Non-physical factors that impact return to work in individuals with upper extremity injuries: A scoping review

3.1 Review of articles

The initial search of the literature yielded 40 articles that met the inclusion criteria. After duplicate titles were removed, 31 articles remained. Four researchers reviewed the remaining titles and abstracts and 10 additional articles were excluded as a result. The final 21 articles were read in full and matrixed by the same four researchers. The researchers then met to discuss their findings and 12 additional articles were excluded based on consensus. In order to provide a more accurate representation of information portrayed in the remaining nine articles (see Fig. 1), a thematic analysis was individually conducted by four researchers to categorize similarities. The researchers met to compare the results and the themes that were identified, with debriefing with the fifth author. The information was coded and categorized into three themes including client self-efficacy, social determinants of health, and the need for holistic intervention approaches (See Table 1). See Fig. 2 for a representation of the number of articles that reflected the associated themes.

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Fig. 1

PRISMA diagram.

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Fig. 2

Representation of articles and associated themes.

Self-efficacy was measured in seven of the included studies. Outcome measures included in the studies that provide information related to self-efficacy include self-reported quantitative measures such as the Disability of the Arm, Shoulder and Hand (DASH)/Quick DASH [9] which measures self-rated upper extremity disability; Short Form Health Survey (SF-36) [10] which measures self-perceived health; and the International Classification of Functioning Hand Assessment (ICF Hand_A) [11] which measures factors that affect RTW after a hand injury [12–17]. Ramel et al. [16] measured self-efficacy within the broader context of Sense of Coherence (SOC). Another outcome measure that was used in the majority of the studies, but did not measure self-efficacy directly, was the Hand Injury Severity Score (HISS) or Modified Hand Injury Severity Score (MHISS) [18] which measures self-perceived injury severity of the hand, wrist, and forearm. Of the nine studies, two used the DASH/QuickDASH [15, 16], two used SF-36 [12, 13], two studies used ICF Hand_A [14, 15], and five included the MHISS [12, 20]. In two articles, higher self-efficacy resulted in earlier RTW and in one article, negative affect was found to postpone RTW [15, 19] (see Table 1).

3.3 Social determinants of health

The importance of culture has been demonstrated to have an influence in RTW status. Eight out of the nine articles discussed the possible role that social determinants of health may have as a predictor of RTW. The aspects of social determinants of health that were identified to correlate with impacting RTW include gender, education, and type of occupation (blue collar vs. white collar), insurance culture, and support systems. The literature that was included in this review originated from a variety of different countries. Of the nine articles, two articles were published in both Taiwan and Australia and the remaining five articles were published in Germany, the United States, Israel, the Netherlands, and Sweden (see Table 1).

Gender was analyzed in two studies [14, 15] which discussed how men are more affected by work related injuries and women are less susceptible to hand strain due to less strenuous job demands. Three articles [15, 20] described education as a possible prognostic determinant in RTW in which individuals with a higher education are more likely to have a white-collar occupation. Individuals with a white-collar job are more likely to have lower physical demand on the upper extremity in their work role as opposed to blue collar workers. Additionally, Chen et al. [13] and Eisle et al. [14] found that sick leave as a result of insurance type and worker’s compensation benefits had an impact on RTW. Lastly, five articles identified support systems to have an impact on RTW. Support is inclusive of family or caregiver support and employer/co-worker support [15–17, 21].

3.4 Need for holistic intervention approaches

In addition to traditional physical rehabilitative hand therapy techniques focusing on the biological components of strength, range of motion, proprioceptive input, etc., the selected studies also demonstrated the importance of treating the whole person including the psychological and socio-cultural (social determinants of health) components. The majority of the studies (89%) recommend incorporating some form of psychosocial intervention during the early stages of recovery. Three studies report the efforts of using a biopsychosocial approach to reduce time off work. Additionally, five studies report the effects of PTSD on RTW and the importance of establishing psychological screenings for PTSD as early as possible to increase rates of early RTW [16, 19–21]. Lastly, Chen et al. [13] reported the benefit of incorporating vocational evaluation or counseling into the rehabilitative program to increase rates of early RTW.

4.1 Client self-efficacy

An important contributor to study findings was the inclusion of outcome measures that assess the client’s sense of self-efficacy. Self-efficacy was described by Bandura [22] as being highly predictive of the initiation and continuous execution of behaviors. If an individual has the perception of lower self-efficacy with regard to work, it has been found that predictive validity exists with regard to successful RTW rates [23]. In two articles included in this scoping review, higher self-efficacy resulted in earlier RTW [15, 19] and in one article, negative affect was found to postpone RTW [17]. Negative affect was described as being the result of “emotional distress” and it was found that individuals with high negative affect report symptoms of aches and pains that are more psychosomatic in nature and have no discernable physiological basis.

Variance was observed in the type of outcome measure used, whether it be quantitative, qualitative, or both. Outcomes measures that were utilized to assess self-efficacy included the DASH [9], SF-36 [10], and ICF Hand_A [11], while the HISS/MHISS [18] indirectly measures self-efficacy. While these four outcome measures were the primary, more established measures that were used to determine self-efficacy, other outcome measures were also utilized. These measures that were least represented throughout the reviewed research include the use of self-developed questionnaires which look at self-perceived function, vitality, and motivation towards their recovery and what stage the subjects were in during the rehabilitative process. Furthermore, some studies included using the Visual Analog Scale (VAS) [24] for pain assessment, and a self-rating scale for post-traumatic stress disorder (PTSD) [12–17] because post-injury depression and/or PTSD can be resultant after an upper extremity injury, especially if it was traumatic in nature (i.e., getting a hand crushed by a machine) [25].

The DASH is a 30 question self-reported questionnaire specific to the upper extremity only and is used to measure a patient’s perceived disability [15, 26]. The QuickDASH is a shortened version of the DASH with only eleven questions. Advantages of using the DASH and QuickDASH include versatility and cultural competence as they are available in a variety of languages [26]. In Ramel et al. [16], the DASH yielded the most compelling data in which authors discovered that as the DASH score decreased, RTW increased. Marom et al. [15] used the QuickDASH to analyze any correlations with RTW and found that most of the participants reported moderate disability.

The SF-36 is a multiple-choice questionnaire of 36 questions that gathers information related to self-perceived health. There are eight concepts derived from the assessment including physical functioning, role-physical, bodily pain, general health, vitality, social functioning, role-emotional and mental health. Each question is scored and calculated between zero and 100. A higher score is interpreted as higher self-perceived health [13]. Findings from Chen et al. [12] indicate self-perceived physical functioning has a negative correlation with time off work; however, self-perceived mental health is positively correlated with time off work. Additionally, Chen et al. [13] found self-perceived vitality to play an important role in early RTW. Furthermore, Ramel et al. [16] found that participants who reported lower physical quality of life did not RTW after 12 months. Thus, SF-36 is a useful tool for identifying self-perceived health factors that assist with determining predictors of RTW.

The ICF Hand_A is based on the ICF Core Set for Hand Conditions and it’s four domains including Body Function, Body Structures, Activities and Participation, and Environmental Factors [14, 15]. The ICF Hand_A provides instruments that gather data from patient-reported outcomes, physical examination, and clinical assessments [14]. Eisele et al. [14] discovered factors that affect RTW are represented in all domains; however, emphasis is placed on variables in the domains of Body Structure and Body Functions. Variables found to best predict time off work included mobility of joint functions, hand strain at work and sensory functions related to various stimuli such as temperature [14]. However, the authors noted that variables in the domains of Personal Factors, Environmental Factors, and Activities & Participation had an influence on RTW and recommend that a comprehensive, biopsychosocial approach to rehabilitation of upper extremity injuries is necessary. Similarly, Marom et al. [15] found RTW after a hand injury to be influenced by variables in all four domains.

The MHISS is a condensed version of the HISS developed by Campbell and Kay to classify injury severity of the hand distal to the carpus [13]. Urso-Bairda et al. [18] developed the MHISS to include the wrist and forearm limiting severity to hand injuries only. Both the MHISS and HISS categorize injury severity according to the patient’s total score. A score of < 20 is Minor, 21–50 Moderate, 51–100 Severe, and > 100 Major [13]. A positive correlation is apparent between MHISS and RTW in which those with more severe injuries take longer to return to work [12, 17]. It should be noted that this assessment tool did not measure self-efficacy directly but may contribute to an individual’s sense of self-efficacy because this is a self-reported assessment of injury severity. Also, it is limited in its utility because it does not address injuries to the upper extremity proximal to the forearm.

The final concept that was found to be utilized to measure self-efficacy is Sense of Coherence (SOC). SOC is a concept that is presented by Ramel et al. [16], which is identified as an individual factor in RTW determination. SOC is a salutogenic theory introduced by Dr. Aaron Antonovsky in 1987 which consists of three dimensions: comprehensibility, manageability, and meaningfulness. With a salutogenic approach, factors influencing health are in focus, in contrast to a pathogenic approach that focuses on risk factors for disability [16]. SOC is assessed with a 13-item scale, referred to as the SOC-13 that reflects an individual’s capacity to cope in stressful situations. In this study, this assessment was utilized six months post injury when study participants no longer had restrictions in use of their upper extremities. The findings indicated that the participants who did not RTW after 12 months experienced lower SOC than the participants that had returned to work within 2 months. Additionally, these participants reported less satisfaction with daily occupations, less physical quality of life, perception of lower health and poorer hand function. Another noteworthy finding in this study showed that those participants who did not RTW and were injured on the job due to external factors showed lower SOC scores. Ramel et al. [16] suggest this finding supports the use of the SOC-13 in identifying individuals who may need extra coaching to successfully RTW following an injury. Individualizing rehabilitation is a crucial factor when working with those who have RTW goals following a hand injury. Utilizing a tool like the SOC-13 allows the therapist to determine those who may require additional support and coaching to strengthen their self-belief and motivation, resulting in improved RTW rates. While this concept is only represented by one article in this review, the authors of this scoping review deemed it worth mentioning because it demonstrates that an individual’s health is influenced by the way they view life [16]. Although other articles do not mention SOC specifically, there are a variety of components mentioned throughout the other articles that are considered sub-components of the concept of SOC including self-efficacy, self-perception, and negative affect. Sixty-seven percent of the articles discussed self-perception and its role in predicting return to work. Individuals with negative self-perception often view themselves as having low vitality and physical functioning thus leading to later RTW [12, 19].

4.2 Social determinants of health

There are various levels of culture that help shape an individual’s customary ideas, values, and beliefs that are all inclusive of the individual and how that individual may be influenced on a personal level to a societal level. The first level, the individual level, is relational in which one-on-one interactions aid in identifying the individual’s perception of their culture. The next level, family, includes beliefs and values that are perceived from a primary social group. Beyond the level of family is the community level which includes the input from neighborhoods, ethnic groups, and economic factors. Lastly, the regional level of culture impacts how an individual carries out life in society by way of their geographical location, use of language, and source of industry [27].

When understanding the general themes that have evolved through close analysis of the articles, it is important to keep in mind that the studies were published in countries all over the world including Taiwan, Australia, Germany, the United States, Israel, the Netherlands, and Sweden. Each country has adopted their own policies and systems that are based on cultural values, belief systems, and traditions that may differ from country to country, which may play a significant role in self-perception and health, which could affect RTW outcomes. A trend for culture and the social determinants of health to be an influence that affects RTW outcomes is mentioned in eight of the nine articles including gender work roles, education and job type, insurance culture, and support systems.

Gender may impact the type of job attained due to cultural views. Women may have different roles than men which can impact RTW. Marom et al. [15] report work related upper extremity injuries are more common amongst male, manual workers. Furthermore, Eisele et al. [14] reported women sustain shorter time off work than men and have less strenuous job demands. Thus, there is an indication that job type or job tasks may be culturally assigned according to gender.

When looking at education as a social determinant of health, the literature indicates a difference among cultures in the value that they place on education. This difference in value can impact the types of jobs attained within a population. Marom et al. [15] found higher education enables more flexible employment opportunities. Due to the increased opportunities presented to those with higher education, it was found that white collar workers with upper extremity injuries were more likely to RTW earlier when compared to blue collar workers. Opsteepgh et al. [20] supports this suggestion by stating job flexibility may hasten RTW, although more research is needed to provide evidence for this claim.

In relation to education, an additional topic that was discussed frequently in the literature that was determined to influence RTW rates, was blue collar vs white collar jobs. This was identified most significantly in the articles by Osteepgh et al. [20] and Marom et al. [15]. Osteepgh et al. [20] found that 38% of the blue-collar workers in their study group returned to work in less than 10 weeks when compared to 61% of white-collar workers. Blue-collar jobs were deemed to delay RTW in that they are often more physically demanding; therefore, upper extremity injuries could be more debilitating in this sector than in white collar jobs [20]. More significant upper extremity injuries were also found to occur more frequently in workers who held manual labor positions and those that required physical skill and unskilled work [15]. While significant upper extremity injuries can occur in those who hold either blue- or white-collar positions, returning to work in the same capacity following such an injury would be much more difficult for an individual holding a job that requires significant use of the upper extremities through repetitive motion, heavy lifting and a high demand workload [15].

Insurance culture is another significant social determinant of health that was found to impact RTW. Each country has developed its own “insurance culture” based upon the laws and policies that are created to replace lost income from not being able to work due to an injury or illness. For example, in Israel, many injured workers return to work on the 92nd day post-injury. This could be due to the National Insurance Institute policy which grants injured workers with compensation for up to 91 days [15]. Because of the legal involvement in the compensation process, injured workers may have negative RTW outcomes and may choose to delay RTW for fear of losing compensation rights.

In Taiwan, workers may receive compensation for two years as a result of work-related injury; however, for the first year, workers may receive 70% of their salary which decreases to 50% in the second-year post-injury. For situations such as this, early RTW can be impacted by higher or uninterrupted compensation [13]. Interestingly, Eisele et al. [14] discovered in their study a high proportion of Swiss manual workers to have one insurance type. This could have played a factor in the association between accident insurance and longer time off work.

Support systems are important in the RTW process and are another component categorized under social determinants of health. Support systems identified in this review encompass family support, colleague support, and employer support. Based on results from various studies, the different support systems appear to play distinct roles which ultimately facilitate RTW. Two studies described support as physical assistance, phone calls, encouragement, supportive employers, and job modifications [19, 21]. Additionally, family has also been found to be linked to RTW after an upper extremity injury. Family support can include physical or economic support and may vary across cultures. Roesler et al. [17] found living alone to be an important determinant of delayed RTW which may pose a challenge for individuals to RTW faster. Living alone delays RTW due to the likelihood for the individual to engage in tasks that require the use of the injured upper extremity because of lack of assistance. This, in turn, may exacerbate the injury and prolong recovery. Injured workers who live with a significant other or family members can delegate tasks in order to facilitate recovery of the injured limb [17]. Family culture may vary based on whether the society they exist in are collectivist or individualistic because the support provided to the injured will differ. Marom et al. [15] found in their study between Jewish and Arab populations that the Jewish population may RTW earlier because they have adopted a more individualistic society and time constraints are more strictly adhered to whereas Arabic individuals may RTW at a later time because their culture considers family as the primary unit in which extended family members may contribute to alleviating economic pressures and other individual demands [15]. Collectivist societies provide additional support to ease economic pressures, and to facilitate any needs of the injured worker; however, these features are not prominent amongst individualistic societies [15]. In fact, people that belong to individualistic societies fear being dependent, asking for help, and bothering others [21]. This indicates that different cultural values and beliefs can have an impact on the timing of RTW.

Employer and colleague support are also influenced by culture and are possible predictors of RTW. Individuals who have a strong social support system at work are more likely to have an increased motivation for recovery [21]. This is particularly important for individuals who are injured at work as they are less motivated to RTW [16]. In a study of 40 people with severe or major upper extremity injury, only a third of them were injured at work; however, over half of the individuals who did not RTW after 12 months were injured at work [16]. This study suggests that motivation to RTW is directly influenced by where the injury occurred [16]. Employers should be flexible and responsive with work-related injuries to facilitate a prompt and safe return of their employees. From a stakeholder (employers, insurers, lawyers, and healthcare providers) perspective, one study found most factors influencing RTW belonged to the same category; support from the workplace [19]. This study suggests that an injured worker’s perception regarding the ability or willingness of their employer to modify their job could delay RTW. The researchers concluded that employer support impacts RTW by way of willingness to provide accommodations or modifications to job tasks [19]. Employers can facilitate earlier RTW by making environmental changes or job function modifications. Changes to the environment or job function portray that the injured worker is a valued team member [21]. Modifications may also ease fear and anxiety about returning to work, specifically among workers who were injured on the job [21].

4.3 Need for holistic intervention approaches

As is evident from this scoping review, various non-physical factors can influence RTW. Practitioners should consider utilizing a comprehensive, holistic intervention approach to facilitate the RTW process. A comprehensive approach many include a holistic and/or biopsychosocial approach [12–14, 17]. A holistic approach should consider psychological, physical, and socio-cultural aspects to improve RTW outcomes [12]. One study called for holistic approaches to include vocational evaluation or counseling; in doing so, work accommodations or avoidance could be properly recommended [13]. Additionally, a holistic approach should not be limited to the client and the therapist, but would benefit from the development of a collaborative relationship between the various medical practitioners (i.e., therapist, surgeon, nurse case manager) and the client [28] with the ultimate objective to be facilitating the client establishing realistic expectations as that has been found to have the client demonstrate better adjustment to her post-injury extremity and better overall function [29]. The goal in a holistic therapeutic approach should be to, ultimately, have the client take responsibility for their therapeutic program as that has been shown to demonstrate better functional outcomes [30]. One holistic intervention method that should be considered is the development of a symptom self-management program for those experiencing chronic effects of an upper extremity injury to prepare them for manage the physical, psychological, and social consequences of the injury while supporting them in a successful and sustainable RTW [31]. There has been evidence of this type of a program being effective to support RTW in individuals with low back pain and other chronic conditions [31–33]. One of the demonstrated effects of one of these programs is that it facilitates improvement of perceived self-efficacy in subjects [31].

Psychosocial factors affect the recovery process with increasing influence over time [17]. Based on the studies from this review, there is a need to intervene for negative affect, motivation, fear of re-injury, anxiety, and PTSD. Negative affect can delay RTW, as it has been associated with pain that has no physiological basis [17]. In practice, therapists can use therapeutic use of self to alleviate negative feelings associated with the injury. Another study found that even a small number of symptoms of PTSD can delay RTW [20]. Participants who had been caught in heavy machinery expressed anxiety about getting close to the machine [16]. Therapists can work with employers to facilitate job modifications on a temporary or permanent basis depending on the injury. Additionally, stakeholders reported multiple psychological factors that delay RTW; including difficulty coping, post-operative psychological status, and recovery expectations [19]. Routine care should include psychological screening as psychosocial factors can delay RTW and work performance [16, 21]. This would allow for early, comprehensive intervention in the rehabilitation process, which researchers agree would be optimal [16, 20]. Therapists can address psychosocial issues in their treatment which can facilitate recovery, but also refer to other healthcare practitioners if necessary.

4.4 Limitations

Due to differences in terminology, it is possible that relevant research may have been missed during the literature search process. To ensure the integrity of this process, researchers used the controlled vocabulary of each database in efforts to acquire all relevant literature as well as a gray literature search of two well-known, peer-reviewed journals that publish articles related to work and hand therapy. Additionally, the second, third, and fourth authors conducted an in-depth literature search prior to keyword selection to ensure consistency of terms. In order to mitigate the differences in terminology, it is recommended to use a universal language to better understand the psychosocial factors involved with these types of injuries, such as the ICF Hand_A . 

Likewise, there is some documented evidence that personality or temperament can influence self-efficacy motivation [34]. These terms were not included in the search process in this scoping review. Future research in this area should include the addition of “personality” and “temperament” as search terms.

4.5 Implications for practice

This review found a need for practitioners involved in upper extremity rehabilitation to not only tend to the physical aspects of the injury, and the severity of pain, but to also address clients’ perceptions of the injury. It is necessary to remain conscious of culture and the social determinants of health as it can influence injury perception, recovery, and motivation to RTW. A variety of self-efficacy measures can be used to facilitate measuring where their clients are in this process, namely the DASH, SF-36, and the subjective portion of the ICF Hand_A. Based on the outcomes, upper extremity rehabilitation practitioners can guide treatment more appropriately and refer to other healthcare providers as needed. Early intervention and monitoring of the psychosocial factors that can develop as a result of an upper extremity injury is highly recommended.

Rehabilitation practitioners can address psychosocial issues in their treatment by using a variety of techniques. They can incorporate therapeutic use of self when building therapeutic relationships with their clients. These practitioners are encouraged to provide objective feedback when instructing clients through various therapeutic activities. Additionally, involving the client in the evaluation and reassessments is important because their sense of self efficacy has been linked as being a non-physical factor that can impact RTW. When reassessing clients, the upper extremity rehabilitation practitioner can compare the scores from evaluation and emphasize the improvements that have been made. This should be used with all clients because it can be difficult for them to see progress on a day to day basis, especially with lengthy recoveries. Lastly, therapists can facilitate home and workplace support by making recommendations on environmental modifications and symptom self-management techniques to maximize engagement in occupations. These tools can be used on a daily basis to promote overall health and wellness during the rehabilitation process and beyond to support and sustain RTW.