The effect of employment on quality of life and community integration after traumatic brain injury

Job stability in skilled work and communication ability after moderate-severe traumatic brain injury

PURPOSE

Communication deficits may play a critical role in maintaining employment after traumatic brain injury (TBI), but links between specific communication deficits and employment outcomes have not been determined. This study identified communication measures that distinguished stably employed versus unstably employed adults with TBI.

METHODS

Participants were 31 adults with moderate-severe TBI who were employed full-time for at least 12 consecutive months before injury in skilled jobs and had attempted return to skilled jobs after injury. Sixteen had achieved stable employment (SE) post-injury, defined as full-time employment for ≥12 consecutive months; and 15 had unstable employment (UE). Participants completed a battery of communication tests identified in a prior qualitative study of communication skills required for skilled work.

RESULTS

Measures of spoken language comprehension, verbal reasoning, social inference, reading and politeness in spoken discourse significantly discriminated between SE and UE groups. Two nested models were completed and compared. The first model excluded discourse data because of missing data for two UE and one SE participant. This model revealed that measures of verbal reasoning speed (β = -0.18, p = 0.05) and social inference (β = 0.19, p = 0.05) were predictive independent of the overall model. The second model included discourse politeness data and was a better overall predictor of group membership (Likelihood ratio test, Model 1: 3.824, Model 2: 2.865).

CONCLUSION

Communication measures were positively associated with SE in skilled jobs after TBI. Clinicians should include assessment of communication for adults attempting return to work after TBI, paying specific attention to social inference and speed of verbal reasoning skills.

IMPLICATIONS FOR REHABILITATION

Traumatic brain injury (TBI) often results in communication impairments associated with the cognitive skills underlying interpersonal skills. Communication impairment after TBI has been anecdotally associated with job instability. This research associate communication functioning with work stability after TBI in skilled jobs. These findings indicate that communication impairment should be assessed in persons with TBI returning to skilled employment after injury.

Long term efficacy of an integrated neurological and vocational rehabilitation programme for young adults with acquired brain injury

PURPOSE

To characterise and determine the pre-injury, injury and post-injury factors associated with vocational outcome 1-9 years post-discharge from a mixed therapy/educational/vocational rehabilitation (VR) residential programme.

METHODS

119 clients of working age when they acquired their brain injury and who had attended the centre between 2002 and 2011 were followed up at least 1 year post-discharge to determine their vocational outcome as part of an ongoing review/audit of the service. All clients had had a severe/very severe brain injury. Clients were classified as having a positive vocational outcome (working-paid/voluntary, full/part-time or undertaking full or part-time vocationally related education) or negative vocational outcome (undertaking neither work nor education).

RESULTS

Over half of the clients attained a positive vocational outcome. Length of time since discharge did not differ between those clients with a positive or negative vocational outcome. Vocational outcome was predicted by cognitive and motor ability at discharge, and gender. Together these variables correctly classified the vocational outcome of 76 % of the clients.

CONCLUSION

Clients with severe/very severe brain injury can attain a positive vocational outcome following intensive neurorehabilitation consisting of traditional therapies in addition to educational and VR.

Do depressed patients on adjunctive atypical antipsychotics demonstrate a better quality of life compared to those on antidepressants only? A comparative cross-sectional study of a nationally representative sample of the US population

BACKGROUND

The adjunctive use of some atypical antipsychotics (AAPs) has been popular for patients with treatment-resistant depression. However, little is known about the impact of these agents on patients' Health-related quality of life (HRQoL).

OBJECTIVES

The objective of this study is to examine the impact of the adjunctive AAPs use on HRQoL among users of antidepressants with self-reported depression.

METHODS

Patients with depression (ICD-9-CM: 296, 300, and 311), and to have used the given AAPs and/or antidepressants for at least a year, were identified in the Medical Expenditure Panel Survey of 2008-2011. The patients were classified into users of adjunctive AAPs (i.e., antidepressants plus AAPs) and users of antidepressants only. Adjusted multivariate linear regression analyses were conducted to examine the association between the utilization of AAPs and HRQoL measure.(c)

RESULTS

A total of 3638 participants who met the inclusion criteria were identified (306 on AAPs vs. 3332 on antidepressants only). The study subjects were ≥18 years, predominately White (91.9%) and female (71%). The AAPs utilization was not associated with higher scores in the Physical Component Summary (PCS-12) of the Short Form Health Survey (SF-12v2) (β = 1.542, 95% CI = -0.0142 to 3.0977, P = 0.0521). Rather, it was negatively associated with the Mental Component Summary (MCS-12) scores of the SF-12v2 (β = -1.5537, 95% CI = -3.0247 to -0.0827, P = 0.0385).

CONCLUSIONS

The utilization of AAPs was not associated with higher scores of HRQoL. The findings of this study should underscore the need to consider other treatment options as add-on therapy for depression before resorting to AAPs.

Relationship between employment status and sexual functioning after traumatic brain injury

OBJECTIVE

To determine if correlations exist between employment status and sexual functioning in persons with traumatic brain injury (TBI).

DESIGN

Descriptive cross-sectional.

SETTING

Community.

PARTICIPANTS

One hundred and forty-six English-speaking, community dwelling adults, without other neurological or psychiatric disorder that could impact outcome and (1) enrolled in TBI Model Systems sexuality study database or (2) admitted to Rehabilitation Institute of Chicago with primary diagnosis of TBI between 2004-2006.

MAIN OUTCOME MEASURES

Employment status, annual income, Derogatis Interview for Sexual Functioning Self Report (DISF-SR) sum and sub-scale scores, Global Sexual Satisfaction Index (GSSI).

RESULTS

No significant difference was found in GSSI scores between employed, unemployed or students/volunteers (p = 0.20); however, lower income marginally correlated with lower GSSI scores (p = 0.09). Marginally significant lower DISF-SR Sexual Cognition sub-group (p = 0.09) scores were found in unemployed vs. employed. Lower annual income also correlated with lower DISF-SR sum scores (p = 0.06), Sexual cognition/fantasy (p = 0.07), Orgasm/ejaculation (p = 0.003) and Sexual drive and relationship (p = 0.01) scores.

CONCLUSIONS

Lower quality sexual functioning and satisfaction was present in persons with TBI and concomitant unemployment or lower annual income. Efforts are needed to increase awareness amongst the TBI population and rehabilitation professionals of the potential impact unemployment or financial stress has on sexual functioning and satisfaction.

Work stress and quality of life in persons with disabilities from four European countries: the case of spinal cord injury

BACKGROUND

Evidence on the adverse effects of work stress on quality of life (QoL) is largely derived from general populations, while respective information is lacking for people with disabilities. We investigated associations between work stress and QoL and the potentially moderating role of socioeconomic circumstances in employed persons with spinal cord injury (SCI).

METHODS

Cross-sectional data from 386 employed men and women with SCI (≥18 work h/week) from the Netherlands, Switzerland, Denmark, and Norway were analyzed. Work stress was assessed with the 'effort-reward imbalance' (ERI) model and the control component of the 'demand/control' model. QoL was operationalized with five WHOQoL BREF items. Socioeconomic circumstances were measured by years of formal education and perception of financial hardship. We applied ordinal and linear regressions to predict QoL and introduced interaction terms to assess a potential moderation of socioeconomic circumstances.

RESULTS

Multivariate analyses showed consistent associations between increased ERI and decreased overall QoL (coefficient -1.55, p < 0.001), domain-specific life satisfaction (health -1.32, p < 0.001; activities of daily living -1.28, p < 0.001; relationships -0.84, p = 0.004; living conditions -1.05, p < 0.001), and the QoL sum score (-2.40, p < 0.001). Low job control was linked to decreased general QoL (0.13, p = 0.015), satisfaction with relationships (0.15, p = 0.004), and QoL sum score (0.15, p = 0.029). None of the tested interaction terms were significant.

CONCLUSION

ERI was consistently related to all indicators of QoL, while associations with job control were less consistent. Our results do not support the notion that unfavorable socioeconomic circumstances moderate the association between work stress and QoL among persons with SCI.

Predicting health-related quality of life 2 years after moderate-to-severe traumatic brain injury

AIMS

To describe health-related quality of life (HRQL) 2 years after moderate-to-severe traumatic brain injury (TBI) and to assess predictors of HRQL.

MATERIALS AND METHODS

A prospective cohort study of 91 patients, aged 16-55 years, admitted with moderate-to-severe TBI to a trauma referral centre between 2005 and 2007, with follow-up at 1 and 2 years. Mean age was 31.1 (SD = 11.3) years, and 77% were men. Injury severity was evaluated by the Glasgow Coma Scale (GCS), head CT scan (using a modified Marshall Classification), Injury Severity Score (ISS) and post-traumatic amnesia (PTA). The Functional Independence Measure (FIM), Community Integration Questionnaire (CIQ), Beck Depression Inventory (BDI) and Medical Outcomes 36-item Short Form Health Survey (SF-36) were administered at follow-up visits. The main outcome measures were the Physical Component Summary (PCS) and Mental Component Summary (MCS) of the SF-36.

RESULTS

HRQL appears to be relatively stable between 1 and 2 years after injury. In the multivariate linear regression, younger age (β = -0.20, P = 0.032), more severe TBI (β = 0.28, P = 0.016), more severe overall trauma (β = 0.22, P = 0.026), higher levels of community integration (β = 0.36, P = 0.019) and higher positive change in PCS scores from 1 to 2 years (β = 0.41, P < 0.001) predicted better self-reported physical health 2 years post-TBI. Lower scores for depression (β = -0.70, P < 0.001) and a higher positive change in MCS scores (β = 0.62, P < 0.001) predicted better self-reported mental health.

CONCLUSIONS

Future interventions should focus on aspects related to HRQL that are more easily modified, such as physical functioning, home and social integration, productivity, and mental and emotional status.

Health-related quality of life in traumatic brain injury: is a proxy report necessary?

Despite its importance to care, clinicians and researchers often discount patient-reported outcomes in favor of proxy reports, in persons with traumatic brain injury (TBI). The rationale relates to concerns about lack of awareness of patients regarding their functioning. However, although lack of awareness occurs in some patients with severe TBI, or in TBI involving certain lesion locations, or very soon after injury, this conclusion has been overgeneralized. The objective of this study is to determine the validity of patient-reported health-related quality of life by evaluating its relationship to injury severity and more objective indices of outcome, in a representative series of adults with TBI. A consecutive sample of 374 persons with TBI at least 14 years old, and having a post-resuscitation Glasgow Coma Scale score ≤12, an acute seizure, or a CT scan showing TBI- related findings. Seventy-six percent (374/491) of the eligible survivors were assessed at 6 months post-injury on the Life Satisfaction Survey. The greatest decrease in satisfaction was in the ability to think and remember, work, receive adequate income, and participate in leisure and recreational activities. Dissatisfaction significantly related to the functional limitation in that area as judged by the patients themselves (p<0.001) or by someone who knew them well (p≤0.001). The most severely injured group reported the most dissatisfaction for 13 out of 17 areas assessed. Patients with TBI, in general, do not need a proxy to report on their behalf regarding their functional limitations or health-related quality of life.

A health and wellness intervention for those with moderate to severe traumatic brain injury: a randomized controlled trial

OBJECTIVES

To assess the efficacy of a standardized 12-week health and wellness group intervention for those with moderate to severe traumatic brain injury (TBI).

STUDY DESIGN

Randomized controlled trial.

PARTICIPANTS

Seventy-four individuals with moderate to severe TBI recruited from the outpatient program at a rehabilitation hospital, a Veterans Affairs Medical Center, and the community.

METHOD

Eligible participants were randomized to treatment (health and wellness therapy group) or wait-list control (treatment, n = 37; wait-list, n = 37). The primary outcome was the Health Promoting Lifestyle Profile-II.

RESULTS

The results of the mixed-model repeated-measures analysis indicated no differences between treatment and control groups engaging in activities to increase their health and well-being.

CONCLUSIONS

Findings did not support the efficacy of the intervention. Results may have been impacted by the wide variability of individualized health and wellness goals selected by group members, the structure and/or content of the group, and/or the outcome measures selected.

Inter-professional clinical practice guideline for vocational evaluation following traumatic brain injury: a systematic and evidence-based approach

INTRODUCTION

This paper introduces an inter-professional clinical practice guideline for vocational evaluation following traumatic brain injury. This guideline aims to explicate the processes and factors relevant to vocational evaluation to assist evaluators (i.e. health care teams, individuals and employers) in collaboratively determining if clients are able to work and to make recommendations for work entry, re-entry or vocational planning.

METHODS

Methods in the Canadian Medical Association's (CMA) Handbook on Clinical Practice Guideline and the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument were utilized to ensure rigour. Steps in the CMA handbook were followed and included: (1) identifying the guideline's objective and questions; (2) systematic literature review; (3) study selection and quality appraisal; (4) development of clear recommendations by key stakeholders; (5) guideline pilot testing and endorsement.

RESULTS

The resulting guideline includes 17 key recommendations within the seven domains: (1) evaluation purpose and rationale; (2) initial intake process; (3) assessment of the personal domain; (4) assessment of the environment; (5) assessment of occupational/job requirements; (6) analysis and synthesis; (7) evaluation recommendations.

CONCLUSIONS

The guideline may be useful to individually practicing clinicians, health care teams, employers and individuals with TBI. Future research will formally examine the success of the guideline's implementation.

Community Integration Following Severe Traumatic Brain Injury: Outcomes and Best Practice

Community integration is often cited as the ultimate aim of rehabilitation. However, outcome studies show that following severe traumatic brain injury (TBI), many people do not return to valued life roles or reach previous levels of integration within their community. More recent research, in association with extensive clinical experience, reveals significant variability in outcomes within this group. Although some people return to productive activity and maintain a network of family and friends, others lead lives characterised by boredom and loneliness. This paper has two aims. The first is to examine TBI community integration outcome literature and selected theoretical models. The second is to describe a Community Approach to Participation (CAP), an individualised and collaborative model of community-based practice, which endeavours to address the poor outcomes identified following TBI. The CAP will be illustrated in the detailed case study of Sarah.

An integrated review of the processes and factors relevant to vocational evaluation following traumatic brain injury

INTRODUCTION

In order to develop the evidence base for a clinical practice guideline (CPG) for vocational evaluation following traumatic brain injury (TBI), we undertook a review to identify the key processes evaluators should follow and the key factors they should consider when completing a vocational evaluation.

METHODS

Processes outlined in the Cochrane Handbook of Systematic Review guided our processes and included: development of review questions, search strategies and selection criteria; quality appraisal; extraction, analysis and data synthesis; drawing conclusions. Four data bases (i.e. Medline; PsychInfo; Embase; The Cochrane Library of Systematic Reviews) were searched for descriptive articles, quantitative and qualitative studies, and nine websites were searched for CPGs (e.g. Scottish Intercollegiate Guideline Network; US National Guideline Clearinghouse; New Zealand Guideline Group). Two reviewers independently appraised methodological quality. Data were extracted into evidence tables which included: study purpose; location; participants; design/method; themes; findings; relevant processes and factors. Directed content analysis was utilized to analyze and synthesize the descriptive process evidence. A constant comparative method was employed to compare study findings in relation to factors associated with successful employment.

RESULTS

Results from process and factors syntheses are integrated into the Evidence-based Framework for Vocational Evaluation Following TBI. This framework identifies seven key processes in a vocational evaluation, including: (1) identification of the evaluation purpose and rationale; (2) intake process; (3) assessment of the person; (4) assessment of the environment; (5) assessment of the occupation/job requirements; (6) analysis and synthesis of assessment results; (7) development of evaluation recommendations. Relevant factors are integrated into each key process.

CONCLUSIONS

This framework outlines the key information evaluators should gather, the domains of the person, environment and occupation they should assess, and elements of rigour they should consider when completing a vocational evaluation and making recommendations for work re-entry following a TBI.

Racial and ethnic disparities in employment outcomes for persons with traumatic brain injury: a longitudinal investigation 1-5 years after injury

OBJECTIVE

To determine whether differences exist in employment rates between whites, blacks, and Hispanics with traumatic brain injury (TBI) at 1, 2, or 5 years after injury; to determine whether changes occur in postinjury employment rates over time for whites, blacks, and Hispanics; and to determine whether changes in postinjury employment rates over time are different for whites, blacks, and Hispanics.

SETTING

Sixteen TBI Model System centers.

PATIENTS OR OTHER PARTICIPANTS

Persons (3,940) with moderate-to-severe TBI who self-reported as white, black, or Hispanic.

MAIN OUTCOME MEASUREMENTS

Employment status dichotomized as competitively employed versus not competitively employed.

RESULTS

The odds of competitive employment were significantly greater for whites versus blacks at 1, 2, and 5 years after injury and were greater for whites versus Hispanics at 1 and 2 years after injury; whites and Hispanics did not differ significantly at 5 years after injury; and blacks and Hispanics were not significantly different at 1, 2, or 5 years after injury. The odds of employment increased significantly from 1-2, 2-5, and 1-5 years after injury for whites and Hispanics, whereas the odds of employment increased from 2-5 and 1-5 years after injury for blacks, with no significant difference between 1 and 2 years after injury for blacks. No evidence was found that the changes in employment rates over time were significantly different among the race and/or ethnicity groups.

CONCLUSION

Future researchers should seek to identify causative factors for employment disparities, and rehabilitation professionals should work to mitigate inequalities in employment among racial and ethnic groups with TBI.

A prospective study to evaluate a residential community reintegration program for patients with chronic acquired brain injury

OBJECTIVE

To examine the effects of a residential community reintegration program on independent living, societal participation, emotional well-being, and quality of life in patients with chronic acquired brain injury and psychosocial problems hampering societal participation.

DESIGN

A prospective cohort study with a 3-month waiting list control period and 1-year follow up.

SETTING

A tertiary rehabilitation center for acquired brain injury.

PARTICIPANTS

Patients (N=70) with acquired brain injury (46 men; mean age, 25.1y; mean time post-onset, 5.2y; at follow up n=67).

INTERVENTION

A structured residential treatment program was offered directed at improving independence in domestic life, work, leisure time, and social interactions.

MAIN OUTCOME MEASURES

Community Integration Questionnaire (CIQ), Employability Rating Scale, living situation, school, work situation, work hours, Center for Epidemiological Studies Depression Scale, EuroQOL quality of life scale (2 scales), World Health Organization Quality of Life Scale Abbreviated (WHOQOL-BREF; 5 scales), and the Global Assessment of Functioning (GAF) scale.

RESULTS

There was an overall significant time effect for all outcome measures (multiple analysis of variance T(2)=26.16; F(36,557) 134.9; P=.000). There was no spontaneous recovery during the waiting-list period. The effect sizes for the CIQ, Employability Rating Scale, work hours, and GAF were large (partial η(2)=0.25, 0.35, 0.22, and 0.72, respectively). The effect sizes were moderate for 7 of the 8 emotional well-being and quality of life (sub)scales (partial η(2)=0.11-0.20). The WHOQOL-BREF environment subscale showed a small effect size (partial η(2)=0.05). Living independently rose from 25.4% before treatment to 72.4% after treatment and was still 65.7% at follow up.

CONCLUSIONS

This study shows that a residential community reintegration program leads to significant and relevant improvements of independent living, societal participation, emotional well-being, and quality of life in patients with chronic acquired brain injury and psychosocial problems hampering societal participation.

Sense of coherence and disability and the relationship with life satisfaction 6-15 years after traumatic brain injury in northern Sweden

The objective of the study was to assess sense of coherence (SOC) many years after traumatic brain injury (TBI) and explore the relationship between SOC and self-rated life satisfaction (LS) as well as measures of functioning and disability, sex, age at injury, injury severity and time post-injury. Sixty-six individuals (aged 18-65 years) who were 6-15 years post-injury were interviewed. Data on SOC (SOC-13 item scale), measures of functioning and disability (Mayo-Portland Adaptability Inventory, MPAI-4), LS (Satisfaction with Life Scale, SWLS), and sex, age at injury, injury severity and time post-injury were analysed with hierarchical multiple regression analyses. The results showed that SOC in the study group did not differ from the general population and was strongly associated with LS. Regression analyses revealed that emotional factors, social participation, SOC, and time since injury, were more influential than sex, age at injury, and injury severity in explaining LS. It was concluded that SOC in this group of individuals with TBI who were many years post-injury was similar to nondisabled individuals. SOC, together with emotional factors, social participation and injury-related factors, were determinants of LS. These results confirm that LS after TBI is a complex phenomenon dependent on several factors that are important targets for rehabilitation professionals.

Outcome measures for traumatic brain injury

Traumatic brain injury (TBI) is a major public health problem resulting in death and disabilities of young and productive people. Though the mortality of TBI has decreased substantially in recent years the disability due to TBI has not appreciably reduced. Various outcome scales have been proposed and used to assess disability after TBI. A few, commonly used are Glasgow Outcome Scale (GOS) with or without extended scores, Disability Rating Scale (DRS), Functional Independence Measure (FIM), Community Integration Questionnaire (CIQ), and the Functional Status Examination (FSE). These scales assess disability resulting from physical and cognitive impairments. For patients with good physical recovery a cognitive and neuropsychological outcome measure is required. Such measures include Neurobehavioural Function Inventory and specific neuropsychological tests like Rey Complex Figure for visuoconstruction and memory, Controlled Oral Word Association for verbal fluency, Symbol Digit Modalities (verbal) for sustained attention and Grooved Pegboard for fine motor dexterity. A more holistic and complete outcome measure is Quality of Life (QOL). Disease specific QOL measure for TBI, Quality of Life after Brain Injury (QOLIBRI) has also been recently proposed. The problems with outcome measures include poor operational definitions, lack of sensitivity or low ceiling effects, inability to evaluate patients who cannot report, lack of integration of morbidity and mortality categories, and limited domains of functioning assessed. GOSE-E satisfies most of the criteria of good outcome scale and in combination with neuropsychological tests is a near complete instrument for assessment of outcome after TBI.

The personal and workplace factors relevant to work readiness evaluation following acquired brain injury: occupational therapists' perceptions

OBJECTIVE

This study examined the personal and workplace/environmental factors perceived most relevant to work readiness evaluations following acquired brain injury.

RESEARCH DESIGN

Using a qualitative secondary analysis design 'indicators of success' and 'risks of failure', identified as relevant in a primary study of occupational therapists' evaluation practices, were explored further.

METHOD

Data collected in the primary study, e.g. interviews, practice surveys, evaluation protocols, were re-analysed. Surveys and protocols were used to define participant and practice context characteristics. Interviews were coded, by three investigators, using a constructivist grounded theory approach.

RESULTS

Four themes emerged describing relevant personal client attributes: (1) motivation; (2) physical and functional independence; (3) cognitive abilities; and (4) use of compensatory strategies and feedback. Four themes emerged describing relevant workplace factors: (1) workplace demands; (2) employer risks and burden; (3) risks associated with information sharing; and (4) financial implications associated with return to work.

CONCLUSIONS

Findings suggest that work readiness needs to be viewed as both a client and a workplace issue. Findings are translated into questions for rehabilitation professionals to guide evaluations of work readiness. Recommendations for future research include investigating how professionals weigh factors in their decision-making and exploring strategies relevant from a workplace perspective.

Traumatic brain injury and long-term quality of life: findings from an Australian study

Recent calls have been made for the inclusion of health-related quality of life (HRQoL) in traumatic brain injury studies. This study reports the impact of TBI on traditional measures (general health, depression, social isolation, labor force participation), self-assessed health function status using the SF-36 version 2 (SF-36V2), and self-assessed health preference using two generic utility instruments, the assessment of quality of life (AQoL) and the SF6D. A random sample of TBI cases (n = 66) was drawn from a trauma registry and matched (gender, age, education, and relationship status) with non-trauma-exposed cases from a population health survey. All participants were interviewed and the two cohorts compared. When compared with matched comparators, TBI cases experienced worse general health, elevated probabilities of depression, social isolation, and worse labor force participation rates. The TBI-cohort reported worse health status on the SF-36V2. The most affected areas were social function, role emotion, and mental health (effect sizes -0.70 to -0.86). The reported utility values indicative of a HRQoL between 13 and 24% worse than their non-TBI contemporaries (effect sizes -0.80 to -0.81). The findings suggest that TBI has long-term consequences across all aspects of peoples' lives, and that these consequences can be self-assessed using generic instruments. The challenge is to provide and evaluate long-term services targeted at the life areas that those with TBI find particularly difficult.

Racial differences in employment outcome after traumatic brain injury at 1, 2, and 5 years postinjury

Gary KW, Arango-Lasprilla JC, Ketchum JM, Kreutzer JS, Copolillo A, Novack TA, Jha A. Racial differences in employment outcome after traumatic brain injury at 1, 2, and 5 years postinjury.

OBJECTIVES

To examine racial differences in competitive employment outcomes at 1, 2, and 5 years after traumatic brain injury (TBI) and to determine whether changes in not competitive employment rates over time differ between blacks and whites with TBI after adjusting for demographic and injury characteristics.

DESIGN

Retrospective cohort study.

SETTING

Sixteen TBI Model System Centers.

PARTICIPANTS

Blacks (n=615) and whites (n=1407) with moderate to severe TBI.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Employment status dichotomized as competitively employed versus not competitively employed.

RESULTS

After adjusting for demographic and injury characteristics, repeated-measures logistic regression indicated that (1) the odds of not being competitively employed were significantly greater for blacks than whites regardless of the follow-up year (all P<.001); (2) the odds of not being competitively employed declined significantly over time for each race (P< or =.004); and (3) changes over time in the odds of not being competitively employed versus being competitively employed were not different between blacks and whites (P=.070). In addition, age, discharge FIM and Disability Rating Scale, length of stay in acute and rehabilitation, preinjury employment, sex, education, marital status, and cause of injury were significant predictors of employment status postinjury.

CONCLUSIONS

Short- and long-term employment is not favorable for people with TBI regardless of race; however, blacks fare worse in employment outcomes compared with whites. Rehabilitation professionals should work to improve return to work for all persons with TBI, with special emphasis on addressing specific needs of blacks.

Volunteer work and psychological health following traumatic brain injury

OBJECTIVES

To compare the long-term psychological functioning of 3 groups of survivors of traumatic brain injury (TBI): (1) those who report being regularly active either by working or studying, (2) those who are not competitively employed but are active volunteers, and (3) those who report neither working, studying, nor volunteering. PARTICIPANTS AND PROCEDURE: Two hundred eight participants aged 16 years and older with minor to severe TBI were classified as (1) Working/Studying (N = 78), (2) Volunteering (N = 54), or (3) Nonactive (N = 76).

MAIN OUTCOME MEASURES

Measures of psychological distress (anxiety, depression, cognitive disturbance, irritability/anger), fatigue, sleep disturbance, and perception of pain.

RESULTS

Survivors of TBI who report being active through work, studies, or volunteering demonstrate a significantly higher level of psychological adjustment than persons who report no activity. Even among participants who are unable to return to work and are declared on long-term disability leave, those who report engaging in volunteer activities present significantly better psychological functioning than participants who are nonactive.

CONCLUSION

Volunteering is associated with enhanced psychological well-being and should be encouraged following TBI.

Approaches to vocational rehabilitation after traumatic brain injury: a review of the evidence

BACKGROUND

Return to work after traumatic brain injury (TBI) is an important outcome but frequently problematic to achieve. Vocational rehabilitation is commonly recommended as a means of facilitating return to work after TBI. However, there are several different approaches to vocational rehabilitation after TBI and little guidance regarding how to identify the best option for a particular context.

OBJECTIVES

To (1) identify approaches most commonly underpinning vocational interventions in TBI and (2) evaluate the evidence for effectiveness, strengths and weaknesses, and application of each approach for the TBI population.

METHODS

Principles of systematic review were used for searching and critiquing articles. Findings are expressed as descriptive synthesis owing to heterogeneity of designs and outcome measures.

RESULTS

Three broad categories of vocational rehabilitation for people with TBI were identified on the basis of models that underpin them-program-based vocational rehabilitation, supported employment, and case coordinated. The characteristics, similarities, differences, and applications of each approach are described, as are their strengths and limitations.

CONCLUSIONS

There is little clear evidence to suggest what should be considered the "best practice" approach to vocational rehabilitation.

Participation in everyday occupations in a late phase of recovery after brain injury

The aim of this study was to describe to what extent individuals of working age, in a late phase after an acquired brain injury, participate in everyday occupations related to home maintenance, work, and leisure. The aim was also to evaluate if participation in different occupations influences their life satisfaction. A sample of 157 people consecutively admitted to a rehabilitation clinic between June 1995 and December 2000 answered a mailed questionnaire. The subjects who were of working age had had a brain injury on average 6 years before this study. The perceived participation was reported using the Reintegration to Normal Living Index (RNL) and life satisfaction according to an expanded version of the LiSat 11. This study showed that in this late phase of recovery after brain injury the subjects still experienced many restrictions in participation in everyday occupations. The area with the lowest reported participation was work activity while most comfort with the situation was reported for self-care. The RNL subscales showed a significant connection with satisfaction with life as a whole. Furthermore an interaction was found between the two subscales "Daily living" and "Perception of self". This study showed restrictions in participation in the community even several years after brain injury, which underlines the need for rehabilitation services long after injury.

Self-concept and quality of life following aquired brain injury: A pilot investigation

OBJECTIVE

To investigate through pilot exploration the relationships between depression, self-concept and perceived quality of life (QoL) in post-acute patients with acquired brain injury (ABI).

METHODS

Nineteen patients with ABI were administered the Beck Depression Inventory-II and the Quality of Life Inventory, along with the Tennessee Self-Concept Scale-2 and the Head Injury Semantic Differential Scale, measures of self-concept. The relationships between these measures were explored using correlational analyses.

RESULTS

Ratings of self-concept were correlated with perceived QoL, suggesting that poorer view of self was associated with lower subjective QoL. Additionally, depressive symptoms were associated with lower QoL ratings, consistent with previous research.

CONCLUSIONS

These results suggest that intra-personal variables, such as self-concept and depression, impact the perceived QoL of the ABI survivor. Future research exploring the mediating effects of these variables on QoL may clarify this relationship and may aid in developing more effective interventions for these individuals.

Psychosocial outcomes 1–7 years after comprehensive milieu-oriented neurorehabilitation: The role of pre-injury status

PRIMARY OBJECTIVE

To explore pre-injury variables related to post-discharge psychosocial status and identify factors related to work and driving outcomes.

METHODS AND PROCEDURES

Ninety-three brain-injured patients attended a holistic milieu-oriented neurorehabilitation program and were contacted 1-7 years post-discharge.

EXPERIMENTAL INTERVENTIONS

Questionnaire data addressing pre-injury and post-injury work, driving, income, marital status and living situation.

MAIN OUTCOMES AND RESULTS

74.3% were involved in competitive work and/or school with 86.0% productive at follow-up. Post-injury income decreased significantly compared with pre-injury levels. Pre-injury relationship status did not differ significantly from post-injury; 81.1% remaining in a stable relationship or married at follow-up. Pre-injury and post-injury accident rates were related; 73.1% drove at follow-up. Higher education, non-right hemispheric injury, shorter treatment length and return to work related to driving. Younger age, higher education, non-right hemispheric injury and driving post-injury related to positive work status.

CONCLUSIONS

Pre-injury psychosocial data provide an important context for understanding post-discharge outcome after brain injury. Holistic milieu-oriented rehabilitation facilitates long-term successful work, driving and relationship stability.

Financial and vocational outcomes 2 years after traumatic brain injury

PURPOSE

To determine outcomes for persons with traumatic brain injury (TBI) in terms of employment status, income and public assistance received at 2 years after injury.

METHOD

This study was part of a non-experimental, longitudinal survey. Participants included 49 persons with new TBI from one US national Traumatic Brain Injury Model Systems centre. Main outcome measures included employment status, earned monthly income and monthly income from public sources, at the time of injury and at 2-years follow-up.

RESULTS

At 2-year follow-up, individuals with TBI reported higher levels of employment and earned income than was previously reported for 1-year post-injury, but continued to experience declines relative to pre-injury baseline. Frequency and amount of major public agency payments continued to be increased relative to baseline.

CONCLUSIONS

The costs associated with brain injury remain high for individuals, families and society, as those with TBI move into the more chronic phase of recovery.

Traumatic brain injury research priorities: the Conemaugh International Brain Injury Symposium

In 2005, an international symposium was convened with over 100 neuroscientists from 13 countries and major research centers to review current research in traumatic brain injury (TBI) and develop a consensus document on research issues and priorities. Four levels of TBI research were the focus of the discussion: basic science, acute care, post-acute neurorehabilitation, and improving quality of life (QOL). Each working group or committee was charged with reviewing current research, discussion and prioritizing future research directions, identifying critical issues that impede research in brain injury, and establishing a research agenda that will drive research over the next five years, leading to significantly improved outcomes and QOL for individuals suffering brain injuries. This symposium was organized at the request of the Congressional Brain Injury Task Force, to follow up on the National Institutes of Health Consensus Conference on TBI as mandated by the TBI ACT of 1996. The goal was to review what progress had been made since the National Institutes of Health (NIH) Consensus Conference, and also to follow up on the 1990's Decade of the Brain Project. The major purpose of the symposium was to provide recommendations to the U.S. Congress on a priority basis for research, treatment, and training in TBI over the next five years.

Validation of the Spanish version of the Side Effect and Life Satisfaction Inventory in patients with epilepsy

OBJECTIVE

The goal of the study described here was to obtain psychometric validation of the Spanish version of the 38-item Side Effects and Life Satisfaction (SEALS) Inventory.

METHODS

A cross-cultural adaptation of the inventory was performed. A total of 595 patients with epilepsy were included in a multicenter cross-sectional study. The SEALS Inventory was completed, together with the Hospital Anxiety and Depression Scale and SF-12 Health Survey.

RESULTS

The mean SEALS score was 60.7. SEALS presented high internal consistency, with a Cronbach alpha coefficient of 0.93, and good test-retest reliability, with an intraclass correlation coefficient of 0.92. The pattern of correlations with the Hospital Anxiety and Depression Scale and SF-12 Health Survey indicated good convergent and divergent validity. SEALS scores discriminated patients according to epilepsy-related factors, emotional disturbances, and the generic quality of life.

CONCLUSION

The Spanish version of the SEALS Inventory is a valid psychometric instrument. It may be used in routine clinical practice and in clinical trials in patients with epilepsy to capture the cognitive and behavioral aspects of quality of life.

Achieving a successful and sustainable return to the workforce after ABI: a client-centred approach

PRIMARY OBJECTIVE

This paper describes the approach used by the Victorian Acquired Brain Injury (ABI) specialist team of CRS Australia (formerly Commonwealth Rehabilitation Service) to facilitate participation in the workforce for its clients. The approach and results achieved are compared and contrasted with other models nationally and internationally.

METHOD AND PROCEDURES

This two part study involves a survey of the specialist team members regarding use and efficacy of assessment and intervention strategies and data mining of closed case files to identify predictors of sustainable employment outcomes for people with ABI.

MAIN OUTCOMES AND RESULTS

CRS Australia's results compare favourably with other published results (50% achieved a minimum of 13 weeks open employment compared to population estimates of 38-46.5%). Results were achieved with people with mild, moderate and severe injury. Assessments and interventions that correlate with successful employment outcome are described.

CONCLUSIONS

A client-centred approach, combining specialist ABI expertise, skilled assessment and practical workplace-based interventions results in favourable employment outcome rates.

Perceived self-efficacy and life satisfaction after traumatic brain injury

OBJECTIVE

To investigate the contribution of activity-related satisfaction and perceived self-efficacy to global life satisfaction after traumatic brain injury (TBI).

PARTICIPANTS

Convenience sample of 97 adults who were living in their community at least 6 months after sustaining a TBI.

MEASURES

Community Integration Questionnaire, Quality of Community Integration Questionnaire, Self-Efficacy Questionnaire for TBI, Perceived Quality of Life Scale, Satisfaction with Life Scale.

RESULTS

Among demographic and injury-related variables, gender and time since injury made significant contributions to the prediction of global life satisfaction. Productivity made a modest, significant contribution to life satisfaction. Satisfaction with productivity and with leisure/social activities both contributed to global life satisfaction. The greatest contribution to the prediction of global life satisfaction was made by the person's perceived self-efficacy, particularly perceived self-efficacy for the management of cognitive symptoms. Perceived cognitive self-efficacy also appeared to mediate the relation between community integration and global life satisfaction.

CONCLUSION

Community integration, activity-related satisfaction, and global life satisfaction represent distinct constructs, and dissociable aspects of psychosocial outcome after TBI. Perceived self-efficacy for the management of cognitive symptoms may mediate the relation between the individual's expectations and achievements and thereby contribute to overall subjective well-being.

Sociodemographic correlates of health-related quality of life in pediatric epilepsy

In most chronic conditions, better health-related quality of life (HRQOL) is associated with higher socioeconomic status (SES) and ethnic majority status, with disadvantaged groups typically reporting lower HRQOL. In 163 children with intractable epilepsy, we evaluated the relationship between HRQOL and a broad spectrum of demographic variables (SES, parental education, gender, age, marital status, family size, and ethnic and linguistic status), in relation to known neurological and behavioral correlates of HRQOL. No demographic variable was found to be related to child HRQOL, except for marital status, where children from divorced/separated parents had lower HRQOL. However, marital status was not uniquely predictive of HRQOL when neurological and behavioral variables were taken into account. Exploratory analyses indicated that children of separated/divorced parents were more likely to have early epilepsy onset, lower adaptive/developmental levels, and worse seizure frequency, suggesting that severe epilepsy may be a risk factor for marital stress. In sum, contrary to research in other chronic conditions, sociodemographic variables in pediatric epilepsy were weak predictors of HRQOL in comparison to neurological and behavioral variables. The results are discussed with respect to epilepsy-specific determinants of HRQOL.

Health-related Quality of Life in Multiple Sclerosis: The Impact of Disability, Gender and Employment Status

OBJECTIVES

(1) Evaluate the impact of the patient characteristics of disability, gender and employment status on health-related quality of life (HRQOL) in multiple sclerosis (MS) and (2) Characterize the functional relationship between HRQOL and disability overall, and by gender and employment status.

METHODS

We assessed the HRQOL of 215 MS outpatients in our clinic using the MSQOL-54 and Fatigue Severity Scale (FSS), and that of 172 healthy controls, using the SF-36 (a subset of MSQOL-54). We compared QOL between MS subgroups defined by disability, gender and employment, and computed the linear and non-linear relationships between disability level measured by the Expanded Disability Status Scale (EDSS) and MSQOL-54 dimensions.

RESULTS

QOL of MS patients measured by SF-36 is lower than controls, varying by QOL dimension with the greatest difference emerging for physical aspects of the disease. The relationship of physical disability, measured by EDSS, and all 14 MSQOL-54 dimensions and FSS is negative; for 12 of the 14 dimensions and FSS it is also non-linear. Non-linearity is most pronounced among women, who show a weak EDSS/QOL relationship at higher levels of physical disability, suggesting women better able to "psychologically buffer" the debilitating aspects of MS. While employed have higher QOL than unemployed, the former are more affected by physical disability.

CONCLUSIONS

Multiple attributes, including disability, gender and employment status, affect QOL. QOL's relationship with disability is complex, displaying non-linearity and interacting with patient characteristics. This has implication for QOL research methodology and provides insight into factors affecting patients' perceptions of well-being.

Factors That Lead to Successful Community Integration Following Severe Traumatic Brain Injury

OBJECTIVE

To assess and identify predictive factors of community integration of people 3 to 15 years after severe traumatic brain injury (TBI).

PARTICIPANTS

Forty participants with severe TBI (an average of 8.8 years postinjury).

MAIN OUTCOME MEASURES

The Community Integration Questionnaire, the Community Integration Measure, and the Sydney Psychosocial Reintegration Scale. Data related to factors that may predict community integration were also collected.

RESULTS

There was considerable variation in the level of community integration. Discriminant function analyses identified the following factors as predictive of the level of community integration: severity of injury, age at the time of injury, level of disability, and challenging behavior.

CONCLUSION

Interventions that minimize challenging behavior and disability may make a significant difference to the level of community integration experienced by people with severe TBI.