Return-to-Work Barriers Among Manual Workers After Hand Injuries: 1-Year Follow-up Cohort Study

Archives of Physical Medicine and Rehabilitation journal homepage: www.archives-pmr.org Archives of Physical Medicine and Rehabilitation 2018;-:-------

ORIGINAL RESEARCH

Return-to-Work Barriers Among Manual Workers After Hand Injuries: 1-Year Follow-up Cohort Study Batia S. Marom, PhD,a Navah Z. Ratzon, PhD,b Rafael S. Carel, PhD, MD,c Moshe Sharabi, PhDd From the aOccupational Therapy Unit, Clalit Health Services, North and Haifa District, School of Public Health, The University of Haifa, Haifa; b Department of Occupational Therapy, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv; cSchool of Public Health, The University of Haifa, Haifa; and dSociology and Anthropology Department, Max Stern Yezreel Valley College, Yezreel Valley, Israel.

Abstract Objective: To determine time of return to work (TRTW) in relation to multivariable predictors among male manual workers after hand injury (HI) over a 12-month follow-up. Design: A cohort study with baseline medical information, functional evaluation, and 3-, 6-, 9-, and 12-month follow-up telephone interviews. Setting: Seven physical rehabilitation community occupational therapy clinics. Participants: Participants (NZ178) with acute HI aged 22-65. Two participants were lost to follow-up. Intervention: Not applicable. Main Outcome Measure: The dependent variable was TRTW. The independent variables originated from 4 domains: personal factors, environmental factors, body function and structure, and activity limitation and participation restriction. The proportion of return to work (RTW) at each time point was calculated. Multiple Cox regressions established a predictive model for TRTW. Results: At the end of the study, 75.3% participants returned to work. The median TRTW was 94 days. In the final model, only compensation factors and education contributed significantly to overall RTW, but when separate analyses were performed, decreased level of self-efficacy, higher workplace demands, level of pain, level of emotional response to trauma, reduced physical capability of the hand, and higher level of disability were significantly associated with delayed TRTW. Conclusions: TRTW was determined by the physical capability of the hand, pain, and psychosocial factors, but it was also affected by legal factors. Participants who did not return to work during the first 9 months are at risk for long-term disability. Developing treatment programs for those who are at risk for not returning to work, taking into consideration these factors, is recommended. Archives of Physical Medicine and Rehabilitation 2018;-:------ª 2018 by the American Congress of Rehabilitation Medicine

The hand is an active and exposed body structure important in almost every daily activity. Hand injuries (HIs) are common, accounting for approximately 10%-30% of all patients admitted to hospital emergency departments and up to 20% of all injuries treated.1-4 HI are especially common among male manual workers, that is, those whose job involves physical skilled or unskilled work, but these injuries also occur during leisure time. HI may result in long-term physical and functional disability2 that limits participation in a wide range of activities, including work. Furthermore, because a large share of HIs are work related,

Supported by a grant from the National Insurance Institute of Israel (grant no. 12379). Disclosures: none.

particularly among young men,5 it is important to optimize recovery, specifically in this group, because these workers potentially possess a long working life expectancy requiring a wide range of hand function. Difficulties in return to work (RTW) may cause economic and social distress.1,5,6 Moreover, when time away from work increases, the probability of returning to work decreases, and those who do not return to work at an early stage are at increasing risk for long-term disability.7,8 Thus, identifying and understanding factors that are likely to encourage or discourage RTW after injuries is important.1,3 Studies show that other factors besides impairments in body functions and structures can predict RTW.5 Current literature emphasizes the need to consider medical, psychosocial, personal, and environmental variables.3,5 Shi et al5

0003-9993/18/$36 - see front matter ª 2018 by the American Congress of Rehabilitation Medicine https://doi.org/10.1016/j.apmr.2018.07.429

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concluded in their systematic review that there was insufficient evidence that demonstrated a consistent relation between different predictors to RTW. Therefore, additional high-quality studies are needed to improve our understanding of the complexity that affects RTW after HI. The International Classification of Functioning, Disability and Health (ICF) is a framework that can be used to characterize the complexity of factors affecting RTW after HI; RTW can be influenced by prognostic factors in all 4 ICF domains6: the body dimension (function and structures), the activities and participation dimension (execution of a task or action by the individual and involvement in life situations), and the contextual factors (the background of an individual’s life, including environmental and personal factors).9 The purpose of the present prospective cohort study was to determine which variables included in the 4 (ICF) domains mentioned above affected time of return to work (TRTW) 3, 6, 9, and 12 months after HI among manual workers. This study hypothesizes that variables in these domains will influence RTW.

Ethical approval was obtained from the Health Service Ethics/ Helsinki Committee (057/2014). Informed consent was provided by all persons who participated in the study. Figure 1 presents a flow chart for study enrollment.

Procedure During the first 2 occupational therapy sessions, trained bilingual Arabic- and Hebrew-speaking occupational therapists completed participants’ assessments (ie, baseline) in the 4 domains of the ICF. Medical records were reviewed at baseline by the first author for relevant information. Assessment of TRTW was based on self-reporting during the 4 telephone follow-up interviews, which were conducted in Hebrew or Arabic by the first author. Treatment was standardized and given according to the protocols used by hand therapists10 in all 7 clinics. Because our study group included different types of injuries that affected the protocol and duration of treatment, the outcome of the treatment was evaluated by the physical capability of the hand. About 168 participants completed the 4 follow-up interviews. Information regarding TRTW was available for 176 participants.

Methods Participants

Measures

This prospective study was conducted in physical rehabilitation occupational therapy clinics that provide rehabilitation services in the community. The sample included individuals in occupations requiring manual work. Inclusion criteria were male participants aged 22-65 who (1) sustained acute HI below the elbow, either during or outside working hours; (2) were employed as manual workers prior to the HI; and (3) were referred by a physician to 1 of the 7 designated occupational therapy clinics. Individuals with central nervous system lesions, carpal tunnel syndrome, mallet finger, trigger finger, De Quervain syndrome, or Dupuytren; injuries of both hands; injuries that involved other organs or body structures; or mental illnesses diagnosis or a history of drug/ alcohol abuse were excluded. Those unable to read or write Arabic or Hebrew were excluded. Participants were recruited and given follow-up between August 2012 and August 2015. For all participants, follow-up telephone interviews were conducted by the first author at 3, 6, 9, and 12 months after the injury. We conducted the telephone interviews at all 4 time points whether or not the participants reported that they returned or did not RTW in the previous interview. The final sample included 178 participants (90 Arabs, 88 Jews). Over the course of the 12 months, 2 (1.1%) participants were lost to follow-up; 8 (4.5%) did not complete the 4 interviews, but information regarding their work status was available. Those lost to the final follow-up did not differ greatly in age, education, or baseline hand and health examination from those who remained in the study.

The assessment instruments are summarized in table 1.

List of abbreviations: 95% CI 95% confidence interval HI hand injury ICF International Classification of Functioning, Disability and Health NII National Insurance Institute of Israel RTW return to work TRTW time of return to work

Independent variables Personal factors Sociodemographic variables studied included age, education, ethnicity (categorized according to those who self-reported as Arabs or Jews), partner working (works/does not work), legal counsel to file an injury compensation claim, and participants’ perceptions of self-efficacy.11 These details were obtained from medical file reviews or participants’ interviews. Environmental variables Recognition for work disability claim was categorized according to those who self-reported as recognized, not recognized, or in the process of recognition. Report of job demands included hand strength required for job, repetitive hand movement, lifting heavy loads, and the level of workload support and job control in the work environment. These characteristics were assessed using the Occupational Hand Use Questionnaire12 and the Occupational Stress Questionnaire.13 Body function and structure variables These variables related to the effects of the injury were studied regardless of hand dominance, because neither HI side nor dominance was associated with RTW.14 The physical capability of the hand was characterized using the Global Wrist Impairment Score.15,16 Pain was described using the visual analog scale.17 The Impact of Event Scale18 was used to assess the extent of mental and psychological effects resulting from a traumatic event, including avoidance and intrusive thoughts. Activity limitation and participation restriction Physical function and symptoms and severity of disability were assessed using the validated self-report known as the short version www.archives-pmr.org

Work participation, hand injury, predictors

3

221 meet the inclusion criteria

43 refused

178 recruited

2 paents were lost to follow-up

176 parcipants remaining 8 did not complete the four interviews, but informaon regarding their work status was available 168 with full follow-up data Fig 1

Study enrollment.

of the Quick Disability of Arm, Shoulder and Hand Outcome Measure19 and the World Health Organization Disability Assessment Schedule 2.0 (12-item).9,20 All instruments used in this study were found to be reliable and valid and are described elsewhere.9,11-13,15-23

Dependent variable The dependent variable was time in number of days to RTW based on a yes/no answer in the interviews 3, 6, 9, and 12 months postinjury.

Statistical analysis Data were processed using SPSS (SPSS Statistics for Windows, version 20.0). Descriptive statistics included frequencies, means, standard deviations, and confidence intervals. To examine the potential association and to determine the individual contribution of the independent variables and the dependent variable TRTW, we first performed a univariate survival analysis using a Cox regression for continuous variables and applied the Kaplan-Meier method for categorical variables. Only variables that remained significant at this step of the analysis were included in the next 2 steps. Simultaneous multiple Cox regressions were performed, including all variables that were significant in the univariate survival analysis. In addition, 4 individual multiple Cox regressions were performed for variables associated with each of 4 domains from the ICF, with TRTW as a dependent variable.

Results Table 2 summarizes data at baseline for the 178 participants included in the study. The mean age of participants was 37.4
11.0. Most participants were skilled workers or production workers. Overall, the Arab participants were younger and had lower levels of education than the Jewish participants (zZ4.27, P<.01, c2(1)Z3.52, P<.05, respectively). Most www.archives-pmr.org

participants had fractures or tendon injuries, of which 70.1% occurred during working hours. Most participants reported a high level of job requirements specific to use of the hand. The right hand was dominant in 91% of participants, and half had injured their right hand. According to the baseline hand evaluation (data not shown), there was no difference in physical capability of the hand, pain, or functional ability between participants who were injured in the dominant hand (regardless of right or left dominance) versus the nondominant hand; therefore, a separate analysis for dominancy was not performed. Most of the participants reported a moderate physical capability of the hand, pain, mild emotional response to trauma, and a moderate disability according to the Quick Disability of Arm, Shoulder and Hand Outcome Measure and World Health Organization Disability Assessment Schedule 2.0.

Employment status 12 months after HI Table 3 outlines the employment status for the study cohort and the cumulative proportion of study participants’ RTW at 3, 6, 9, and 12 months postinjury. As the table shows, 75.3% of participants return to work at the end of the study (79.5% Jews vs 71.1% Arabs). The mean time of RTW was 121
68.3 days. The median TRTW was 94 days. Of those who did return to work, 90% returned to the same workplace and to the same work position. Of those who return to work, 13.8% returned to reduced working hours and 10.6% of participants had work restrictions. As table 3 describes, the main reason for not returning to work at the 12-month follow-up interview, according to the participants’ reports, was related to severity of the injury (50%) or physician decision (19.04%). Among those who returned to work during the follow-up period, 3 participants changed their jobs due to factors other than the injury; 1 participant quit his job; and 5 participants were fired, only 1 of whom was fired from his job due to the injury. Four participants were reinjured during the follow-up period; 2 of those did not return to work during the 12-month follow-up. Three participants returned to work but stopped working by the end of the follow-up time because of their HI. Only 2 participants were in National Insurance Institute of Israel

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B.S. Marom et al Table 1

Description of the assessment instruments

Assessment Instrument

Scoring

Reliability and Validity

Perception of self-efficacy Self-reported assessment includes 6 items regarding the capability of the person to participate in work, social activity, and activities that require mobility and general functioning A. Occupational Hand Use Questionnaire.12 Self-reported assessment of type of work/classification according to level of hand use B. Self-reported assessment of occupational stress based on psychosocial factors, job demands, control, support model 3-part questionnaire: workload, job control, social support.13

5-point Likert scale Final scoreZaverage score of all items; higher scoreZhigher self-efficacy

Internal reliability, Cronbach aZ0.94

A. Each item scored separately on a 5-point Likert scale; 5Zhighest requirement level. B. 5-point Likert scale; 5Zhighest level of stress. In each section, the average score for all items in the section is calculated. Two separate final scores: workload/job control, social support.

The GWIS15 A. AROM, standard/universal goniometer performed according to standard protocol.49 Score combines 6 measured motions of the wrist and finger flexion. B. Hand grip, standard JAMAR hydraulic hand dynamometer according to protocol recommended by the American Society of Hand Therapists.21 Calculated on unaffected side with adjustment for the effect of dominance. C. Dexterity score, Jebsen-Taylor Hand Function Test, checkers subtest.23 Calculated on unaffected side with adjustment for the effect of dominance.

A. AROM scale from 0 to 30 B. Hand grip, score from 0 to 40 C. Dexterity, score from 0 to 15 Total GWIS sum of the scores, 0-85; 85Zno deficit/full capability

Visual analog scale17

Scale range from 0 to 10; 10Zunbearable pain

A. Content validity, predictive validity, divergent validity, and convergent validity were established in research conducted with 605 industrial workers. It was also found that the person’s subjective assessment of occupational hand use corresponds with the assessment of a professional. B. In a cross-national validity and reliability study of the JCQ scales that examined 6 broadly representative populations from 4 advanced industrial societies (the United States, Canada, the Netherlands, and Japan), Cronbach a of the main JCQ scales ranged from 0.63 to 0.84. In a study that examined the cross-national validity and reliability of the JCQ scales in 5 European countries, Cronbach a of the main JCQ scales ranged from 0.66 to 0.86. A. The American Society of Hand Therapists’ clinical assessment recommendation attributed prominence to the ROM. The goniometer was more reliable. Reliability of active ROM was found to be more than the passive ROM. B. Considered the most reliable and valid. Reliability among judges was 0.94-0.99, testeretest 0.88 can distinguish between healthy and unhealthy population. C. Testeretest reliability ranged between 0.69 and 0.99. Moderate parallel validity with NK Hand Dexterity Test ranged from 0.38 to 0.88. Parallel validity of 0.52 was also reported with the Functional Dexterity Test with the dominant hand. There is no criterion standard that is currently agreed on, but it has high reliability validity and is quick to administer. Testeretest 0.97-0.99. Sensitive to changes in pain.

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(continued on next page)

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Work participation, hand injury, predictors

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Table 1 (continued ) Assessment Instrument

Scoring

Reliability and Validity

Impact of Event Scale Self-reported assessment of extent of mental disorder resulting from a traumatic event based on 15 patterns of intrusive thoughts and patterns of avoidance related to the hand injury. The short version of the Disability of Arm, Shoulder and Hand (DASH) Outcome Measure19 Self-reported assessment of physical function and symptoms relating to musculoskeletal disorders of the upper limbs

4-point Likert scale; 4Zhighest effect of the injury Final scores are the average of 7 questions on intrusion and 8 questions on avoidance.

World Health Organization Disability Assessment Schedule 2.09 Self-reported assessment of function and disability exploring capabilities in 6 domains: cognition, mobility, self-care, interpersonal interactions, life activities, and participation in society, mapped onto the International Classification of Functioning, Disability and Health

5-point Likert scale; 5Zhighest limitation Score from 0 to 100; 100 indicates greater disability

Coefficients of internal consistency for the 9 items of the intrusion factors were Cronbach aZ.091, and for 4 items of avoidance factor, Cronbach a was .84. Fulfilled a high required level of reliability. The DASH has been shown to be reliable and valid with different languages and in patient or working populations with various upper extremity disorders. The quick DASH has similar reliability to the DASH. High testeretest ICCZ0.96. Structure validity was found by correlation between the DASH and other measurements of upper extremity. The DASH has more than 0.90 internal consistency. Parallel validity with hand grasp of 0.48, with Nine Hall Peg Test of 0.16 and with Moberg pickup test of 0.60. All questions have proven metric qualities in sensitivity, specificity, reliability, validity, and cross-population comparability shown in the general population surveys and clinical sensitivity to changes in studies and cost-effectiveness studies. High internal consistency, Cronbach aZ0.86. High testeretest reliability intra-class, correlation coefficient 0.98. Good concurrent validity in patient’s classification when compared with other recognized disability measurement instruments: conformity to Rasch scaling properties across populations and good responsiveness (ie, sensitivity to change). Effect sized ranged from 0.44 to 1.38 for different health interventions targeting various health conditions.

18

5-point Likert scale; 5Zhighest level of disability Score from 0 to 100; a higher score indicates greater disability.

Abbreviations: AROM, active range of motion; JCQ, job content questionnaire; GWIS, Global Wrist Impairment Score.

(NII) work rehabilitation programs or in the process of entering such a program. The univariate survival analyses for TRTW are presented in table 4 and fig 2. Factors related to earlier RTW were increased self-efficacy, less occupational stress, lower level of jobrequired repetitive hand movements and lifting heavy loads, lower pain, less severe injury, less distress due to emotional response to trauma, and less functional distress. A significant difference was found between the RTW rates over time between the Jewish and Arab participants. TRTW decreased with increased level of education and among participants who did not engage a lawyer and filed no claim for work disability benefit. Our simultaneous multiple Cox regressions showed that education, recognized for work disability benefit claim, and legal

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counsel contributed significantly to overall RTW. The hazard of delayed RTW for participants that were with low level of education was 60% compared to those who were with high level of education (95% confidence interval [95% CI] for hazard or risk ratioZ1.21-2.43; PZ.011). The hazard of delayed RTW for participants that were recognized for work disability benefit claim was 48%, compared to those who were not recognized for work disability claim (95% CI for hazard or risk ratioZ.48-2.26; PZ.011). The hazard of delayed RTW for participants who involved lawyers in the process of the work disability benefit claim was 66% compared to that of participants who did not involve a lawyer (95% CI for hazard or risk ratioZ.44-.98; PZ.040). Table 5 shows the results of the 4 individual multiple Cox regressions.

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B.S. Marom et al Table 2

Summary of data at baseline (NZ178)

A. Categorical Variables

Total n (%)

Education 12 y >12 y Legal counsel Yes No Partner working Yes No Nature of work Skilled workers Production, agriculture, unskilled labor Construction Driver Service industry Type of injury Fracture Tendon injury Soft tissue injury Amputation Injury involving >1 compartment of the hand

135 (76.3) 42 (23.7) 77 (43.7) 99 (56.3) 67 (57.7) 49 (42.3) 78 39 25 21 15

(43.8) (21.9) (14.0) (11.8) (8.4)

69 34 34 19 19

(38.8) (19.1) (19.1) (10.7) (10.7)

B. Continuous Variables

Mean
SD

Min-Max

Age Level of self-efficacy Job requirements Repetitive hand movement Hand strength required for job Lifting heavy loads Workload/job control Level of work social support

37.4
11.0 3.16
1.17

22-65.30 0-5

4.24
1.15 4.54
0.82 3.99
1.23 1.07
0.68 4.14
0.80

1-5 1-5 1-5 0.20-4.67 1.5-6.0

Body Function and Structure

Mean
SD

Physical capability of the hand Pain Emotional response to trauma, intrusion Emotional response to trauma, avoidance

52.20
15.94 3.74-85.95 5.73
2.38 0-10 1.82
1.34 0-5 1.48
1.06

Min-Max

0-4

Activity Limitation and Participation Restriction

Mean
SD

Min-Max

Physical function and symptoms Severity of disability

55.78
21.38 30.21
16.45

0-97.73 0-72

The dependent variable TRTW in model 1 indicates that the personal variables that contributed significantly to overall RTW were education, level of self-efficacy, and legal counsel, even after adjustment for other personal prognostic factors. Thus, participants with higher self-efficacy scores and higher level of education returned to work earlier. The hazard of delayed RTW for participants who involved lawyers in the process of the work disability benefit claim was twice that of participants who did not involve a lawyer. No other personal factors caused a significant difference in overall RTW. For TRTW in model 2, the environmental variables that contributed significantly to the overall RTW were job-required repetitive hand movement, workload or job control, and

Table 3 Rates for return to work by month intervals and reasons for not returning to work (NZ178) A. Employment profile by months

RTW in Each Time Point n (%)

Not Working in Each Time Point n (%)

3 mo 6 mo 9 mo 12 mo

66 115 130 134

112 62 46 42

(37.1) (65) (73.9) (75.3)

(62.9) (35) (26.1) (23.6)

B. Reasons for not Returning to Work by the End of the Study

n (%)

The injury Physician not approved Other* Lawyer did not recommend Got fired because of the injury Quit their job Reinjured

21 8 4 3 2 2 2

(50) (19.04) (9.5) (7.1) (4.8) (4.8) (4.8)

* Relocation, house arrest, and no specific reason.

recognition for work disability benefit claim, after adjustment for other environmental prognostic factors. Therefore, increased repetitive movements and workload decreased TRTW by 20%-42%. A decrease in TRTW by 60% was also found for those who were recognized for work disability benefit claims. For TRTW in model 3, higher pain and intrusive thoughts (more psychological distress) scores decreased the TRTW 10%30%, whereas less severe injuries were associated with early RTW compared to more severe injuries. Finally, for TRTW in model 4, the physical function and symptoms used for the activities and participation domains were associated with delayed RTW. More functional distress decreased the TRTW by 2%.

Discussion The aim of this study was to examine the factors that predict TRTW among manual workers after HI. During the follow-up study, 25% of participants did not return to work, even by the end of the 12-month follow-up period. According to the literature, those who do not return to work are at risk for long-term disability.7 The median time off work in our study was 92 days, more than reported previously (66 days for participants with a single injury).24 A possible explanation of the prolonged absence from work may relate to NII policy in our country. According to NII rules, patients with HI may be granted injury allowance up to 91 days, during which they may stop working due to the injury.25 Indeed, our simultaneous multiple model showed that the legal factors were found to be significant. This is reinforced by other studies26,27 showing that legal involvement in the compensation process has been associated with negative outcomes of RTW.26 If workers with injuries are afraid to lose their compensation rights when they return to work, they may choose to delay the RTW, keeping them focused on their limitations.26-28 Using only simultaneous multiple Cox regressions does not give a complete and reliable picture of the complexity of factors affecting RTW. Indeed, the 4 separate regressions revealed that various factors contribute significantly to TRTW. These results are consistent with other studies.29-32 www.archives-pmr.org

Work participation, hand injury, predictors Table 4

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Individual contribution of the independent variables and the dependent variable TRTW

Prognostic Factor

A. Univariate Kaplan-Meier Number of Participants Who did not Return to Work 12 Sig*log mo Postinjury, n (%) rank 95% CI

Ethnicity Jews 18 (20.5) ArabsRef 24 (27.3) Education 12 y 15 (17.6) 27 (33.3) >12 yRef Partner working Yes 16 (20.8) 16 (29.6) NoRef Legal counsel Yes 31 (41.3) 11 (11.1) NoRef Recognized for work disability benefit claim Yes 30 (44.1) No 0 (00) 10 (26.3) In processRef

.05

B. Univariate Cox SurvivalZRTW Analysis

Sig HR* (CI)

Age

.73 .99 (.98-1.0)

Level of self-efficacy

.00 1.42 (1.26-1.66)

Level of workload/job control

.00 .60 (.43-.84)

Level of work social support

.06 1.23 (.99-1.54)

101 (78.0-123.9) 151 (104.8-197.2) .00 93 (87.7-98.3) 184 (129.1-238.9) .05 95 (86.4-103.6) 156 (95.9-216.2) .00 184 (88.3-279.7) 95 (79.6-110.4) .00

Job requirements 234 (78.4-389.5) 86 (77.5-94.5) 121 (53.0-188.93)

Hand strength required for job Repetitive hand movement Lifting heavy loads Pain Physical capability of the hand Emotional response to Trauma Intrusion Avoidance Physical function and symptoms Severity of the disability

.07 .00 .03 .00 .00

.83 .84 .86 .90 1.03

.00 .01 .00 .00

.70 .80 .98 .97

(.68-1.01) (.70-.91) (.75-.98) (.84-.96) (1.01-1.03) (.61-.80) (.67-.94) (.97-.99) (.96-.98)

Abbreviation: Ref, reference group. * Hazard ratio risk of RTW.

Consistent with other studies,5,6 education was a predicting factor associated with TRTW. Indeed, better education enables more flexible employment opportunities and better mobility in the work market.5 Nevertheless, in the current study all the participants were employed as manual workers, and they returned to their previous jobs. We believe that education in this case may be an indirect indicator for ethnicity. According to the ICF, ethnicity is considered a personal variable, but the researchers assert that ethnicity includes the cultural context, which comprises elements such as beliefs, and activity patterns.9 This concept is supported by the biopsychosocial model, which claims that ethnicity not only refers to race but also includes social, psychological, and cultural characteristics.33 Ethnicity was a significant predictor in the univariate survival analyses, though according to model 1’s regression analysis the ethnicity was not associated with TRTW. The discrepancy between lower rates of RTW among Jews and Arabs together with the fact that ethnicity did not predict RTW, can be attributed to the fact that ethnicity is a variable concealed within education. In addition, it can be attributed to family roles and collectivist characteristics in Arab society, including family as a primary unit, harmony and cooperation, and interdependence.34,35 Although Israel is characterized by strong family and social support among both ethnic groups,36 traditionally, Arab culture is characterized by an extended family (hamula) and by strong social and family support systems, which can compensate for economic pressures and other aspects of the needs of the injured persons. In contrast, Jewish society is more individualistic35; individuals are www.archives-pmr.org

characterized as independent, and time constraints are often strictly adhered to, encouraging them to return to work earlier than Arab workers. It is also possible that the significance assigned to the hands in Islam has a psychological effect that may have affected RTW.37 The results are congruent with existing literature concerning different injuries indicating that minorities are more functionally disabled.29,33,38,39 Coping with cultural diversity is one of the most significant challenges facing health service providers. As part of a client-centered practice, clinicians are required to be aware of the existence of cultural diversity and are required to learn about and respect unique cultural and ethnic characteristics. Cultural issues should be taken into account in the assessment and intervention process to promote RTW of different ethnic groups. Consistent with other studies,1,5,6,14,15,26-29,40-48 self-efficacy, the job requirement of repetitive hand movement, workload or job control, impairment severity, degree of pain, and emotional responses because of a traumatic event, specifically, intrusive thoughts and higher disability and activity limitation, were predicting factors associated with TRTW. Our results stress the rationale of using the ICF classification, because RTW/TRTW after HI can be influenced by factors in all ICF domains. Clinicians should consider interventions targeting a patient’s ability to cope with disability and pain at an early stage. Furthermore, because the probability of RTW decreased for participants who did not return to work during the first 9 months, we recommend emphasizing this group in the rehabilitation process. Finally, our study underlines the importance of involving

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B.S. Marom et al Education:

Ethnicity: 100

100

80

80

60

60 % RTW

% RTW

rates

over time

rates

over time

40

40

Up to 12 y

20

Graduate+

Arab 20

Jew 0

0 0

100

200

300

0

400

100

200

Days

Partner working: 100

80

80

60

rates

over time

400

NII work disability benefit claim:

100

60 % RTW

300

Days

% RTW

40

over time

No

20

rates

Yes

Yes 40

In process 20

0

No

0 0

100

200

300

400

0

Days

100

200

300

400

Days

Lawyer involvement: 100

80

60 % RTW

rates

over time

Yes

40

20

No

0 0

100

200

300

400

Fig 2 The Kaplan-Meier curve indicates the estimated percentage of patient’s RTW at various times after the injury by patient’s ethnicity, education, partner working, lawyer involvement, and NII work disability benefit claim.

different stakeholders, including the employer and the NII, in the rehabilitation process after HI. Because litigation in particular affects TRTW, stakeholders should address this factor in a conceptual framework that will facilitate RTW.

Study limitations The primary limitation of this study was that participants’ own statements concerning if and when they returned to work were used but were not validated by other sources. Second, the satisfaction of the employee and the employer after RTW was not examined. Third, a possible bias could have resulted from the fact that only workers with HI who were referred to occupational therapy clinics were recruited for the study. Including participants

with no comorbidities with the HI might also have caused selection bias.

Conclusion With more people from diverse cultures living with different types of injuries, including HI, the issue of work participation will continue to be a health problem that requires attention and action on the part of various stakeholders, as well as interventions from the rehabilitation profession. Moreover, as this study found, even though medical conditions and objective medical findings are important risk factors for prolonged work disability, it is important to address pain; psychosocial variables, especially trauma-related www.archives-pmr.org

TRTW as a function of several explanatory variables, with multiple Cox regressions of 12-month follow-up Model 1

Personal Factors HR (95% CI)

Model 2 Environmental Factors

Model 3 HR (95% CI)

Education 1.56* (0.97-2.52) Repetitive hand 0.80y (0.68-0.94) movement  12 y >12 y (ref) Ethnicity 1.22 (0.76-1.95) Lifting heavy loads 0.95 (0.81-1.12) Jews Arabs (ref) Partner working 1.07 (0.65-1.75) Workload/job control 0.58y (0.40-0.83) Yes No (ref) Level of 1.34y (1.10-1.64) Recognition by the NII for work disability benefit claim self-efficacy Yes 0.88y (0.42-1.83) No 2.15 (0.95-4.83) In process (ref) Legal counsel 0.53y (0.34-0.82) Yes No (ref)

Model 4 Activities and Participation Domains HR (95% CI)

Body Function and Structure

HR (95% CI)

Pain

0.91* (0.85-0.98) Physical function and symptoms

Physical capability of the hand

1.05* (1.0-1.02)

Severity of disability

Work participation, hand injury, predictors

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0.98y (0.97-0.99)

0.98 (0.97-1.00)

Emotional response to trauma, 0.70y (0.57-0.86) intrusion Emotional response to trauma, 1.130 (0.88-1.40) avoidance

NOTE. A: Univariate Kaplan-Meier and estimates of the cumulative proportion not returning to work by patient’s characteristics. B: Univariate Cox survival analysis. Abbreviation: Ref, reference group. * Sig <.05. y Sig <.01.

9

10 distress variables; cultural issues; workplace factors; and disability level to facilitate RTW. Studies are recommended to examine novel interventions to improve employment outcomes.

Supplier a. SPSS, version 20.0; IBM.

Keywords Hand; Injuries; International Classification of Functioning, Disability and Health; Rehabilitation; Return to work

Corresponding author Batia S. Marom, PhD, Occupational Therapy Unit, Clalit Health Services, North District, 1 Hachashmonaim st’, Tiberias, 1426401, Tiberias, Israel. E-mail address: [email protected].

Acknowledgments We would like to thank our colleagues from the Occupational Therapy Units of the Clalit Health Services for their assistance in collecting data: Jenny Voskoboinikov, BOT, Amany Saleh-Abu Alhof, BOT, Manal Najjar, OT, MSc, Nuha Amer, OT, MSc, Ayelet Shenkar, BOT, Iensaf Haj Mohammed, OT, MSc, Yasmin Haron, BOT, Mor Vainer-Bader, BOT, Areen Ersheid-Manni, BOT, Manar Daher, BOT, Lina Espanioly, BOT, Chen Petrov, BOT, Sigal Svorai, BOT, Sara Dinerman, BOT, Ravit Shay, BOT, Aviva Beutler, BOT, Narmeen Khoury Awwad, BOT, Sharon Kirshner, PhD, OT, Ruti Sagiv, BOT, Inbal Datz-Reis, BOT, Rachela Rozenberg, BOT, Yael Raisman, BOT, Yifat Goldstein, OT, MSc, Hadas Peiser, BOT, Sharon Werech, BOT, Inbar Miller, OT, MSc, Limor Kahana, BOT, Naama Varon, BOT, Graciela Lev, BOT, Orit Palmon, OT, MSc, Dorit Kornmehl-Asis, BOT, Irit Oren-Bossidan, BOT, Hala Zoabi Abdalla, BOT, Batya Movchine, BOT, Khawla Loubani, OT, MSc, Iman Jahshan, BOT, Hasan Abu-Nimer, BOT, and Anat Cons, BOT. We wish to thank Betsi Goorsby for her editorial contribution to the preparation of this manuscript.

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