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Return to work and health-related quality of life after burn injury

Return to work and health-related quality of life after burn injury J Rehabil Med 2007; 39: 49–55 ORIGINAL REPORT RETURN TO WORK AND HEALTH-RELATED QUALITY OF LIFE AFTER BURN INJURY 1 2 1 Johan Dyster-Aas, MD , Morten Kildal, MD, PhD and Mimmie Willebrand, PhD 1 2 From the Department of Neuroscience, Psychiatry, Department of Surgical Sciences, Plastic Surgery, Uppsala University, Uppsala, Sweden Objective: Although severe burn injury is associated with from work is expensive for the community, considering health long-term rehabilitation and disability, research on returning insurance (sickness benefit) and high company costs (3). Risk to work in burn patients is limited. The aims of this study factors for longer duration of absence after injury and lower were: (i) to explore injury- and personality-related predictors probability of return to work are admission to an intensive care of returning to work, and (ii) to compare health-related quality unit, long length of stay, and low level of education among of life and health outcome in working versus non-working the patients (4). individuals. The above-mentioned risk factors are prevalent among pa- Design: Cross-sectional study. tients with severe burn injuries (5). A severe burn injury affects Subjects: Forty-eight former patients with pre-burn employ- most systems in the body, and patients often require respiratory ment were evaluated on average 3.8 years after the burn. support in addition to wound treatment. With modern wound Methods: Data were collected from medical records and by care, superficial burns heal spontaneously in about 2 weeks a questionnaire in which the patients were asked about their while deep, full-thickness burns need surgical interventions main activity status described in the terms: work, studies, such as early excision and skin grafting. Patients often expe- pension, disability pension, sick leave or unemployment. It rience severe pain and anxiety during the prolonged treatment. also contained the Swedish universities Scales of Personality, Surgical techniques and treatments have evolved rapidly during SF-36, Burn Specific Health Scale-Brief, items assessing recent decades, and mortality rates have decreased dramati- fear-avoidance, Impact of Event Scale-Revised and Hospital cally. Following this trend, there is now greater focus on the Anxiety and Depression Scale. consequences of surviving a massive burn, and the social and Results: Thirty-one percent had not returned to work. In psychological factors involved in recovery. logistic regression, returning to work was associated with Burn injuries are associated with long-term health problems. time since injury, the extent of full-thickness injuries, and Common physical symptoms after a burn injury are pain and the personality trait embitterment. Those who did not work sensory problems, pruritus, and loss of strength. Recently, it has had lower health-related quality of life, poorer burn-specific health, more fear-avoidance and more symptoms of post- been shown that perceived health problems (6) after burn injury traumatic stress disorder, but they did not differ from those can persist for several decades. In addition, between 13% and who were working regarding general mood. 23% of patients develop depression, and 13–45% develop post- Conclusion: Returning to work was explained by both injury traumatic stress disorder (PTSD) after hospital discharge (7). severity and personality characteristics. Those who did not Although burn patients experience several health problems work were characterized by low health-related quality of life in the long term, a follow-up of adult burn patients after 2–10 and poorer trauma-related physical and psychological health. years showed that they generally do not differ regarding health- Key words: adjustment, burns, BSHS-B, personality, SF-36, related quality of life (HRQoL) compared with normative data trauma. (8). Previous studies have also indicated that most burn patients return to work. It was found that although job disruption was J Rehabil Med 2007; 39: 49–55 common, 90% of burn patients returned to work within 2 years Correspondence address: Johan Dyster-Aas, Department (9). In a Swedish sample of burn patients who had been injured of Neuroscience, Psychiatry, Uppsala University Hospital, at work, 83% were working again on average 9 years after the SE-751 85 Uppsala, Sweden. E-mail: johan.dyster-aas@ injury (10). The individuals who were not working at follow- uaspsyk.uu.se up reported more pain and a poorer outcome in the areas of Submitted December 9, 2005; accepted May 22, 2006 perceived ability to work, body image, affect, interpersonal relationships, and ability to take care of the skin (10). Factors that have been related to return-to-work rates are INTRODUCTION total body surface area burned (TBSA) (9, 11–13), extent of Being in employment is associated with a higher degree of full-thickness burns (TBSA-FT), length of stay (LOS) in the satisfaction with life, both in the general population (1) and burn unit, number of surgical procedures, perceived function- in patients with physical injuries (2). In addition, absence ing (12), age (11, 13), and prior psychiatric illness (9, 14). One © 2007 Foundation of Rehabilitation Information. ISSN 1650-1977 J Rehabil Med 39 DOI: 10.2340/16501977-0005 50 J. Dyster-Aas et al. each worth about 2.5 Euros, as a reward. The study was conducted of the most influential factors is pre-burn employment (13–15). according to the ethical principles of the Helsinki Declaration and It is highly likely that some of these factors are interrelated: for approved by the ethics committee of Uppsala University. instance, being employed before the burn is likely to be related Eighty-six former patients (74.1%) returned the questionnaire to pre-burn psychiatric illness and physical functioning (16). booklet. Of these, 51 former patients had been employed at the time In order to find factors that impede return to work – and not of the burn injury. Three patients had retired due to age at the time of the investigation. Thus, there were 48 patients (11 women, 37 men) employment as such – those who were unemployed before the who could be expected to return to work and they constituted the cur- burn should be excluded from the analysis.When including only rent sample, while the remaining 38 were excluded. All 48 patients patients who were employed before the burn, return to work were below the common retirement age of 65 years. Mean age at has been predicted by ethnicity, marital status and not blaming injury was 40.8 years (SD 10.2, range 20–61 years), and at the time oneself for the injury (15). This indicates that psychological of the investigation it was 44.4 years (SD 10.2, range 23–64 years). Mean time since injury was 3.6 years (SD 1.1, range 1.4–5.6 years). factors are involved in the process of returning to work. In Average burn size was 17.5% TBSA (SD 15.3, range 0.1–80.0%), other patient groups, it has been seen that personality traits of which 7.9% (SD 11.2, range 0–48%) were TBSA-FT. TBSA and can be predictive of working status. For example, patients with TBSA-FT were assessed by two experienced burn surgeons who used introverted personality traits are more likely to fail in returning all available medical records including photographs and the surgeon’s to work after suffering a myocardial infarction (17). Further- notes during the time in care. The average LOS in the Burn Unit was 19.7 days (SD 21.8, range 1–95 days). Forty-three patients had thermal more, dysfunctional beliefs such as fear-avoidance have also burns, 5 had electrical burns. Twelve burn injuries were occupational, been associated with functional outcome. Fear-avoidance is the 11 occurred at home, 20 in leisure time, and 4 were self-inflicted. fear of re-injury or harm, which is accompanied by avoidant Thirty-one patients had injuries to the face and 39 had injuries to the behaviour and poor functioning. It is a known risk factor for hands. Twenty-four patients had been on sick leave for less than 6 development of chronic pain (18). Fear-avoidance was recently months and 23 for a longer period. According to the medical records, 7 patients had a history of psychiatric problems such as psychosis, investigated in burn patients and a strong association was found depression, anxiety or substance abuse. Twenty-seven were married, with perceived ability to work (19). To our knowledge, there 18 single and 3 were widowed. Nineteen patients had 9 years of formal have been no studies on the association between fear-avoidance education and 29 had more than 9 years. and actual working status after burn injury. The current subsample differed from the excluded 38 responders in being more likely to be married [χ (1) = 5.9, p < 0.05], to have injuries to The aims of the present study were: (i) to evaluate which 2 2 the hands [χ (1) = 10.9, p < 0.01] and face [χ (1) = 4.3, p < 0.05], to factors are associated with the likelihood of returning to have employment after the burn [χ (1) = 11.7, p < 0.001], and (not work, and (ii) to investigate what differentiates the group that surprisingly) to have had occupational injuries (other causes were has returned to work from the group that has not, in terms of 2 merged into one category) [χ (1) = 6.1, p < 0.05]. No other differences HRQoL, perceived burn-specific health, dysfunctional beliefs were found regarding the above-mentioned burn-specific or socio - demographic data. In comparison with the 30 who did not respond to and psychological symptoms. the survey, the members of the current subsample were less likely to In this study, the term ‘‘predictive variable’’ is used for (i) have a record of substance abuse [χ (1) = 12.1, p < 0.001] and more burn-related and socio-demographic variables that reflect the likely to have injuries to the hands [χ (1) =4.2, p < 0.05]. Data on the patient’s status at the time of injury, although the information nonresponders were restricted to the medical records (age, sex, TBSA, was extracted from medical records at a later time point, and LOS, localization of burn injury, documented psychiatric problems). (ii) personality traits that reflect stable behaviour patterns in an Measures individual with respect to time and different situations (20, 21). Work status. Information on pre-burn and current work status was These variables are considered to be statistically predictive, gathered in the survey. The respondents were asked about their main and their causal relationships to the criterion variable cannot be activity status described by the alternatives: working, studying, retired firmly established using this cross-sectional research design. due to age, unemployed, sick-listed, disability pension. Only those who responded that they had been working before the burn were considered for the study. Those who were working at the time of the investigation were referred to as group 1 (‘‘working’’), and the rest were referred METHODS to as group 0 (‘‘non-working’’). Participants and procedure Former patients were included if they: (i) had been admitted to the Burn Predictive variables. Socio-demographic and injury-related variables. Unit at Uppsala University Hospital between January 1996 and March Based on the current literature, the following variables were considered 2000, and (ii) were 18 years or older at the time of the investigation in relevant and were extracted from the medical records: age, gender, October 2001. Former patients who had no registered address (n = 6), TBSA, TBSA-FT, LOS, localization of burn to the hands or the face, were not Swedish citizens and did not live in Sweden (n = 4), or who and a documented history of psychiatric illness (including substance had dementia (n = 2) were excluded. The final sample of eligible abuse). Time since injury was added as a factor that most likely affects participants consisted of 116 former burn patients. The Burn Unit in the return to work rate. In addition, the survey contained questions Uppsala is 1 of the 2 existing Burn Units in Sweden with national about marital status and level of education. The original 3 levels of responsibility for burn care. The main referral area covers about 3 education were merged into 2 groups, group 0 (0–9 years of education) million of the 9 million inhabitants in Sweden. and group 1 (more than 9 years of education). A survey covering HRQoL, health status, personality, fear-avoidance The Swedish universities Scales of Personality (SSP) contains 91 items and socio-demographic variables (of which previous and current work divided into 13 subscales with 7 items in each: (1) Somatic Trait Anxiety, status was one) was sent to the 116 former patients together with an (2) Psychic Trait Anxiety, (3) Stress Susceptibility, (4) Lack of information letter and a pre-paid response envelope. Reminder letters Assertiveness, (5) Detachment, (6) Embitterment, (7) Trait Irritability, and questionnaires were sent one month later, and again after another (8) Mistrust, (9) Impulsiveness, (10) Adventure Seeking, (11) Social 3 weeks. The participants could choose a flower check or a lottery ticket, Desirability, (12) Verbal Trait Aggression and (13) Physical Trait J Rehabil Med 39 Return to work after burn injuries 51 Aggression. The items were rated on a scale from 1 =‘‘Does not was used with the variable ‘‘returned to work (1/0)’’ as a dependent apply at all’’ to 4 = ‘‘Applies completely’’. The alpha values for the dichotomous variable. In step 1, the predictor variables were examined subscales ranged from 0.59 to 0.84 (22). The data were adjusted for in simple regressions and only those having a p-value ≤ 0.10 were age. T-scores were calculated for each gender separately, based on the included in the multiple models (Table I). In step 2, separate multiple Swedish normative sample (22). logistic regressions (stepwise forward, conditional) were performed for variables associated with injury severity and for variables associated Post-burn variables. The Short-Form 36 Health Survey (SF-36) contains with individual characteristics. In step 3, a final multiple model was 36 items measuring HRQoL (23). It assesses 8 aspects: Physical Func- achieved by a stepwise forward procedure for the injury-related and tioning, Role-Physical, Bodily Pain, General Health, Vitality, Social individual variables that remained in step 2. Functioning, Role-Emotional, and Mental Health. The first 4 subscales form the Physical Composite Scale (PCS) and the last 4 form the Mental Composite Scale (MCS). The Swedish version of the SF-36 has shown RESULTS adequate reliability, construct and clinical validity (24, 25). The Burn Specific Health Scale-Brief (BSHS-B) is a questionnaire Post-burn work status with 40 items divided into 9 subscales that measure perceived function and well-being: Simple Abilities, Heat Sensitivity, Hand Function, Thirty-three participants (69%) had returned to work (1 = Treatment Regimens, Work, Body Image, Affect, Interpersonal Rela- working) while 15 (31%) had not (0 = non-working). tionships and Sexuality. The items were rated on a scale from 0 =‘‘All the time/great difficulty’’ to 4 = ‘‘Never/no difficulty’’. The alpha values ranged from 0.75 to 0.93 (26). Prediction of post-burn work status Step 1. The following variables were evaluated in simple logis- Fear-avoidance was assessed by 4 questions: tic regression analyses: age, gender, TBSA, TBSA-FT, LOS, 1. My burn injury has put my body at risk for the rest of my life. facial burns, hand burns, time since injury, education, marital 2. I can’t do the same things as other people do since there is a too big risk that I might be burn-injured again. status, documented history of psychiatric illness, and the 13 3. I’m afraid that I might get hurt again if I put myself in risky situations. SSP subscales (Table I). An evaluation of intercorrelations 4. It is really not safe for a person with a condition like mine to be suggested the exclusion of some burn severity and personality physically active. variables. TBSA, TBSA-FT and LOS were highly correlated Items 1, 2 and 4 were taken from the Tampa Scale of Kinesiophobia (range r = 0.69–0.78) and therefore only one of them (TBSA- (TSK) (27) and adapted to the burn population. The TSK measures FT) could be included. LOS was excluded on theoretical and fear-avoidance beliefs and fear of (re)injury due to movement. Item 3 statistical grounds, as it can depend on many things other than was constructed specifically for this sample. The answers were given on a 5-point scale ranging from 0 = ‘‘Always applicable’’ to 4 = ‘‘Never burn severity, such as administration and availability of home applicable’’, with a higher score indicating a lower degree of fear- care facilities, and TBSA was excluded as it was marginally wea- avoidance beliefs. In the statistical analysis the scores were reversed, ker statistically. The personality variables with p-values ≤ 0.10 so that a higher score indicates a higher degree of fear-avoidance were also intercorrelated (average r = 0.51, range 0.22–67). beliefs. The 4 items had a Cronbach’s alpha value of 0.69. The mean The one with the lowest p-value (Embitterment) was chosen score of the 4 items was used in the statistical analyses. The Impact of Event Scale-Revised (IES-R) was used to assess first. Subsequently, Adventure Seeking was selected as it had symptoms of PTSD. It contains 22 items and 3 subscales: Intrusion, an acceptable intercorrelation (r = 0.36) with Embitterment. The Avoidance and Arousal. The items are rated on a 4-grade scale from 0, remaining variables had intercorrelations above 0.50. 1, 3, 5, where 0 = no symptom, and 5 = a high frequency of the symp- tom. The IES-R has shown good internal consistency and test-retest Step 2. The following predictor variables were considered for reliability (28). The IES-R total scores were used in the analyses. The Hospital Anxiety and Depression Scale (HADS) was used to the initial multiple regression model for injury-related variables: assess current mood. It consists of 2 subscales, Anxiety and Depres- TBSA-FT, extent of Hand burns and Time since injury. Only sion, with 7 items in each (29). The items are rated on a scale from TBSA-FT (odds ratio 0.48, CI 0.27–0.57) and Time since injury 0 to 3, where 0 = no symptom and 3 = severe symptom. The HADS (odds ratio 2.26, CI 1.04–4.93) were significant at the last step was developed to study mood in non-psychiatric patient samples and (Table II). The following predictor variables were considered has shown satisfactory reliability and validity (30). The HADS total scores were used in the analyses. for the initial multiple regression model for individual characte- ristics: Psychiatric history, Stress Susceptibility, Impulsiveness, Care contacts and sick leave. Information was gathered regarding care Adventure Seeking, and Embitterment. Only Embitterment contacts immediately after discharge from the Burn Unit and currently (at the time of investigation). The respondents could choose one or (odds ratio 0.93, CI 0.87–0.99) was statistically significant at more of the following: primary care facility (general practitioner, the last step (Table II). district nurse, etc.), surgical clinic, rehabilitation clinic, physiotherapy, occupational therapy, psychiatric clinic, industrial health care service, Step 3. TBSA-FT (odds ratio 0.44, CI 0.25–0.77), Time since or other. The question about length of sick leave had seven response injury (odds ratio 2.81, CI 1.15–6.84) and Embitterment (odds categories in the survey. It was subsequently merged into 2 categories, ratio 0.91, CI 0.83–0.99) were considered for the final multiple with 6 months of sick leave as the cut-off. logistic regression and all 3 were statistically significant at the Data analysis last step (Table II). All 3 models had adequate fit according to The statistical analyses were logistic regression, Mann-Whitney U test, the Hosmer and Lemeshow test (not significant). The final model and χ test. Fisher’s exact test was applied when the expected number had the highest effect size and the highest overall classification of observations was less than 5 in each cell. Total TBSA, TBSA-FT, accuracy (83.3%). The accuracy was better for the group that and LOS were positively skewed and therefore square root transformed before analysis. To establish a predictive model, logistic regression was working throughout the 3 steps of the analysis. J Rehabil Med 39 52 J. Dyster-Aas et al. Health status Table I. Simple logistic regression analyses with return to work (1/0) as the dependent variable The group of former patients who had returned to work had a better burn-specific health status, as reflected in their scores Step 1: Simple logistic regressions for the following BSHS-B subscales: Simple Abilities [Z = 4.3, Independent variables 2 p-value * Incl. p < 0.0001], Heat Sensitivity [Z = 2.5, p < 0.05], Hand Function Injury-related [Z = 4.4, p < 0.0001], Treatment Regimens [Z = 3.6, p < 0.001], a) TBSA 6.3 0.01 Work [Z = 5.0, p < 0.0001], Affect [Z = 3.8, p < 0.001], In- TBSA-FT 8.9 0.003 * terpersonal Relationships [Z = 2.6, p < 0.01] and Sexuality a) LOS 8.7 0.003 Hand burns 2.9 0.09 * [Z = 3.3, p < 0.01] (Table IV). The groups did not differ re- Facial burns 1.4 0.23 garding Body Image. Furthermore, those who were working Time since injury 3.5 0.06 * expressed less fear-avoidance beliefs [Z = 3.2, p < 0.01] and Socio-demographic lower total scores on the IES-R [Z = 2.4, p < 0.05], signifying Age 0.0 0.98 fewer symptoms of PTSD. There was no difference between Gender 0.1 0.75 groups with regard to HADS scores. Education 1.7 0.19 Marital status 0.8 0.37 Care contacts and sick leave Psychological Psychiatric history 5.0 0.02 * Those who were employed at the time of the study had had Somatic Trait Anxiety 0.4 0.52 less contact with a surgical clinic [χ (1) = 3.9, p < 0.05], a Psychic Trait Anxiety 0.6 0.43 psychiatric clinic [χ (1) = 11.2, p < 0.01] and a physiotherapist a) Stress Susceptibility 2.8 0.10 [χ (1) = 7.8, p < 0.01] directly after the injury. Currently, they Lack of Assertiveness 0.5 0.47 Detachment 0.0 0.87 were less likely to have contact with a rehabilitation clinic [χ Embitterment 5.6 0.02 * 2 (1) = 8.7, p < 0.01] and an occupational therapist [χ (1) = 6.2, Trait Irritability 0.4 0.55 p < 0.05]. In addition, they were more likely to have had a Mistrust 0.1 0.79 period of sick leave that was shorter than 6 months [χ (1) Impulsiveness 3.7 0.06 a) = 15.4, p < 0.0001]. In fact, only one of those who had not Adventure Seeking 2.9 0.09 * Social Desirability 1.3 0.25 returned to work had had less than 6 months of sick leave, and Verbal Trait Aggression 0.2 0.67 14 had had a longer absence. Physical Trait Aggression 0.7 0.41 DISCUSSION This investigation suggests that predictors of working status after burn injury are both burn-related and personality-related. Compared with those who were working, those who were not working had considerably lower HRQoL, more care contacts and longer sick leave, poorer burn-specific health status, more dysfunctional beliefs, and more symptoms of PTSD, but they Health-related quality of life were no different regarding symptoms of general anxiety and The group that was working scored higher than the group depression. The final predictive model was adequate with respect to that was not working on the following subscales in the SF-36 Physical Domain: Physical Functioning [Z = 4.4, p < 0.0001], effect size and classification accuracy. The classification accuracy was especially high for those who had returned to Role-Physical [Z = 3.3, p < 0.001], Bodily Pain [Z = 2.4, p < 0.05], and General Health [Z = 2.9, p < 0.01]. Consequent- work. Longer time since injury was associated with a higher likelihood of returning to work, while a greater extent of full- ly, they differed significantly on the Physical Composite Scale [Z = 3.9, p < 0.0001]. Furthermore, those who were working thickness injuries was associated with a lower likelihood of returning to work. These were the strongest available predictors had higher means on the following subscales in the Mental Domain: Social Functioning [Z = 2.6, p < 0.01] and Mental Health in this material, as can be seen in their respective odds ratios (2.81 for time and 0.44 for TBSA-FT). The association [Z = 2.1, p < 0.05]. The groups did not differ regarding Vitality, Role-Emotional, or the Mental Composite Scale (Table III). between TBSA-FT and return to work is supported by previous research (12). In addition, likelihood of returning to work was The means in the group that was working was very close to the normative Swedish means and in some cases they were slightly significantly impeded by high scores for the personality trait Embitterment (odds ratio 0.91). The subscale Embitterment higher, although all values were within 1 SD of the normative mean. The mean scores of the group that did not work were contains statements such as ‘‘I have had my fair share of troubles in life’’, ‘‘I have often got into trouble even when it considerably lower than normative values and 1 SD below the normative means on the subscales Physical Functioning and was not my fault’’, ‘‘It looks as if I will never get the chance to get anywhere in life’’, and ‘‘There have been times when I Role Physical, and the Physical Composite Scale. J Rehabil Med 39 Return to work after burn injuries 53 Table II. Steps 2 and 3 of the logistic regressions with return to work (1/0) as the dependent variable Step 2: Stepwise logistic regression (forward selection) Classification Percentage correct Independent variables * Incl Effect size Wald p-value Odds ratio CI RTW = 1 RTW = 0 Overall Injury-related variables Model characteristics 0.447 90.9 53.3 79.2 TBSA-FT * 9.27 0.002 0.48 0.27–0.75 Time since injury * 4.22 0.040 2.26 1.04–4.93 Hand burns 0.154 Psychological variables Model characteristics 0.184 93.9 40.0 77.1 Embitterment * 5.55 0.018 0.93 0.87–0.99 Psychiatric history 0.097 Adventure Seeking 0.274 Final model Step 3: Stepwise logistic regression (forward selection) Model characteristics 0.575 90.9 66.7 83.3 TBSA-FT 8.20 0.004 0.44 0.25–0.77 Time since injury 5.17 0.023 2.81 1.15–6.84 Embitterment 4.79 0.029 0.91 0.83–0.99 CI: Confidence Interval, TBSA-FT : Total Body Surface Area burned – Full Thickness, RTW: return to work (1 denotes the group that was working, 0 denotes the group that was not working ). a 2 Denotes Nagelkerke’s R . *Incl.: considered for inclusion in the next step. was jealous of the good fortunes of others’’. The items assess on comparing patients with thermal injuries with those with discontent with how life has turned out and feelings of injustice. electrical injuries, which results in a sample with narrow ranges A personality disposition characterized by Embitterment may of TBSA (0–13%) and only a period of weeks until return to be a possible risk factor in adjustment after burn injury. work (0.5–4.5) (33). An alternative explanation for the discre- In group analyses, the group that was working had higher pancy between physical and psychological domains could be scores than the group that was not working for all physical that the mental health items on the SF-36 do not adequately aspects of HRQoL (SF-36), and for 2 out of the 4 mental health correspond to the psychological issues of burn-injured patients aspects. The results imply that there are differences in both at this time point after the injury. The SF-36 is moderately physical and mental domains 1–6 years after the burn injury, associated with general psychological symptoms (34) and and that the differences in the physical health domain are more cannot be expected to reveal specific concerns. In support of pronounced. This seems logical, from the fact that the physical this interpretation, significant differences between the groups ‘‘predictor’’ TBSA-FT was a stronger factor in the logistic were found using trauma- and burn-specific instruments but regression than the personality variable. However, the find - not by using a general anxiety and depression instrument (i.e. ing is difficult to interpret as there have been no previously the HADS). For example, those who were working perceived published investigations into this matter. Earlier studies have their health as better on 3 of the BSHS-B subscales that can had shorter time to follow-up (31), have not evaluated return be judged as mainly psychological and social in content (Af- to work in relation to the SF-36 (8, 31, 32), or have focused fect, Interpersonal Relationships and Sexuality). Moreover, Table III. Comparisons between the group that was working (RTW = 1) and the group that was not working (RTW = 0) regarding quality of life Normative data (23) RTW = 1 RTW = 0 Mann-Whitney U test (tied) SF-36 Mean SD Mean SD Mean SD z-value p-value Physical functioning 87.9 19.6 91.7 11.9 55.6 † 26.3 4.4 < 0.0001 Role-Physical 83.2 31.8 88.6 21.7 50.0 † 41.6 3.3 < 0.001 Bodily pain 74.8 26.1 82.0 22.9 62.3 26.5 2.4 < 0.05 General health 75.8 22.2 78.0 19.0 57.6 20.9 2.9 < 0.01 Vitality 68.8 22.8 66.4 24.1 54.3 23.8 1.6 ns Social functioning 88.6 20.3 88.3 18.5 69.2 26.7 2.6 < 0.01 Role-Emotional 85.7 29.2 80.8 37.3 64.4 46.2 1.2 ns Mental health 80.9 18.9 79.2 18.8 64.0 24.0 2.1 < 0.05 PCS 50.3 9.4 53.2 7.2 39.6 9.5 3.9 < 0.0001 MCS 50.1 10.1 47.5 13.0 44.2 13.8 0.9 ns SF-36: Short Form-36, PCS: Physical Composite Scale; MCS: Mental Composite Scale, SD: Standard Deviation, RTW: return to work, ns: not significant. One standard deviation below normative mean. J Rehabil Med 39 54 J. Dyster-Aas et al. Table IV. Comparisons between the group that was working (RTW = 1) and the group that was not working (RTW = 0) groups regarding post- burn health and dysfunctional beliefs RTW = 1 RTW = 0 Mann-Whitney U test (tied) Mean SD Mean SD z-value p-value BSHS-B Simple Abilities 3.8 0.7 2.7 1.3 4.3 < 0.0001 Heat Sensitivity 2.3 1.2 1.3 0.9 2.5 < 0.05 Hand Function 3.9 0.3 2.3 1.5 4.4 < 0.0001 Treatment Regimens 3.4 0.8 2.2 1.1 3.6 < 0.001 Work 3.3 1.0 0.5 1.1 5.0 < 0.0001 Body Image 2.8 1.1 2.1 1.0 1.9 ns Affect 3.6 0.5 2.5 1.0 3.8 < 0.001 Interpersonal Relationships 3.8 0.5 3.5 0.7 2.6 < 0.01 Sexuality 3.8 0.4 3.1 0.9 3.3 < 0.01 Fear-avoidance 0.8 0.9 1.9 1.1 3.2 < 0.01 IES-R Total score 21.4 20.2 40.3 27.4 2.4 < 0.05 HADS Total score 9.4 5.9 11.9 6.8 1.2 ns BSHS-B: Burn Specific Health Scale-Brief, IES-R : Impact of Event Scale Revised, HADS: Hospital Anxiety and Depression Scale, SD: Standard Deviation, RTW: return to work Higher scores denote better perceived health status. those who were not working expressed more fear-avoidance comparison with several previous studies on return to work and symptoms of PTSD, both of which are trauma-related. in burn patients, which were hampered by large attrition rates This finding is of relevance to researchers and clinicians when or inability to locate former patients (12, 13, 33). Another choosing methods for assessment. Established general outcome limitation is that we did not have access to information about measures such as the SF-36 may have to be accompanied by the patients’ occupations and specific work places. Differences more specific measures that target sample specific concerns. in job availability, and possibilities for adjustments at the The differences regarding fear-avoidance and PTSD symp- workplace and for changes in work routines are factors that may toms suggest that there are fear- and anxiety-related concerns have a further impact on the likelihood of returning to work. in the group that was not working. Considering the devastating In conclusion, the likelihood of returning to work after severe effects of fear-avoidance beliefs on health and functioning of burn injury was associated with longer time since injury, smaller other patient groups (18), these issues should become a focus size of full-thickness burns, and less of the personality trait Em- of attention in rehabilitation facilities. In an interdisciplinary bitterment. Those who were working expressed significantly treatment programme, it was shown that a reduction in work- better HRQoL, physical health and psychological health than specific fears was of greater importance regarding improved those who were not working. Psychological concerns were physical working capacity than changes in fear of physical better revealed with trauma-related questionnaires than with activity (35). general questionnaires, which suggests that sample-specific In the present study, the scores of the subgroup of non- instruments are an important adjunct to more general measures. working participants were clearly below the normative means for the SF-36 subscales Physical Functioning, Role-Physical ACKNOWLEDGEMENTS and the Physical Composite Scale. These individuals also had lower scores than the normative group for the remaining This research was supported by the Swedish Research Council, the subscales, but the differences were within 1 SD of the Swedish Council for Working Life and Social Research, the Söderström- normative means. The former burn patients who had returned Königska Foundation, the Vårdal Foundation, the Thuring Foundation, to work did not deviate from the normative values in HRQoL. and the Höök Foundation. There are no conflicts of interest to declare. This might be expected, since the selection of participants was based on a presumed fair to good level of functioning – in that all eligible participants were employed before the burn. Normal REFERENCES values in an unselected burn patient sample (not just working participants) have been seen in a previous investigation 2–10 1. Melin R, Fugl-Meyer KS, Fugl-Meyer AR. Life satisfaction in 18- to years after burn injury (8). Furthermore, Anzarut et al. (32) 64-year-old Swedes: in relation to education, employment situation, recently found that burn patients who had been injured 2–20 health and physical activity. J Rehabil Med 2003; 35: 84–90. 2. Kinney WB, Coyle CP. Predicting life satisfaction among adults years previously had lower scores than a normative sample with physical disabilities. Arch Phys Med Rehabil 1992; 73: on only 2 subscales in the SF-36 (Role Physical and General 863–869. Health). 3. Lindqvist KS, Brodin H. One-year economic consequences of One weakness of the study is the small sample size. However, accidents in a Swedish municipality. Accid Anal Prev 1996; 28: the response rate was satisfactory and was even high in 209–219. J Rehabil Med 39 Return to work after burn injuries 55 4. Meerding WJ, Looman CW, Essink-Bot ML, Toet H, Mulder S, 20. Costa PT Jr, Herbst JH, McCrae RR, Siegler IC. Personality at van Beeck EF. Distribution and determinants of health and work midlife: stability, intrinsic maturation, and response to life events. status in a comprehensive population of injury patients. J Trauma Assessment 2000; 7: 365–378. 2004; 56: 150–161. 21. Gustavsson JP, Weinryb RM, Göransson S, Pedersen NL, Åsberg 5. Darko DF,Wachtel TL,Ward HW, Frank HA. Analysis of 585 burn M. Stability and predictive ability of personality traits across 9 patients hospitalized over a 6-year period. Part I: Demographic years. Pers Individ Diff 1997; 22: 783–791. comparison with the population of origin. 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Work-related beliefs about injury and tion with psychological and somatic symptoms. J Health Psychol physical capability for work in individuals with chronic pain. Pain 2005; 10: 491–502. 2003; 101: 291–298. J Rehabil Med 39 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Rehabilitation Medicine Unpaywall

Return to work and health-related quality of life after burn injury

Journal of Rehabilitation MedicineJan 1, 2007

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J Rehabil Med 2007; 39: 49–55 ORIGINAL REPORT RETURN TO WORK AND HEALTH-RELATED QUALITY OF LIFE AFTER BURN INJURY 1 2 1 Johan Dyster-Aas, MD , Morten Kildal, MD, PhD and Mimmie Willebrand, PhD 1 2 From the Department of Neuroscience, Psychiatry, Department of Surgical Sciences, Plastic Surgery, Uppsala University, Uppsala, Sweden Objective: Although severe burn injury is associated with from work is expensive for the community, considering health long-term rehabilitation and disability, research on returning insurance (sickness benefit) and high company costs (3). Risk to work in burn patients is limited. The aims of this study factors for longer duration of absence after injury and lower were: (i) to explore injury- and personality-related predictors probability of return to work are admission to an intensive care of returning to work, and (ii) to compare health-related quality unit, long length of stay, and low level of education among of life and health outcome in working versus non-working the patients (4). individuals. The above-mentioned risk factors are prevalent among pa- Design: Cross-sectional study. tients with severe burn injuries (5). A severe burn injury affects Subjects: Forty-eight former patients with pre-burn employ- most systems in the body, and patients often require respiratory ment were evaluated on average 3.8 years after the burn. support in addition to wound treatment. With modern wound Methods: Data were collected from medical records and by care, superficial burns heal spontaneously in about 2 weeks a questionnaire in which the patients were asked about their while deep, full-thickness burns need surgical interventions main activity status described in the terms: work, studies, such as early excision and skin grafting. Patients often expe- pension, disability pension, sick leave or unemployment. It rience severe pain and anxiety during the prolonged treatment. also contained the Swedish universities Scales of Personality, Surgical techniques and treatments have evolved rapidly during SF-36, Burn Specific Health Scale-Brief, items assessing recent decades, and mortality rates have decreased dramati- fear-avoidance, Impact of Event Scale-Revised and Hospital cally. Following this trend, there is now greater focus on the Anxiety and Depression Scale. consequences of surviving a massive burn, and the social and Results: Thirty-one percent had not returned to work. In psychological factors involved in recovery. logistic regression, returning to work was associated with Burn injuries are associated with long-term health problems. time since injury, the extent of full-thickness injuries, and Common physical symptoms after a burn injury are pain and the personality trait embitterment. Those who did not work sensory problems, pruritus, and loss of strength. Recently, it has had lower health-related quality of life, poorer burn-specific health, more fear-avoidance and more symptoms of post- been shown that perceived health problems (6) after burn injury traumatic stress disorder, but they did not differ from those can persist for several decades. In addition, between 13% and who were working regarding general mood. 23% of patients develop depression, and 13–45% develop post- Conclusion: Returning to work was explained by both injury traumatic stress disorder (PTSD) after hospital discharge (7). severity and personality characteristics. Those who did not Although burn patients experience several health problems work were characterized by low health-related quality of life in the long term, a follow-up of adult burn patients after 2–10 and poorer trauma-related physical and psychological health. years showed that they generally do not differ regarding health- Key words: adjustment, burns, BSHS-B, personality, SF-36, related quality of life (HRQoL) compared with normative data trauma. (8). Previous studies have also indicated that most burn patients return to work. It was found that although job disruption was J Rehabil Med 2007; 39: 49–55 common, 90% of burn patients returned to work within 2 years Correspondence address: Johan Dyster-Aas, Department (9). In a Swedish sample of burn patients who had been injured of Neuroscience, Psychiatry, Uppsala University Hospital, at work, 83% were working again on average 9 years after the SE-751 85 Uppsala, Sweden. E-mail: johan.dyster-aas@ injury (10). The individuals who were not working at follow- uaspsyk.uu.se up reported more pain and a poorer outcome in the areas of Submitted December 9, 2005; accepted May 22, 2006 perceived ability to work, body image, affect, interpersonal relationships, and ability to take care of the skin (10). Factors that have been related to return-to-work rates are INTRODUCTION total body surface area burned (TBSA) (9, 11–13), extent of Being in employment is associated with a higher degree of full-thickness burns (TBSA-FT), length of stay (LOS) in the satisfaction with life, both in the general population (1) and burn unit, number of surgical procedures, perceived function- in patients with physical injuries (2). In addition, absence ing (12), age (11, 13), and prior psychiatric illness (9, 14). One © 2007 Foundation of Rehabilitation Information. ISSN 1650-1977 J Rehabil Med 39 DOI: 10.2340/16501977-0005 50 J. Dyster-Aas et al. each worth about 2.5 Euros, as a reward. The study was conducted of the most influential factors is pre-burn employment (13–15). according to the ethical principles of the Helsinki Declaration and It is highly likely that some of these factors are interrelated: for approved by the ethics committee of Uppsala University. instance, being employed before the burn is likely to be related Eighty-six former patients (74.1%) returned the questionnaire to pre-burn psychiatric illness and physical functioning (16). booklet. Of these, 51 former patients had been employed at the time In order to find factors that impede return to work – and not of the burn injury. Three patients had retired due to age at the time of the investigation. Thus, there were 48 patients (11 women, 37 men) employment as such – those who were unemployed before the who could be expected to return to work and they constituted the cur- burn should be excluded from the analysis.When including only rent sample, while the remaining 38 were excluded. All 48 patients patients who were employed before the burn, return to work were below the common retirement age of 65 years. Mean age at has been predicted by ethnicity, marital status and not blaming injury was 40.8 years (SD 10.2, range 20–61 years), and at the time oneself for the injury (15). This indicates that psychological of the investigation it was 44.4 years (SD 10.2, range 23–64 years). Mean time since injury was 3.6 years (SD 1.1, range 1.4–5.6 years). factors are involved in the process of returning to work. In Average burn size was 17.5% TBSA (SD 15.3, range 0.1–80.0%), other patient groups, it has been seen that personality traits of which 7.9% (SD 11.2, range 0–48%) were TBSA-FT. TBSA and can be predictive of working status. For example, patients with TBSA-FT were assessed by two experienced burn surgeons who used introverted personality traits are more likely to fail in returning all available medical records including photographs and the surgeon’s to work after suffering a myocardial infarction (17). Further- notes during the time in care. The average LOS in the Burn Unit was 19.7 days (SD 21.8, range 1–95 days). Forty-three patients had thermal more, dysfunctional beliefs such as fear-avoidance have also burns, 5 had electrical burns. Twelve burn injuries were occupational, been associated with functional outcome. Fear-avoidance is the 11 occurred at home, 20 in leisure time, and 4 were self-inflicted. fear of re-injury or harm, which is accompanied by avoidant Thirty-one patients had injuries to the face and 39 had injuries to the behaviour and poor functioning. It is a known risk factor for hands. Twenty-four patients had been on sick leave for less than 6 development of chronic pain (18). Fear-avoidance was recently months and 23 for a longer period. According to the medical records, 7 patients had a history of psychiatric problems such as psychosis, investigated in burn patients and a strong association was found depression, anxiety or substance abuse. Twenty-seven were married, with perceived ability to work (19). To our knowledge, there 18 single and 3 were widowed. Nineteen patients had 9 years of formal have been no studies on the association between fear-avoidance education and 29 had more than 9 years. and actual working status after burn injury. The current subsample differed from the excluded 38 responders in being more likely to be married [χ (1) = 5.9, p < 0.05], to have injuries to The aims of the present study were: (i) to evaluate which 2 2 the hands [χ (1) = 10.9, p < 0.01] and face [χ (1) = 4.3, p < 0.05], to factors are associated with the likelihood of returning to have employment after the burn [χ (1) = 11.7, p < 0.001], and (not work, and (ii) to investigate what differentiates the group that surprisingly) to have had occupational injuries (other causes were has returned to work from the group that has not, in terms of 2 merged into one category) [χ (1) = 6.1, p < 0.05]. No other differences HRQoL, perceived burn-specific health, dysfunctional beliefs were found regarding the above-mentioned burn-specific or socio - demographic data. In comparison with the 30 who did not respond to and psychological symptoms. the survey, the members of the current subsample were less likely to In this study, the term ‘‘predictive variable’’ is used for (i) have a record of substance abuse [χ (1) = 12.1, p < 0.001] and more burn-related and socio-demographic variables that reflect the likely to have injuries to the hands [χ (1) =4.2, p < 0.05]. Data on the patient’s status at the time of injury, although the information nonresponders were restricted to the medical records (age, sex, TBSA, was extracted from medical records at a later time point, and LOS, localization of burn injury, documented psychiatric problems). (ii) personality traits that reflect stable behaviour patterns in an Measures individual with respect to time and different situations (20, 21). Work status. Information on pre-burn and current work status was These variables are considered to be statistically predictive, gathered in the survey. The respondents were asked about their main and their causal relationships to the criterion variable cannot be activity status described by the alternatives: working, studying, retired firmly established using this cross-sectional research design. due to age, unemployed, sick-listed, disability pension. Only those who responded that they had been working before the burn were considered for the study. Those who were working at the time of the investigation were referred to as group 1 (‘‘working’’), and the rest were referred METHODS to as group 0 (‘‘non-working’’). Participants and procedure Former patients were included if they: (i) had been admitted to the Burn Predictive variables. Socio-demographic and injury-related variables. Unit at Uppsala University Hospital between January 1996 and March Based on the current literature, the following variables were considered 2000, and (ii) were 18 years or older at the time of the investigation in relevant and were extracted from the medical records: age, gender, October 2001. Former patients who had no registered address (n = 6), TBSA, TBSA-FT, LOS, localization of burn to the hands or the face, were not Swedish citizens and did not live in Sweden (n = 4), or who and a documented history of psychiatric illness (including substance had dementia (n = 2) were excluded. The final sample of eligible abuse). Time since injury was added as a factor that most likely affects participants consisted of 116 former burn patients. The Burn Unit in the return to work rate. In addition, the survey contained questions Uppsala is 1 of the 2 existing Burn Units in Sweden with national about marital status and level of education. The original 3 levels of responsibility for burn care. The main referral area covers about 3 education were merged into 2 groups, group 0 (0–9 years of education) million of the 9 million inhabitants in Sweden. and group 1 (more than 9 years of education). A survey covering HRQoL, health status, personality, fear-avoidance The Swedish universities Scales of Personality (SSP) contains 91 items and socio-demographic variables (of which previous and current work divided into 13 subscales with 7 items in each: (1) Somatic Trait Anxiety, status was one) was sent to the 116 former patients together with an (2) Psychic Trait Anxiety, (3) Stress Susceptibility, (4) Lack of information letter and a pre-paid response envelope. Reminder letters Assertiveness, (5) Detachment, (6) Embitterment, (7) Trait Irritability, and questionnaires were sent one month later, and again after another (8) Mistrust, (9) Impulsiveness, (10) Adventure Seeking, (11) Social 3 weeks. The participants could choose a flower check or a lottery ticket, Desirability, (12) Verbal Trait Aggression and (13) Physical Trait J Rehabil Med 39 Return to work after burn injuries 51 Aggression. The items were rated on a scale from 1 =‘‘Does not was used with the variable ‘‘returned to work (1/0)’’ as a dependent apply at all’’ to 4 = ‘‘Applies completely’’. The alpha values for the dichotomous variable. In step 1, the predictor variables were examined subscales ranged from 0.59 to 0.84 (22). The data were adjusted for in simple regressions and only those having a p-value ≤ 0.10 were age. T-scores were calculated for each gender separately, based on the included in the multiple models (Table I). In step 2, separate multiple Swedish normative sample (22). logistic regressions (stepwise forward, conditional) were performed for variables associated with injury severity and for variables associated Post-burn variables. The Short-Form 36 Health Survey (SF-36) contains with individual characteristics. In step 3, a final multiple model was 36 items measuring HRQoL (23). It assesses 8 aspects: Physical Func- achieved by a stepwise forward procedure for the injury-related and tioning, Role-Physical, Bodily Pain, General Health, Vitality, Social individual variables that remained in step 2. Functioning, Role-Emotional, and Mental Health. The first 4 subscales form the Physical Composite Scale (PCS) and the last 4 form the Mental Composite Scale (MCS). The Swedish version of the SF-36 has shown RESULTS adequate reliability, construct and clinical validity (24, 25). The Burn Specific Health Scale-Brief (BSHS-B) is a questionnaire Post-burn work status with 40 items divided into 9 subscales that measure perceived function and well-being: Simple Abilities, Heat Sensitivity, Hand Function, Thirty-three participants (69%) had returned to work (1 = Treatment Regimens, Work, Body Image, Affect, Interpersonal Rela- working) while 15 (31%) had not (0 = non-working). tionships and Sexuality. The items were rated on a scale from 0 =‘‘All the time/great difficulty’’ to 4 = ‘‘Never/no difficulty’’. The alpha values ranged from 0.75 to 0.93 (26). Prediction of post-burn work status Step 1. The following variables were evaluated in simple logis- Fear-avoidance was assessed by 4 questions: tic regression analyses: age, gender, TBSA, TBSA-FT, LOS, 1. My burn injury has put my body at risk for the rest of my life. facial burns, hand burns, time since injury, education, marital 2. I can’t do the same things as other people do since there is a too big risk that I might be burn-injured again. status, documented history of psychiatric illness, and the 13 3. I’m afraid that I might get hurt again if I put myself in risky situations. SSP subscales (Table I). An evaluation of intercorrelations 4. It is really not safe for a person with a condition like mine to be suggested the exclusion of some burn severity and personality physically active. variables. TBSA, TBSA-FT and LOS were highly correlated Items 1, 2 and 4 were taken from the Tampa Scale of Kinesiophobia (range r = 0.69–0.78) and therefore only one of them (TBSA- (TSK) (27) and adapted to the burn population. The TSK measures FT) could be included. LOS was excluded on theoretical and fear-avoidance beliefs and fear of (re)injury due to movement. Item 3 statistical grounds, as it can depend on many things other than was constructed specifically for this sample. The answers were given on a 5-point scale ranging from 0 = ‘‘Always applicable’’ to 4 = ‘‘Never burn severity, such as administration and availability of home applicable’’, with a higher score indicating a lower degree of fear- care facilities, and TBSA was excluded as it was marginally wea- avoidance beliefs. In the statistical analysis the scores were reversed, ker statistically. The personality variables with p-values ≤ 0.10 so that a higher score indicates a higher degree of fear-avoidance were also intercorrelated (average r = 0.51, range 0.22–67). beliefs. The 4 items had a Cronbach’s alpha value of 0.69. The mean The one with the lowest p-value (Embitterment) was chosen score of the 4 items was used in the statistical analyses. The Impact of Event Scale-Revised (IES-R) was used to assess first. Subsequently, Adventure Seeking was selected as it had symptoms of PTSD. It contains 22 items and 3 subscales: Intrusion, an acceptable intercorrelation (r = 0.36) with Embitterment. The Avoidance and Arousal. The items are rated on a 4-grade scale from 0, remaining variables had intercorrelations above 0.50. 1, 3, 5, where 0 = no symptom, and 5 = a high frequency of the symp- tom. The IES-R has shown good internal consistency and test-retest Step 2. The following predictor variables were considered for reliability (28). The IES-R total scores were used in the analyses. The Hospital Anxiety and Depression Scale (HADS) was used to the initial multiple regression model for injury-related variables: assess current mood. It consists of 2 subscales, Anxiety and Depres- TBSA-FT, extent of Hand burns and Time since injury. Only sion, with 7 items in each (29). The items are rated on a scale from TBSA-FT (odds ratio 0.48, CI 0.27–0.57) and Time since injury 0 to 3, where 0 = no symptom and 3 = severe symptom. The HADS (odds ratio 2.26, CI 1.04–4.93) were significant at the last step was developed to study mood in non-psychiatric patient samples and (Table II). The following predictor variables were considered has shown satisfactory reliability and validity (30). The HADS total scores were used in the analyses. for the initial multiple regression model for individual characte- ristics: Psychiatric history, Stress Susceptibility, Impulsiveness, Care contacts and sick leave. Information was gathered regarding care Adventure Seeking, and Embitterment. Only Embitterment contacts immediately after discharge from the Burn Unit and currently (at the time of investigation). The respondents could choose one or (odds ratio 0.93, CI 0.87–0.99) was statistically significant at more of the following: primary care facility (general practitioner, the last step (Table II). district nurse, etc.), surgical clinic, rehabilitation clinic, physiotherapy, occupational therapy, psychiatric clinic, industrial health care service, Step 3. TBSA-FT (odds ratio 0.44, CI 0.25–0.77), Time since or other. The question about length of sick leave had seven response injury (odds ratio 2.81, CI 1.15–6.84) and Embitterment (odds categories in the survey. It was subsequently merged into 2 categories, ratio 0.91, CI 0.83–0.99) were considered for the final multiple with 6 months of sick leave as the cut-off. logistic regression and all 3 were statistically significant at the Data analysis last step (Table II). All 3 models had adequate fit according to The statistical analyses were logistic regression, Mann-Whitney U test, the Hosmer and Lemeshow test (not significant). The final model and χ test. Fisher’s exact test was applied when the expected number had the highest effect size and the highest overall classification of observations was less than 5 in each cell. Total TBSA, TBSA-FT, accuracy (83.3%). The accuracy was better for the group that and LOS were positively skewed and therefore square root transformed before analysis. To establish a predictive model, logistic regression was working throughout the 3 steps of the analysis. J Rehabil Med 39 52 J. Dyster-Aas et al. Health status Table I. Simple logistic regression analyses with return to work (1/0) as the dependent variable The group of former patients who had returned to work had a better burn-specific health status, as reflected in their scores Step 1: Simple logistic regressions for the following BSHS-B subscales: Simple Abilities [Z = 4.3, Independent variables 2 p-value * Incl. p < 0.0001], Heat Sensitivity [Z = 2.5, p < 0.05], Hand Function Injury-related [Z = 4.4, p < 0.0001], Treatment Regimens [Z = 3.6, p < 0.001], a) TBSA 6.3 0.01 Work [Z = 5.0, p < 0.0001], Affect [Z = 3.8, p < 0.001], In- TBSA-FT 8.9 0.003 * terpersonal Relationships [Z = 2.6, p < 0.01] and Sexuality a) LOS 8.7 0.003 Hand burns 2.9 0.09 * [Z = 3.3, p < 0.01] (Table IV). The groups did not differ re- Facial burns 1.4 0.23 garding Body Image. Furthermore, those who were working Time since injury 3.5 0.06 * expressed less fear-avoidance beliefs [Z = 3.2, p < 0.01] and Socio-demographic lower total scores on the IES-R [Z = 2.4, p < 0.05], signifying Age 0.0 0.98 fewer symptoms of PTSD. There was no difference between Gender 0.1 0.75 groups with regard to HADS scores. Education 1.7 0.19 Marital status 0.8 0.37 Care contacts and sick leave Psychological Psychiatric history 5.0 0.02 * Those who were employed at the time of the study had had Somatic Trait Anxiety 0.4 0.52 less contact with a surgical clinic [χ (1) = 3.9, p < 0.05], a Psychic Trait Anxiety 0.6 0.43 psychiatric clinic [χ (1) = 11.2, p < 0.01] and a physiotherapist a) Stress Susceptibility 2.8 0.10 [χ (1) = 7.8, p < 0.01] directly after the injury. Currently, they Lack of Assertiveness 0.5 0.47 Detachment 0.0 0.87 were less likely to have contact with a rehabilitation clinic [χ Embitterment 5.6 0.02 * 2 (1) = 8.7, p < 0.01] and an occupational therapist [χ (1) = 6.2, Trait Irritability 0.4 0.55 p < 0.05]. In addition, they were more likely to have had a Mistrust 0.1 0.79 period of sick leave that was shorter than 6 months [χ (1) Impulsiveness 3.7 0.06 a) = 15.4, p < 0.0001]. In fact, only one of those who had not Adventure Seeking 2.9 0.09 * Social Desirability 1.3 0.25 returned to work had had less than 6 months of sick leave, and Verbal Trait Aggression 0.2 0.67 14 had had a longer absence. Physical Trait Aggression 0.7 0.41 DISCUSSION This investigation suggests that predictors of working status after burn injury are both burn-related and personality-related. Compared with those who were working, those who were not working had considerably lower HRQoL, more care contacts and longer sick leave, poorer burn-specific health status, more dysfunctional beliefs, and more symptoms of PTSD, but they Health-related quality of life were no different regarding symptoms of general anxiety and The group that was working scored higher than the group depression. The final predictive model was adequate with respect to that was not working on the following subscales in the SF-36 Physical Domain: Physical Functioning [Z = 4.4, p < 0.0001], effect size and classification accuracy. The classification accuracy was especially high for those who had returned to Role-Physical [Z = 3.3, p < 0.001], Bodily Pain [Z = 2.4, p < 0.05], and General Health [Z = 2.9, p < 0.01]. Consequent- work. Longer time since injury was associated with a higher likelihood of returning to work, while a greater extent of full- ly, they differed significantly on the Physical Composite Scale [Z = 3.9, p < 0.0001]. Furthermore, those who were working thickness injuries was associated with a lower likelihood of returning to work. These were the strongest available predictors had higher means on the following subscales in the Mental Domain: Social Functioning [Z = 2.6, p < 0.01] and Mental Health in this material, as can be seen in their respective odds ratios (2.81 for time and 0.44 for TBSA-FT). The association [Z = 2.1, p < 0.05]. The groups did not differ regarding Vitality, Role-Emotional, or the Mental Composite Scale (Table III). between TBSA-FT and return to work is supported by previous research (12). In addition, likelihood of returning to work was The means in the group that was working was very close to the normative Swedish means and in some cases they were slightly significantly impeded by high scores for the personality trait Embitterment (odds ratio 0.91). The subscale Embitterment higher, although all values were within 1 SD of the normative mean. The mean scores of the group that did not work were contains statements such as ‘‘I have had my fair share of troubles in life’’, ‘‘I have often got into trouble even when it considerably lower than normative values and 1 SD below the normative means on the subscales Physical Functioning and was not my fault’’, ‘‘It looks as if I will never get the chance to get anywhere in life’’, and ‘‘There have been times when I Role Physical, and the Physical Composite Scale. J Rehabil Med 39 Return to work after burn injuries 53 Table II. Steps 2 and 3 of the logistic regressions with return to work (1/0) as the dependent variable Step 2: Stepwise logistic regression (forward selection) Classification Percentage correct Independent variables * Incl Effect size Wald p-value Odds ratio CI RTW = 1 RTW = 0 Overall Injury-related variables Model characteristics 0.447 90.9 53.3 79.2 TBSA-FT * 9.27 0.002 0.48 0.27–0.75 Time since injury * 4.22 0.040 2.26 1.04–4.93 Hand burns 0.154 Psychological variables Model characteristics 0.184 93.9 40.0 77.1 Embitterment * 5.55 0.018 0.93 0.87–0.99 Psychiatric history 0.097 Adventure Seeking 0.274 Final model Step 3: Stepwise logistic regression (forward selection) Model characteristics 0.575 90.9 66.7 83.3 TBSA-FT 8.20 0.004 0.44 0.25–0.77 Time since injury 5.17 0.023 2.81 1.15–6.84 Embitterment 4.79 0.029 0.91 0.83–0.99 CI: Confidence Interval, TBSA-FT : Total Body Surface Area burned – Full Thickness, RTW: return to work (1 denotes the group that was working, 0 denotes the group that was not working ). a 2 Denotes Nagelkerke’s R . *Incl.: considered for inclusion in the next step. was jealous of the good fortunes of others’’. The items assess on comparing patients with thermal injuries with those with discontent with how life has turned out and feelings of injustice. electrical injuries, which results in a sample with narrow ranges A personality disposition characterized by Embitterment may of TBSA (0–13%) and only a period of weeks until return to be a possible risk factor in adjustment after burn injury. work (0.5–4.5) (33). An alternative explanation for the discre- In group analyses, the group that was working had higher pancy between physical and psychological domains could be scores than the group that was not working for all physical that the mental health items on the SF-36 do not adequately aspects of HRQoL (SF-36), and for 2 out of the 4 mental health correspond to the psychological issues of burn-injured patients aspects. The results imply that there are differences in both at this time point after the injury. The SF-36 is moderately physical and mental domains 1–6 years after the burn injury, associated with general psychological symptoms (34) and and that the differences in the physical health domain are more cannot be expected to reveal specific concerns. In support of pronounced. This seems logical, from the fact that the physical this interpretation, significant differences between the groups ‘‘predictor’’ TBSA-FT was a stronger factor in the logistic were found using trauma- and burn-specific instruments but regression than the personality variable. However, the find - not by using a general anxiety and depression instrument (i.e. ing is difficult to interpret as there have been no previously the HADS). For example, those who were working perceived published investigations into this matter. Earlier studies have their health as better on 3 of the BSHS-B subscales that can had shorter time to follow-up (31), have not evaluated return be judged as mainly psychological and social in content (Af- to work in relation to the SF-36 (8, 31, 32), or have focused fect, Interpersonal Relationships and Sexuality). Moreover, Table III. Comparisons between the group that was working (RTW = 1) and the group that was not working (RTW = 0) regarding quality of life Normative data (23) RTW = 1 RTW = 0 Mann-Whitney U test (tied) SF-36 Mean SD Mean SD Mean SD z-value p-value Physical functioning 87.9 19.6 91.7 11.9 55.6 † 26.3 4.4 < 0.0001 Role-Physical 83.2 31.8 88.6 21.7 50.0 † 41.6 3.3 < 0.001 Bodily pain 74.8 26.1 82.0 22.9 62.3 26.5 2.4 < 0.05 General health 75.8 22.2 78.0 19.0 57.6 20.9 2.9 < 0.01 Vitality 68.8 22.8 66.4 24.1 54.3 23.8 1.6 ns Social functioning 88.6 20.3 88.3 18.5 69.2 26.7 2.6 < 0.01 Role-Emotional 85.7 29.2 80.8 37.3 64.4 46.2 1.2 ns Mental health 80.9 18.9 79.2 18.8 64.0 24.0 2.1 < 0.05 PCS 50.3 9.4 53.2 7.2 39.6 9.5 3.9 < 0.0001 MCS 50.1 10.1 47.5 13.0 44.2 13.8 0.9 ns SF-36: Short Form-36, PCS: Physical Composite Scale; MCS: Mental Composite Scale, SD: Standard Deviation, RTW: return to work, ns: not significant. One standard deviation below normative mean. J Rehabil Med 39 54 J. Dyster-Aas et al. Table IV. Comparisons between the group that was working (RTW = 1) and the group that was not working (RTW = 0) groups regarding post- burn health and dysfunctional beliefs RTW = 1 RTW = 0 Mann-Whitney U test (tied) Mean SD Mean SD z-value p-value BSHS-B Simple Abilities 3.8 0.7 2.7 1.3 4.3 < 0.0001 Heat Sensitivity 2.3 1.2 1.3 0.9 2.5 < 0.05 Hand Function 3.9 0.3 2.3 1.5 4.4 < 0.0001 Treatment Regimens 3.4 0.8 2.2 1.1 3.6 < 0.001 Work 3.3 1.0 0.5 1.1 5.0 < 0.0001 Body Image 2.8 1.1 2.1 1.0 1.9 ns Affect 3.6 0.5 2.5 1.0 3.8 < 0.001 Interpersonal Relationships 3.8 0.5 3.5 0.7 2.6 < 0.01 Sexuality 3.8 0.4 3.1 0.9 3.3 < 0.01 Fear-avoidance 0.8 0.9 1.9 1.1 3.2 < 0.01 IES-R Total score 21.4 20.2 40.3 27.4 2.4 < 0.05 HADS Total score 9.4 5.9 11.9 6.8 1.2 ns BSHS-B: Burn Specific Health Scale-Brief, IES-R : Impact of Event Scale Revised, HADS: Hospital Anxiety and Depression Scale, SD: Standard Deviation, RTW: return to work Higher scores denote better perceived health status. those who were not working expressed more fear-avoidance comparison with several previous studies on return to work and symptoms of PTSD, both of which are trauma-related. in burn patients, which were hampered by large attrition rates This finding is of relevance to researchers and clinicians when or inability to locate former patients (12, 13, 33). Another choosing methods for assessment. Established general outcome limitation is that we did not have access to information about measures such as the SF-36 may have to be accompanied by the patients’ occupations and specific work places. Differences more specific measures that target sample specific concerns. in job availability, and possibilities for adjustments at the The differences regarding fear-avoidance and PTSD symp- workplace and for changes in work routines are factors that may toms suggest that there are fear- and anxiety-related concerns have a further impact on the likelihood of returning to work. in the group that was not working. Considering the devastating In conclusion, the likelihood of returning to work after severe effects of fear-avoidance beliefs on health and functioning of burn injury was associated with longer time since injury, smaller other patient groups (18), these issues should become a focus size of full-thickness burns, and less of the personality trait Em- of attention in rehabilitation facilities. In an interdisciplinary bitterment. Those who were working expressed significantly treatment programme, it was shown that a reduction in work- better HRQoL, physical health and psychological health than specific fears was of greater importance regarding improved those who were not working. Psychological concerns were physical working capacity than changes in fear of physical better revealed with trauma-related questionnaires than with activity (35). general questionnaires, which suggests that sample-specific In the present study, the scores of the subgroup of non- instruments are an important adjunct to more general measures. working participants were clearly below the normative means for the SF-36 subscales Physical Functioning, Role-Physical ACKNOWLEDGEMENTS and the Physical Composite Scale. These individuals also had lower scores than the normative group for the remaining This research was supported by the Swedish Research Council, the subscales, but the differences were within 1 SD of the Swedish Council for Working Life and Social Research, the Söderström- normative means. The former burn patients who had returned Königska Foundation, the Vårdal Foundation, the Thuring Foundation, to work did not deviate from the normative values in HRQoL. and the Höök Foundation. 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Journal of Rehabilitation MedicineUnpaywall

Published: Jan 1, 2007

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