4. Postacute rehabilitation and community integration

Financial and vocational outcomes 2 years after traumatic brain injury

PURPOSE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Occupational Categories and Return to Work After Traumatic Brain Injury: A Multicenter Study

OBJECTIVE

To further evaluate determinants of return to work (RTW) after traumatic brain injury (TBI), with focus on the relation between preinjury occupational category and RTW outcome.

DESIGN

Prospective collaborative cohort study.

SETTING

Seventeen National Institute on Disability and Rehabilitation Research-designated Traumatic Brain Injury Model Systems.

PARTICIPANTS

Consecutive sample of 1341 patients (age range, 18-62y) who were hospitalized with a TBI diagnosis, received both acute neurotrauma services and inpatient rehabilitation services, consented to participate, were employed before injury, and completed a 1-year follow-up assessment.

INTERVENTION

An inpatient interdisciplinary brain injury rehabilitation program.

MAIN OUTCOME MEASURE

Competitive employment at 1 year postinjury.

RESULTS

Participants were categorized into 1 of 3 groups depending on preinjury occupational title: professional/managerial (n=192), skilled (n=751), or manual labor (n=398). Chi-square analyses were computed to examine changes across occupation groups between preinjury occupation group and postinjury RTW. The rate of successful RTW was greatest for professional/managerial (56%), lower for skilled (40%), and lowest for manual labor (32%), yielding an odds ratio of 2.959 between the highest and lowest groups. Of those with successful RTW, most did so within the same occupational category grouping. A multiple logistic regression showed that preinjury occupation, education level, discharge FIM score, age, sex, marital status, and hospital length of stay each influenced RTW.

CONCLUSIONS

Prior research has shown that preinjury employment status (employed vs unemployed) greatly influences the odds of successful RTW after TBI. A related hypothesis, that occupational classification also influences RTW outcome, has been understudied and has yielded conflicting results. The current study shows convincingly that the type of occupation influences RTW outcome, with the best prospect for RTW among people with professional/managerial jobs. Occupational category should be examined in the future development of predictive models for RTW after TBI.

4: Rehabilitation after traumatic brain injury

Traumatic brain injury (TBI) commonly affects younger people and causes life-long impairments in physical, cognitive, behavioural and social function. The cognitive, behavioural and personality deficits are usually more disabling than the residual physical deficits. Recovery from TBI can continue for at least 5 years after injury. Rehabilitation is effective using an interdisciplinary approach, and close liaison with the patient, family and carers. The focus is on issues such as retraining in activities of daily living, pain management, cognitive and behavioural therapies, and pharmacological management. The social burden of TBI is significant, and therefore family education and counselling, and support of patient and carers, is important. General practitioners play an important role in providing ongoing support in the community, monitoring for medical complications, behavioural and personality issues, social reintegration, carer coping skills and return-to-work issues.

Moderating factors in return to work and job stability after traumatic brain injury

OBJECTIVE

To examine job stability moderating variables and develop a postinjury work stability prediction model.

DESIGN

Multicenter analysis of individuals with traumatic brain injury (TBI) who returned for follow-up at 1, 2, and 3, or 4 years postinjury, were of working age (between 18 and 62 years of age at injury), and were working preinjury.

SETTING

Six National Institute on Disability and Rehabilitation Research TBI Model System centers for coordinated acute and rehabilitation care.

PARTICIPANTS

A total of 186 adults with TBI were included in the study.

MAIN OUTCOME MEASURES

Job stability was categorized as stably employed (employed at all 3 follow-up intervals); unstably employed (employed at one or two of all three follow-up intervals); and unemployed (unemployed at all three follow-up intervals).

RESULTS

After injury, 34% were stably employed, 27% were unstably employed, and 39% were unemployed at all three follow-up intervals. Minority group members, people who did not complete high school, and unmarried people were more likely to be unemployed. Driving independence was highly influential and significantly related to employment stability. A discriminant function analysis, which included age, length of unconsciousness and Disability Rating Scale scores at 1 year postinjury, accurately predicted job stability groupings.

CONCLUSION

Data analysis provided evidence that employment stability is predictable with a combination of functional, demographic, and injury severity variables. Identification of people at risk for poor employment outcomes early on can facilitate rehabilitation planning and intervention.

Acute predictors of return to employment after traumatic brain injury: a longitudinal follow-up

OBJECTIVE

To investigate the relation between selected acute injury and patient characteristics and subsequent return to work 1 to 5 years postinjury.

DESIGN

Longitudinal design with prospectively collected data. Data were collected on patients at the time of injury and each year postinjury for up to 5 years.

SETTING

Four medical centers in the federally sponsored Traumatic Brain Injury Model Systems project that provide emergency medical services, intensive and acute medical care, inpatient rehabilitation, and a spectrum of community rehabilitation services.

PARTICIPANTS

Patients were selected from a national database of 538 rehabilitation inpatients admitted to acute care within 8 hours of traumatic brain injury (TBI) and seen at 1 to 5 years follow-up.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Employment status (employed vs not employed) at 1 to 5 years postinjury. Logistic regression analyses were performed to determine the extent to which selected variables predicted employment status at years 1 to 5 postinjury.

RESULTS

At year 1 postinjury, preinjury productivity, age, education, and rehabilitation length of stay were all significantly associated with postinjury employment. Preinjury employment and productivity and age significantly predicted employment at postinjury year 2. At year 3 postinjury, preinjury productivity, age, and FIMtrade mark instrument discharge score significantly predicted employment status. Age was significantly associated with employment status at year 4 postinjury. Preinjury employment and productivity and Disability Rating Scale discharge score were found to be significant predictors of postinjury employment at year 5 follow-up.

CONCLUSIONS

The relationship between certain acute injury and patient variables (eg, age, preinjury productivity, education, discharge FIM) and subsequent return to work may provide rehabilitation professionals with useful information regarding the intensity and types of services needed for individuals in the vocational rehabilitation planning process.