Vocational rehabilitation for enhancing return-to-work in workers with traumatic upper limb injuries

  • Review
  • Intervention

Authors

  • Wen-Hsuan Hou,

    1. Taipei Medical University, School of Gerontology Health Management, College of Nursing, Taipei Medical University, Taipei, Taiwan, Taipei, Taiwan
    2. Taipei Medical University Hospital, Department of Physical Medicine and Rehabilitation, Taipei, Taiwan
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  • Ching-Chi Chi,

    Corresponding author
    1. Chang Gung Memorial Hospital, Department of Dermatology and Centre for Evidence-Based Medicine, Chiayi, Taiwan
    2. Chang Gung University, College of Medicine, Taoyuan, Taiwan
    • Ching-Chi Chi, Department of Dermatology and Centre for Evidence-Based Medicine, Chang Gung Memorial Hospital, 6, Sec West, Chia-Pu Road, Puzih, Chiayi, 61363, Taiwan. chingchi@cgmh.org.tw. chingchichi@gmail.com.

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  • Heng-Lien Daniel Lo,

    1. Taipei Medical University, Center for Evidence-Based Medicine, Taipei, Taiwan
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  • Ken N Kuo,

    1. College of Medicine, Taipei Medical University, Center for Evidence-Based Medicine, Taipei, Taiwan
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  • Hung-Yi Chuang

    1. Kaohsiung Medical University Hospital and Kaohsiung Medical University, Occupational and Environmental Medicine, Kaohsiung City, Taiwan
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Abstract

Background

Traumatic upper limb injury is a leading cause of work-related disability. After return-to-work (RTW), many survivors of injuries are able to regain a quality of life (QoL) comparable with the normal population. Since RTW plays an important role in economic productivity and regaining health-related QoL, enhancing RTW in workers with traumatic limb injuries is the primary goal of rehabilitation. Vocational rehabilitation has been adapted in the field of occupational safety and health to enhance the number of injured people returning to the labour market, prevent illness, increase well-being, and reduce disability.

Objectives

To assess the effects of vocational rehabilitation programs in enhancing RTW of workers with traumatic upper limb injuries.

Search methods

We searched OSH UPDATE databases (CISDOC, HSELINE, International Bibliographic, NIOSHTIC, NIOSHTIC-2, RILOSH) (up to 10 December 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (2012, Issue 11), MEDLINE through PubMed (up to 15 November 2012), EMBASE (up to 28 November 2012), CINAHL (up to 5 May 2013), PsycINFO (up to 7 December 2012), and handsearched the reference lists of relevant review articles.

Selection criteria

We aimed to include all randomised controlled trials (RCTs) comparing vocational rehabilitation with an alternative (control) intervention such as standard rehabilitation, an incomplete form of the vocational rehabilitation intervention (such as with limited advice on RTW, referral information, or liaison with employer), or waiting-list controls.

Data collection and analysis

Two authors independently inspected abstracts and we obtained full papers when necessary. When the two authors disagreed about the inclusion of a study, we resolved disagreements by discussion. A third author arbitrated when necessary.

Main results

Our search identified 332 citations. Based on assessments of their titles and abstracts, we decided to evaluate the full texts of 15 citations. In the end, none of these 15 citations met our inclusion criteria.

Authors' conclusions

There is currently no high-level evidence to support or refute the efficacy of vocational rehabilitationin enhancing RTW in workers with traumatic upper limb injuries. Since vocational rehabilitation has frequently been provided to injured people in occupational settings with the aim of decreasing work disability, enhancing RTW, increasing productivity, and containing the welfare cost, further high-quality RCTs assessing the efficacy of vocational rehabilitation for workers with traumatic upper limb injury are needed to fill this gap in knowledge.

Résumé scientifique

La réadaptation professionnelle pour faciliter le retour au travail des travailleurs victimes de lésions traumatiques des membres supérieurs

Contexte

Les lésions traumatiques du membre supérieur sont l’une des principales causes d’incapacité professionnelle. Après le retour au travail, de nombreux accidentés sont capables de retrouver une qualité de vie comparable à celle de la population générale. Dans la mesure où le retour au travail joue un rôle important dans la productivité économique et en termes de récupération de la qualité de vie liée a la santé, le but premier de la réadaptation des travailleurs ayant subi une blessure traumatique des membres est de permettre leur retour au travail dans les meilleures conditions possibles. La réadaptation professionnelle a été adaptée au domaine de l’hygiène et de la sécurité au travail dans le but d’accroître le nombre d’accidentés qui reviennent sur le marché du travail, de prévenir les maladies, d’augmenter le bien-être et de réduire les incapacités.

Objectifs

Évaluer les effets des programmes de réadaptation professionnelle pour améliorer le retour au travail des travailleurs souffrant de lésions traumatiques des membres supérieurs.

Stratégie de recherche documentaire

Nous avons effectue des recherches dans les bases de données OSH UPDATE (CISDOC, HSELINE, International Bibliographic, NIOSHTIC, NIOSHTIC-2, RILOSH) (jusqu’au 10 décembre 2012), le registre Cochrane des essais contrôlés (CENTRAL) (2012, numéro 11), MEDLINE via PubMed (jusqu’au 15 novembre 2012), EMBASE (jusqu’au 28 novembre 2012), CINAHL (jusqu’au 5 mai 2013), PsycINFO (jusqu’au 7 décembre 2012), et effectué une recherche manuelle dans les références bibliographiques des articles pertinents de la revue.

Critères de sélection

Nous avons cherché à inclure tous les essais contrôlés randomisés (ECR) comparant la réadaptation professionnelle à une autre intervention (témoin), telle que la rééducation standard, une forme incomplète d’intervention de réadaptation professionnelle (avec par exemple peu de conseils sur le retour au travail, d’informations d’orientation ou de liaison avec employeur), ou des témoins sur liste d’attente.

Recueil et analyse des données

Deux auteurs ont examiné indépendamment les résumés et nous nous sommes procuré les articles complets lorsque cela était nécessaire. Lorsque les deux auteurs n’étaient pas d’accord sur l’inclusion d’une étude, nous avons résolu les désaccords par la discussion. Un troisième auteur a joué le rôle d’arbitre lorsque cela était nécessaire.

Résultats principaux

Notre recherche a identifié 332 références bibliographiques. D’après l’évaluation de leurs titres et de leurs résumés, nous avons décidé d’évaluer les textes complets de 15 références bibliographiques. En définitive, aucune de ces 15 références répondait à nos critères d’inclusion.

Conclusions des auteurs

Il n’existe actuellement aucun élément de preuve de haut niveau pour appuyer ou réfuter l’efficacité de la réadaptation professionnelle pour améliorer le retour au travail après une lésion traumatique des membres supérieurs. Dans la mesure où la réadaptation professionnelle est souvent proposée en lien avec l’activité professionnelle dans le but de réduire l’incapacité au travail, d’améliorer le retour au travail, d’accroître la productivité et de maîtriser les coûts pour la collectivité, d’autres ECR de bonne qualité, évaluant l’efficacité de réadaptation professionnelle après les lésions traumatiques des membres supérieurs, sont nécessaires pour combler cette lacune.

Plain language summary

Vocational rehabilitation for helping workers return to work after injuring their fingers, hand, or arm

Review question

Can vocational rehabilitation help workers return to work after having injured their fingers, hand or arm?

Background

Injuries sustained to fingers, hand, or arm can seriously limit a person's ability to continue working normally. In many countries law compels employers to help injured workers when the injury affects their work ability. This help is often referred to as vocational rehabilitation.

What is vocational rehabilitation?

Vocational rehabilitation consists of a range of ways to help disabled workers return to work or to find a new job. Return-to-work (RTW) can be supported by helping the injured worker cope better, by workplace adjustments, or by physical exercises. Although all these strategies are used in practice, there is no evidence in the form of systematic reviews on which approach is best and in which circumstances.

What does the research show?

We examined all the published research up to 5 May 2013. We wanted to include studies only if getting vocational rehabilitation or some other treatment was determined by chance. This way of conducting research, known as a randomised controlled trial (RCT), is the best way to ensure that any measured improvement is really caused by the treatment. We did not find any RCTs that had studied if vocational rehabilitation can help workers with upper limb injuries return to work.

Conclusion

There is no evidence from RCTs to say if vocational rehabilitation can help workers with upper limb injuries return to work. We need RCTs conducted with workers with upper limb injuries to see if vocational rehabilitation can improve their RTW. These studies should be conducted and reported according to agreed standards for high quality research. They should describe the content of vocational rehabilitation in detail. They should also report the number of workers that have returned to work at the end of follow-up or the time it took for them to return to work.

Résumé simplifié

Facilitation du retour au travail après les blessures des doigts, de la main ou du bras par la réadaptation professionnelle

Question

La réadaptation professionnelle peut-elle aider les travailleurs à reprendre le travail après été blessés aux doigts, à la main ou au bras ?

Contexte

Les blessures aux doigts, à la main ou au bras peuvent considérablement limiter la capacité de la personne à travailler normalement. Dans de nombreux pays, les employeurs sont tenus par la loi d’aider les travailleurs blessés lorsque la blessure affecte la capacité de travail de ceux-ci. Cette aide est souvent appelée réadaptation professionnelle.

Qu’est-ce que la réadaptation professionnelle ?

La réadaptation professionnelle comprend diverses méthodes destinées à aider les travailleurs handicapés à reprendre leur travail ou à trouver un autre emploi. Le retour au travail peut être soutenu en aidant les travailleurs blessés à mieux gérer leur incapacité, par des ajustements sur le lieu de travail ou par des exercices physiques. Bien que toutes ces stratégies soient utilisées dans la pratique, il n’existe aucune revue systématique qui démontrerait quelle approche est la meilleure, et dans quelles circonstances.

Que disent les recherches ?

Nous avons examiné toutes les recherches publiées jusqu’au 5 mai 2013. Nous ne voulions inclure que les études dans lesquelles les sujets étaient dirigés de façon aléatoire vers la réadaptation professionnelle ou vers un autre traitement. Cette méthode de recherche, connue sous le nom d’essai contrôlé randomisé (ECR), est la meilleure façon de s’assurer que toute amélioration mesurée est réellement causée par le traitement. Nous n’avons trouvé aucun ECR étudiant si la réadaptation professionnelle peut aider les travailleurs souffrant de blessures aux membres supérieurs à retourner au travail.

Conclusion

Il n’existe aucune preuve issue d’ECR indiquant si la réadaptation professionnelle peut aider les employés souffrant de blessures aux membres supérieurs de retourner au travail. Nous avons besoin d’ECR menés avec des travailleurs blessés aux membres supérieurs pour savoir si la réadaptation professionnelle peut améliorer leur retour au travail. Ces études devront être réalisées et documentés conformément aux règles reconnues pour les recherches de qualité. Elles devront décrire le contenu de la réadaptation professionnelle en détail. Elles devront également rapporter le nombre de travailleurs qui auront repris le travail à la fin du suivi, ou le temps qu’il leur aura fallu pour retourner au travail.

Notes de traduction

Traduit par: French Cochrane Centre 9th January, 2014
Traduction financée par: Financeurs pour le Canada : Instituts de Recherche en Sant� du Canada, Minist�re de la Sant� et des Services Sociaux du Qu�bec, Fonds de recherche du Qu�bec-Sant� et Institut National d'Excellence en Sant� et en Services Sociaux; pour la France : Minist�re en charge de la Sant�

Background

Description of the condition

The World Health Organization (WHO) defines injury as "a bodily lesion at the organic level, resulting from acute exposure to energy in the work environment (mechanical, thermal, electrical, chemical or radiant) in amounts that exceed the threshold of physiological tolerance. In some cases (e.g. drowning, strangulation, freezing), the injury results from an insufficiency of a vital element" (Baker 1984). Among the various injuries, traumatic upper limb injuries frequently occur in mechanised industry when people interact with machines, at home, during transportation, and in recreation and sports activities (King 1992). Due to the complex physical arrangement, traumatic upper limb injuries often involve varying degrees of damage to, or even loss of, tissue such as the skin, tendons, nerves, blood vessels, bones, or the whole upper limb. Due to the multiple systems affected (that is musculoskeletal, vascular, nervous, or tendinous) in traumatic upper limb injuries, the resultant impairment is often devastating (Cooper 2007). Therefore, a comprehensive return-to-work (RTW) rehabilitation programme following traumatic upper limb injuries aims to enable resumption of participation in work and leisure activities (Blackmore 1992).

In Taiwan, traumatic upper limb injuries are the most frequent type of occupational injury and the major cause of functional impairment and work-related disability (accounting for 45% of 14,261 occupational injuries and 55.8% of occupational permanent disability benefits in 2010) (CLA 2011). In the UK, upper limb injuries were the most frequent type (47.3%) of non-fatal injury to employees in 2010 to 2011 (HSE 2012). In Australia, during the period 1 July 2002 to 30 June 2004, there were 16,712 cases (32%) of work-related hand and wrist injuries resulting in hospitalisation. In Victoria alone, 12,491 (32.7%) of emergency department presentations were work-related hand and wrist injuries over the two-year period (ASCC 2008). The incidence of upper extremity injury in the US was slightly lower. In 2010, about 25.1 % of nonfatal occupational injuries and illnesses with days away from work per 10,000 full-time workers were related to upper limb injuries (BLS 2010). Undoubtedly traumatic upper limb injuries cause considerable losses in working days and productivity (Ebel 2004). However, survivors of severe injuries can achieve a quality of life (QoL) comparable with the normal population after returning to their previous jobs (Post 2006). On the other hand the permanent dysfunction of limb injured workers not only limits their daily activities but also directly affects their outcomes in their RTW. For a worker with traumatic upper limb injuries, RTW plays an important role in economic productivity and regaining meaningfulness in life. Therefore, the goals of rehabilitation for patients with traumatic upper limb injuries should be functional independence and RTW.

Description of the intervention

A person's ability to work can be profoundly affected by their disease, disability, and a range of contextual factors. Rehabilitation medicine is integral to the process leading to going back to working life after illness or injury, but other rehabilitation disciplines are also essential. It is important to clarify what rehabilitation physicians or trainees in rehabilitation medicine need to know about vocational rehabilitation (VR).

VR is a process whereby those disadvantaged by illness or disability can be enabled to access, maintain, or return to employment. This applies to those with temporary and permanent impairments. Miscellaneous VR programmes are involved, in parallel, during the process of returning to the labour market after an injury. In this review, VR is defined as changes or interventions with the aim of facilitating a worker's employment after injury. These may include one or more of the following: education, follow-up by a case manager, occupational therapy, worksite visits, on-site management, vocational guidance, occupational health services, work hardening, work modification, job accommodation, work adjustments, work reintegration plans, or ergonomic interventions. VR deals mainly with rehabilitation on the basis of the International Classification of Functioning, Disability and Health (ICF)-level of 'participation' (WHO 2001).

Workers who have not returned to work within two to three months after injury are at high risk of disability and dropping out of the work arena completely (Frank 1996). Therefore, encouraging early RTW by intervening at the workplace may be an efficient way to minimise socioeconomic and personal consequences (Elders 2004).

How the intervention might work

VR targets promoting employment opportunities for the disabled. When a defect due to trauma affects functional capacity for work or employment, the need for VR should be considered (Gobelet 2006). There are various factors influencing RTW. The chance of RTW is higher among patients who have more positive factors such as younger age, male gender, higher education, white collar work, less injury severity, less disability, more self-efficacy, and better psychological or QoL condition (Chamberlain 2009). Factors may be personal or medical, and some are external influences, that is where the context is outside the individual such as activity, participation, and environmental factors in the International Classification of Functioning, Disability and Health (ICF), which are categorised in the ICF Environmental factors (WHO 2001).

Although the interventions of VR vary, their purpose is in general "to maximise the ability of an individual to return to meaningful employment" (BSRM 2000). In other words, the best rehabilitation practice in RTW enhances work and activity tolerance, prevents illness behaviour, and reduces pain and the effects of illness or disability (Gobelet 2006). Therefore, VR helps the injured people in mitigating work disability, accelerating return to meaningful employment, minimising workdays lost, increasing the productivity of injured workers, reducing premature retirement, and containing the welfare cost (Disler 2001).

Alhough the Association of British Insurers has suggested that functional and vocational rehabilitation for severe injuries should be administered after a medical plateau is reached (that is when the worker's medical condition has stabilised and further significant medical improvement is unlikely) (ABI & TUC 2002), early intervention (after sufficient time for healing of injured structures) and the patient's active involvement have been shown to decrease deconditioning (that is due to immobility, the decrease of physiological adaptation to normal conditions) and illness behaviour and foster higher RTW rates (ABI & TUC 2002). Early VR programmes are likely to increase both job and physical well-being and to decrease the need for a disability pension and sick leave. According to a review on the general effects of rehabilitation on unspecified disability by Kuoppala 2008, VR and multimodal medical treatment combined with VR increase the RTW risk ratio (RR) to 1.53 (95% confidence interval (CI) 1.42 to 2.00) and RR 1.5 (95% CI 0.93 to 2.41), respectively. Moreover, VR delivered to people at risk of job loss (but still employed) can delay job loss (Allaire 2003). In this respect, VR can improve patients' QoL and well-being as well as reduce loss of workforce.

Why it is important to do this review

Several VR programmes have been used for traumatic upper limb injuries without a critical appraisal of their benefits. Traditional rehabilitation has emphasised training to improve strength, endurance, sensory function, and range of motion. However, recent reviews have shown that various novel VR programmes are effective in enhancing RTW in workers with various diseases or conditions (Aas 2011; Arends 2012; de Boer 2011; Khan 2009; Schaafsma 2010; van Oostrom 2009). Yet only a few systematic reviews have examined the effectiveness of VR in enhancing early RTW. According to the systematic review by Franche 2005, there is moderate to strong evidence that five kinds of VR, including early contact by the workplace, work accommodation, contact between healthcare provider and workplace, an ergonomic worksite intervention, or the use of a RTW co-ordinator, can shorten the duration of work disability (Franche 2005). The van Oostrom 2009 review on the other hand focused on people with low back pain, recurrent musculoskeletal disorders, job stress, or chronic work-related upper extremities disorders. Other published Cochrane reviews have assessed the effectiveness of measures to improve RTW in a range of patient populations including those with brain injuries (Nair 2008), back pain (Schaafsma 2010), neck pain (Aas 2011), multiple sclerosis (Khan 2009), and cancer (de Boer 2011), which are all different from our target population of people with traumatic upper limb injuries. To date, no-one has used Cochrane methods to assess the effectiveness of VR interventions to enhance RTW for workers with traumatic upper limb injuries.

Objectives

To assess the effects of VR in enhancing RTW of workers with traumatic upper limb injuries.

Methods

Criteria for considering studies for this review

Types of studies

We planned to include all randomised controlled trials (RCTs) that compared VR with an alternative (control) intervention such as standard rehabilitation or an incomplete form of VR intervention (such as with limited advice on RTW, referral information, or liaison with employer), or wait-list controls.

Types of participants

We planned to include trials where participants were working age adults (18 to 65 years) who had been in paid employment (employee or self-employed) at the time of sustaining an acute episode of traumatic upper limb injury involving any parts of the fingers, hand, wrist, forearm, elbow, or arm, regardless of injury type and mechanism. We excluded trials where participants suffered from a subacute or chronic upper limb injury for over three months.

When a study included workers with various kinds of injuries, we planned to include it if 50% or more of the participants had sustained upper limb injuries and the study authors reported separate analyses for participants with upper limb injuries.

We excluded studies where participants had cumulative trauma disorders or repetitive strain injuries such as tendonitis or tendosynovitis, epicondylitis, carpal tunnel syndrome, or the like. We also excluded studies where participants had coexisting injuries to the central nervous system (that is brain or spinal cord), or to internal organs.

Types of interventions

We planned to include any type of intervention with the aim of enhancing RTW. Interventions may have been carried out either with an individual or in a group, and in a clinical setting or in the community. Interventions could primarily focus on different factors which influence RTW, for example on coping (in psychological interventions), workplace adjustments (in vocational interventions), or physical exercises (in physical interventions). Interventions were divided into the following.

  • Psychological: any type of psychological intervention such as counselling, education, training in coping skills, cognitive-behavioural interventions, and problem solving therapy (PST) undertaken by any qualified professional (such as a psychologist, social worker, or nurse).

  • Vocational: any type of intervention focused on employment. Vocational interventions may be person-directed or work-directed. Person-directed vocational interventions are aimed at the patient and incorporate programmes which aim to encourage RTW, vocational rehabilitation, or occupational rehabilitation. Work-directed vocational interventions are aimed at the workplace and include workplace adjustments such as modified work hours, modified work tasks, or modified workplace, and improved communication with or between managers, colleagues, and health professionals.

  • Physical: any type of physical training (such as functional capacity training, work hardening training), physical exercises (such as tendon exercises, nerve gliding exercises), or training of bodily functions (such as muscle strengthening, balance training, endurance training, sensory re-education, range of motion).

  • Multifaceted: a combination of psychological, vocational, and physical interventions.

Where there were multiple intervention groups within a trial, we planned to conduct pairwise comparisons of an intervention versus no intervention, placebo, or another intervention.

Types of outcome measures

Primary outcomes

RTW included return to either full- or part-time employment, to the same or a reduced role, and to either the previous job or any new employment (Clay 2010). We planned to perform separate subgroup analyses of: return to the previous role (either under the same or a new employer), return to a reduced role (either under the same or a new employer), change from full-time to part-time employment, and change to a reduced pay employment. We planned to consider two types of RTW data:

• RTW measured as event data, such as RTW rates, or as (change in) disability pension rates (Arnetz 2003; Loisel 2003);

• RTW measured as time-to-event data, such as number of days between reporting sick and any work resumption, or the number of days on sick leave during the follow-up period (Ebel 2004; MacKenzie 1998; MacKenzie 2006).

Secondary outcomes

• Functional status: measures related to job demands or activities of daily living that are expressed in terms of 'can perform the task' or 'cannot perform the task' (Burke 1994; Pransky 2005; Soberg 2010).

• Quality of life (QoL), measures including overall QoL, physical QoL, emotional QoL, and pain (Bültmann 2007; Post 2006).

Search methods for identification of studies

Electronic searches

We searched the following electronic databases, from inception:

1. CISDOC, HSELINE, International Bibliographic, NIOSHTIC, NIOSHTIC-2, RILOSH (OSH update, searched on 10 December 2012);

2. Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 11) (November);

3. MEDLINE through PubMed (1946 to 15 November 2012);

4. EMBASE (1947 to 28 November 2012);

5. CINAHL (1937 to 5 May 2013);

6. PsycINFO (searched on 7 December 2012).

We have presented the search strategies for OSH update, CENTRAL, PubMed, EMBASE, CINAHL, and PsycINFO in Appendix 1, Appendix 2, Appendix 3, Appendix 4, Appendix 5, and Appendix 6, respectively.

Searching other resources

In an effort to identify further published, unpublished, and ongoing studies, we:

  1. scanned the reference lists of relevant review articles and planned to scan the reference lists of included studies;

  2. contacted experts in the field of occupational health and safety;

  3. planned to write to the authors of included studies to obtain additional references, unpublished trials, and ongoing trials, or to obtain missing data not reported in the original publication. 

We had no limitations on language, publication status, or date of publication.

Data collection and analysis

Selection of studies

Two authors (WHH and CCC) independently selected suitable studies for inclusion in this review by screening the titles and abstracts of studies identified from the electronic databases. If the title and abstract provided sufficient information to determine that the inclusion criteria were not met, we excluded the study. We further checked the full text of the study if the study could not be excluded with certainty. When the two authors disagreed about the inclusion of a study, we resolved disagreements by discussion. A third author (HLL) arbitrated when necessary. We listed the studies that could only be excluded after reading the full text and have provided the reasons for exclusion in the 'Characteristics of excluded studies' table.

Data extraction and management

We planned to extract and summarise details of included studies using a standardised data extraction form. Where studies had been published more than once, we planned to extract data from all reports and consider the one with the greatest amount of data as the primary reference. Two authors (WHH and CCC) planned to independently extract the following data:

  • author, title, source of reference, country, and publication year;

  • number and description of participants;

  • intervention and comparison;

  • concomitant interventions;

  • who delivered the intervention;

  • primary and secondary outcome data and methods of measurement;

  • duration of follow-up.

Assessment of risk of bias in included studies

Two authors (WHH and CCC) planned to independently assess each included study using the Cochrane Collaboration tool for assessing risk of bias as described in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). This tool addresses specific domains, namely random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, selective reporting, and other sources of biases (for example extreme baseline imbalance) (see Appendix 7 for details of the criteria). We planned to assess the blinding and completeness of the outcome data for each outcome separately and generate a 'Risk of bias' table for each included study. When the two authors disagreed about a particular judgment for the risk of bias, we planned to resolve disagreements by discussion and a third author (HLL) would arbitrate if necessary.

We planned to present the assessments of risk of bias in a summary figure to illustrate all of the judgments in a cross-tabulation of studies.

Measures of treatment effect

We planned to plot the results of each RCT as point estimates, such as risk ratios (RRs) for dichotomous outcomes, means and standard deviations (SDs) for continuous outcomes, or other types of data as reported by the authors of the studies. When the results could not be plotted, we planned to describe them in the 'Characteristics of included studies' table, or enter the data into 'Additional tables'.

We planned to plot time-to-event data as hazard ratios (HRs). If Kaplan-Meier curves were presented, we planned to extract the data from the graphs and calculate HRs according to the methods given in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011).

Unit of analysis issues

All observed participants in the intervention and control groups were the planned primary unit of analysis. For studies that employed a cluster-randomised design but did not make an allowance for the design effect, we planned to calculate the design effect based on a fairly large assumed intra-cluster correlation of 0.10. We based this assumption, by analogy, on studies about implementation research (Campbell 2001). We planned to follow the methods stated in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011) for the calculations.

Dealing with missing data

We planned to contact study authors to obtain missing data. Where we could not obtain missing data from study authors, we planned to judge the trials with incomplete outcome data according to the criteria recommended by the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). For example, if statistics were missing, such as SDs, we planned to calculate them from other available statistics such as P values.

Assessment of heterogeneity

We planned to assess clinical homogeneity based on similarity of population, intervention, outcomes, and follow-up. We planned to categorise study participants into jobs with high hand load, such as typing or lifting small objects, and into jobs with low upper limb load, such as in monitoring or receptionist work. Otherwise we planned to consider study populations as similar if the participants had been in paid employment when 50% or more of them had sustained an acute episode of traumatic upper limb injury involving any parts of the fingers, hand, wrist, forearm, elbow, or arm, regardless of injury type and mechanism, and regardless of occupation or type of work. We planned to consider interventions as similar if they fell into one of the predefined categories of interventions (as stated in the paragraph on criteria for including studies). We planned to consider the RTW outcomes and sick leave duration outcomes as similar. We planned to regard follow-up periods of less than three months, three months to one year, and more than one year as different. In addition, we planned to test for statistical heterogeneity by means of the Chi2 test as implemented in the forest plots in the software RevMan 2012. This test examines the percentage of total variation across studies due to heterogeneity rather than to chance. We planned to use a significance level of P < 0.10 to indicate whether there was a problem with heterogeneity. Moreover, we planned to quantify the degree of heterogeneity using the I2 statistic, where an I2 value of 25% to 50% indicates a low degree of heterogeneity, 50% to 75% a moderate degree of heterogeneity, and > 75% a high degree of heterogeneity (Higgins 2003).

Assessment of reporting biases

We planned to reduce the effects of reporting bias by including studies and not publications to avoid the introduction of duplicate data (that is two articles may represent duplicate publications of the same study). Following the Cho 2000 statement on redundant publications, we attempted to detect duplicate studies and, if more than one article reported on the same study, we planned to extract data only once. We prevented location bias by searching across multiple databases. We prevented language bias by not excluding any article based on language. We planned to assess publication bias with a funnel plot if at least 10 studies were available for the primary outcome and could be included in the funnel plot.

Data synthesis

We planned to pool data from studies judged to be clinically homogeneous using RevMan 2012. If sufficient data were available, we planned to perform meta-analyses. When studies were statistically heterogeneous, we planned to use a random-effects model; otherwise we planned to use a fixed-effect model. When using the fixed-effect model, we planned to conduct a sensitivity analysis by using the random-effects model to test if there were differences in the results. We planned to include 95% CIs for all estimates. For the analysis of HRs, we planned to use the inverse variance method in RevMan 2012. For RTW outcomes we planned to deem time to RTW, the rate of RTW, and the number of days on sick leave sufficiently similar to be combined in a meta-analysis. We planned to use effect sizes to combine continuous and dichotomous RTW outcome data. We planned to use the mean number of days off work to calculate the effect size for the days on sick leave with the following formula: mean change difference over standard deviation (Håland 2002). For the HRs and rate ratios, we planned to take their natural logarithms and transform them into effect sizes as recommended in the Cochrane Handbook for Systematic Reviews of Interventions (Chinn 2000; Higgins 2011). We planned to use effect sizes and their standard errors as input in the meta-analysis using the generic inverse variance method. After meta-analysis, we planned to re-calculate a mean difference in time-to-RTW from the pooled effect size using the median SD of the included studies in the formula: pooled mean difference = pooled effect size x median SD.

We planned to use the GRADE approach as described in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011) and implemented in the GRADEPro 3.6 software (GRADEpro) to present the quality of evidence and 'Summary of findings' tables.

The downgrading of the quality of a body of evidence for a specific outcome would be based on five factors:

  1. limitations of study;

  2. indirectness of evidence;

  3. inconsistency of results;

  4. imprecision of results;

  5. publication bias.

The GRADE approach specifies four levels of quality (high, moderate, low, and very low) (van Tulder 2003).

Subgroup analysis and investigation of heterogeneity

We planned to perform subgroup analyses according to injury severity or body parts, setting, and quality of the study, because these variables could potentially affect the intervention effect estimates.

Sensitivity analysis

We planned to conduct a sensitivity analysis to test the robustness of our meta-analysis results by excluding studies judged to have a high risk of bias.

Results

Description of studies

Results of the search

We identified a total of 332 records and assessed 15 as full text for eligibility for this review. See Figure 1 for a study flow diagram.

Figure 1.

Study flow diagram.

Included studies

None of the studies that we assessed for eligibility met our inclusion criteria.

Excluded studies

We considered 15 studies potentially eligible and retrieved their full texts. However, all of them failed to meet the inclusion criteria and therefore we excluded them. We present descriptions of all 15 studies with the reasons why we excluded them in the Characteristics of excluded studies.

Risk of bias in included studies

We did not include any randomised controlled trials and so there was no risk of bias to assess.

Effects of interventions

We did not include any randomised controlled trials and so we did not conduct any analyses.

Discussion

Summary of main results

We did not identify any RCTs addressing the efficacy of VR in enhancing RTW in workers with traumatic upper limb injuries. Most of the studies identified from the searches evaluated the effects of range of motion exercise and physical training to facilitate early RTW. A number of identified RCTs compared different policies of workplace accommodation, counselling, case management, or worksite visits for workers with chronic musculoskeletal problems of the upper extremities (Cheng 2007; Haahr 2005; Li 2006). There were also clinical trials comparing surgical intervention and medical rehabilitation (that is splinting, mobilising, or strengthening) for upper limb injuries during hospitalisation (Feehan 2004; Lubbert 2008; Unsworth-White 1994). Various VR programs have been developed to help workers who have sustained traumatic upper limb injury to return to the labour market. However, we found no high-level evidence to either support or refute the effects of VR in enhancing RTW in workers with traumatic upper limb injuries.

Overall completeness and applicability of evidence

The absence of randomised trials eligible for inclusion in this review illustrates that the evidence on VR for enhancing RTW in workers with traumatic upper limb injuries is unclear and incomplete. All of the studies that we retrieved in the searches had assessed the effects of different rehabilitation after immobilisation or enhancing range of motion strategies at acute medical stages, which we had pre-specified as exclusion criteria for this review.

Potential biases in the review process

We made every attempt to limit bias in the review process by ensuring a comprehensive search for potentially eligible studies. The authors' independent assessments of eligibility of studies for inclusion in this review minimised the potential for additional bias.

Agreements and disagreements with other studies or reviews

We found a systematic review of early prognostic factors for RTW following orthopaedic trauma (Clay 2010). This review used prospective and retrospective cohort studies and explored prognostic factors either at pre-injury or at the early post-injury phase. Two prospective studies that used survival analysis found that providing modified work (Seland 2006) and strong practical support (MacKenzie 1998) increased the likelihood of RTW, to 1.24 and 1.7 times respectively. However, none of the studies included in the Clay 2010 review assessed the effectiveness of VR intervention for acute orthopaedic injuries.

There are several RCTs focusing on the effects of rehabilitation intervention for adults with distal radial fractures. Their results have been pooled in a Cochrane systematic review by Handoll 2006. The types of rehabilitation interventions examined in these studies are limited to hand therapy or medical rehabilitation and no further VR programs have been arranged for patients with orthopaedic trauma.

Authors' conclusions

Implications for practice

Despite a thorough search for evidence relating to the efficacy of VR for enhancing RTW in workers with traumatic upper limb injuries, we found no relevant randomised trials. This review therefore found no evidence on the effect of VR for enhancing RTW in workers with traumatic upper limb injuries.

Implications for research

VR programmes have been proposed to help injured people in mitigating work disability, accelerating return to meaningful employment, minimising workdays lost, increasing productivity, reducing premature retirement, and containing the welfare cost (Disler 2001). The fact that VR has been constantly provided as part of occupational health care despite a lack of high-quality evidence for its effectiveness in this population underlines the necessity for RCTs of this intervention.

Another way to fill the evidence gap is to make better use of RCTs of general rehabilitation measures which should also include RTW outcomes, preferably the number at work at end of follow-up or the time taken to return-to-work. The intervention should be well-described according to the elements that make up vocational rehabilitation. A careful process evaluation should show how well the intervention was implemented. Reporting should conform to the Consolidated Standards of Reporting Trials (CONSORT) statement (http://www.consortstatement.org), which will enable appraisal and interpretation of results and accurate judgments to be made about the risk of bias and the overall quality of the evidence.

Acknowledgements

We would like to thank Jos Verbeek, Jani Ruotsalainen, Risto Rautiainen, Wim van Veelen, Anneli Ojajärvi, and Leena Isotalo from the Cochrane Occupational Safety and Health Review Group for their extensive feedback, and Jani Ruotsalainen, Joey Kwong and Janet Wale for copy editing the text. We also thank Kaisa Neuvonen for her help in developing search strategies and executing searches.

Data and analyses

Download statistical data

This review has no analyses.

Appendices

Appendix 1. OSH update search strategy and results

Database: OSH update

Date run: 10.12.2012 (KN)

databases within OSH update: CISDOC, HSELINE, International Bibliographic, NIOSHTIC, NIOSHTIC-2, RILOSH

#1 735300  DC{OUBIB or OUCISD or OUHSEL or OUNIOC or OUNIOS or OURILO}
#2 1166  GW{hand injur*}
#3 19  GW{tendon injur*}
#4 310  GW{arm injur*}
#5 113  GW{wrist injur*}
#6 14  GW{(brachium and fractur*) or (brachial and fractur*)}
#7 5  GW{(ulna fracture or (ulna and fractur*))}
#8 69  GW{finger injur*}
#9 105  GW{(radius fracture or (radius and fractur*))}
#10 1578  #2 or #3 or #4 or #5 or #6 or #7 or #8 or #9
#11 194345  GW{occupational medicine or occupational health service or rehabilitation or employment or work or education or educational status}
#12 2193  GW{counseling or counselling}
#13 259  GW{vocational guidance}
#14 663  GW{vocational training}
#15 1156  GW{vocational rehabilitation or work rehabilitation or occupational rehabilitation}
#16 51  GW{workplace intervention}
#17 4435  GW{work* and intervention}
#18 3  GW{workplace adjustment}
#19 116  GW{work* adjustment}
#20 8  GW{modified duties or modified duty}
#21 13  GW{case manager}
#22 0  GW{work reintegration*}
#23 0  GW{vocational workplace}
#24 8341  #12 or #13 or #14 or #15 or #16 or #17 or #18 or #19 or #20 or #21
#25 3945  GW{absenteeism*}
#26 2155  GW{medical leave or sick leave or sickness leave or sickness absence}
#27 5393  #25 or #26
#28 827927  GW{return to work}
#29 0  GW{"return to work"}
#30 278  GW{return-to-work}
#31 3139  GW{return and work}
#32 2701  GW{unemployment}
#33 26434  GW{employable or employability or employee}
#34 31078  #30 or #31 or #32 or #33
#35 147  GW{(disability management) or (disab* management)}
#36 423  GW{workability or (work* ability)}
#37 236  GW{work disability}
#38 444  GW{work activity or (work* activity)}
#39 43  GW{(work retention) or (work* retention) or (job retention)}
#40 116  GW{(work status) or (work* status)}
#41 1378  #35 or #36 or #37 or #38 or #39 or #40
#42 36136  #27 or #34 or #41
#43 145  #10 and #11 and #42

Appendix 2. CENTRAL search strategy and results

Database CENTRAL

Date Run: 12/12/12 (KN)

IDSearchhits
#1MeSH descriptor: [Hand Injuries] explode all trees178
#2"hand injury" or "hands injury" or "hand injur*" or "hands injur*"147
#3MeSH descriptor: [Tendon Injuries] explode all trees353
#4"tendon injury" or "tendon injur*"216
#5MeSH descriptor: [Forearm Injuries] explode all trees233
#6"forearm injury" or "forearm injur*" or "forearms injur*"39
#7MeSH descriptor: [Wrist Injuries] explode all trees102
#8"wrist injuries" or "wrist injury" or "wrist injur*" or "wrists injur*"120
#9MeSH descriptor: [Humeral Fractures] explode all trees59
#10"humeral fracture" or "humeral fractures" or "humeral fractur*" or "humerus fracture" or "humerus fractur*" or "humeri fracture" or "humeri fractur*"139
#11MeSH descriptor: [Shoulder Fractures] explode all trees44
#12"shoulder fractur*" or "brachium fractur*" or "brachial fractur*"51
#13MeSH descriptor: [Radius Fractures] explode all trees253
#14"radius fractur*" or "radii fractur*"311
#15MeSH descriptor: [Ulna Fractures] explode all trees35
#16"ulna fractur*"50
#17MeSH descriptor: [Upper Extremity] explode all trees4921
#18#17 and injur*390
#19"upper extremity injury" or "upper extremity injur*"27
#20MeSH descriptor: [Finger Injuries] explode all trees84
#21"finger injur*" or " digit injur*"99
#22#1 or #2 or #3 or #4 or #5 or #6 or #7 or #8 or #9 or #10 or #11 or #12 or #13 or #14 or #15 or #16 or #18 or #19 or #20 or #211530
#23MeSH descriptor: [Occupational Medicine] explode all trees57
#24#23 or "occupational medicine"346
#25MeSH descriptor: [Occupational Health] explode all trees321
#26#25 or "occupational health"1248
#27MeSH descriptor: [Occupational Health Services] explode all trees270
#28#27 or "occupational health service*"456
#29MeSH descriptor: [Rehabilitation] explode all trees12150
#30#29 or "rehabilitation"30286
#31MeSH descriptor: [Employment] explode all trees965
#32#31 or "employment"2626
#33MeSH descriptor: [Work] explode all trees247
#34#33 or "working"7989
#35MeSH descriptor: [Education] explode all trees16645
#36MeSH descriptor: [Educational Status] explode all trees959
#37#35 or #36 or "education"33155
#38#24 or #26 or #28 or #30 or #32 or #34 or #3765899
#39MeSH descriptor: [Rehabilitation, Vocational] explode all trees307
#40MeSH descriptor: [Counseling] explode all trees2656
#41MeSH descriptor: [Vocational Guidance] explode all trees26
#42"work rehabilitation"32
#43"vocational*"850
#44"counseling*" or "counsell*"9081
#45"training*"25094
#46"occupational rehabilitation*"103
#47"workplace intervention*"90
#48"workplace accomodation*"0
#49"workplace adjustment*"10
#50"modified-duty" or "modified-duties" or "modified work*"25
#51"case manager*"341
#52"work reintegration*"6
#53"work-site-visit*" or "work site visit"13
#54"workplace vocational*"1
#55#54 or "vocational workplace*"3
#56#39 or #40 or #41 or #42 or #43 or #44 or #45 or #46 or #47 or #49 or #50 or #51 or #52 or #53 or #5533245
#57MeSH descriptor: [Absenteeism] explode all trees377
#58#57 or "absenteeism*"833
#59MeSH descriptor: [Sick Leave] explode all trees336
#60#59 or "sick leave*" or "sickness leave*" or "sickness absence*"978
#61#58 or #601620
#62"return-to-work" or "return to work"1143
#63MeSH descriptor: [Unemployment] explode all trees56
#64#63 or "unemployment" or "unemployed"517
#65"employability" or "employable" or "employee*"1591
#66#62 or #64 or #653087
#67"disability management"18
#68"work ability" or "work activity"110
#69"work disability" or "work disabilities"136
#70"work status"209
#71"work retention" or "job retention"24
#72"workability"13
#73#67 or #68 or #69 or #70 or #71 or #72448
#74#38 or #5681363
#75#61 or #66 or #734426
#76#22 and #74 and #7558
#77#76 limit to trial13

Appendix 3. PubMed search strategy and results

Database: PubMed

Date run: 15.11.2012 (KN)

(("hand injuries"[MeSH Terms] OR hand injury[Text Word] OR hands injury[Text Word] OR hand injur*[Text Word] OR hands injur*[Text Word] OR "tendon injuries"[MeSH Terms] OR tendon injury[Text Word] OR tendon injur*[Text Word] OR "forearm injuries"[MeSH Terms] OR forearm injury[Text Word] OR forearm injur*[Text Word] OR forearms injur*[Text Word] OR "wrist injuries"[MeSH Terms] OR wrist injuries[Text Word] OR wrist injury[Text Word] OR wrist injur*[Text Word] OR wrists injur*[Text Word] OR "humeral fractures"[MeSH Terms] OR humeral fractures[Text Word] OR humeral fracture[Text Word] OR humeral fractur*[Text Word] OR humerus fracture[Text Word] OR humerus fractur*[Text Word] OR humeri fracture[Text Word] OR humeri fractur*[Text Word] OR "shoulder fractures"[MeSH Terms] OR shoulder fractures[Text Word] OR brachium fractur*[Text Word] OR brachial fractur*[Text Word] OR "radius fractures"[MeSH Terms] OR radius fractures[Text Word] OR radius fracture[Text Word] OR radius fractur*[Text Word] OR radii fractur*[Text Word] OR "ulna fractures"[MeSH Terms] OR ulna fractures[Text Word] OR ulna fracture[Text Word] OR ulna fractur*[Text Word] OR "Upper Extremity/injuries"[Mesh] OR upper extremity injury[Text Word] OR upper extremity injur*[Text Word] OR "finger injuries"[MeSH Terms] OR finger injuries[Text Word] OR finger injury[Text Word] OR finger injur*[Text Word] OR digit injury[Text Word] OR digit injur*[Text Word]) AND (("occupational medicine"[MeSH Terms] OR occupational medicine[Text Word] OR "occupational health"[MeSH Terms] OR occupational health[Text Word] OR "occupational health services"[MeSH Terms] OR occupational health services[Text Word] OR "rehabilitation"[Subheading] OR "rehabilitation"[MeSH Terms] OR rehabilitation[Text Word] OR "employment"[MeSH Terms] OR employment[Text Word] OR "work"[MeSH Terms] OR working[Text Word] OR "education"[Subheading] OR "educational status"[MeSH Terms] OR "education"[MeSH Terms] OR education[Text Word]) OR ("Rehabilitation, Vocational"[Mesh] OR "Counseling"[Mesh] OR "Vocational Guidance"[Mesh] OR work rehabilitation[Text Word] OR vocational*[Text Word] OR counseling*[Text Word] OR training*[Text Word] OR occupational rehabilitation*[Text Word] OR workplace intervention*[Text Word] OR workplace accommodation*[Text Word] OR workplace adjustment*[Text Word] OR modified-duty[Text Word] OR modified-duties[Text Word] OR modified work*[Text Word] OR case manager*[Text Word] OR work reintegration*[Text Word] OR work-site-visit*[Text Word] OR workplace vocational*[Text Word])) AND (("absenteeism"[MeSH Terms] OR absenteeism[Text Word] OR absenteeism*[Text Word] OR "sick leave"[MeSH Terms] OR sick leave[Text Word] OR sick leaves[Text Word] OR sickness leave[Text Word] OR Sickness absence[Text Word]) OR (return to work[Text Word] OR return-to-work[Text Word] OR "unemployment"[MeSH Terms] OR unemployment[Text Word] OR unemployed[Text Word] OR employability[Text Word] OR employable[Text Word] OR employee*[Text Word]) OR (disability management[Text Word] OR work ability[Text Word] OR work activity[Text Word] OR work disability[Text Word] OR work status[Text Word] OR work retention[Text Word] OR job retention[Text Word] OR workability[Text Word]))) AND (randomized controlled trial[pt] OR controlled clinical trial[pt] OR randomized[tiab] OR placebo[tiab] OR drug therapy[sh] OR randomly[tiab] OR trial[tiab] OR groups[tiab] NOT (animals[mh] NOT humans[mh]))

Search history

SearchQueryItems found
#11Search #10 AND #7 45
#10Search #1 AND #8 AND #9 258
#9Search #4 OR #5 OR #6 74182
#8Search #2 OR #3 1390446
#7Search (randomized controlled trial[pt] OR controlled clinical trial[pt] OR randomized[tiab] OR placebo[tiab] OR drug therapy[sh] OR randomly[tiab] OR trial[tiab] OR groups[tiab] NOT (animals [mh] NOT humans [mh])) 2629467
#6Search disability management[Text Word] OR work ability[Text Word] OR work activity[Text Word] OR work disability[Text Word] OR work status[Text Word] OR work retention[Text Word] OR job retention[Text Word] OR workability[Text Word] 3932
#5Search return to work[Text Word] OR return-to-work[Text Word] OR "unemployment"[MeSH Terms] OR unemployment[Text Word] OR unemployed[Text Word] OR employability[Text Word] OR employable[Text Word] OR employee*[Text Word] 61319
#4Search "absenteeism"[MeSH Terms] OR absenteeism[Text Word] OR absenteeism*[Text Word] OR "sick leave"[MeSH Terms] OR sick leave[Text Word] OR sick leaves[Text Word] OR sickness leave[Text Word] OR Sickness absence[Text Word] 13142
#3Search "Rehabilitation, Vocational"[Mesh] OR "Counseling"[Mesh] OR "Vocational Guidance"[Mesh] OR work rehabilitation[Text Word] OR vocational*[Text Word] OR counseling*[Text Word] OR training*[Text Word] OR occupational rehabilitation*[Text Word] OR workplace intervention*[Text Word] OR workplace accommodation*[Text Word] OR workplace adjustment*[Text Word] OR modified-duty[Text Word] OR modified-duties[Text Word] OR modified work*[Text Word] OR case manager*[Text Word] OR work reintegration*[Text Word] OR work-site-visit*[Text Word] OR workplace vocational*[Text Word] 319628
#2Search "occupational medicine"[MeSH Terms] OR occupational medicine[Text Word] OR "occupational health"[MeSH Terms] OR occupational health[Text Word] OR "occupational health services"[MeSH Terms] OR occupational health services[Text Word] OR "rehabilitation"[Subheading] OR "rehabilitation"[MeSH Terms] OR rehabilitation[Text Word] OR "employment"[MeSH Terms] OR employment[Text Word] OR "work"[MeSH Terms] OR working[Text Word] OR "education"[Subheading] OR "educational status"[MeSH Terms] OR "education"[MeSH Terms] OR education[Text Word] 1243699
#1Search "hand injuries"[MeSH Terms] OR hand injury[Text Word] OR hands injury[Text Word] OR hand injur*[Text Word] OR hands injur*[Text Word] OR "tendon injuries"[MeSH Terms] OR tendon injury[Text Word] OR tendon injur*[Text Word] OR "forearm injuries"[MeSH Terms] OR forearm injury[Text Word] OR forearm injur*[Text Word] OR forearms injur*[Text Word] OR "wrist injuries"[MeSH Terms] OR wrist injuries[Text Word] OR wrist injury[Text Word] OR wrist injur*[Text Word] OR wrists injur*[Text Word] OR "humeral fractures"[MeSH Terms] OR humeral fractures[Text Word] OR humeral fracture[Text Word] OR humeral fractur*[Text Word] OR humerus fracture[Text Word] OR humerus fractur*[Text Word] OR humeri fracture[Text Word] OR humeri fractur*[Text Word] OR "shoulder fractures"[MeSH Terms] OR shoulder fractures[Text Word] OR brachium fractur*[Text Word] OR brachial fractur*[Text Word] OR "radius fractures"[MeSH Terms] OR radius fractures[Text Word] OR radius fracture[Text Word] OR radius fractur*[Text Word] OR radii fractur*[Text Word] OR "ulna fractures"[MeSH Terms] OR ulna fractures[Text Word] OR ulna fracture[Text Word] OR ulna fractur*[Text Word] OR "Upper Extremity/injuries"[Mesh] OR upper extremity injury[Text Word] OR upper extremity injur*[Text Word] OR "finger injuries"[MeSH Terms] OR finger injuries[Text Word] OR finger injury[Text Word] OR finger injur*[Text Word] OR digit injury[Text Word] OR digit injur*[Text Word] 56913

Appendix 4. EMBASE search strategy and results

Database: Embase

Date run: 28.11.2012 (KN)

   
NoQueryResults
#95#92 AND [humans]/lim192
#94#92 AND 'human'/de192
#93#91 AND [embase]/lim196
#92#91 NOT ([medline]/lim NOT [embase]/lim)196
#91#90 AND ([controlled clinical trial]/lim OR [randomized controlled trial]/lim)237
#90#28 AND #46 AND #873,753
#89#74 OR #80 OR #87378,705
#88#46 OR #692,778,374
#87#81 OR #82 OR #83 OR #84 OR #85 OR #86339,607
#86'work'/exp OR work AND status55,445
#85'work'/exp OR work AND retention OR 'job'/exp OR job AND retention9,808
#84'work'/exp OR work AND activity200,129
#83'work'/exp OR work AND ('disability'/exp OR disability)24,869
#82'work'/exp OR work AND ('ability'/exp OR ability) OR workability44,771
#81'disability'/exp OR disability AND ('management'/exp OR management)68,389
#80#75 OR #77 OR #7940,526
#79'employability' OR 'employability'/exp OR employability OR employable OR 'employee'/exp OR employee23,020
#78'employability'/exp OR employability OR employable OR employe*282,158
#77'unemployment' OR 'unemployment'/exp OR unemployment11,769
#76'unemployment'/exp9,133
#75'return to work'6,587
#74#71 OR #7317,535
#73'medical leave'/exp OR 'medical leave' OR 'sick leave'/exp OR 'sick leave' OR sick AND leave OR 'sickness leave' OR 'sickness absence'/exp OR 'sickness absence'16,185
#72'medical leave'/exp2,775
#71'absenteeism' OR 'absenteeism'/exp OR absenteeism OR absenteeism*13,714
#70'absenteeism'/exp12,279
#69#48 OR #50 OR #52 OR #55 OR #56 OR #58 OR #59 OR #60 OR #61 OR #62 OR #63 OR #64 OR #67 OR #68574,423
#68vocation* AND ('workplace'/exp OR workplace)757
#67'vocational workplace'1
#64'work site visit'4
#63'work'/exp OR work AND reintegration*745
#62'case manager'/exp OR 'case manager'2,008
#61'modified-duty' OR 'modified-duties' OR modified AND work*26,978
#60'workplace adjustment' OR (work* AND adjustmet)10
#59'workplace accomodation' OR (work* AND accomodation)99
#58'workplace intervention' OR (work* AND intervention)44,043
#57'workplace intervention'137
#56'vocational rehabilitation'/exp OR 'vocational rehabilitation' OR 'work rehabilitation' OR 'occupational rehabilitation'/exp OR 'occupational rehabilitation'10,740
#55‘training’/exp358,522
#54training*358,522
#53'vocational rehabilitation'/exp OR 'vocational rehabilitation' OR 'work rehabilitation'9,853
#52'vocational guidance'/exp OR 'vocational guidance' OR vocation*27,282
#51'vocational guidance'/exp2,306
#50'counseling'/exp OR 'counseling' OR counsel*143,002
#49'counseling'/exp95,845
#48'vocational rehabilitation'/exp OR 'vocational rehabilitation'9,685
#47'vocational rehabilitation'/exp8,675
#46#38 OR #39 OR #40 OR #41 OR #42 OR #43 OR #44 OR #452,517,303
#45'educational status'/exp OR 'educational status'31,641
#44'education'/exp OR 'education'1,163,555
#43'work'/exp OR 'work'918,154
#42'employment'/exp OR 'employment'70,323
#41'rehabilitation'/exp OR 'rehabilitation'467,402
#40'occupational health service'/exp OR 'occupational health service'9,623
#39'occupational health'/exp OR 'occupational health'192,978
#38'occupational medicine'/exp OR 'occupational medicine'81,626
#37'occupational medicine'/exp OR 'occupational medicine' OR occupation* AND ('medicine'/exp OR medicine)550,218
#36'educational status'/exp30,279
#35'education'/exp907,663
#34'work'/exp222,735
#33'employment'/exp44,921
#32'rehabilitation'/exp204,240
#31'occupational health service'/exp9,080
#30'occupational health'/exp168,102
#29'occupational medicine'/exp60,756
#28#13 OR #14 OR #15 OR #19 OR #20 OR #23 OR #24 OR #25 OR #26 OR #27160,001
#27'finger injuries'/exp OR 'finger injuries' OR 'finger injury'/exp OR 'finger injury' OR 'finger'/exp OR finger AND injur* OR 'digit injury' OR 'digit'/exp OR digit AND injur*16,988
#26'ulna fractures'/exp OR 'ulna fractures' OR 'ulna fracture'/exp OR 'ulna fracture' OR 'ulna'/exp OR ulna AND fractur*4,521
#25'radius fracture'/exp OR 'radius fracture' OR 'radius'/exp OR radius AND fractur* OR radii AND fractur*11,552
#24brachium AND fractur* OR brachial AND fractur*1,563
#23'shoulder fracture'/exp OR 'shoulder fracture' OR ('shoulder' OR 'shoulder'/exp OR shoulder AND fracture*)9,202
#22'shoulder fracture'/exp OR 'shoulder fracture' OR 'shoulder'/exp OR shoulder AND fracture*9,202
#21'humeral fracture'/de OR 'humeral fracture' OR 'humeral fractures'/de OR 'humeral fractures' OR humeral AND fractur* OR 'humerus fracture'/de OR 'humerus fracture' OR 'humeri fracture' OR humeri AND fractur*9,334
#20'humeral fracture'/exp OR 'humeral fracture' OR 'humeral fractures'/exp OR 'humeral fractures' OR humeral AND fractur* OR 'humerus fracture'/exp OR 'humerus fracture' OR 'humeri fracture' OR humeri AND fractur*9,334
#19'wrist injury'/exp OR 'wrist injury' OR ('wrist'/exp OR 'wrist' OR wrist* AND injur*)17,766
#18'wrist injury'/exp OR 'wrist injury' OR ('wrist'/exp OR 'wrist' AND injur*)17,520
#17'wrist injury'/exp OR 'wrist injury' OR 'wrist'/exp OR 'wrist' OR ('wrist'/exp OR wrist AND injur*)44,743
#16'wrist injury'/exp OR 'wrist injury' OR 'wrist'/exp OR wrist AND injur* OR wrists AND injur*17,720
#15'arm injury'/exp OR 'arm injury' OR 'arm'/exp OR arm AND injur*96,099
#14'tendon injury'/exp OR 'tendon injury' OR 'tendon'/exp OR tendon AND injur*43,791
#13'hand injury'/exp OR 'hand injury' OR 'hand'/exp OR 'hand' AND ('injury'/exp OR 'injury' OR injur*)71,393
#12'hand injury'/exp OR 'hand injury' OR 'hand' OR 'hand'/exp OR hand AND ('injury'/exp OR 'injury') OR injur*1,627,237
#11'hand injury'/exp OR 'hand injury' OR 'hand'/exp OR hand AND injur*71,393
#10'hand injury'/exp OR 'hand injury' OR 'hand'/exp OR hand AND ('injury'/exp OR injury) OR hands AND ('injury'/exp OR injury) OR 'hand'/exp OR hand AND injur* OR hands AND injur*74,838
#9'hand'/exp OR hand AND ('injury'/exp OR injury) OR hands AND ('injury'/exp OR injury) OR 'hand'/exp OR hand AND injur* OR hands AND injur*74,838
#8'ulna fracture'/exp2,326
#7'radius fracture'/exp6,894
#6'shoulder fracture'/exp420
#5'humerus fracture'/exp7,478
#4'wrist injury'/exp3,878
#3'arm injury'/exp48,544
#2'tendon injury'/exp15,191
#1'hand injury'/exp15,411

Appendix 5. CINAHL search strategy and results

Database: CINAHL

Data run: 05.05.2013

NoSearchCINAHL Heading or free textControl (Explode + Major Concept)Items found
#1hand injuriesCINAHL HeadingExplode+Major2644
#2hand injur*Text Word 4177
#3hands injur*Text Word 654
#4tendon injuriesCINAHL HeadingExplode+Major2762
#5tendon injur*Text Word 4200
#6forearm injuriesCINAHL HeadingExplode+Major1524
#7forearm injur*Text Word 797
#8forearms injur*Text Word 27
#9wrist injuriesCINAHL HeadingExplode+Major922
#10wrists injur*Text Word 104
#11wrist injur*Text Word 1867
#12humeral fracturesCINAHL HeadingExplode+Major833
#13humeral fractur*Text Word 1286
#14humerus fractur*Text Word 957
#15brachium fractur*Text Word 0
#16brachial fractur*Text Word 163
#17wrist fracturesCINAHL HeadingExplode+Major291
#18wrists fractur*Text Word 45
#19radius fracturesCINAHL HeadingMajor991
#20ulna fracturesCINAHL HeadingExplode+Major317
#21ulna fractur*Text Word 557
#22upper extremityCINAHL HeadingExplode+Major11403
#23upper extremity injur*Text Word 1716
#24finger injuriesCINAHL HeadingExplode+Major667
#25finger injur*Text Word 1184
#26fingers injur*Text Word 513
#27digit injur*Text Word 192
#28arm injuriesCINAHL HeadingExplode+Major7042
#29arms injur*Text Word 332
#30arm injur*Text Word 2391
#31elbow fracturesCINAHL HeadingMajor158
#32elbow fractur*Text Word 1042
#33elbows fractur*Text Word 80
#35elbow injuriesCINAHL HeadingExplode+Major1322
#34elbow injur*Text Word 2210
#36elbows injur*Text Word 131
#37#1 OR #2 OR #3 OR #4 OR #5 OR #6 OR #7 OR #8 OR #9 OR #10 OR #11 OR #12 OR #13 OR #14 OR #15 OR #16 OR #17 OR #18 OR #19 OR #20 OR #21 OR #22 OR #23 OR #24 OR #25 OR #26 OR #27 OR #28 OR #29 OR #30 OR #31 OR #32 OR #33 OR #34 OR #35 #36  30346
#38Occupational MedicineCINAHL HeadingMajor84
#39Occupational MedicineText Word 2045
#40Occupational Health NursingCINAHL HeadingMajor4631
#41Occupational Health NursingText Word 11071
#42Work EnvironmentCINAHL HeadingExplode+Major7198
#43Work EnvironmentText Word 22806
#44Rehabilitation, VocationalCINAHL HeadingExplode+Major3428
#45Vocational RehabilitationText Word 4998
#46Occupational healthCINAHL HeadingExplode+Major22982
#47Occupational healthText Word 47098
#48Occupational health servicesCINAHL HeadingExplode+Major3544
#49Occupational health service*Text Word 10835
#50rehabilitationCINAHL HeadingExplode+Major106793
#51rehabilitationText Word 105593
#52Occupational rehabilitationText Word 7775
#53workplace rehabilitationText Word 590
#54trainingText Word 91852
#55counselingCINAHL HeadingExplode+Major10611
#56counselingText Word 29864
#57counsellingText Word 6896
#58job accommodationCINAHL HeadingMajor267
#59job accommodationText Word 720
#60workplace accommodationText Word 209
#61#38 OR #39 OR #40 OR #41 OR #42 OR #43 OR #44 OR #45 OR #46 OR #47 OR #48 OR #49 OR #50 OR #51 OR #52 OR #53 OR #54 OR #55 OR #56 OR #57 OR #58 OR #59 OR #60  338214
#62#61 AND #37  7428
#63return to workText Word 3343
#64return-to-workText Word 2314
#65unemploymentCINAHL HeadingMajor843
#66unemploymentText Word 3435
#67employment of disableCINAHL HeadingExplode+Major3013
#68employment of disabledText Word 4982
#69absenteeismCINAHL HeadingMajor1247
#70absenteeism*Text Word 3371
#71employabilityText Word 193
#72employableText Word 38
#73employee*Text Word 31578
#74work abilityText Word 4599
#75work activityText Word 5788
#76work disabilit*Text Word 6402
#77sick leaveCINAHL HeadingMajor1289
#78sick leaveText Word 3272
#79#63 OR #64 OR #65 OR #66 OR #67 OR #68 OR #69 OR #70 OR #71 OR #72 OR #73 OR #74 OR #75 OR #76 OR #77 OR #78  59269
#80#79 AND #62  366
 limit trial  20
 limit RCT  6

 

Appendix 6. PsycINFO search strategy and results

Database: PsycINFO (Ovid) 1967 to December Week 1/2012

Date run: 7.12.2012 (KN)

# Searches Results
1hand injur*.mp.39
2tendon injur*.mp.7
3arm injur*.mp.11
4wrist injur*.mp.4
5((brachium and fractur*) or (brachial and fractur*)).mp.3
6(ulna fracture or (ulna and fractur*)).mp.4
7finger injur*.mp.1
8(radius fracture or (radius and fractur*)).mp.22
91 or 2 or 3 or 4 or 5 or 6 or 7 or 887
10occupational medicine.mp.162
11occupational health.mp.1477
12occupational health service*.mp.84
13rehabilitation.mp.62313
14employment.mp.34759
15work.mp.284934
16education.mp.277958
17educational status.mp.702
1810 or 11 or 12 or 13 or 14 or 15or 16 or 17589819
19(counseling or counselling).mp.71696
20vocational guidance*.mp.657
21vocational training.mp.1218
22(vocational rehabilitation or work rehabilitation or occupational rehabilitation).mp.5461
23workplace intervention.mp.68
24(work* and intervention).mp.29621
25workplace adjustment.mp.17
26work* adjustment.mp.693
27(modified duty or modified duties).mp. [14
28case manager.mp.578
29work reintegration*.mp.13
30vocational workplace.mp.1
3119 or 20 or 21 or 22 or 23 or 24 or 25 or 26 or 27 or 28
or 29 or 30
105636
32absenteeism*.mp.3158
33(medical leave or sick leave or sickness leave or sickness absence).mp.1263
3432 or 333997
35return to work.mp.1444
36unemployment.mp.6366
37(employable or employability or employee).mp.38583
3835 or 36 or 3745710
39(disability management or disab* management).386
40(workability or work* ability).mp.508
41work disability.mp.322
42(work activity or work* activity).mp.538
43(work retention or work* retention or job retention).mp.281
44(work status or work* status).mp.961
4539 or 40 or 41 or 42 or 43 or 442924
4634 or 38 or 4549496
479 and 18 and 46 6

Appendix 7. Risk of bias assessment

1. Was the allocation sequence randomly generated?

Yes, low risk of bias

The investigators describe a random component in the sequence generation process such as: referring to a random number table; using a computer random number generator; coin tossing; shuffling cards or envelopes; throwing dice; drawing of lots.

No, high risk of bias

The investigators describe a non-random component in the sequence generation process. Usually, the description would involve some systematic, non-random approach, for example: sequence generated by odd or even date of birth; sequence generated by some rule based on date (or day) of admission; sequence generated by some rule based on hospital or clinic record number.

Unclear

Insufficient information about the sequence generation process to permit judgement of 'Yes' or 'No'.

2. Was the treatment allocation adequately concealed?

Yes, low risk of bias

Participants and investigators enrolling participants could not foresee assignment because one of the following, or an equivalent method, was used to conceal allocation: central allocation (including telephone, web-based and pharmacy-controlled randomisation); sequentially-numbered drug containers of identical appearance; sequentially-numbered, opaque, sealed envelopes.

No, high risk of bias

Participants or investigators enrolling participants could possibly foresee assignments and thus introduce selection bias, such as allocation based on: using an open random allocation schedule (e.g. a list of random numbers); assignment envelopes were used without appropriate safeguards (e.g. if envelopes were unsealed or non­opaque or not sequentially numbered); alternation or rotation; date of birth; case record number; any other explicitly unconcealed procedure.

Unclear

Insufficient information to permit judgment of 'Yes' or 'No'. This is usually the case if the method of concealment is not described or not described in sufficient detail to allow a definite judgment, for example if the use of assignment envelopes is described, but it remains unclear whether envelopes were sequentially numbered, opaque and sealed.

3. Blinding - was knowledge of the allocated interventions adequately prevented during the study?

Yes, low risk of bias

Any one of the following.

  • No blinding, but the review authors judge that the outcome and the outcome measurement are not likely to be influenced by lack of blinding.

  • Blinding of participants and key study personnel ensured, and unlikely that the blinding could have been broken.

  • Either participants or some key study personnel were not blinded, but outcome assessment was blinded and the non-blinding of others unlikely to introduce bias.

No, high risk of bias

Any one of the following.

  • No blinding or incomplete blinding, and the outcome or outcome measurement is likely to be influenced by lack of blinding.

  • Blinding of key study participants and personnel attempted, but likely that the blinding could have been broken.

  • Either participants or some key study personnel were not blinded, and the non-blinding of others likely to introduce bias.

Unclear

Any one of the following.

  • Insufficient information to permit judgement of 'Yes' or 'No'.

  • The study did not address this outcome.

4. Were incomplete outcome data adequately addressed?

Yes, low risk of bias

Any one of the following.

  • No missing outcome data.

  • Reasons for missing outcome data unlikely to be related to true outcome (for survival data, censoring unlikely to be introducing bias).

  • Missing outcome data balanced in numbers across intervention groups, with similar reasons for missing data across groups.

  • For dichotomous outcome data, the proportion of missing outcomes compared with observed event risk not enough to have a clinically relevant impact on the intervention effect estimate.

  • For continuous outcome data, plausible effect size (difference in means or standardised difference in means) among missing outcomes not enough to have a clinically relevant impact on observed effect size.

  • Missing data have been imputed using appropriate methods.

No, high risk of bias

Any one of the following.

  • Reason for missing outcome data likely to be related to true outcome, with either imbalance in numbers or reasons for missing data across intervention groups.

  • For dichotomous outcome data, the proportion of missing outcomes compared with observed event risk enough to induce clinically relevant bias in intervention effect estimate.

  • For continuous outcome data, plausible effect size (difference in means or standardised difference in means) among missing outcomes enough to induce clinically relevant bias in observed effect size.

  • 'As-treated' analysis done with substantial departure of the intervention received from that assigned at randomisation.

  • Potentially inappropriate application of simple imputation.

Unclear

Any one of the following.

  • Insufficient reporting of attrition/exclusions to permit judgement of 'Yes' or 'No' (e.g. number randomised not stated, no reasons for missing data provided).

  • The study did not address this outcome.

5. Are reports of the study free of suggestion of selective outcome reporting?

Yes, low risk of bias

Any of the following.

  • The study protocol is available and all of the study's pre-specified (primary and secondary) outcomes that are of interest in the review have been reported in the pre-specified way.

  • The study protocol is not available but it is clear that the published reports include all expected outcomes, including those that were pre-specified (convincing text of this nature may be uncommon).

No, high risk of bias

Any one of the following.

  • Not all of the study's pre-specified primary outcomes have been reported.

  • One or more primary outcomes is reported using measurements, analysis methods or subsets of the data (e.g. subscales) that were not pre-specified.

  • One or more reported primary outcomes were not pre-specified (unless clear justification for their reporting is provided, such as an unexpected adverse effect).

  • One or more outcomes of interest in the review are reported incompletely so that they cannot be entered in a meta-analysis.

  • The study report fails to include results for a key outcome that would be expected to have been reported for such a study.

Unclear

Insufficient information to permit judgement of 'Yes' or 'No'. It is likely that the majority of studies will fall into this category.

6. Other sources of potential bias

Yes, low risk of bias

The study appears to be free of other sources of bias.

No, high risk of bias

There is at least one important risk of bias. For example, the study:

  • had a potential source of bias related to the specific study design used; or

  • stopped early due to some data-dependent process (including a formal-stopping rule); or

  • had extreme baseline imbalance; or

  • has been claimed to have been fraudulent; or

  • had some other problem.

Unclear

There may be a risk of bias, but there is either:

  • insufficient information to assess whether an important risk of bias exists; or

  • insufficient rationale or evidence that an identified problem will introduce bias.

Contributions of authors

WHH initiated and planned the review. WHH and HLL wrote the draft of the protocol. KKN provided related information for the traumatic upper limb injury background. CCC and HYC revised the protocol. WHH and HLL planned the search strategy. WHH and HLL undertook the search with the assistance of Trials Search Coordinator Kaisa Neuvonen from the editorial base of the Cochrane Occupational Safety and Health Review Group. WHH, CCC, and HLL participated in the decision-making process regarding inclusion and exclusion of trials. WHH, CCC, and HLL planned to participate in the data extraction and assessment of risk of bias of included studies. WHH is responsible for circulating progressive drafts of the review to all co-authors.

Declarations of interest

None known

Sources of support

Internal sources

  • Graduate Institute of Occupational Safety and Health (GIOSH), Kaohsiung Medical University, Taiwan.

    Motivational and free electronic database support for undertaking this review.

  • Department of Physical Medicine and Rehabilitation, E-Da Hospital / I-Shou University, Taiwan.

    Salary and time to enable the author to perform this review.

  • Department of Dermatology and Centre for Evidence-Based Medicine, Chang Gung Memorial Hospital-Chiayi, Chang Gung University College of Medicine, Taiwan.

    Salary and time to enable the author to perform this review.

  • Center for Evidence-Based Medicine, Taipei Medical University, Taiwan.

    Salary and time to enable the author to perform this review.

External sources

  • No sources of support supplied

Differences between protocol and review

None

Characteristics of studies

Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion
Bear-Lehman 1983A non-randomised study investigating the factors affecting return-to-work after hand injury
Berecki-Gisolf 2012An observational study investigating the predictors of sustained return-to-work after work-related injury or disease
Burton 2008A review examining the evidence on management strategies for work-relevant upper limb disorders and the extent to which the biopsychosocial model can be applied
Chang 2011A non-randomised study investigating the correlation of return-to-work and the overall hand impairment measures in workers with chronic traumatic hand injury
Cheng 2011A retrospective cohort study using job-specific functional capacity evaluation to predict the return-to-work of people with a distal radius fracture
Feehan 2004A systematic review investigating the effect of early motion (< 21 days) of joints surrounding an extra-articular hand fracture on fracture healing or functional outcomes
Freeland 2007A review on the treatment, rehabilitation, psychological and social impact, and complications of below-elbow amputations
Hales 1992A review on the management of upper extremity cumulative trauma disorders
Lohstrater 2006A randomised trial examining the effects of special hand management but no RTW outcome
Meijer 2006The study subjects had nonspecific upper extremity musculoskeletal disorders instead of traumatic injury
Pasila 1974A randomised trial investigating whether recovery was hastened when physiotherapy was supervised by a physiotherapist
Schenck 1989A review on the prevention and treatment of hand injuries
Shaw 2003A randomised trial in which participants were not the unit of randomisation but case management services for work-related upper extremity disorders
Shaw 2004A randomised trial in which participants were not the unit of randomisation but integrating case management for work-related upper extremity disorders
Unsworth-White 1994A randomised trial comparing early mobilisation with immobilisation in flexion and extension, but not vocational or physical training VR, for radial head fractures

Ancillary