Return to work following traumatic brain injury: Trends and challenges

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.

Time trend analysis of return to work after stroke in Denmark 1996-2006

BACKGROUND

In the period 1997-2005, the Danish government initiated a series of legislative changes aimed at facilitating RTW (return to work) in the Danish population. In the present study, we investigated the odds of being gainfully occupied ca. two years after stroke as a function of onset calendar year, 1996-2006.

METHODS

All previously employed 20-57 year-old stroke patients in Denmark 1996-2006 (N = 19985) were followed prospectively through national registers. The analysis was controlled for the type of stroke and a series of demographic, structural and occupational variables.

RESULTS

The odds for RTW increased significantly during the study period (P < 0.0001). The odds at the end of the period were more than twice as high as they were at the beginning, even after post hoc control for improved survival and decreased unemployment rates. The most conspicuous increase coincided with a change in the sickness benefit act that took place in 2005.

CONCLUSION

The study provides quite strong circumstantial evidence that the legislative changes had an effect on the odds of return to work after stroke. More direct evidence is desirable, but such can only be obtained through a randomized controlled study.

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.

Quality of Life after Brain Injury (QOLIBRI): scale development and metric properties

The consequences of traumatic brain injury (TBI) for health-related quality of life (HRQoL) are poorly investigated, and a TBI-specific instrument has not previously been available. The cross-cultural development of a new measure to assess HRQoL after TBI is described here. An international TBI Task Force derived a conceptual model from previous work, constructed an initial item bank of 148 items, and then reduced the item set through two successive multicenter validation studies. The first study, with eight language versions of the QOLIBRI, recruited 1528 participants with TBI, and the second with six language versions, recruited 921 participants. The data from 795 participants from the second study who had complete Glasgow Coma Scale (GCS) and Glasgow Outcome Scale (GOS) data were used to finalize the instrument. The final version of the QOLIBRI consists of 37 items in six scales (see Appendix ). Satisfaction is assessed in the areas of "Cognition," "Self," "Daily Life and Autonomy," and "Social Relationships," and feeling bothered by "Emotions," and "Physical Problems." The QOLIBRI scales meet standard psychometric criteria (internal consistency, alpha = 0.75-0.89, test-retest reliability, r(tt) = 0.78-0.85). Test-retest reliability (r(tt) = 0.68-0.87) as well as internal consistency (alpha = 0.81-0.91) were also good in a subgroup of participants with lower cognitive performance. Although there is one strong HRQoL factor, a six-scale structure explaining additional variance was validated by exploratory and confirmatory factor analyses, and with Rasch modeling. The QOLIBRI is a new cross-culturally developed instrument for assessing HRQoL after TBI that fulfills standard psychometric criteria. It is potentially useful for clinicians and researchers conducting clinical trials, for assessing the impact of rehabilitation or other interventions, and for carrying out epidemiological surveys.

A nationwide prospective cohort study on return to gainful occupation after stroke in Denmark 1996-2006

BACKGROUND

Return to work is an important outcome factor for working-age patients poststroke. Previous epidemiological studies on this topic have been small (on average 125 patients per study). Their estimated effects are therefore associated with a tremendous statistical uncertainty. The present study estimates the effect of various predictors on the odds of returning to work after stroke in the total population of 20-57-year-old previously employed hospital treated patients with stroke in Denmark 1996-2006 (N=19,985).

METHODS AND RESULTS

The patients were followed through national registers; 62% were gainfully occupied 2 years after stroke. The odds of returning to work were higher among people with intracerebral infarction, OR 1.0 (the reference group), than they were among people with subarachnoid haemorrhage, OR 0.79 (95% CI 0.71 to 0.88), and intracerebral haemorrhage, OR 0.39 (0.35 to 0.43). The odds of returning to work were lower among workers in elementary occupations OR 1.0 (reference group) than they were among workers in occupations that require skills at a basic level, OR 1.50 (1.38 to 1.64), technicians and associate professionals, OR 2.33 (2.05 to 2.65) and professionals, OR 3.04 (2.70 to 3.43). Patients in municipalities with a brain-injury rehabilitation centre did not have a better prognosis than patients in other municipalities, OR 0.91 (0.78 to 1.06). Being a woman, OR 0.79 (0.74 to 0.84), self-employed, OR 0.87 (0.78 to 0.96), or ≥ 50 years, OR 0.61 (0.57 to 0.65), was associated with an adverse prognosis.

CONCLUSION

Further research is needed to explain the gender inequality, which suggests either a potential to improve return-to-work rates among the females or a tendency among the males to return too early.

The return to work after a neuropsychological programme and prognostic factors for success

INTRODUCTION

Several factors influence the return to work (RTW) after brain injury (BI). The aims of the study were to follow-up the RTW after a vocational neuropsychological programme for individuals with a brain injury and to explore factors predicting RTW. The hypothesis was that as self-awareness was already addressed in the programme, severity of injury would have a greater impact on RTW.

METHOD

Sixty-five of 72 persons (median age 27) who had attended the programme 1998-2003 were interviewed about their occupation at 1, 2, 3 and 5 years after the programme. A logistic regression was made with the variables concerning process skill, somatic problems and irritability, the digit symbol coding and pre-morbid occupation to explore predictors of RTW.

RESULTS

The main cause was TBI (44.6%). Before injury 77% were employed or studied and after the injury 80% did not have any occupation. After 5 years 40% had returned to work. The only significant variable in the regression was the pre-morbid occupation.

DISCUSSION

The study stresses the difficulty to know the key elements involved in RTW which confirms the need for rehabilitation to focus on several factors in different contexts in order to affect the outcome.

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.

Study protocol to a nationwide prospective cohort study on return to gainful occupation after stroke in Denmark 1996 - 2006

Background

Successful return to work is regarded as one of the most important outcome factors for working-age post stroke patients. The present study will estimate the effect of various predictors on the odds of returning to work after stroke. Nearly twenty thousand 20-57 year-old stroke patients in Denmark who were gainfully occupied prior to the stroke will be included in the study.

Methods/design

Stroke patients will be followed prospectively through national registers. Multi-level logistic regression will be used to model the odds of being gainfully occupied ca. two years after the stroke as a function of the following predictors: Age (20-49 years, 50-57 years) gender, occupational class, self-employment (yes; no), onset calendar year (1996, 1997, ..., 2006), diagnosis (subarachnoid haemorrhage; intracerebral haemorrhage; cerebral infarction; stroke, not specified as haemorrhage or infarction) and 'type of municipality' (the variable is set to 1 if the person lived in a municipality which had a brain injury rehabilitation centre at the time of the stroke. Otherwise it is set to 0).

Municipalities will be treated as the subjects while individual observations within municipalities are treated as correlated repeated measurements.

Discussion

Since our follow-up is done through registers and all people in the target population are included, the study is free from sampling bias, recall bias and non-response bias. The study is also strengthened by its size. The major weakness of the study is that it does not contain any stroke severity measures. Thus, it cannot accurately predict whether a particular stroke patient will in fact return to work. The study is, however, quite useful from a public health perspective. It can be used to estimate the proportion of patients in a certain group that is expected to return to work, and thereby provide a comparison material, which e.g. municipalities can use to evaluate their success in returning their stroke patients to work.

Traumatic brain injuries in the construction industry

OBJECTIVE

This study analyses factors associated with work-related traumatic brain injury (TBI), specifically in the construction industry in Ontario, Canada.

METHODS

This cross-sectional study utilized data extracted from the Ontario Workplace Safety and Insurance Board (WSIB) records indicating concussion/intracranial injury that resulted in days off work in 2004-2005.

RESULTS

Analyses of 218 TBI cases revealed that falls were the most common cause of injury, followed by being struck by or against an object. Mechanisms of injury and the temporal profile of injury also varied by age. For instance, a significantly higher proportion of injuries occurred in the mornings for young workers compared to older workers.

CONCLUSIONS

The results of this study provide important information for prevention of TBI which suggest important age-specific strategies for workers in the construction industry.

How many people return to work after acquired brain injury?: a systematic review

PRIMARY OBJECTIVE

To investigate how many people return to work (RTW) after acquiring brain injury (ABI) due to traumatic or non-traumatic causes. Secondary objectives were to investigate the differences in outcome between traumatic and non-traumatic causes, the development of RTW over time and whether or not people return to their former job.

METHODS

A systematic literature search (1992-2008) was performed using terms of ABI and RTW. The methodological quality of the studies was determined. An overall estimation of percentage RTW 1 and 2 years post-injury was calculated by data pooling.

MAIN OUTCOMES AND RESULTS

Finally, 49 studies were included. Within 2 years post-injury, 39.3% of the subjects with non-traumatic ABI returned to work. Among people with traumatic ABI, 40.7% returned to work after 1 year and 40.8% after 2 years. No effect of cause or time since injury was found. Some people with traumatic ABI who returned to work were not able to sustain their job over time. Changes of occupation and job demands are common among people with ABI.

CONCLUSIONS

About 40% of the people with traumatic or non-traumatic ABI are able to return to work after 1 or 2 years. Among those with acquired traumatic brain injury a substantial proportion of the subjects were either not able to return to their former work or unable to return permanently.

Sick leave after traumatic brain injury. The person or the diagnosis--which has greater impact?

PURPOSE

The aim of this study was to describe if and when a sample of traumatic brain injury (TBI) patients could finish their time of sick leave during a 4-year follow up and to explore which factors that influenced the time for sick leave.

MATERIALS AND METHODS

All persons, 1999-2002, between 18 and 64 years of age (250 in total), admitted to the emergency room and diagnosed according to ICD 10 as S062 and S063, were included. Demographic data were gathered from medical charts and data concerning sick leave 1 year before trauma and 4 years after trauma, were collected from the Swedish social insurance system. To explore predictors of sick leave, two logistic regressions were performed.

RESULTS

The sample (mean age 39.68) consisted of 78% men. More than half of the accidents were due to fall. In the sample, 28 % was on sick leave on the day of trauma and 96 % of these were still on sick leave 4 years after trauma, compared with 39 % in the group not on sick leave on the day of TBI. Sick leave at the day for trauma was found to be a predictor for sick leave 4 years after trauma for the whole group (p = 0.000) together with Glasgow Coma Scale (GCS) (p = 0.002) and length of stay (p = 0.049). In the logistic regression with only the group not on sick leave, the only significant variable was GCS (p = 0.003).

CONCLUSION

The findings support the necessity to consider premorbid and social factors in the TBI rehabilitation.

The description of severe traumatic brain injury in light of the ICF classification

PURPOSE

To review on the application of the ICF Classification to assess the person with traumatic brain injury (TBI) and his/her interaction with the environment.

METHOD

Studies and reviews about the use of ICF in TBI have been included, by searching in Pubmed and in the proceedings of international meetings.

RESULTS

Eleven studies have been identified and classified into three types: (a) application of the classification; (b) single case study; (c) the use of other scales. Some studies are related to the application of ICF checklist. Finally, we analyse the most used ICF codes.

CONCLUSIONS

The ICF is a useful tool describes conditions and needs of patients with TBI. A diffuse utilisation could become the key resource for both health professionals and administrators that are in charge of allocating resources to pursue quality of life improvement. The ICF could be applied as a shared language to define health programmes' goals and as system for carrying out epidemiological studies. For this reason, it is desirable to define and validate the ICF Core Sets for TBI to provide a mean to be easily used, comprehensive and universal.

Disability and return to work outcomes after traumatic brain injury: results from the Washington State Industrial Insurance Fund

INTRODUCTION

This article contains a description of community traumatic brain injury (TBI) treatment patterns and outcomes based solely on workers' compensation administrative records for Washington State.

METHODS

Administrative records available from the Washington State Department of Labor and Industries data warehouse of administrative records are used to describe medical rehabilitation services and return to work (RTW) referrals for cases of TBI between 1 January 1998 and 31 December 2002. These data represent official records for disability determination and referral for vocational rehabilitation (VR) services.

RESULTS

At total of 797 cases were identified all of which had identifiable treatment trajectories. No disability was the outcome in 9.0% of cases; temporary disability in 53.5% of cases, permanent disability in 31.1% of cases. Only 48% of surviving cases include a medical rehabilitation phase. This phase included only inpatient services in 26.5% of referred cases, only ambulatory services in 59.6% and both inpatient and ambulatory services in 13.9%. Only about half of surviving cases were referred for RTW services. Employment rates were similar to those published from other state rehabilitation programs.

CONCLUSIONS

State/community treatment and disability outcome patterns are more diverse than the expected sequence of acute treatment, medical rehabilitation and VR. Employment rates after referral for VR were 65%.

Evaluating work readiness following acquired brain injury: building a shared understanding

BACKGROUND

Despite occupational therapists' role in work-related evaluations, there are no guidelines for evaluating clients' work readiness.

PURPOSE

This study explored how occupational therapists evaluate work readiness following acquired brain injury in order to develop an integrated model of the factors, processes, stakeholders, and contextual elements relevant to this evaluation.

METHODS

Ten occupational therapists with expertise in vocational and brain injury rehabilitation were interviewed. Data were analyzed using grounded theory methods to develop the work readiness evaluation model.

FINDINGS

This model describes five processes formative to therapists' evaluation: (1) drawing upon diverse sources of information and perspectives; (2) assessing occupational capacity; (3) contextualizing occupational potential; (4) building a shared understanding of work readiness among stakeholders, including, clients, employers, insurers, and rehabilitation teams; and (5) transforming the work readiness question.

IMPLICATIONS

The model highlights the importance of building a shared understanding amongst stakeholders and provides a provisional framework to guide practice.

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.