Gradual reintegration after minor stroke ▷ fit for work at the second attempt

The case in practice: Mr. Meier is caught up with everyday reality

Mr. Meier, 44, was lucky in his misfortuneHe suffered only a slight stroke and was helped in time. At the hospital, the blood clot was immediately dissolved. It had caused a vascular occlusion of a small cerebral artery. Visible brain damage did not remain, as well as no paralysis, speech disorder or other noticeable symptoms.

Four weeks after discharge from the hospital, he resumed his work as a clerk at an insurance company. Physically he was fine, and mentally he had recovered from the horror quite quickly with the support of his wife. Therefore, he wanted to get back to normal and work as soon as possible. In everyday life at home everything worked well so far. He needed longer for some things, but he saw no problem in that. So, after consulting with his family doctor, he went back to work full time. Thus he was able to work.

In the reality of everyday work, however, he increasingly noticed, that he can hardly concentrate on his tasks. He could not process the urgent orders fast enough. He found the many telephone calls in between exhausting, and in some cases he was unable to remember the content of the conversation. He did not know this about himself at all. It irritated him and made him feel insecure. He tried to avoid phone calls and to clarify matters in writing via e-mail.

Toward the second half of the day, he often became tired and occasionally nodded off briefly. A younger colleague once asked him flippantly if he did not get any sleep at night. He was very embarrassed about. He found himself in need of explanation as to why his performance had dropped so suddenly. Fear and self-doubt came along. He found it difficult to maintain his otherwise positive attitude and motivation. He reacted irritably more often, which annoyed him and frustrated him even more at the same time. The worst thing for him was that he did not feel understood.

When a conflict with his boss escalated, he pulled the ripcord at the urging of a colleague. Three weeks after his start, he took another sick leave. He felt the limits of his resilience, was overwhelmed and asked himself after this unsuccessful attempt at work: "What is wrong with me??" and "What should happen now??"

Often underestimated: the return to work after a stroke

Returning to work and how vocational reintegration will take place is sooner or later a crucial issue for many stroke victims.

In general, work is a central issue in life for many people. Not only to secure his livelihood, but also for his social participation, well-being and self-esteem.

A stroke usually leads to a longer-term inability to work. In many cases, restrictions and a permanent reduction in earning capacity remain. Of those who return to work, a large proportion later pursue a job with lower demands, often associated with qualitative and financial losses. Very few people return to the same job and previous activity without limitations.

The individual prognosis for a successful return to work and gainful employment depends on many factors. These include, above all:

  • the type, localization and extent of the brain damage,
  • Impact on physical, cognitive and psychological functions and abilities,
  • Personal resources and strategies for coping, compensating, and adapting,
  • Requirements of the occupational activity and conditions of the workplace,
  • Support in the social environment and financial possibilities.

And although a stroke does not have to leave any visible traces, working life can be disrupted even if the consequences are mild. Especially when problems become apparent in everyday working life, as soon as those affected are confronted with more complex tasks, unpredictability and time pressure.

In addition, psychological complaints and psychosocial aspects, a dismissal or conflicts at work can complicate the process.

As in the case of Mr. Meier. He suddenly could no longer act as he wanted and could not explain it to himself. That put him in distress. His environment reacted to his changed behavior with incomprehension and conflicts arose. Initially underestimated and misjudged indications were diagnosed in the course as neuropsychological symptoms as a result of the stroke.

The good news: Functional impairments are treatable and regress over time. However, this phase of rehabilitation lasts longer. Meanwhile, returning to work can be done through a gradual reintegration process.

With a careful inventory of critical requirements as well as individual and company opportunities, the return to work can be well prepared. Thus, the chances of success for a successful restart increase.

Taking stock: "What is wrong with me??"

Pronounced physical, cognitive and psychological impairments after a stroke are not always the cause of a prolonged inability to work. Limitations in resilience and a disability with problems in re-entering working life can occur even with mild consequences, as in Mr. Meier’s case.

Particularly relevant to work in the case of acquired brain damage are impairments of neurocognitive and organic-psychic functions and partial performance disorders caused by this. 1

Detailed information on cognitive disorders after a stroke, the symptoms, treatment options and everyday tips can be found here.

Frequent ability disorders that lead to significantly reduced work performance:

  • rapid exhaustion and increased fatigue (fatigue syndrome)
  • perceptual disturbances, word-finding disorders and speech problems
  • Attention deficit, memory impairment and learning difficulties
  • Behavioral and personality changes, emotional-affective instability
  • Problems with reading, arithmetic, writing and PC work
  • General physical and mental underload capacity

Specific examples of impairments caused by neuropsychological symptoms at work and why the return to work should not take place too early can be found here.

If these symptoms are mild, it is challenging to identify them at an early stage, especially since they are invisible and manifest themselves unspecifically. However, they intensify in everyday life and at the latest at work with increasing demands. New and inexplicable complaints should therefore make you alert and lead to a medical consultation.

If cognitive impairment is suspected a neuropsychological examination will provide clarity. If possible, this should be arranged before reintegration in order to support the return to work from the outset with suitable measures.

If necessary, an additional occupational medical-therapeutic clarification is advisable in case of special requirements of the occupational activity, specific tasks or difficult conditions in the work environment.

The basis for successful reintegration is sound diagnostics to identify and assess cognitive deficits and existing abilities. This is done in comparison with the concrete requirement profile of the occupational activity. Only with a careful inventory and a clear picture of the actual situation can the question of how to proceed professionally be answered adequately.

The second attempt: Reintegration into the workplace

The better the preparation, the better the chances of successful reintegration after a stroke. In practice, a structured approach has proven to be effective. Ideally, the return to work is tailored to the individual needs of the person affected, systematically planned, coordinated and accompanied by personal contacts.

With the company integration management (BEM), a legal basis exists for this at the same time 2 This obliges employers to offer BEM to all employees who have been incapacitated for work for more than six weeks in the course of a year.

The BEM is a procedure that is intended to facilitate and sustainably support the return to work from a longer period of illness. The aim is also to take countermeasures at an early stage if problems occur, z. B. Show tendencies to overwork in order to reduce the risk of a renewed incapacity to work.

Companies handle the implementation differently and there are a number of concepts and measures within the framework of BEM. One of these is the so-called Gradual reintegration.

Detailed information on BEM, advice centers and contact addresses can be found, for example, in the brochure from the Federal Ministry of Labor and Social Affairs 3 .

What is gradual reintegration??

Gradual reintegration (SWE), colloquially known as the "Hamburg model," is a medically initiated measure to increase the workload. 4

The aim is to gradually bring people who are partially able to return to work after a long period of serious illness up to full workload. The therapeutic purpose consists in a gradual work and stress testing, which is at the same time an everyday life training under real conditions. Therefore, reintegration is usually planned at the previous workplace.

According to the phase model of neurorehabilitation, the gradual reintegration is to be located in phase E – in aftercare. SWE links the transition from medical rehab (phase A to D) to vocational rehab.

It is important for you as a patient to know:

During gradual reintegration, you are unable to work. The employer can use you for reasonable activities according to the doctor’s recommendation, but has no contractual claim to your work performance as in the case of part-time employment. This is to reduce the risk for employees in the integration phase to get into an overload and overstrain due to performance pressure.

You will therefore not receive a salary during this period, but as a rule will continue to receive sick pay if the benefit provider is the statutory health insurance fund. It is important that the incapacity for work is certified by a doctor without any gaps.

The statutory pension insurance is responsible if a rehabilitation was previously carried out at their expense and the reintegration follows directly thereafter. Transitional allowance is paid for the period of loss of earnings.

If the need for gradual reintegration is determined in the rehab facility, it is usually initiated from there. This is done with the help of the social service and via the attending physicians. If necessary and with your consent, they can discuss the workload with the company physician.

What are the requirements and how does it work in practice??

Gradual reintegration takes place

  • in consultation with the attending physician, who initiates the measure, accompanies you during the course and adjusts the load if necessary.
  • in consultation with the employer (possibly also with the staff council, works council, representative of the employee’s interests and the integration office in the case of severe disability)
  • If necessary, with the involvement of the company doctor, which makes sense due to the knowledge of the workplaces.

Gradual reintegration is applied for via an application form to the relevant social insurance agency, which decides whether the costs of the measure will be covered. In most cases, this is the statutory health or pension insurance company.

In addition to the intended increase in stress, the aim is to increase cognitive capacities for concentration, stamina and other skills. For this purpose, technical requirements are to be designed in such a way that they are linked to remaining abilities and competencies. It is also important to enable and report a sense of achievement, as this strengthens self-confidence and self-assurance.

From a medical point of view, it is checked at the beginning whether there is a partial ability to work under pressure for the essential functional requirements and tasks of the job. The working time should be at least two to three hours a day, if necessary starting with individual weekdays, z. B. on therapy-free days. The route to work and the test of fitness to drive must be taken into account.

If it turns out during the course that changes in work design or a modification of the workplace are necessary, this can be part of the reintegration process. Likewise, ergonomic or technical aids can be tested and benefits for participation in working life can be applied for.

Through a rehabilitation consultation and needs analysis, suitable measures can often be initiated in good time beforehand. If the last activity is no longer possible or not foreseeable, other measures for occupational rehabilitation must be examined.

The stress build-up is defined in a reintegration plan.

Usually, the return to work begins with reduced (at least halved) working hours. In the course, a medically supervised increase in both the working hours and the requirements takes place step by step. The total duration for SWE is between six weeks and six months. After a stroke, it can take considerably longer in individual cases.
The reintegration plan, which is drawn up by a doctor before the start, provides precise information on the individual stress levels and a forecast of when full work capacity can be expected 4 .

The step-by-step plan specifies the type of activities that are possible with health-related restrictions and the stresses that should be avoided. Likewise supportive measures at the workplace, possibly accompanying therapies and further details (see own example below).

Recommendations beyond that:

Based on experience and clinical observation studies, it is recommended that the return to work be accompanied therapeutically and according to individual needs, if necessary with external counseling or coaching.

Competent professional care and practical help for self-help can support stroke victims in becoming aware of their abilities and competences, in specifically expanding them in coping with work and everyday life, and in strengthening their self-confidence. This in turn helps to stabilize progress, exploit potential and take action in good time during difficult phases. In this way, setbacks in the course can be averted or appropriately dealt with and employability can be secured in the long term.

In many cases, a gradual reintegration process tailored to individual needs can lead to a prompt and successful return to work. In order for this to be implemented nationwide in Germany, it is necessary to expand cross-sector structures for stroke aftercare. In health and social care systems and in the world of work in companies and businesses.

Regular consultation and close cooperation with the treating physician, the involved therapeutic and company actors and the responsible service providers is recommended during the course of the treatment. Teamwork is essential for full participation in professional and social life.

If it becomes apparent that resumption of the former activity at the previous workplace is not promising in the long term, a transfer within the company to a workplace with performance-related activities can be considered. The extent to which further qualification or retraining is possible must be examined on a case-by-case basis. The degree of disability determined by the pension office is also decisive.

If affected persons can only work for a limited period of time, there are also various support and funding options for occupational rehabilitation, e.g., for the return to work. B. from the German Pension Insurance, the Federal Employment Agency and the Integration Offices.

It is also possible to apply for a partial reduction in earning capacity pension in order to be able to earn some additional income. The pension insurance provides information on this.

The case in practice: The gradual reintegration of Mr. Meier

Taking stock: neuropsychological diagnostics and therapy

After Mr. Meier had given up trying to work, his family doctor referred him to a neuropsychologist for clarification of the cognitive disorders. The investigation confirmed the clinical indications with the following findings:

"Slightly to moderately pronounced symptoms such as poor concentration, memory problems and lack of drive. Limited mental skills such as completing more complex tasks, solving problems, and structuring. Gradual reintegration recommended, possible immediately. Progress review in six months."

Brain training through occupational therapy and a special online learning program, which he completed daily as a home training program, were also recommended and prescribed by a doctor.

In the course, Mr. Meier made continuous small progress in attention and memory performance.

The clarification and return to work conversation

He had talked to his boss shortly after the quarrel. The latter responded with understanding of his situation and signaled that he would welcome and support gradual reintegration. His team was also behind him.

Talked openly about the health limitations and the impact on work performance in a subsequent interview. Together they considered which changes were possible from an operational point of view, and how the organization and design of work could be adapted. Mutual expectations and needs were communicated and short weekly feedback meetings were arranged.

The gradual reintegration

The family doctor then suggested to Mr. Meier a gradual reintegration over three months. She saw this duration as necessary after the first unsuccessful work attempt.

The goal was to prevent relapses due to renewed overexertion, to stabilize progress in the long term, and to increase the stress testing step by step.

She consulted with the company doctor on the step-by-step plan and both agreed on the following recommendations for reintegration:

"Simple, plannable, repetitive work, PC work is possible without restriction as of now. Complicated and new tasks are possible after structured implementation and guidance. In customer service (z. B. telephone calls) support from colleagues is recommended if needed. Work under time and deadline pressure should be avoided for the next three months."

The reintegration plan looked like this:

Started with reduced working hours daily for a 5-day week: two hours in the first month – four hours in the second month – six hours in the third month – the last two weeks full-time. Implementation taking into account the above-mentioned health restrictions.

All parties involved were in agreement with this procedure. Mr. Meier resumed work a few weeks later following this pattern.

Supporting measures at the workplace:

Both the work organization and the workplace were adapted:

  • Mr. Meier initially relinquished critical tasks and responsibilities in order to be exposed to less pressure to perform and meet deadlines. The time factor was currently essential because he needed longer for mental activities, the more complex the requirements were.
  • Customer service phone calls were handled by his colleague as a substitute during the first month.
  • Moved to a smaller office next door where he could close the door and work undisturbed shielded from ambient noise.

Through the psychosocial counseling service of the company’s health management, he accepted the offer of counseling on stress management in everyday working life.

Once the work situation was clarified, Mr. Meier was better able to engage in the therapies and accept that it would take longer to.

Psychosocial process support

Once a week, he took part in the company’s internal consultation Talks with a psychologist in demand. He was also able to talk to him in confidence about unpleasant feelings, fears and concerns that came up in the meantime. This relieved him and he tried methods to support himself.

Self-coaching and meditation exercises helped Mr. Meier to become aware of his thoughts, feelings and body signals and to understand his behavior in difficult situations. Together with the discussions, he was able to identify his inner drivers for the high performance demands and to recognize personal resources that provide strength. He learned to reflect on how he was feeling and to look out for warning signs of symptoms of overwork and stress.

To prevent this, he developed strategies to deal with current challenges in his workday and better manage tasks. For example, by structuring workflows differently, prioritizing tasks and pre-planning time windows with buffers. Initially, the focus was on completing simple and repetitive tasks. For more comprehensive subjects, he has been given written instructions so that he can learn at his own pace.

With regard to self-management, a further focus was on roughly matching the degree of demand and his performance capacity for new tasks. From this, Mr. Meier was able to identify more demanding activities that require more preparation time, greater effort, and support when necessary. He learned to compensate for longer and more intense periods of stress with relaxation exercises and active breaks.

Transfer in everyday life

Mr. Meier found it increasingly easy to cope with everyday workloads. He was able to focus better on his tasks. Gradually, he was able to get back to working on more comprehensive jobs that weren’t time-critical. He temporarily took over customer telephone calls again and assisted colleagues with projects. The demands were challenging, but they now stressed him less than when he first tried to work.

By returning to work part-time and receiving occupational therapy guidance on adjusting his daily structure, he has been able to balance his therapies and personal life well with work. In the beginning, it was difficult for him to schedule enough rest periods and to allow himself time off in between. But he succeeded, feeling fitter and less tired during the day.

Successful reintegration

The gradual reintegration was successfully completed after three months with the return to full working capacity.

So far, there have been no longer periods of sick leave. Mr. Meier continues to do therapy, and he goes to psychosocial counseling as needed. He can largely compensate for remaining cognitive deficits as long as he watches his own pace and limits. This is still not easy for him, but he takes it seriously and is motivated to keep at it.


For a successful return to work after a stroke, it is important to focus on opportunities and the individual development process: By promoting skills, by strengthening personal, health and psychosocial resources and by creating suitable framework conditions. Everyone involved is pulling in the same direction.

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