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

Racial and Ethnic Differences in Traumatic Brain Injury Outcomes From 2009 to 2023: Protocol for a Systematic Review

BACKGROUND

In 2009, Gary and colleagues reviewed prior research examining racial and ethnic differences in outcomes after traumatic brain injury (TBI). Over the past 15 years, advances in research and changes in the demographic composition of the United States warrant a comprehensive understanding of racial and ethnic disparities after TBI.

OBJECTIVE

A systematic review will be conducted to examine racial and ethnic differences in TBI outcomes from 2009 to 2023.

METHODS

Preliminary searches and study screening processes will identify relevant English-language articles published from January 2009 to December 2023 using the CINAHL, Gale OneFile, PsycINFO (Ovid), and PubMed electronic databases. Relevant articles will include quantitative or mixed method approaches, involve individuals with TBI or their caregivers, and compare 2 or more groups by race or ethnicity on post-TBI outcomes. Quality will be assessed using the Newcastle-Ottawa Scale. This systematic review protocol was developed following PRISMA-P (Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols) guidelines. Results will be summarized, and a subgroup analysis may be conducted based on demographics (eg, age, gender, or sex).

RESULTS

We have already identified abstracts using the search strategy for all 4 of the included electronic databases. We recently updated the search and will begin abstract screening of the additional abstracts identified from the last search completed in January 2024. This systematic review is anticipated to be completed by fall 2024, and its findings will be disseminated to the scientific community, persons with TBI, caregivers, and the lay audience.

CONCLUSIONS

This systematic review will advance our understanding regarding outcome disparities among minoritized individuals with TBI, examine progress over the past 15 years in minimizing barriers encountered by these racial and ethnic groups, and provide professionals with a roadmap illustrating existing gaps in rehabilitation care, making way for further development and implementation of evidence-based interventions to improve health equity in TBI outcomes.

TRIAL REGISTRATION

PROSPERO CRD42023394529; https://tinyurl.com/53mtcz9b.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/58763.

"If you do not have Black futures in mind…then what's guiding the steps": anti-racist recommendations for traumatic brain injury rehabilitations' investments in hopeful Black futures

PURPOSE

The need for specialized rehabilitation considerations to address racial health disparities and optimize functional outcomes such as participation in daily life for Black people with traumatic brain injury (TBI) has been acknowledged. This study uses anti-racism as an entry point for addressing institutional racism by examining what the experiences of Black survivors of TBI, rehabilitation providers, and family caregivers tell us about imagined possibilities for rehabilitation to promote Black futures.

MATERIAL AND METHODS

A constructivist-informed narrative inquiry using critical race theory and in-depth narrative interviewing was applied across ten women and four men. Reflexive thematic analysis within and across groups of participants led to conceptualizing two main themes and five sub-themes.

RESULTS

Conceptualized themes captured requirements for TBI rehabilitations' investments in Black futures: (1) the need for critical information and specialized educational supports and particular requirements for supporting participation in meaningful life situations, and (2) responsibilities of delivering rehabilitation care for Black service users.

CONCLUSION

TBI rehabilitation must be tailored to the realities of living while being Black, integrate personal values, beliefs, interests, and equitable supports to maximize optimal functioning and participation if the goal of rehabilitation is community integration for all persons living with the impacts of TBI.

"Somewhere along the line, your mask isn't going to be fitting right": institutional racism in Black narratives of traumatic brain injury rehabilitation across the practice continuum

BACKGROUND

Over two decades of research about traumatic brain injury (TBI) rehabilitation emphasized the persistence of racial health disparities in functional outcomes that disproportionately impact Black populations without naming or addressing racism as the root problem. Further, the experiences of Black people with TBI have yet to be documented and accounted for in scientific scholarship from the perspectives of Black persons in Canada.

PURPOSE

This study intended to examine the rehabilitation narratives of Black TBI survivors, family caregivers, and rehabilitation providers and use critical race theory as a conceptual framework to understand how anti-Black racism manifests in those experiences.

METHODS

Through critical narrative inquiry informed by a critical constructivist paradigm and a critical race theory lens, in-depth narrative interviewing were conducted with seven survivors, three family caregivers, and four rehabilitation providers. Data were analyzed using reflexive thematic analysis within and across groups of participants to conceptualize themes and sub-themes.

FINDINGS

Themes captured how racism becomes institutionalized in TBI rehabilitation: (1) the institutional construction of deficient Black bodies, (2) the institutional construction of rehabilitation access, (3) the institutional investment in resisting and approximating whiteness in rehabilitation practice, and (4) the institutional construction of deficient Black futures.

CONCLUSION

Study findings point to the dire need to ensure rehabilitation programs, services, and the delivery of care are not determined based on inequitable practices, racial biases and assumptions about Black people, which determine who deserves to get into rehabilitation and have opportunities to be supported in working towards living a full and meaningful life.

Mapping the institutionalization of racism in the research about race and traumatic brain injury rehabilitation: implications for Black populations

PURPOSE

Traumatic brain injury (TBI) is a chronic disease process and a public health concern that disproportionately impacts Black populations. While there is an abundance of literature on race and TBI outcomes, there is a lack of scholarship that addresses racism within rehabilitation care, and it remains untheorized. This article aims to illuminate how racism becomes institutionalized in the scientific scholarship that can potentially inform rehabilitation care for persons with TBI and what the implications are, particularly for Black populations.

MATERIAL AND METHODS

Applying Bacchi's What's the Problem Represented to be approach, the writings of critical race theory (CRT) are used to examine the research about race and TBI rehabilitation comparable to CRT in other disciplines, including education and legal scholarship.

RESULTS

A CRT examination illustrates that racism is institutionalized in the research about race and TBI rehabilitation through colourblind ideologies, meritocracy, reinforcement of a deficit perspective, and intersections of race and the property functions of whiteness. A conceptual framework for understanding institutional racism in TBI rehabilitation scholarship is presented.

CONCLUSIONS

The findings from this article speak to the future of TBI rehabilitation research for Black populations, the potential for an anti-racist agenda, and implications for research and practice.

Racial Disparities in Employment Status After Moderate/Severe Traumatic Brain Injuries in Southeast Michigan

OBJECTIVE

To examine the progress made in recent decades by assessing the employment rates of Black and non-Hispanic White (NHW) patients after traumatic brain injury (TBI), controlling for pre-TBI employment status and education status.

DESIGN

Retrospective analysis in a cohort of patients treated in Southeast Michigan at major trauma centers in more recent years (February 2010 to December 2019).

SETTING

Southeastern Michigan Traumatic Brain Injury Model System (TBIMS): 1 of 16 TBIMSs across the United States.

PARTICIPANTS

NHW (n=81) and Black (n=188) patients with moderate/severe TBI (N=269).

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Employment status, which is separated into 2 categories: student plus competitive employment and noncompetitive employment.

RESULTS

In 269 patients, NHW patients had more severe initial TBI, measured by percentage brain computed tomography with compression causing >5-mm midline shift (P<.001). Controlling for pre-TBI employment status, we found NHW participants who were students or had competitive employment prior to TBI had higher rates of competitive employment at 2-year (P=.03) follow-up. Controlling for pre-TBI education status, we found no difference in competitive and noncompetitive employment rates between NHW and Black participants at all follow-up years.

CONCLUSIONS

Black patients who were students or had competitive employment before TBI experience worse employment outcomes than their NHW counterparts after TBI at 2 years post TBI. Further research is needed to understand better the factors driving these disparities and how social determinants of health affect these racial differences after TBI.

Integrated Care Pathways for Black Persons With Traumatic Brain Injury: A Critical Transdisciplinary Scoping Review of the Clinical Care Journey

Objectives: This novel critical transdisciplinary scoping review examined the literature on integrated care pathways that consider Black people living with traumatic brain injury (TBI). The objectives were to (a) summarize the extent, nature, and range of literature on care pathways that consider Black populations, (b) summarize how Blackness, race, and racism are conceptualized in the literature, (c) determine how Black people come to access care pathways, and (d) identify how care pathways in research consider the mechanism of injury and implications for human occupation. Methods: Six databases were searched systematically identifying 178 articles after removing duplicates. In total, 43 articles on integrated care within the context of Black persons with TBI were included. Narrative synthesis was conducted to analyze the data and was presented as descriptive statistics and as a narrative to tell a story. Findings: All studies were based in the United States where 81% reported racial and ethnic disparities across the care continuum primarily using race as a biological construct. Sex, gender, and race are used as demographic variables where statistical data were stratified in only 9% of studies. Black patients are primarily denied access to care, experience lower rates of protocol treatments, poor quality of care, and lack access to rehabilitation. Racial health disparities are disconnected from racism and are displayed as symptoms of a problem that remains unnamed. Conclusion: The findings illustrate how racism becomes institutionalized in research on TBI care pathways, demonstrating the need to incorporate the voices of Black people, transcend disciplinary boundaries, and adopt an anti-racist lens to research.

Exploring racial/ethnic disparities in rehabilitation outcomes after TBI: A veterans affairs model systems study

BACKGROUND

Almost one-third of the U.S. military population is comprised of service members and veterans (SMVs) of color. Research suggests poorer functional and psychosocial outcomes among Black and Hispanic/Latine vs. White civilians following traumatic brain injury (TBI).

OBJECTIVE

This study examined racial/ethnic differences in 5-year functional independence and life satisfaction trajectories among SMVs who had undergone acute rehabilitation at one of five VA TBI Model Systems (TBIMS) Polytrauma Rehabilitation Centers (PRCs).

METHODS

Differences in demographic and injury-related factors were assessed during acute rehabilitation among White (n = 663), Black (n = 89) and Hispanic/Latine (n = 124) groups. Functional Independence Measure (FIM) Motor, FIM Cognitive, and Satisfaction with Life Scale (SWLS) scores were collected at 1, 2, and 5 years after injury. Racial/ethnic comparisons in these outcome trajectories were made using hierarchical linear modeling.

RESULTS

Black SMVs were less likely than White and Hispanic/Latine SMVs to have been deployed to a combat zone; there were no other racial/ethnic differences in any demographic or injury-related variable assessed. In terms of outcomes, no racial/ethnic differences emerged in FIM Motor, FIM cognitive, or SWLS trajectories.

CONCLUSION

The absence of observable racial/ethnic differences in 5-year outcome trajectories after TBI among SMVs from VA TBIMS PRCs contrasts sharply with previous research identifying disparities in these same outcomes and throughout the larger VA health care system. Individuals enrolled in VA PRCs are likely homogenized on key social determinants of health that would otherwise contribute to racial/ethnic disparities in outcome trajectories.

Measurement of prospective memory in Spanish speakers

Introduction

This study aimed to provide preliminary evidence on the psychometric properties of a measure of prospective memory in Spanish speakers, the Memory for Intentions Test (MIST) Spanish translation.

Methods

In addition, this study investigated whether acculturation influenced performance on the MIST. Finally, we measured other cognitive factors that might be impacting the relationship between culture and prospective memory performance. These factors were working memory, autobiographical memory, and episodic future thought.

Results

Overall, the psychometric properties of the Spanish MIST appear to be similar to the English language MIST, but our sample size was too small to allow for the creation of a normative database. The MIST recognition item was significantly related to years of education and years of speaking either Spanish or English.

Discussion

This suggests a need to investigate ways to improve the test to eliminate these effects. In addition, acculturation was related to the measure of episodic future thought.

Predictors of 10-year functional independence trajectories in older adults with traumatic brain injury: A Model Systems study

BACKGROUND

Older adults have the highest traumatic brain injury (TBI)-related morbidity and mortality, and rates in older adults are increasing, chiefly due to falls.

OBJECTIVE

This study used hierarchical linear modeling (HLM) to examine baseline predictors of functional independence trajectories across 1, 2, 5, and 10 years after TBI in older adults.

METHODS

Participants comprised 2,459 individuals aged 60 or older at the time of TBI, enrolled in the longitudinal TBI Model Systems database, and had Functional Independence Measure Motor and Cognitive subscale scores and Glasgow Outcome Scale-Extended scores during at least 1 time point.

RESULTS

Functional independence trajectories generally declined over the 10 years after TBI. Individuals who were older, male, underrepresented minorities, had lower education, were unemployed at time of injury, had no history of substance use disorder, or had difficulties with learning, dressing, and going out of the home prior to the TBI, or longer time in posttraumatic amnesia had lower functional independence trajectories across at least one of the functional independence outcomes.

CONCLUSION

These predictors of functional independence in older adults with TBI may heighten awareness of these factors in treatment planning and long-term health monitoring and ultimately as a way to decrease morbidity and mortality.

Employment probability trajectories in hispanics over the 10 years after traumatic brain injury: A model systems study

BACKGROUND: Research has found that Hispanics with traumatic brain injury (TBI) have reduced functional outcomes compared to non-Hispanic Whites, including lower probabilities of post-injury employment. However, previous studies were cross-sectional, combined racial/ethnic minority groups, and did not examine the factors that predict return to work of Hispanics longitudinally. OBJECTIVE: To determine the demographic and injury-related predictors of employment probability trajectories during the first 10 years after TBI. METHODS: 1,346 Hispanics in the TBI Model Systems Database was included. Hierarchical linear modeling was used to examine baseline predictors of employment probability trajectories across this time period. RESULTS: Employment probability demonstrated a quadratic movement over time, with an initial increase followed by a plateau or slight decrease. Hispanics with TBI had higher employment probability trajectories if they had been younger at the time of injury, spent less time in posttraumatic amnesia, had greater years of education, had been employed at the time of injury, had higher annual earnings at the time of injury, and had experienced a non-violent mechanism of injury. CONCLUSION: Culturally adapted treatment programs with a focus on early intervention incorporating vocational rehabilitation and employment programs for Hispanics with TBI who present with these risk factors are needed.

Assessment of the individual and compounding effects of marginalization factors on injury severity, discharge location, recovery, and employment outcomes at 1 year after traumatic brain injury

Objective

The aim of this study is to examine the effect of eight distinct marginalized group memberships and explore their compounding effect on injury severity, recovery, discharge location, and employment outcomes 1-year after traumatic brain injury (TBI).

Methods

Individuals with medically confirmed, complicated mild-severe TBI (N = 300) requiring inpatient rehabilitation care between the ages of 18 and 65 were recruited at two urban (public and private) health systems between 2013 and 2019. Data were collected from self-report and medical record abstraction. Marginalized group membership (MGM) includes racial and ethnic minority status, less than a high school diploma/GED, limited English proficiency, substance abuse, homelessness, psychiatric hospitalizations, psychiatric disorders, and incarceration history. Membership in four or more of these groups signifies high MGM. In addition, these factors were explored individually. Unadjusted and adjusted linear and logistic regressions and Kruskal–Wallis tests were used to assess the associations of interest in RStudio.

Results

After adjusting for age, sex, and cause of injury, compared to TBI patients with low MGM, those with high MGM experience significantly longer post-traumatic amnesia (95% CI = 2.70, 16.50; p = 0.007) and are significantly more likely to have a severe TBI (per the Glasgow-Coma Scale) (95% CI = 1.70, 6.10; p ≤ 0.001) than a complicated mild-moderate injury. Individuals with high MGM also are significantly less likely to be engaged in competitive paid employment 1 year after injury (95% CI = 2.40, 23.40; p = 0.001). Patients with high MGM are less likely to be discharged to the community compared to patients with low MGM, but this association was not significant (95% CI = 0.36, 1.16; p = 0.141). However, when assessing MGMs in isolation, certain associations were not significant in unadjusted or adjusted models.

Conclusion

This exploratory study's findings reveal that when four or more marginalization factors intersect, there is a compounding negative association with TBI severity, recovery, and employment outcomes. No significant association was found between high MGM and discharge location. When studied separately, individual MGMs had varying effects. Studying marginalization factors affecting individuals with TBI has critical clinical and social implications. These findings underline the importance of addressing multidimensional factors concurrent with TBI recovery, as the long-term effects of TBI can place additional burdens on individuals and their economic stability.

Race/Ethnicity and Community Participation Among Veterans and Service Members With Traumatic Brain Injury: A VA Traumatic Brain Injury Model Systems Study

OBJECTIVE

To examine racial/ethnic disparities in community participation among veterans and active duty service members with traumatic brain injury (TBI).

SETTING

Five Department of Veterans Affairs (VA) TBI Model Systems (TBIMS) Polytrauma Rehabilitation Centers (PRCs). Participants: Three hundred forty-two community-dwelling adults (251 White, 34 Black, and 57 Hispanic) with TBI enrolled in the VA TBIMS National Database who completed a 1-year follow-up interview. Mean age was 38.6 years (range, 19-84 years).

DESIGN

Cross-sectional analysis of a prospective observational cohort study. Main Measures: Community participation at 1 year postinjury assessed by 3 domains of the Participation Assessment with Recombined Tools-Objective (PART-O): Out & About, Productivity, and Social Relations.

RESULTS

Significant differences were observed among race/ethnicity groups in PART-O Productivity and Out & About domains without controlling for relevant participant characteristics; Productivity scores were significantly higher for non-Hispanic Black than for non-Hispanic White participants (t = 2.40, P = .0169). Out & About scores were significantly higher for Hispanic than for non-Hispanic White participants (t = 2.79, P = .0056). However, after controlling for demographic, injury severity, and 1-year follow-up characteristics, only differences in the Out & About domain remained statistically significant (t = 2.62, P = .0094), with scores being significantly higher for Hispanics than for non-Hispanic Whites.

CONCLUSIONS

The results, which differ from findings from studies conducted in non-VA healthcare settings where there are greater racial/ethnic disparities in participation outcomes, could reflect differences between military and civilian samples that may reduce disparities.

What are the functional consequences after TBI? The SHEFBIT cohort experience

OBJECTIVES

To investigate functional outcome after TBI and identify variables that predict outcome in a multiordinal regression model.

BACKGROUND

The results of global outcome studies after Traumatic Brain Injury(TBI) differ widely due to differences in outcome measure, attrition to follow-up and selection bias. Outcome information would inform patients/families, guide service development and target high-risk individuals.

SUBJECTS/SETTING

prospective cohort of 1322 admissions with TBI, assessed by face to face interviews at 1 yr.

MEASURES

Extended Glasgow Outcome Scale (GOSE) by structured questionnaire.

RESULTS

At 1 year, outcome was determined in 1207(91.3%). Mean age was 46.9(SD17.3); Almost half(49.2%) had mild injury. At one year, 42.9% achieved Good Recovery but GOSE declined in 11.4% of the cohort compared to 10 weeks including 60(4.9%) deaths. In an ordinal logistic regression, increasing TBI severity, etiology (assault), more prominent CT abnormality, past psychiatric history and alcohol intoxication were independent predictors of worse GOSE. A pseudo-R² of 0.38 suggested that many unmeasured factors also contribute to TBI outcome. Future work needs to identify other variables that may influence outcome.

CONCLUSIONS

In a large TBI cohort, there is still considerable functional disability at 1 year. It may be possible to target high-risk groups for rehabilitation.

Factors associated with sustaining work after an acquired brain injury: a scoping review

PURPOSE

Maintaining work in the long term represents a major challenge for people with acquired brain injury (ABI) as evidenced by a high rate of premature labour market dropouts. The present study aimed to compile factors associated with working in the long term after sustaining an ABI.

MATERIALS AND METHODS

We carried out a scoping review synthesizing quantitative and qualitative research conducted between 2000 and 2021. Databases searched comprised PubMed, CINAHL Complete, PsycINFO, Scopus, and Web of Science.

RESULTS

Ten quantitative and nine qualitative studies were included, all but one from high-resource countries. Quantitative research predominantly comprised longitudinal follow-ups on individuals' work status several years post ABI onset, showing an effect of injury-related and sociodemographic factors. Qualitative studies mostly dealt with work maintenance and revealed a key role of cognitive difficulties, psychological personal factors (e.g., adequate coping strategies) and environmental factors (e.g., flexible work schedules, supportive colleagues).

CONCLUSIONS

The factors identified in our review should receive particular attention in vocational integration and job retention programs to support work participation of people with ABI in the long term. There is a need for measures that regularly monitor and promote a good match between individuals and their work environment.Implications for RehabilitationPeople with acquired brain injury (ABI) often have long-lasting and invisible injury-related difficulties that hamper their labour market participation.Factors identified as positively associated with working in the long term, such as coping strategies and self-awareness, should be strengthened.Future interventions should educate affected persons, employers and health care professionals about long-lasting injury-related difficulties and promote a supportive work environment for people with ABI.Prolonged availability of vocational services could be beneficial for supporting work maintenance of people with ABI.

Employment status after traumatic brain injury and the effect of concomitant injuries on return to work

PURPOSE

This study aims to describe the employment status and pattern among survivors of traumatic brain injury after motor vehicle accidents, and to explore the effects of demographic, injury variables and concomitant injuries on the employment status .

METHOD

A retrospective analyses of 370 medical reports written for patients who sustained traumatic brain injury from motor vehicle accidents was conducted. To establish the employment pattern, the pre-injury employment history was compared to the latest employment status documented. Types and severity of concomitant injuries were rated according to Abbreviated Injury Scale criteria. All significant variables were further analyzed using logistic regression to explore predictors of employment.

RESULTS

Up to 87% of the patients sustained concomitant injuries, with more than two-thirds (72%) scoring ≤ 2 on the Abbreviated Injury Scale. One hundred and eighty-two patients (49.2%) successfully returned to work. Among those who returned to work, 34% returned to former employment with pre-injury job description. Severity of traumatic brain injury, length of acute hospital stay, ambulation status and cognitive status were found to be significant predictive factors for employment status post traumatic brain injury. Presence of concomitant extremity injuries was found to influence the employment pattern among traumatic brain injury survivors.

CONCLUSION

The return to work rate was somewhat low and was not influenced by presence of concomitant injuries. .

Using Decision Tree Methodology to Predict Employment After Moderate to Severe Traumatic Brain Injury

Objective:

To build decision tree prediction models for long-term employment outcomes of individuals after moderate to severe closed traumatic brain injury (TBI) and assess model accuracy in an independent sample.

Setting:

TBI Model Systems Centers.

Participants:

TBI Model Systems National Database participants injured between January 1997 and January 2017 with moderate to severe closed TBI. Sample sizes were 7867 (year 1 postinjury), 6783 (year 2 postinjury), and 4927 (year 5 postinjury).

Design:

Cross-sectional analyses using flexible classification tree methodology and validation using an independent subset of TBI Model Systems National Database participants.

Main Measures:

Competitive employment at 1, 2, and 5 years postinjury.

Results:

In the final employment prediction models, posttraumatic amnesia duration was the most important predictor of employment in each outcome year. Additional variables consistently contributing were age, preinjury education, productivity, and occupational category. Generally, individuals spending fewer days in posttraumatic amnesia, who were competitively employed preinjury, and more highly educated had better outcomes. Predictability in test data sets ranged from a C-statistic of 0.72 (year 5; confidence interval: 0.68-0.76) to 0.77 (year 1; confidence interval: 0.74-0.80).

Conclusion:

An easy-to-use decision tree tool was created to provide prognostic information on long-term competitive employment outcomes in individuals with moderate to severe closed TBI. Length of posttraumatic amnesia, a clinical marker of injury severity, and preinjury education and employment status were the most important predictors.

Aspects of Executive Dysfunction and Racial/Ethnic Minority Status Are Associated With Unemployment Duration in Veterans With a History of Mild-to-Moderate Traumatic Brain Injury

OBJECTIVE

To examine demographic, psychiatric symptom, and neuropsychological performance factors associated with duration of unemployment in Iraq/Afghanistan Veterans with a history of mild-to-moderate traumatic brain injury (TBI).

DESIGN

Cross-sectional, secondary data analysis of baseline measures in a supported employment study.

SETTING

VA medical center.

PARTICIPANTS

Participants (N=50) were veterans with a history of mild-to-moderate TBI who were unemployed, stating a goal of returning to work, and had documented impairment in at least 1 neuropsychological domain. Participants were referred from VA vocational and assessment-based clinics.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Duration of unemployment, neuropsychological, and psychiatric symptom assessments.

RESULTS

Bivariate correlations revealed that longer duration of unemployment was associated with greater posttraumatic stress disorder (P<.10) and depressive (P<.05) symptom severity, worse executive functioning (P<.05), and racial/ethnic minority status (P<.05). A multiple linear regression analysis including these independent variables explained 26.5% of the variance in duration of unemployment. Worse executive functioning, specifically reasoning and set-shifting, and minority status were each associated with longer duration of unemployment in the context of multiple independent variables.

CONCLUSIONS

Our results underscore the importance of objective assessment of cognitive functioning in job-seeking Veterans with TBI histories. It may be useful to target aspects of executive functioning in vocational rehabilitation interventions and to provide additional assistance to Veterans from racial/ethnic minority groups.

Relationship Between Hispanic Nativity, Residential Environment, and Productive Activity Among Individuals With Traumatic Brain Injury: A TBI Model Systems Study

OBJECTIVE

To examine the influence of nativity and residential characteristics on productive activity among Hispanics at 1 year after traumatic brain injury (TBI).

SETTING

Acute rehabilitation facilities and community follow-up.

PARTICIPANTS

A total of 706 Hispanic individuals in the TBI Model Systems National Database.

DESIGN

Secondary data analysis from a multicenter longitudinal cohort study.

MAIN MEASURES

Nativity (foreign born or US native), productive activity derived from interview questions regarding employment status, and other demographic information. Census data were extracted by zip code to represent residential characteristics of aggregate household income and proportion of foreign language speakers (FLS).

RESULTS

Among foreign-born individuals with TBI, those living in an area with a higher proportion of FLS were 2.8 times more likely to be productive than those living in areas with a lower proportion of FLS. Among individuals living in an area with a lower proportion of FLS, US-born Hispanics were 2.7 times more likely to be productive compared with Hispanic immigrants.

CONCLUSION

The relationship between nativity and productive activity at 1 year post-TBI was moderated by the residential proportion of FLS. Findings underscore the importance of considering environmental factors when designing vocational rehabilitation interventions for Hispanics after TBI.

Returning to work after a hand injury: Does ethnicity matter?

Background

Hand injuries (HI) are common and may limit participation in work. The objective of this study is to examine the effect of ethnicity and other prognostic variables on return-to-work (RTW) among male manual workers after acute HI.

Methods

A cohort of 178 subjects (90 Arabs, 88 Jews) aged 22 to 65 was studied. Trained bilingual occupational therapists evaluated and interviewed the subjects, using structured validated questionnaires for evaluating personal and environmental factors, body function and structure, and activity limitation and participation restrictions. Employment status 3 months post injury was assessed by a telephone interview. To establish a predictive model for RTW, ethnicity and certain variables of the four domains mentioned above were analyzed using logistic regression analysis.

Results

A significant difference in the rate of RTW between Jews and Arabs was found (45.5% for Jews, 28.9% for Arabs, p = 0.03) three months post HI. In the univariate regression analysis, ethnicity was associated with RTW (OR = 2.05; CI: 1.10–3.81) for Jews vs. Arabs. Using a multivariate analysis, only legal counseling, educational attainment, and the severity of disability were significantly associated with RTW.

Conclusion

RTW three months post HI among manual workers is directly related to variables such as education and legal counseling and only indirectly related to ethnicity. Patients with a lower level of education and those who were engaged in legal counseling need special attention and close guidance in the process of RTW.

Baseline Predictors of Survival, Neurological Recovery, Cognitive Function, Neuropsychiatric Outcomes, and Return to Work in Patients after a Severe Traumatic Brain Injury: an Updated Review

Introduction

Severe traumatic brain injury (sTBI) is a common cause of death and disability worldwide, with long-term squeal among survivors that include cognitive deficits, psychosocial and neuropsychiatric dysfunction, failure to return to pre-injury levels of work, school and inter-personal relationships, and overall reduced quality of and satisfaction with life.

Aim

The aim of this work is to review the current literature on baseline predictors of outcomes in adults post sTBI.

Method

Most of available literature on baseline predictors of outcomes in adults post sTBI were reviewed and summarized in this work.

Results

Currently, a sizeable number of composite predictors of mortality and overall function exists; however, these instruments tend to over-estimate poor outcomes and fail to address issues like cognition, psychosocial/ neuropsychiatric dysfunction, and return to work or school.

Conclusion

This article reviews currently-identified predictors of all these outcomes.

Long-term employment outcomes following moderate to severe traumatic brain injury: a systematic review and meta-analysis

Background: Returning to employment following moderate to severe traumatic brain injury (msTBI) is critical for a survivor's well-being, yet currently there are no systematic reviews that comprehensively describe employment outcomes following msTBI. The objective of this study was to systematically synthesize literature on employment outcomes following msTBI.Methods: Original studies published through April 2018 on MEDLINE/PubMed, PsychINFO, and CINAHL were eligible if the objective was to investigate employment outcomes following msTBI; outcome was measured ≥1 year; participants were ≥15; and size was ≥60. Post-injury employment prevalence and return to pre-injury level of work were summarized through meta-analysis.Results: Of 38 eligible studies, post-injury employment prevalence was most often reported (n = 35), followed by job stability (n = 6), and return to pre-injury level of work (n = 4). Overall post-injury employment prevalence was 42.2%; whereas the return-to-previous-work prevalence was 33.0%. Post-injury employment prevalence appeared to increase over time, from 34.9% at 1 year to 42.1% up to 5 years and 49.9% beyond 5 years.Conclusion: Nearly half of individuals with msTBI were employed post-injury, yet only a third returned to pre-injury level of work. Future researchers are recommended to standardize employment outcome measures to enable better comparison of outcomes across studies.

State-Federal Vocational Rehabilitation in Traumatic Brain Injury: What Predictors Are Associated With Employment Outcomes?

This study identified predictors of employment for individuals with traumatic brain injury (TBI). Data from 4,923 individuals with TBI were extracted from the Rehabilitation Services Administration’s Case Service Report (RSA-911) database. A multiple logistic regression model using demographics, disability-related variables, vocational rehabilitation (VR) service variables, and their interactions correctly classified 69.5% of the cases as successfully employed or not successfully employed. The model explained approximately 27.1% of the variance in employment outcomes. Results indicated that level of education, race/ethnicity, age at application, preemployment status, Supplemental Security Income (SSI), Social Security Disability Insurance (SSDI), comorbid depression, and case expenditure were significantly associated with employment outcomes (all p ≤ .05). VR variables that showed the most significant positive effect on employment outcomes were on-the-job support, job placement, and on-the-job training. Race/ethnicity moderated the effect of college training, supported employment, transportation, and extended evaluation or work trial assessment services on employment outcomes. The findings have implications for promoting the use of those VR services that are strongly related to employment outcomes for persons with TBI. They also point to the need for rehabilitation personnel to address some of the demographic and disability-related barriers to successful employment.

Employment Status Among U.S. Military Veterans With Traumatic Brain Injury: Mediation Analyses and the Goal of Tertiary Prevention

For most individuals with traumatic brain injury (TBI), the ability to work is crucial to financial and psychological well-being. TBI produces a wide range of cognitive, physical, emotional, and interpersonal impairments that may undermine the ability to work. Employment is therefore a primary goal of TBI rehabilitation and has been the focus of extensive research. Although this literature has identified predictors of employment outcomes, few studies have examined the mechanisms that underlie these associations. Mediation analysis can identify these mechanisms, provide a more nuanced view of how predictors jointly affect rehabilitation outcomes, and identify predictors that, if treatable conditions, could be useful targets for tertiary prevention. Such efforts are aimed at reducing long-term impairments, disability, or suffering resulting from the injury. The study sample comprised 83 U.S. military veterans with TBI who had participated in a larger rehabilitation study and were interviewed in their homes. Bivariate tests revealed significant associations of employment with pain, cognitive functioning, self-rated health, depressive symptoms and physical functioning; the latter variable was operationalized in two ways—using the Patient Competency Rating Scale and the SF–36V physical functioning subscales. Because these physical functioning measures were highly intercorrelated (r = 0.69, p < 0.0001), separate regression models were conducted. In the hierarchical binary logistic regression models, predictors were entered in order of modifiability, with comorbidities (pain) entered in block 1, physical health/functioning sequelae in block 2, and depressive symptoms in block 3. In the regression using the SF-36V measure of physical functioning, pain's effect was mediated by the physical functioning/health predictors, with only physical functioning emerging as significant, but this effect was itself mediated by depressive symptoms. In the regression using the PCRS physical-function measure, only depressive symptoms emerged as a mediator of other effects. Findings underscore the central role of depression in the employment status of veterans with TBI, suggesting that negative effects of other problems/limitations could be mitigated by more effective treatment of depression. Thus, for many with chronic TBI who live with vocational limitations, outcomes may improve with lower depression. Findings argue for the wider use of mediation approaches in TBI research as a means of identifying targets for tertiary prevention of poor outcomes.

Impact of racial-ethnic minority status and systemic vulnerabilities on time to acute TBI rehabilitation admission in an urban public hospital setting

PURPOSE/OBJECTIVE

Racial/ethnic minorities and other vulnerable social groups experience health care disparities. There is a lack of research exploring how time to acute rehabilitation admission is impacted by race/ethnicity and other marginalizing systemic vulnerabilities. The purpose of this study is to investigate whether race/ethnicity and other sociodemographic vulnerabilities impact expediency of acute rehabilitation admission following traumatic brain injury (TBI). Research Method/Design: This study is a secondary analysis of an existing dataset of 111 patients admitted for acute TBI rehabilitation at an urban public hospital. Patient groups were defined by race/ethnicity (People of color or White) and vulnerable group status (high or low vulnerable group membership [VGM]).

RESULTS

White patients are admitted to acute TBI rehabilitation significantly faster than people of color. After taking vulnerabilities into account, high VGM people of color experience the most severe injuries and take the longest to receive acute TBI rehabilitation. Despite small differences in injury severity, low VGM people of color take longer to be admitted to acute TBI rehabilitation than White patients. High VGM White patients have less severe injuries yet take longer to be admitted to acute rehabilitation than low VGM White patients. Finally, notable differences exist between White patients and patients of color on rater-based injury severity scales that are discordant with severity as measured by more objective markers.

CONCLUSIONS/IMPLICATIONS

Overall, findings indicate that sociodemographic factors including race/ethnicity and systemic vulnerabilities impact injury severity and time to acute TBI rehabilitation admission. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Employment Probability Trajectories Up To 10 Years After Moderate-To-Severe Traumatic Brain Injury

Aims: To examine trajectories of employment probability up to 10 years following moderate-to-severe traumatic brain injury (TBI) and identify significant predictors from baseline socio-demographic and injury characteristics. Methods: A longitudinal observational study followed 97 individuals with moderate-to-severe TBI for their employment status up to 10 years post injury. Participants were enrolled at the Trauma Referral Center in South-Eastern Norway between 2005 and 2007. Socio-demographic and injury characteristics were recorded at baseline. Employment outcomes were assessed at 1, 2, 5, and 10 years. Hierarchical linear modeling (HLM) was used to examine employment status over time and assess the predictors of time, gender, age, relationship status, education, employment pre-injury, occupation, cause of injury, acute Glasgow Coma Scale (GCS) score, duration of post-traumatic amnesia (PTA), CT findings, and injury severity score, as well as the interaction terms between significant predictors and time. Results: The linear trajectory of employment probabilities for the full sample remained at ~50% across 1, 2, 5, and 10-years post-injury. Gender (p = 0.016), relationship status (p = 0.002), employment (p < 0.001) and occupational status at injury (p = 0.005), and GCS (p = 0.006) yielded statistically significant effects on employment probability trajectories. Male gender, those in a partnered relationship at the time of injury, individuals who had been employed at the time of injury, those in a white-collar profession, and participants with a higher acute GCS score had significantly higher overall employment probability trajectories across the four time points. The time*gender interaction term was statistically significant (p = 0.002), suggesting that employment probabilities remained fairly stable over time for men, but showed a downward trend for women. The time*employment at injury interaction term was statistically significant (p = 0.003), suggesting that employment probabilities were fairly level over time for those who were employed at injury, but showed an upward trend over time for those who had been unemployed at injury. Conclusion: Overall employment probability trajectories remained relatively stable between 1 and 10 years. Baseline socio-demographic and injury characteristics were predictive of employment trajectories. Regular follow-up is recommended for patients at risk of long-term unemployment.

Combined cognitive and vocational interventions after mild to moderate traumatic brain injury: study protocol for a randomized controlled trial

Background

A considerable proportion of patients with mild to moderate traumatic brain injury (TBI) experience long-lasting somatic, cognitive, and emotional symptoms that may hamper their capacity to return to work (RTW). Although several studies have described medical, psychological, and work-related factors that predict RTW after TBI, well-controlled intervention studies regarding RTW are scarce. Furthermore, there has traditionally been weak collaboration among health-related rehabilitation services, the labor and welfare sector, and workplaces.

Methods/design

This study protocol describes an innovative randomized controlled trial in which we will explore the effect of combining manualized cognitive rehabilitation (Compensatory Cognitive Training [CCT]) and supported employment (SE) on RTW and related outcomes for patients with mild to moderate TBI in real-life competitive work settings. The study will be carried out in the southeastern region of Norway and thereby be performed within the Norwegian welfare system. Patients aged 18–60 years with mild to moderate TBI who are employed in a minimum 50% position at the time of injury and sick-listed 50% or more for postconcussive symptoms 2 months postinjury will be included in the study. A comprehensive assessment of neurocognitive function, self-reported symptoms, emotional distress, coping style, and quality of life will be performed at baseline, immediately after CCT (3 months after inclusion), following the end of SE (6 months after inclusion), and 12 months following study inclusion. The primary outcome measures are the proportion of participants who have returned to work at 12-month follow-up and length of time until RTW, in addition to work stability as well as work productivity over the first year following the intervention. Secondary outcomes include changes in self-reported symptoms, emotional and cognitive function, and quality of life. Additionally, a qualitative RTW process evaluation focused on organizational challenges at the workplace will be performed.

Discussion

The proposed study will combine cognitive and vocational rehabilitation and explore the efficacy of increased cross-sectoral collaboration between specialized health care services and the labor and welfare system. If the intervention proves effective, the project will describe the cost-effectiveness and utility of the program and thereby provide important information for policy makers. In addition, knowledge about the RTW process for persons with TBI and their workplaces will be provided.

Trial registration

ClinicalTrials.gov, NCT03092713. Registered on 10 March 2017.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2218-7) contains supplementary material, which is available to authorized users.

Employment outcome four years after a severe traumatic brain injury: results of the Paris severe traumatic brain injury study

OBJECTIVE

To describe employment outcome four years after a severe traumatic brain injury by the assessment of individual patients' preinjury sociodemographic data, injury-related and postinjury factors.

DESIGN

A prospective, multicenter inception cohort of 133 adult patients in the Paris area (France) who had received a severe traumatic brain injury were followed up postinjury at one and four years. Sociodemographic data, factors related to injury severity and one-year functional and cognitive outcomes were prospectively collected.

METHODS

The main outcome measure was employment status. Potential predictors of employment status were assessed by univariate and multivariate analysis.

RESULTS

At the four-year follow-up, 38% of patients were in paid employment. The following factors were independent predictors of unemployment: being unemployed or studying before traumatic brain injury, traumatic brain injury severity (i.e., a lower Glasgow Coma Scale score upon admission and a longer stay in intensive care) and a lower one-year Glasgow Outcome Scale-Extended score.

CONCLUSION

This study confirmed the low rate of long-term employment amongst patients after a severe traumatic brain injury. The results illustrated the multiple determinants of employment outcome and suggested that students who had received a traumatic brain injury were particularly likely to be unemployed, thus we propose that they may require specific support to help them find work. Implications for rehabilitation Traumatic brain injury is a leading cause of persistent disablity and can associate cognitive, emotional, physical and sensory impairments, which often result in quality-of-life reduction and job loss. Predictors of post-traumatic brain injury unemployment and job loss remains unclear in the particular population of severe traumatic brain injury patients. The present study highlights the post-traumatic brain injury student population require a close follow-up and vocational rehabilitation. The study suggests that return to work post-severe traumatic brain injury is frequently unstable and workers often experience difficulties that caregivers have to consider.

Effectiveness of an Educational Intervention on Reducing Misconceptions Among Ethnic Minorities With Complicated Mild to Severe Traumatic Brain Injury

OBJECTIVE

To evaluate the effectiveness of an educational intervention designed to reduce traumatic brain injury (TBI)-related misconceptions among blacks and Latinos with complicated mild to severe TBI.

DESIGN

Randomized controlled trial with masked 1-month follow-up.

SETTING

Community.

PARTICIPANTS

Persons (N=52) with complicated mild to severe TBI (mean best day 1 Glasgow Coma Scale score, 11.27±3.89) were randomly recruited from 141 eligible participants (mean age, 37.71±13.88y; age range, 19-66y; mean months postinjury, 24.69±11.50); 25 participants (48.1%) of participants were black and 27 (51.9%) were Hispanic/Latino. Of the Hispanic/Latino participants, 18 (66.7%) were non-U.S. born and 12 (44.4%) spoke Spanish as their primary language. Twenty-seven individuals were randomized to the educational intervention group and 25 were randomized to the wait-list control group.

INTERVENTIONS

Single-session educational intervention with written materials provided in English or Spanish.

MAIN OUTCOME MEASURES

Forty-item Common Misconceptions about Traumatic Brain Injury Questionnaire administered at baseline and 1-month follow-up.

RESULTS

After controlling for ethnic and language differences, a significant between-group main effect (P=.010) and a significant time-group interaction for the Common Misconceptions about Traumatic Brain Injury Questionnaire were noted (Wilks Λ=.89; F_1,46=6.00; P=.02). The intervention group showed a decrease in TBI misconception percentages, whereas the wait-list control group maintained similar percentages. At 1-month follow-up, the wait-list control group reported more misconceptions than did the intervention group (P=.019).

CONCLUSIONS

An educational intervention developed to address the recovery process, common symptoms, and ways to handle the symptoms provides promise as a tool to decrease TBI misconceptions among persons from ethnically and educationally diverse backgrounds. The effects of therapist characteristics and the client-therapist relation on outcomes should be further explored.

Prediction of occupational disability from psychological and neuropsychological evidence in forensic context

Within the fields of psychiatry, psychology, and neuropsychology, medical examiners are often tasked with providing an opinion about an injured individual's health prognosis and likelihood of returning to work. Traditionally, examiners have conducted such assessments by employing clinical intuition, expert knowledge, and judgment. More recently, however, an accumulation of research on factors predictive of disability has allowed examiners to provide prognostications using specific empirically supported evidence. This paper integrates current evidence for four common clinical issues encountered in forensic assessments-musculoskeletal pain, depression, Posttraumatic Stress Disorder, and traumatic brain injury. It discusses an evidence-informed, cross-diagnostic and multifactorial model of predicting disability that is emerging from the literature synthesis, along with recommendations for best forensic assessment practice.

Implementation of resource facilitation to assess referral needs and promote access to state vocational rehabilitation services in people with traumatic brain injury

Resource facilitation (RF) has shown promise for improving return to work (RTW) after traumatic brain injury (TBI), but little is known about the RF needs of people recruited from acute trauma settings. In this descriptive study, we sought to track referral needs, describe problems in accessing state vocational rehabilitation (VR) services, and highlight the role of RF in overcoming these difficulties in 45 adults with complicated mild to severe TBI seeking RTW who were recruited from acute trauma care. Participants received a referral to the state VR agency, along with RF services for up to one year. Case coordinators (CCs) conducted biweekly assessments, provided referrals, and helped address problems in accessing services. On average 4.92 referrals were generated per participant; 91% required referrals. CCs made 44% of referrals, while physicians/other healthcare professionals generated 33% and VR counsellors generated 23%. CCs filled a gap in referring for financial and transportation difficulties. Two case studies illustrate implementation of the RF paradigm. RF provides systematic assessment and referral for services needed to facilitate utilisation of state VR services. Among persons with TBI recruited from acute trauma settings in the US, CCs provide referrals that are often not generated by other sources.

Identifying contextual influences of community reintegration among injured servicemembers

Research suggests that community reintegration (CR) after injury and rehabilitation is difficult for many injured servicemembers. However, little is known about the influence of the contextual factors, both personal and environmental, that influence CR. Framed within the International Classification of Functioning, Disability and Health and Social Cognitive Theory, the quantitative portion of a larger mixed-methods study of 51 injured, community-dwelling servicemembers compared the relative contribution of contextual factors between groups of servicemembers with different levels of CR. Cluster analysis indicated three groups of servicemembers showing low, moderate, and high levels of CR. Statistical analyses identified contextual factors (e.g., personal and environmental factors) that significantly discriminated between CR clusters. Multivariate analysis of variance and discriminant analysis indicated significant contributions of general self-efficacy, services and assistance barriers, physical and structural barriers, attitudes and support barriers, perceived level of disability and/or handicap, work and school barriers, and policy barriers on CR scores. Overall, analyses indicated that injured servicemembers with lower CR scores had lower general self-efficacy scores, reported more difficulty with environmental barriers, and reported their injuries as more disabling.

Stability of employment over the first 3 years following traumatic brain injury

OBJECTIVE

To examine the stability of employment between 1 and 3 years following traumatic brain injury (TBI) and to identify the variables associated with continued employment throughout this time span.

PARTICIPANTS

This study included 236 individuals with predominantly moderate to very severe TBI, who had received rehabilitation in the context of a no-fault accident compensation system. Participants were eligible for the current study if they were employed before injury and reported their employment status at 1, 2, and 3 years following their injury as part of a longitudinal head injury outcome study.

RESULTS

Only 44% of participants remained employed at each of the 3 years following TBI. There was also substantial transition into and out of employment across the 3 years. Significantly greater instability in employment was reported by individuals who were machinery operators or laborers before injury, had a longer duration of posttraumatic amnesia, reported more cognitive difficulties, and were less mobile 1 year following their injury.

CONCLUSION

A number of important factors determine the likelihood of achieving stability in employment following TBI. Findings from the current study support the continued need to identify ways in which physical as well as cognitive changes contribute to employment following TBI. Further examination is needed to identify possible compensatory strategies or job modifications to maximize the likelihood of job retention.

Unemployment in the United States after traumatic brain injury for working-age individuals: prevalence and associated factors 2 years postinjury

OBJECTIVE

To estimate the prevalence of unemployment and part-time employment in the United States for working-age individuals completing rehabilitation for a primary diagnosis of traumatic brain injury (TBI) between 2001 and 2010.

DESIGN

Secondary data analysis.

SETTING

Acute inpatient rehabilitation facilities.

PARTICIPANTS

Patients aged 16 to 60 years at injury who completed inpatient rehabilitation for TBI between 2001 and 2010.

MAIN OUTCOME MEASURES

Unemployment; Part-time employment.

RESULTS

The prevalence of unemployment for persons in the selected cohort was 60.4% at 2-year postinjury. Prevalence of unemployment at 2-year postinjury was significantly associated with the majority of categories of age group, race, gender, marital status, primary inpatient rehabilitation payment source, education, preinjury vocational status, length of stay, and Disability Rating Scale. The direction of association for the majority of these variables complement previous research in this area, with only Hispanic ethnicity and the FIM Cognitive subscale demonstrating disparate findings. For those employed at 2-year postinjury, the prevalence of part-time employment was 35.0%. The model of prevalence for part-time employment at 2-year postinjury was less robust, with significant relationships with some categorical components of age group, gender, marital status, primary payment source, preinjury vocational status, and Disability Rating Scale.

CONCLUSIONS

The prevalence of unemployment for patients completing inpatient rehabilitation for TBI was substantial (60.4%). The majority of factors found to associate with 2 years' unemployment were complementary of previously published research; however, these were often smaller in magnitude than previous reports. The prevalence of part-time employment was also an issue for this cohort and included 35.0% of all employed individuals. In regard to the determination of factors associated with part-time employment, additional analyses that include more fine-grained factors associated with employment, including physical and psychosocial functioning, are recommended.

Traumatic Brain Injury in United States Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Hispanic Veterans-A Review Using the PRISMA Method

Traumatic brain injury (TBI) is commonly defined by Menon et al. as an "alteration of the brain function, or other evidence of brain pathology, caused by an external force." TBI can be caused by penetrating trauma to the head in which the magnitude of the injury is dependent on the magnitude of the forces that are applied to the head. The consequences of TBI can range from minimal to severe disability and even death. The major objectives of this systematic review are to survey the current literature on Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) Hispanic veterans with TBI. To complete this analysis, the Preferred Reporting Items for Systematic Reviews and MetaAnalysis (PRISMA) identified 875 articles in common and retrieved a total of 34 articles that met the inclusion criteria, consisted of OEF/OIF Hispanic veterans, reported quantitative data, and were conducted with adult U.S. veterans living in the United States. Since TBI diagnosis was unclear in most articles, only five articles that used the VATBIST instrument were analyzed. The results suggested that there is a lack of research on OEF/OIF Hispanic veterans and Hispanic subgroups. Future studies need to be conducted to consider minority groups while analyzing data involving TBI.

Ten-Year Employment Patterns of Working Age Individuals After Moderate to Severe Traumatic Brain Injury: A National Institute on Disability and Rehabilitation Research Traumatic Brain Injury Model Systems Study

OBJECTIVE

To describe the 10-year patterns of employment for individuals of working age discharged from a Traumatic Brain Injury Model Systems (TBIMS) center between 1989 and 2009.

DESIGN

Secondary data analysis.

SETTING

Inpatient rehabilitation centers.

PARTICIPANTS

Patients aged 16 to 55 years (N=3618) who were not retired at injury, received inpatient rehabilitation at a TBIMS center, were discharged alive between 1989 and 2009, and had at least 3 completed follow-up interviews at postinjury years 1, 2, 5, and 10.

INTERVENTIONS

Not applicable.

MAIN OUTCOMES MEASURE

Employment.

RESULTS

Patterns of employment were generated using a generalized linear mixed model, where these patterns were transformed into temporal trajectories of probability of employment via random effects modeling. Covariates demonstrating significant relations to growth parameters that govern the trajectory patterns were similar to those noted in previous cross-sectional research and included age, sex, race/ethnicity, education, preinjury substance misuse, preinjury vocational status, and days of posttraumatic amnesia. The calendar year in which the injury occurred also greatly influenced trajectories. An interactive tool was developed to provide visualization of all postemployment trajectories, with many showing decreasing probabilities of employment between 5 and 10 years postinjury.

CONCLUSIONS

These results highlight that postinjury employment after moderate to severe traumatic brain injury (TBI) is a dynamic process, with varied patterns of employment for individuals with specific characteristics. The overall decline in trajectories of probability of employment between 5 and 10 years postinjury suggests that moderate to severe TBI may have unfavorable chronic effects and that employment outcome is highly influenced by national labor market forces. Additional research targeting the underlying drivers of the decline between 5 and 10 years postinjury is recommended, as are interventions that target influencing factors.

Prognostic factors of return to work after traumatic or non-traumatic acquired brain injury

PURPOSE

To investigate and to determine evidence of prognostic factors for return to work (RTW) after acquired brain injury (ABI).

METHOD

A systematic literature search was conducted in PubMed (2008-2014), applying terms for ABI and RTW. In addition, studies published after 2003 of a previous review on the same topic were added. The methodological quality of the included studies was assessed and evidence was classified.

RESULTS

Twenty-seven studies were included. There is strong evidence that a high education level is positively associated with RTW after traumatic ABI; a low education level, unemployment and length of stay in rehabilitation are negatively associated, and a clear tendency has been deduced from the studies that conscious state in the Emergency Department is not associated with RTW. After non-traumatic ABI, there is strong evidence that independence in activities of daily living is positively associated with RTW and aetiology of stroke is not.

CONCLUSIONS

This study confirms earlier findings that after both traumatic and non-traumatic ABI injury related factors in the Emergency Department are not associated with RTW. In addition, it provides further evidence that personal factors after traumatic ABI and activity-related factors after non-traumatic ABI are strongly associated with RTW. Implications for Rehabilitation We found strong evidence for a significant association between RTW and personal factors (education level, unemployment) after traumatic ABI, and activities of daily living (ADL) after non-traumatic ABI. We advise to focus on work-related activities during the RTW process besides ADL-training and pay attention to and support patients at risk for not returning to work.

An introduction to analyzing dichotomous outcomes in a longitudinal setting: a NIDRR traumatic brain injury model systems communication

An untapped wealth of temporal information is captured within the Traumatic Brain Injury Model Systems National Database. Utilization of appropriate longitudinal analyses can provide an avenue toward unlocking the value of this information. This article highlights 2 statistical methods used for assessing change over time when examination of noncontinuous outcomes is of interest where this article focuses on investigation of dichotomous responses. Specifically, the intent of this article is to familiarize the rehabilitation community with the application of generalized estimating equations and generalized linear mixed models as used in longitudinal studies. An introduction to each method is provided where similarities and differences between the 2 are discussed. In addition, to reinforce the ideas and concepts embodied in each approach, we highlight each method, using examples based on data from the Rocky Mountain Regional Brain Injury System.

Multi-level modelling of employment probability trajectories and employment stability at 1, 2 and 5 years after traumatic brain injury

PRIMARY OBJECTIVES

To examine trajectories of employment probability and stability over the first 5 years after traumatic brain injury (TBI) by using multi-level modelling and multinomial logistic regressions.

RESEARCH DESIGN

A longitudinal cohort study.

METHODS AND PROCEDURES

One hundred and five individuals with moderate-to-severe TBI who had been admitted to the Trauma Referral Centre for the Southeast region of Norway were followed up at 1, 2 and 5 years after the injury.

MAIN OUTCOMES AND RESULTS

Employment status was dichotomized into employed and unemployed, while employment stability was categorized into stably employed, unstably employed and unemployed at 1, 2 and 5 years after injury. Being single, unemployment prior to injury, blue collar occupation, lower Glasgow Coma Scale (GCS) score at hospital admission and greater length of post-traumatic amnesia (PTA) were significantly associated with being unemployed at 1, 2 and 5 years post-injury. Further, younger patients, those with a lower GCS, greater length of PTA and greater length of hospital stay were negatively associated with employment stability.

CONCLUSIONS

It could be wise to target patient population with these demographic and injury characteristics for more extensive follow-ups and vocational rehabilitation to help improve employment outcomes following injury.

The differential contributions of posttraumatic amnesia duration and time since injury in prediction of functional outcomes following moderate-to-severe traumatic brain injury

OBJECTIVE

To examine the relative contributions of preinjury, injury severity, and acute postinjury variables in predicting outcomes at 1 year following moderate-severe traumatic brain injury (TBI).

DESIGN

Secondary analysis of a prospective longitudinal cohort study.

SETTING

Four Veterans Affairs Medical Center acute inpatient rehabilitation programs.

PARTICIPANTS

Active duty military or veterans with a nonpenetrating moderate-to-severe TBI.

MAIN OUTCOME MEASURES

Independent living status (N = 280) and work status (N = 248) at one year postinjury.

RESULTS

Preinjury characteristics as a group accounted for the largest amount of variance in independent living status at 1 year; however, posttraumatic amnesia (PTA) uniquely explained the largest amount of variance (8.8%). Those with less than 60 days PTA were 9 times more likely to be independent; those with less than 30 days PTA were 3 times more likely to be independent. In contrast, acute postinjury characteristics accounted for the largest amount of variance in work status, with time to rehabilitation explaining the most unique variance (10.4%). Those with less than 48 days time to rehabilitation were 2.4 times more likely to be productive.

CONCLUSIONS

This study highlights the differential contribution of variables in the prediction of 2 specific functional outcomes in a military sample, adding to our current body of knowledge to assist clinicians, patients and their families following TBI.

Preliminary investigation of longitudinal sociodemographic, injury and psychosocial characteristics in a group of non-English speaking Latinos with brain injury

PRIMARY OBJECTIVE

To describe the sociodemographic and injury characteristics and psychosocial outcomes at 1 and 10 years post-injury in a group of Spanish-speaking individuals with traumatic brain injury.

RESEARCH DESIGN

Descriptive cross-sectional and longitudinal analyses of prospectively collected data.

METHODS AND PROCEDURES

Assessments were completed on 57 non-English speaking Latinos with TBI, injured between March 1991 and January 2008, who were treated at a Traumatic Brain Injury Model System of Care acute rehabilitation facility. Follow-up data was collected cross-sectionally at 1 year (n = 41) and 10 years (n = 23) post-injury. Longitudinal data (both Y1 and Y10) were available for 17 of those individuals.

MAIN OUTCOMES

Post injury employment and residence, Disability Rating Scale, Functional Independence Measure.

RESULTS

At 1 year, the majority of participants were unemployed (63.4%) and did not require assistance of another individual (58.5%) as measured by the DRS Level of Functioning. FIM scores showed that the greatest difficulty was in the area of problem-solving and memory with over half the sample needing assistance in these areas. At 10 years post-injury, 47.8% were unemployed and remained independent of assistance from a caretaker (56.5%) as measured by the DRS. FIM results revealed that slightly less than half continued to need assistance in areas of problem-solving and memory. Longitudinal changes were seen in that, over time, individuals reported more difficulties in areas of bathing and dressing, but fewer difficulties in areas including social interaction, comprehension and memory.

CONCLUSIONS

Non-English-speaking Latinos with brain injury are at a double disadvantage with regard to obtaining much-needed ongoing services, ultimately impacting long-term outcomes post-injury. If such issues are not adequately addressed, as the Latino population continues to grow, disparities in service delivery and unsuccessful outcomes will continue to grow.

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.