Abstract
Purpose
Upper limb disorders are one of the most common and important types of occupational injuries. Besides, identifying the factors influencing return to work following these injuries is essential to reduce the dimensions of the problem. In this study, we investigated the return to work and associated factors following occupational injuries leading to upper limb impairment.
Methods
In this retrospective cohort study, the rate of return to work and associated factors were assessed in 256 workers with work-related upper limb injury referred to a teaching hospital from March 2011 to December 2018. The inclusion criterion was a history of occupational injury resulting in upper limb impairment, and exclusion criteria included the presence of simultaneous impairment in other organs, congenital or non-occupational limb defects as well as patients with incomplete information in their medical records. Individuals' records, including age at the time of injury, gender, date of injury, marital status, education, level of amputation and injury, whole person impairment (WPI) and physiotherapy (prescribed by the physician) were reviewed. The WPI was calculated to assess the extent of the injury. All analyzes were performed by SPSS version 25.0.
Result
The rate of return to work was 54.3%, in which 51.8% for the same job and 48.2% for a new job. The main factors associated with non-return to work were more days off work (p = 0.001), higher injury severity (p = 0.001), and dominant hand injury (p = 0.034).
Conclusion
The number of days off work, the WPI, and dominant hand injury are the most important determinant in returning to work. In addition, increased job satisfaction and support from co-workers and employers are work-related factors that can lead to an increased return to work.
Keywords: Occupational injury, Upper limb impairment, Return to work, Whole person impairment
Introduction
All individuals of working age, in addition to being exposed to various accidents like other community populations, face countless risks and injuries due to being in different and sometimes unfavourable job situations.1 Situations and factors that endanger the health of the workforce are present in almost all work environments, but their type and severity are different in various environments.2
Financial crises and rising unemployment have increased the prevalence of non-standard forms of employment. It is estimated that today almost a third of European workers have an unfavourable employment situation.3 The International Labour Organization estimated that 2.3 million men and women worldwide are exposed to work-related accidents or illnesses yearly, resulting in more than 6000 deaths per day. There are about 340 million occupational accidents worldwide annually.4
Upper limb injury is one of the most common and important type of injuries which can lead to amputation at different levels of the limb, reduced range of motion or ankylosis of the joints, paralysis, and sensory loss.5,6 According to the official statistical report of the ministry of cooperative labour and social welfare of our country, in 2019, there were 21,562 occupational accidents and injuries, of which 10,420 occurred in the upper extremities.7 At the same time, according to the International Labour Organization's global estimation, the number of fatal and non-fatal occupational accidents in developing countries is much higher than estimated.8
Failure to return to work after an injury in a previously productive person can have significant economic and social impacts on the individual and society.9 Return to work after injury may be affected by many factors other than physical ability. Sometimes, factors such as motivation and job satisfaction affect the patient's decision to return to work more than physical factors.10, 11, 12
So far, most studies have focused on return to work after lower limb injuries and few studies have been conducted on return to work after work-related upper limb injury and amputation.13,14 In our country, a study has been conducted on the quality of life after occupational injury of the upper limb,15 but the return to work has not been studied yet. Therefore, in this study, we tried to examine the rate of return to work after work-related upper limb injuries and associated factors.
Methods
This retrospective cohort study was performed on 256 workers who suffered from upper limb impairment as a result of occupational injuries and were referred to an occupational medicine clinic in a teaching hospital during March 2011 to December 2018. These patients were referred to the clinic for determining the whole person impairment (WPI) and received compensation based on the calculated percentage. The inclusion criterion was a history of occupational injury resulting in upper limb impairment, and the exclusion criteria included the presence of simultaneous impairment in other organs, congenital or non-occupational limb defects as well as patients with incomplete information in their medical records. Individuals' records, including age at the time of injury, gender, date of injury, marital status, education, level of amputation and injury, WPI and physiotherapy (prescribed by the physician) were reviewed. The WPI was calculated by an occupational medicine specialist based on the 6th edition of the guide to the evaluation of permanent impairment. This index estimates the loss of activity, which indicates the severity of the associated health condition, and the degree of associated limitations, in the form of activities of daily living. Based on the principles of the impairment rating, the WPI of all subjects was calculated at the maximum medical improvement condition. By definition “maximum medical improvement refers to a status where patients are as good as they are going to be from the medical and surgical treatment available to them”.16 We also provided a checklist containing the following variables: the dominant hand, use of the prosthesis, monthly income, days away from work, reason for leaving work (getting fired, inability to do work, retirement), date of the first full-time working day, type of insurance, insurance support, employer support, co-workers’ support, and job satisfaction. We called the patients through the contact information listed in their records and asked them about the mentioned variables. To assess insurance support, employer support, co-workers’ support, and job satisfaction, we asked patients to assign a number from 1 to 10, representing the lowest and the highest levels of support, respectively. In our country, most workers are covered by an insurance company (social security) and this company, in addition to the main insurance, gives people an option called supplementary insurance, which includes more services. In this study, we asked subjects about their satisfaction with insurance support, as well as having supplementary insurance.
To assess work demand, individuals were interviewed for the following physical exposures: work in a sitting position, bending, squatting, kneeling, work in above shoulder level, lifting or carrying heavy objects, on a 5-point scale: never, 1/4 of the time, 1/2 of the time, 3/4 of the time, and > 3/4 of the time17; we assigned a score of 1–5 for each item (a higher score indicated a higher physical demand and work in a sitting position reversely coded). Accordingly, work demand ranged from 5 to 30 and was divided into the sedentary, light, medium, and heavy categories.18 Then, all the above-mentioned variables were compared between individuals with and without return to work.
Independent t-test and Chi-square were used to investigate the relationship between the return to work and various factors. For variables with abnormal distribution, proportional non-parametric tests were used. Finally, multivariate logistic regression analysis was used to examine the factors associated with return to work. All analyses were performed by SPSS version 25.0.
Informed written consent was obtained from all the participants before they took part in the study. Participants' personal and medical information was kept confidential. The study was approved by the Ethics Committee (Ethical Code: IR.IUMS.FMD.REC.1398.298).
Results
A total of 256 participants with work-related upper extremity injuries were analysed. The demographic characteristics of the individuals are listed in Table 1.
Table 1.
Description of the study population (n = 256)
| Variables | Mean ± SD or n (%) |
|---|---|
| Age at the time of injury (year) | 34.10 ± 9.04 |
| Work experience (year) | 4.72 ± 6.52 |
| Days off work (day) | 207.77 ± 286.13 |
| Insurance support (1–10) | 2.07 ± 2.38 |
| Employer support (1–10) | 3.55 ± 3.69 |
| Co-workers’ support (1–10) | 3.42 ± 3.56 |
| Job satisfaction (1–10) | 4.77 ± 3.13 |
| Gender | |
| Female | 11 (4.3) |
| Male | 245 (95.7) |
| Marital status | |
| Married | 216 (84.4) |
| Single | 40 (15.6) |
| Smoking | |
| Yes | 43 (16.8) |
| No | 213 (83.2) |
| Complementary insurance | |
| Yes | 158 (61.7) |
| No | 98 (38.3) |
| Work demand in initial job | |
| Low | 74 (28.9) |
| Medium | 120 (46.9) |
| High | 62 (24.2) |
| Work demand in second job | |
| Sedentary | 51 (38.3) |
| Low | 41 (30.8) |
| Medium | 34 (25.6) |
| High | 7 (5.3) |
| Dominant hand injury | |
| Yes | 157 (61.3) |
| No | 99 (38.7) |
| Physiotherapy | |
| Complete | 111 (43.4) |
| Incomplete | 70 (27.3) |
| No | 75 (29.3) |
| Prosthesis use | |
| Yes | 15 (5.9) |
| No | 241 (94.1) |
In this study, out of 256 subjects, 37.5% did not return to work and 54.3% returned to work, of which 51.8% were back to the previous job and 48.2% to a new job. In addition, no information was obtained from the situation of 8.2%.
A 36-year-old man and a 30-year-old man suffered injuries to both hands. The 2 subjects were completely disabled and received monthly compensation and did not return to work. They were not included in the analysis.
About 10.9% of the participant (n = 28) had 10 days or less of work experience and 21.5% (n = 55) had less than 1 month; the minimum work experience was 2 days and the maximum was about 29 years.
Among those who returned to work, 71.2% returned to work after 6 months, 15.8% after 1 year, and 10.1% after 2 years. The reason for not returning to work in 21.1% of cases was getting fired, 34.0% inability to do work, and 44.9% other causes including retirement, and the lack of motivation to return to work due to psychological problems (post-traumatic stress disorder, etc.). The median time to return to work was 120 days.
The mean WPI of the total study population and the involvement of different parts of the upper extremities were shown in Table 2.
Table 2.
Mean whole person impairment and the involvement of different parts of the upper extremities in the total study population.
| Variables | Mean ± SD or n (%) |
|---|---|
| Whole person impairment (%) | 28.11 ± 12.03 |
| Shoulder injury | |
| Yes | 7 (2.7) |
| No | 249 (97.3) |
| Elbow injury | |
| Yes | 14 (5.5) |
| No | 242 (94.5) |
| Wrist injury | |
| Yes | 51 (19.9) |
| No | 205 (80.1) |
| Thumb injury | |
| Yes | 145 (56.6) |
| No | 111 (43.4) |
| Number of injured fingers in hand injury below the wrist (n = 205) | |
| 1 | 1 (0.5) |
| 2 | 40 (19.5) |
| 3 | 70 (34.1) |
| 4 | 49 (23.9) |
| 5 | 45 (22.0) |
The severity of injury (which was determined by WPI) had a significant direct linear correlation with the number of days away from work (p = 0.001, r = 0.750) and work experience (p = 0.048, r = 0.124).
In univariate analysis, non-return to work was significantly associated with lower education, higher work demand, injury at the level of the elbow, wrist, and thumb, dominant hand injury, and being covered by supplementary insurance. Also, for quantitative variables, non-return to work was significantly associated with longer absenteeism, higher injury severity, more insurance support, less employer support, less co-workers’ support, and less job satisfaction.
Among subjects with a hand injury below the wrist, the rate of return to work decreased significantly with the increasing number of fingers involved (p < 0.001). In subjects with 1 finger injury, the rate of return to work was 100% and in the case of all fingers involvement, this rate reached 26.6%. The rate of return to work with 2, 3, and 4 fingers involvement was 91.7%, 88.5%, and 67.4%, respectively. Other information on the relationship between the return to work and injury level is given in Table 3 and Table 4.
Table 3.
Relationship between return to work and demographic characteristic.
| Variables | Return to work |
p value | |
|---|---|---|---|
| Yes (n = 139) | No (n = 96) | ||
| Age at the time of injury (year) | 37.2 ± 9.6 | 37.5 ± 9.8 | 0.823 |
| Work experience (year) | 5.0 ± 6.2 | 4.3 ± 6.7 | 0.409 |
| Days off work (day) | 207.77 ± 286.13 | 1352.79 ± 857.28 | < 0.001 |
| Insurance support (1–10) | 1.5 ± 2.0 | 2.9 ± 2.6 | < 0.001 |
| Employer support (1–10) | 4.5 ± 3.7 | 2.5 ± 3.2 | < 0.001 |
| Co-workers support (1–10) | 4.1 ± 3.7 | 2.6 ± 3.1 | 0.001 |
| Job satisfaction (1–10) | 5.2 ± 3.0 | 4.2 ± 3.1 | 0.014 |
| Gender | 0.540 | ||
| Female | 8 (72.7) | 3 (27.3) | |
| Male | 136 (60.7) | 88 (39.3) | |
| Marital status | > 0.999 | ||
| Married | 116 (58.9) | 81 (41.1) | |
| Single | 23 (60.5) | 15 (39.5) | |
| Smoking | 0.373 | ||
| Yes | 26 (66.7) | 13 (33.3) | |
| No | 113 (57.7) | 83 (42.3) | |
| Education | 0.045 | ||
| Illiterate | 11 (52.4) | 10 (47.6) | |
| Primary | 28 (56.0) | 22 (44.0) | |
| Secondary | 57 (52.8) | 51 (47.2) | |
| Diploma | 38 (76.0) | 12 (24) | |
| Bachelor of science | 5 (83.3) | 1 (16.7) | |
| Child number | 0.704 | ||
| Zero | 32 (61.5) | 20 (38.5) | |
| 1-2 | 84 (57.1) | 63 (42.9) | |
| ≥ 3 | 23 (63.9) | 13 (36.1) | |
| Work demand | 0.001 | ||
| Low | 25 (44.6) | 31 (55.4) | |
| Medium | 59 (55.1) | 48 (44.9) | |
| High | 25 (44.6) | 31 (55.4) | |
| Income | 0.737 | ||
| Low | 57 (57.6) | 42 (42.4) | |
| Medium | 77 (59.2) | 53 (40.8) | |
| High | 5 (83.3) | 1 (16.7) | |
| Complementary insurance | 0.033 | ||
| Yes | 81 (54.4) | 68 (45.6) | |
| No | 58 (67.4) | 28 (32.7) | |
Data are expressed as mean ± SD or n (%).
Table 4.
Relationship between return to work and injury-related features.
| Variables | Return to work |
p value | OR (95% CI) | |
|---|---|---|---|---|
| Yes (n = 139) | No (n = 96) | |||
| Whole person impairment (%) | 21.4 ± 7.2 | 37.8 ± 10.9 | < 0.001 | – |
| Shoulder injury | 0.125 | 3.76 (0.7–19.8) | ||
| Yes | 2 (28.6) | 5 (71.4) | ||
| No | 137 (60.1) | 91 (39.9) | ||
| Elbow injury | 0.004 | 5.86 (1.5–21.6) | ||
| Yes | 3 (21.4) | 11 (78.6) | ||
| No | 131 (70.4) | 55 (29.6) | ||
| Wrist injury | < 0.001 | 12.20 (5.3–27.7) | ||
| Yes | 8 (16.3) | 41 (83.7) | ||
| No | 131 (70.4) | 55 (29.6) | ||
| Thumb injury | < 0.001 | 5.00 (2.7–9.0) | ||
| Yes | 60 (44.1) | 76 (55.9) | ||
| No | 79 (79.8) | 20 (20.2) | ||
| Prosthesis use | 0.766 | 1.40 (0.4–4.8) | ||
| Yes | 8 (66.7) | 4 (33.3) | ||
| No | 131 (58.7) | 92 (41.3) | ||
| Dominant hand injury | < 0.001 | 3.41 (1.9–6.0) | ||
| Yes | 69 (48.3) | 74 (51.7) | ||
| No | 70 (76.1) | 22 (23.9) | ||
| Physiotherapy | 0.714 | – | ||
| Complete | 60 (57.7) | 44 (42.3) | ||
| Incomplete | 40 (63.5) | 23 (36.5) | ||
| No | 39 (57.4) | 29 (42.6) | ||
Data are expressed as mean ± SD or n (%).
The relationship between the return to work and days away from work was shown in Fig. 1. Return to work is inversely related to the number of days off work; the rate of return to work decreases significantly with the increasing number of days off work.
Fig. 1.
The relationship between the return to work and days away from work.
In multivariate logistic regression analysis, the items that were significant in univariate analysis were tested and it was found that more days off work (p = 0.001), higher injury severity (p = 0.001), and dominant hand injury (p = 0.034) were 3 main factors associated with not return to work.
Discussion
Identifying the factors associated with return to work is especially important in individuals who have upper limb impairment and have previously been active. Most studies to date have examined return to work after lower limb injury, and there are few studies on the upper extremity. In this study, we investigated the rate of return to work and the associated factors following occupational injuries leading to upper limb impairment in workers referred to the occupational medicine clinic in a teaching hospital from March 2011 to December 2018.
In this study, more days away from work, higher injury severity and dominant hand injury were the 3 main factors associated with non-return to work.
A cohort study by Craig et al.13 in Canada, published in 2017, identified 49 patients with work-related upper limb amputations, 82% of whom returned to work. Return to work was significantly higher in younger people and mostly returned to the same job. In our study, the rate of return to the previous job was higher, but return to work had no relationship with age.
In a study by Chen et al.14 on 120 subjects with work-related hand injuries, it was found that time off work was positively associated with the severity of the injury and mental health and negatively associated with physical function. In our study, the severity of the injury was one of the important determinants of return to work. Also, return to work was significantly influenced by the support of the employer and co-workers.
A review of the literature on return to work after lower limb amputation by Burger et al.19 in Slovenia found that the rate of return to work after an amputation following work-related injuries was 66%, with 22%–67% of those returned to the same job. When people chose another job when they return to work, the second job had more professional complexity and required a higher level of knowledge, but at the same time, its physical activity was less than the first job. In that review, age, gender, education and the severity of injury leading to amputation were the most important factors that affect a person's return to work. In our study, the rate of return to work was 54.3%, of which 51.8% were back to the previous job. The work demand in the initial job was mostly in the medium group, while after the injury, most people worked in sedentary jobs which confirm the findings of Burger's study. In our study, the severity of the injury was one of the main factors in returning to work. Also, in the initial analysis, it was found that individuals with higher levels of education are more likely to return to work, which was not significant in multivariate analysis.
A cohort study by Journeay et al.20 in Canada, published in 2018, surveyed 147 people with lower extremity amputations and found that 69% of them had returned to work. In that study, with increasing years of amputation, the likelihood of return to work was higher, and the authors explained that as the duration of the injury increased, the worker had more time to rehabilitate and seek employment. In our study, we found that higher numbers of days away from work are associated with a lower probability of return to work. Physical or mental deconditioning as a result of long-term absence from work is one of the most important factors that prevent returning to work. Therefore, based on the results of our study and other studies in the context of other occupational diseases and injuries, it is important to encourage workers to return to work as soon as possible.
In a study by Hebert et al.21 in Canada, 88 people with work-related lower extremity amputations were included in a cohort study. Their rate of return to work was 48% and the level of amputation was effective on return to work. In our study, injuries to the elbows, wrists, and thumbs were significantly associated with less return to work, but no significant relationship was found in the shoulder injury. Also, in subjects with an injury to the hand below the wrist level, the likelihood of return to work decreased as the number of injured fingers increased.
One of the factors assessed in our study was the relationship between the return to work and insurance coverage. According to our findings, subjects who did not return to work had higher levels of insurance support, and more had supplementary insurance. This indicates that subjects were less motivated to return to work because of the assurance that insurance would pay for their expenses.
Based on the findings of our study, given that the severity of the injury was 1 of the 3 main determinants of the rate of return to work, it seems that safety principles education and training for workers before starting their task can play an important role in reducing the occurrence of occupational accidents and the injury severity.
In this study, for the first time in our country, we investigated the rate of return to work after upper limb impairment and the associated factors following occupational injuries. In our study, we calculated the WPI for each worker, which is an accurate index to estimate the extent of the injury. Besides, one of the advantages of using WPI is that it shows the degree of limitation in the activities of daily living of injured cases. Other strengths of our study are the relatively high sample size compared to similar studies in the upper extremities, as well as the consideration of several factors affecting the return to work. Limitations of this study were problems in the field of incomplete information in the patient's records and access to contact information. It was also sometimes difficult for individuals to remember accurate information such as how long they were absent from work, despite their willingness to cooperate. Besides, due to the COVID-19 pandemic, legal proceedings for receiving compensation were delayed in some cases.
Based on the results of this study, it is concluded that the numbers of days away from work, the WPI, and dominant hand injury are the most important factors that affect the return to work after work-related upper limb impairment. In addition, increased job satisfaction and support from co-workers and employers are work-related factors that can lead to an increased return to work.
Funding
Nil.
Ethical statement
Informed written consent was obtained from all the participants before they took part in the study. Participants' personal and medical information was kept confidential. The study was approved by the Ethics Committee (Ethical Code: IR.IUMS.FMD.REC.1398.298).
Declaration of competing interest
The authors have no conflicts of interest associated with the material presented in this paper.
Author contributions
Study conception and design: Mahin Hosseininejad, Elham Mirzamohammadi.
Data collection: Shima Javadifar.
Analysis and interpretation of results: Mahin Hosseininejad, Saber Mohammadi, Shima Javadifar.
Draft manuscript preparation: Mahin Hosseininejad, Saber Mohammadi, Elham Mirzamohammadi.
Acknowledgements
This study was conducted with support from the deputy for research at Iran University of Medical Sciences.
Footnotes
Peer review under responsibility of Chinese Medical Association.
References
- 1.Shendell D.G., Noomnual S., Plascak J., et al. Injuries among young workers in career-technical-vocational education and associations with per pupil spending. BMC Publ Health. 2018;18:1190. doi: 10.1186/s12889-018-6099-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Dillahunt-Aspillaga C., Jorgensen Smith T., Hanson A., et al. Exploring vocational evaluation practices following traumatic brain injury. Behav Neurol. 2015;2015 doi: 10.1155/2015/924027. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Koranyi I., Jonsson J., Rönnblad T., et al. Precarious employment and occupational accidents and injuries–a systematic review. Scand J Work Environ Health. 2018;44:341–350. doi: 10.5271/sjweh.3720. [DOI] [PubMed] [Google Scholar]
- 4.Şen D.Ö. Middle East Technical University; 2019. Examination of Organizational Safety Culture of an Automotive Company. [Google Scholar]
- 5.Stramazzo L., Rovere G., Cioffi A., et al. Peri-implant distal radius fracture: proposal of a new classification. Proposal of a new classification. J Clin Med. 2022;11:2628. doi: 10.3390/jcm110926. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Mocini F., Rovere G., De Mauro D., et al. Newer generation straight humeral nails allow faster bone healing and better functional outcome at mid-term. J Orthop Surg Res. 2021;16:631. doi: 10.1186/s13018-021-02776-w. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Delazimi F. 2018. Statistical Year Book Ministry of Cooperative Labor and Social Welfare.www.amarkar.ir [Google Scholar]
- 8.Hämäläinen P., Takala J., Saarela K.L. Global estimates of occupational accidents. Saf Sci. 2006;44:137–156. [Google Scholar]
- 9.Shendell D.G., Mizan S.S., Marshall E.G., et al. Cut-laceration injuries and related career groups in New Jersey career, vocational, and technical education courses and programs. Workplace Health & Saf. 2012;60:401–409. doi: 10.1177/216507991206000905. quiz 410. [DOI] [PubMed] [Google Scholar]
- 10.Haugli L., Maeland S., Magnussen L.H. What facilitates return to work? Patients experiences 3 years after occupational rehabilitation. J Occup Rehabil. 2011;21:573–581. doi: 10.1007/s10926-011-9304-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Cancelliere C., Donovan J., Stochkendahl M.J., et al. Factors affecting return to work after injury or illness: best evidence synthesis of systematic reviews. Chiropr Man Ther. 2016;24:32. doi: 10.1186/s12998-016-0113-z. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Uys M.E., Buchanan H., Van Niekerk L. Strategies occupational therapists employ to facilitate work-related transitions for persons with hand injuries: a study protocol for a scoping review. BMJ Open. 2019;9 doi: 10.1136/bmjopen-2018-027402. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Craig M., Hill W., Englehart K., et al. Return to work after occupational injury and upper limb amputation. Occup Med (Lond) 2017;67:227–229. doi: 10.1093/occmed/kqx012. [DOI] [PubMed] [Google Scholar]
- 14.Chen Y.H., Lin H.T., Lin Y.T., et al. Self-perceived health and return to work following work-related hand injury. Occup Med (Lond). 2012;62:295–297. doi: 10.1093/occmed/kqr215. [DOI] [PubMed] [Google Scholar]
- 15.Golchin M., Attarchi M., Mirzamohammadi E., et al. Assessment of the relationship between quality of life and upper extremity impairment due to occupational injuries. Med J Islam Repub Iran. 2014;28:15. [PMC free article] [PubMed] [Google Scholar]
- 16.Rondinelli R., Association A.M. AMA press; 2008. Guides to the Evaluation of Permanent Impairment. [Google Scholar]
- 17.Hiesinger K., Tophoven S. Job requirement level, work demands, and health: a prospective study among older workers. Int Arch Occup Environ Health. 2019;92:1139–1149. doi: 10.1007/s00420-019-01451-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Madsen I.E., Gupta N., Budtz-Jørgensen E., et al. Physical work demands and psychosocial working conditions as predictors of musculoskeletal pain: a cohort study comparing self-reported and job exposure matrix measurements. Occup Environ Med. 2018;75:752–758. doi: 10.1136/oemed-2018-105151. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Burger H., Marinček Č. Return to work after lower limb amputation. Disabil Rehabil. 2007;29:1323–1329. doi: 10.1080/09638280701320797. [DOI] [PubMed] [Google Scholar]
- 20.Journeay W., Pauley T., Kowgier M., et al. Return to work after occupational and non-occupational lower extremity amputation. Occup Med (Lond) 2018;68:438–443. doi: 10.1093/occmed/kqy091. [DOI] [PubMed] [Google Scholar]
- 21.Hebert J.S., Ashworth N.L. Predictors of return to work following traumatic work-related lower extremity amputation. Disabil Rehabil. 2006;28:613–618. doi: 10.1080/09638280500265219. [DOI] [PubMed] [Google Scholar]