attention (sus-
tained, divided, and alternating),
memory and new 'learning, reasoning
and judgment, degree of problem solv-
ing, organizatiolzal skills, and ropo-
graphic orientation.
Visual pei-cepr-ual demands: design
work? visual scanning, assembly, and
ability to read blueprints or schematics.
Eva;usiisi~i ~ ~90i.k
f ~ ~ i i d i l i noise
~n~:
level, distractions, exposure to me-
chanical or electrical hazards, exposure
do moving objects or equipment, use of
sharp tools or operation of dangerous
equipment, and requirements to work
on elevated surfaces.
This idoms;ition is h e n used by the team to
simulate work activities in one-on-one treat-
ments, cotreatments, and group activities. The
outpatient Ther~peert-c'fi7~1-kProgram (TIW)
provides padents with structured and super-
vised work activitiesto cernplete relating to the
shlls the patients need to retd1-n to work. Situ-
ational assessments in volruatees work are used
ro evaluate the patient's vocational potential
and readiness to return to competitive employ-
ment. Tlxough work simulations, TWP, and
situational assessments, 'he patient and thera-
pists solve problems m d develop strategies to
iise in a work environment to compensate for
physical, cognitive, language, and/or percep-
tual deficits. Necessary job modifications a.re
identified in t h s process.
While the patient is still lnvolved in the
outpatient program, he or she rnay begin to
transition back to work gradually, At this
stage the frequency cf therapy is ke:ng re-
duced, and the patient's perfamance at work
is regularly monitored by the %~ocational re-
habilitation counselor. Before this, the ern-
pPoyer is coxltacted to discuss modifications
that the patient wili need to perfom job tasks
or to discuss alternative positions withhi the
company in which the patient could pe~form
rf he or she is deemed unable to perfom in his
or her previous position.
Working close@ with the emplqer $0
p l ~ for
n reasonable accommodations
helpsfacilitate a smooth transition for
the patient back lo work,
Appropriate modifications and accarnrno-
dations often include a part-time schedule
with a gradual transition to full-time status
(usually requimng 2 to 3 months), additional
supervision initially to ensure work accu-
racy, reduced job tasks, m d other accommo-
dations specific to the patient's needs. Work-
ing closely with the employer to plan for
reasonable accommodations helps facilitate
a smooth transition for the patient back to
work. During this transition, the patient con-
tinues to meet with the vocational rehabilita-
tion -,ounselsr and other therapists to discuss
his or her perfomance of work activities.
The patient's supervisor is also contacted for
feedback regarding work perfomance and to
identify problems. If issues x e identified,
they are addressed in treatment to develop
and implement alternative or compensatory
strategies. Once issues are addressed and the
patient is doing well with the work transition,
he or she is discharged horn the Young
Stroke Program with perlodic reevaluations
scheduled by therapies to monitor changes in
the patient's functional status at home, in the
community, and at work.
.ALTERNATIVE VOCATIONAL
OPTIONS
Although return to work in a competitive
position within 6to 8 months after CVA is the
goal for the high-level young stroke patient3
kt may not be realistic for those with severe
deficits who are at a lower level of function-
ing. This group, however, may benefit from
avocationak and volunteer activi'iles to in-
crease feelings of self-worth and prodelctiv-
ity and to fill unstmctured time. The recre-
ational kherapis"kassesses these patients'
leisure skills and interests to help direct them
to avocational and volunteer activities of
appropriate complexity. A refenal to the
state department of vocational rehaEilitation
is an option fcr those patients who over the
course of 1 to 2 years may become able to
perform work within a community-based
sheltered or supported work program.
FAGTOWS PREDICTING
VOCATIONAL OUTCOME AFTER
STROKE
A number of studies over the years have
looked io iderlb4-fy prognostic factors for re-
turn to work after stroke. There is overlap
among the various studies in terns of vari-
ables evaluated. Together with functional
improvements, these can be grouped for the
puvose of review into the followiarg areas:
neurologic, cognitive, socioeconomic, and
environmental factors.
NenrolsgHc factors
Patients' neuro1ogic findings are among
the more readily available pieces of informa-
xion ill clinical settings. Among ihese, side of vember 3, "i93j. and inability to drive often
hemipiegia has often been looked at for pos- effectively precludes return to work o~atside
sible relationship to ability to return to work, the home.
brat no consistent relationship has been found
with either rrght- or Sef-sided weakness
Cognitive factors
(Helnemannj Worh, Cichowsk-, & Belts, There is increasing awareness in the litera-
1987;Howard, Stanwood, Took, Ii4atk~~e7wsl 'lure fhzt poststroke cognitive deficits that
& Tmscott, 1985;Kotila, Waitimo, Neini, mag1 not be retidily apparent on general ex-
Laakso~en,& Lcmphen, 1984; "Jcieisbl-otr"?, amination and may requirz neuropsycho-
Esiaill, & Zuger, 1978). This is probabiy due logicel testing to delineate ere important
tc the confounding influence of the aphasia deienxinants of high-level functional out-
m perceptual difficulties presenr along ~vith comes such as rettlm to work (Lindberg,
right or left hemiplegia, respectiive?y,in ihe P,~?gquist, Fodsiad, Fugl-h'leyer, & Eugl-
most common types sf CVA,thsse involving Wieyer, 1992; Ljunggren et al., 1985). Rodla
the anterior circulatio:rr, In an arl;ic1e by e: al. (i984) bund that impairment of intel-
- * Scha.ffer xrid Osberg (199z)93 &istinc^, .ilgeEce 2nd m-~z.~s2;j~
91aclc- ~
.i;s~..ospa&i decicits,
negative conelarion between aphasia, csn- end inadequate emotional reactions, includ-
sidercd apart from side, of herniplegie, and ing indifferegce and anasognosia as well as
return to W O Lwas ~ de~nonstratecitA7eisiDrcchet depression and emotional la"rv.lity, reduced
alPs. (1971)fGnnd glal wifhin 'he group of left Likelihood of returning to wofk ?dore re-
hemiglegjc; those with better upper extysnllc,y cently, Mcrcier, LeCail. "bcbin, Joseph,
,- .- an~baiatioa,and abstract reasoning were
use-, Alhayeb, and Gcy (4998) focnd perfsr-
more likely so return to work and tha.t 2msng mance on a neuropsycho4ogical festbkaery
f;ght herniplegics those with milder communi- to halve the best predictive value vis-8-vis
-
cation and cognitive deEcl;s similarly had bet-
~.
ter vacata-ona! aruti:omes. n he:,: findings sug-
retunn ts previous mploymenl of a number
sf , -
. d ~. sinvestigated, It is anticipated that.
gest that patients with milder or more ps~.rely as a.;..are.sress of this dimension sf recovery
motor strokes do $z&terthan those uiii1h severe becomes nidesp-ead in the medicai care sys-
physical or added cogn3tive/con1rni11nic~~tibjr: ten, use of cognitive evaluation tools wrll
problems, csnciusions that are supported by become more standardized and routine.
I. - ,,r*k
.lilG
Y . ""
e*jCqC-,l,a eb 21.;1954>,
We are unaware sf any studies that have
iooked at homorjil~.oushemia:zopsia. a fre- Several studies kave '.hova~,not sup-is-
quent finding in middle cerebral briery terri- ingly, (hat higher fu~~rctionsl perfomance on
tory CVA, as a deke~rentto retulming to W O T ~ , ADL axd rmobiliry indices at discharge from
although it is our impression that t h ~ skas e rehabilitatioc or at a postrr5k~abiiitation fol!ow-
strong negative effect, Patients with ~p point co~elateswifh greater lillelihood of
hemianopsia and concomitant visual ne- rePdn3 tc :i;iork (Black-$chaffer & Osberg
gkect, even if they have 120"field of vision 1990;Heinemam et al,, 1987;Howard er ai,,
. ~ .
(the state requirercen"rar &+~ing),rarely <
I96s+,
1; L.i one study, abiljty to Y.&JK~
*p-

pass the NERR driving e\ialuation ( K T . was strongly l.rLked to :-eFxn to xi~odcas in~ell
.~

DiPanfilo, personal cornmsmxrcatlon, No- (Slack-Schaffer & Osbecg, 1990).

Socioeconomic factors Nearly half the patients (14 of 35) who re-
turned to work after receiving vocational
A recurring theme in studies that look for
rehabilitation services at NERH in 1992 to
predictive factors regarding return to work is
1993 required modifications in job duties,
interest in the ekdcational level of the patient
and a14 but 6 returned initially part time.
before the stroke and in the category of em-
Close coordination between the vocational
ployment to which thepatient will return.
rehabi4itatisn counselor and the employer
There is a good deal of evidence that patients
must occur to facilitate a s~ccessfulreturn to
with higher educational levels and white 601-
work. Based on feedback from %therehabilita-
lar positions are more likely to return to work
tion team, accommodations are recom-
after a stroke than those with little education
mended that are specific to the patient's
and blue collar positions (Bergmann,
needs. In this way, the vocationai rehabilita-
Kuthmann, von-Ungern-Sternbeirg, &
tion counsePor and the rehabilitation team act
W e i m a ~ ~ n1991;
, Howard et al., 1985;
as a valuable resource to the employer.
Smogkin & Cohen, 1974). The recent experi-
Under the ADA, employers may not dis-
ence of the young stroke unit at NEWH is in
criminate against disabled employees who
agreement with these findings: Of the 35
can perfom the essential functions of a job,
patients followed in the program to their
and reasonable accommodation to enable the
return to work in 1992 to 1993, only 5 re-
person to gerfvm the job must be provided
turned to blue collar jobs, the rest going back
(-William M. Mercer, 1992). Al"rougBs rea-
to secretarsaliclefical (15 patients) and pro-
sonable accommodadons are detemined on
fessionai/technica%(87patients) positions.
a case-by-case basis by the employer, most
The reasons for this are not clear?but several
accommodations fa41 into five broad catego-
speculations recur in the literature,namely that
ries: physical access to work facilities, tech-
those with better education tend to have more
nological equipment or modifications, per-
interesting, better paid, m d less physically
sonal assistance, schedule flexibility, and job
demandingjobs, aU of which make return to the
restmctrarlng, including the reassignment of
job after a stroke both more attractive and more
ta-sks to other workers or the reassignment af
possible. Higher-level jobs may tend to have
the disabled worker to another position.
more flexibiiity in terns of hours &nd duties,
Although the ADA is applicable to labor
and the holders of such jobs often have a
ssnisns,problflns may arise in csilective bar-
personal relatioalship with their employer that
gaining situations. Labor laws require unions
blue collar employees Back,
to represent the interests of all employees
equally, and they do no: allow special accom-
Environmental factors
modations to be negotiated indlv~duallyby
Since the passage of the 1990 Americans union members. Also, because of seniority
with Disabilitnes Act (ADA), we have found rules, it is usually difficult to reassign a
ernmplogiers to be more open to provlding d~sabledwoker to a different unionized po-
accommodasions to allow patlents to return sition. In the Young Stroke Program it has
to work, Most stroke patnenrs require some been diff~cult"r return patients to unionized
degree of work accommodat~onas a result of positions because reasonable accommoda-
physical, cognitive, arrdisr language deficits. tions have not bee^ allowed.
 Additional factors that may make it diffi-
cult to return patients to work are the effects
of economic recession and financial disin-
centives due to disability benefits. The
Young Stroke Program has had cases where
padents have remained on long-term disabil-
ity benefits for fear of returning to work and
then being laid off because of poor business
conditions. Also, resrmcturing job tasks may
be difficult for companies in the process of
downsizing because this would increase the
workload of those who remain. Patients who
are seeking work with new employers have
been hampered by the increased con~petition
for available jobs during a recession, Finally,
for pakierlts who car1receive close to 4 00% of
their take-home salary through a combina-
tion of Bong-tern disability benefits and So-
cial Sec~rritybenefits, there may be a distinct
disincentive to return to work.
Vocational rehabilitation after stroke in
patients with residual impaiment is a com-
plex process that may require extensive ef-
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