How do People get back to Work after Severe Head Injury? A 10 year Follow-up Study

Functioning and disability from 10 to 16 years after traumatic brain injury

OBJECTIVES

With increased long-term survival after traumatic brain injury (TBI), there is a need to understand the life situation many years after the injury. In this study, we have assessed persons on average 16 years after their injury and determined changes over 6 years in overall outcome, living condition, marital status and vocational situation, and in their functioning and disability.

MATERIALS & METHODS

Individuals (n = 49, mean age 45 years, 28-70 years) who were assessed 6-15 years (average 10 years) post-TBI were reassessed 12-21 years after their injury (average 16 years) using internationally established TBI outcome measures.

RESULTS

From the first to the second assessment, overall outcome using the Glasgow Outcome Scale (GOS) was stable for a large majority and no significant changes in marital status or vocational situation were found. There was some significant, but very small, decline regarding cognitive function, home integration and social integration. In the multiple regression analysis, there was a small significant decline in the Mayo-Portland Adaptability Inventory (MPAI-4) Adjustment subscale score for women with a moderate-to-severe injury.

CONCLUSIONS

The very small changes over 6 years imply that persons with a TBI can reach and maintain a stable level of functioning many years post-TBI. Women with a moderate-to-severe TBI seem to be more vulnerable and may experience a small decline in some aspects of their functioning related to anxiety, depression, irritability, pain and headache and fatigue. The relatively small sample requires further studies to confirm these findings.

Early, specialist vocational rehabilitation to facilitate return to work after traumatic brain injury: the FRESH feasibility RCT

BACKGROUND

Up to 160,000 people incur traumatic brain injury (TBI) each year in the UK. TBI can have profound effects on many areas of human functioning, including participation in work. There is limited evidence of the clinical effectiveness and cost-effectiveness of vocational rehabilitation (VR) after injury to promote early return to work (RTW) following TBI.

OBJECTIVE

To assess the feasibility of a definitive, multicentre, randomised controlled trial (RCT) of the clinical effectiveness and cost-effectiveness of early, specialist VR plus usual care (UC) compared with UC alone on work retention 12 months post TBI.

DESIGN

A multicentre, feasibility, parallel-group RCT with a feasibility economic evaluation and an embedded mixed-methods process evaluation. Randomisation was by remote computer-generated allocation.

SETTING

Three NHS major trauma centres (MTCs) in England.

PARTICIPANTS

Adults with TBI admitted for > 48 hours and working or studying prior to injury.

INTERVENTIONS

Early specialist TBI VR delivered by occupational therapists (OTs) in the community using a case co-ordination model.

MAIN OUTCOME MEASURES

Self-reported RTW 12 months post randomisation, mood, functional ability, participation, work self-efficacy, quality of life and work ability. Feasibility outcomes included recruitment and retention rates. Follow-up was by postal questionnaires in two centres and face to face in one centre. Those collecting data were blind to treatment allocation.

RESULTS

Out of 102 target participants, 78 were recruited (39 randomised to each arm), representing 39% of those eligible and 5% of those screened. Approximately 2.2 patients were recruited per site per month. Of those, 56% had mild injuries, 18% had moderate injuries and 26% had severe injuries. A total of 32 out of 45 nominated carers were recruited. A total of 52 out of 78 (67%) TBI participants responded at 12 months (UC, n = 23; intervention, n = 29), completing 90% of the work questions; 21 out of 23 (91%) UC respondents and 20 out of 29 (69%) intervention participants returned to work at 12 months. Two participants disengaged from the intervention. Face-to-face follow-up was no more effective than postal follow-up. RTW was most strongly related to social participation and work self-efficacy. It is feasible to assess the cost-effectiveness of VR. Intervention was delivered as intended and valued by participants. Factors likely to affect a definitive trial include deploying experienced OTs, no clear TBI definition or TBI registers, and repatriation of more severe TBI from MTCs, affecting recruitment of those most likely to benefit/least likely to drop out.

LIMITATIONS

Target recruitment was not reached, but mechanisms to achieve this in future studies were identified. Retention was lower than expected, particularly in UC, potentially biasing estimates of the 12-month RTW rate.

CONCLUSIONS

This study met most feasibility objectives. The intervention was delivered with high fidelity. When objectives were not met, strategies to ensure feasibility of a full trial were identified. Future work should test two-stage recruitment and include resources to recruit from 'spokes'. A broader measure covering work ability, self-efficacy and participation may be a more sensitive outcome.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN38581822.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 33. See the NIHR Journals Library website for further project information.

Five-year follow-up of persons with brain injury entering the French vocational and social rehabilitation programme UEROS: Return-to-work, life satisfaction, psychosocial and community integration

BACKGROUND

Social and vocational reintegration of persons with brain injury is an important element in their rehabilitation.

AIMS

To evaluate the 5-year outcome of persons with brain injury included in 2008 in the Aquitaine Unit for Evaluation, Training and Social and Vocational Counselling programme (UEROS).

METHOD

57 persons with brain injury were recruited from those who completed the 2008 UEROS programme. Five years later, an interview was done to assess family and vocational status, autonomy and life satisfaction. These results were compared with those from persons completing the 1997-1999 programme.

RESULTS

The typical person entered the 2008 UEROS programme 6 years after a severe brain injury (42%) and was male, single and 35 years. At the 5-year follow-up, more persons lived with a partner (+23%) and lived in their own home (+21%). 47% were working vs 11% on entering the programme. Approximately half were satisfied or very satisfied with their quality of life. Having a job in 2013 was associated with a high education level, less cognitive sequelae, having a job in 2008 and no health condition.

CONCLUSIONS

The UEROS programme is effective with regard to return-to-work and improvement of autonomy in persons with brain injury, irrespective of length of time from injury.

Postacute Programming for Community Integration: A Scoping Review

There has been a dramatic increase in recent years in the literature available on community integration among people with acquired brain injuries. At the same time, however, clinicians are calling for information that has utility in the complex environment of community practice. The study was a scoping review to address the question:What is known from the existing literature regarding the best ways to promote community integration in the postacute phase of brain injury recovery?From a preliminary pool of 925 studies identified by electronic searching of 5 databases in a 15-year time window, a final set of 30 was selected for further review, referring to 25 distinct programs. This scoping review has shown that there are 5 types of programs typically offered to survivors of brain injuries to assist with community integration: supported employment, traditional rehabilitation, environmental adaptation, support development and transitional living. These 5 approaches were primarily used to address 2 aspects of community integration: traditional rehabilitation was most commonly used to promote independent living, and supported employment was the most common approach used to promote productive occupation. Themes that emerged from the review were the need for highly individualised programming, in vivo approaches, tailored supports, early intervention and a focus on participation. Methodologically, the study represents an important acknowledgment of the valuable information that is available in the literature in descriptive and small sample research.

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.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The Papworth Early Rehabilitation Programme: Vocational outcomes

BACKGROUND

There are 2.7 million people in the UK receiving incapacity benefits, costing approximately pound 18 billion pa. Government has adopted a policy of helping claimants back into work, through structured vocational rehabilitation schemes. There are no published results of vocational rehabilitation services in the UK. We present the results of the Papworth Trust vocational rehabilitation programme. Depending on the severity of their disability, the 'Early Rehab Programme' aims to get people on incapacity benefits: (a) into employment, (b) fit for and seeking work, (c) involved in voluntary work, (d) education, or (e) able to live independently.

METHODS

Retrospective chart survey and telephone follow up.

SETTING

Cambridgeshire.

RESULTS

Since 1995, 274 people attended for a preliminary interview, of which 107 subsequently started a full rehab programme. Eighty-seven were male and 20 female. Half had been unemployed for more than two years. Ninety-four completed the programme, of whom 53 had gained employment, 33 were 'work ready' and four were doing voluntary work. At long-term follow-up, 52 were employed, 12 were in voluntary work, and 7 had retired on medical grounds.

CONCLUSIONS

This programme demonstrates that long-term Incapacity Benefit recipients can return to sustained employment, as shown in those who participated in the Papworth Trust's vocational rehabilitation programme.

‘Participate to learn’: A promising practice for community ABI rehabilitation

OBJECTIVE

To identify best practices and promising practices to enhance participation in meaningful and productive activities.

METHOD

An electronic search of the ABI rehabilitation research literature since 1990 yielded 974 articles of which 30 focused on interventions that targeted participation and evaluated effectiveness using direct measures of participation. Three reviewers rated these articles according to the standards set out by the Centre for Reviews and Dissemination. Following the systematic review, an interpretive review of the same articles was completed.

RESULTS

Only three studies were rated as strong. No best practices were identified. Three promising practices found some support. The interpretive review suggested 'Participate to learn' as a useful rehabilitation model. The model rests on roles as goals, learning by experience in real-life contexts and the use of personal and environmental support to enable participation.

CONCLUSIONS

'Participate to learn' is both a credible rehabilitation model and deserving of more study.

Return to work following moderate-to-severe traumatic brain injury

PRIMARY OBJECTIVE

To investigate the role of cognitive functioning, fatigue, mood and behaviour in return to work (RTW) following moderate-to-severe traumatic brain injury.

DESIGN AND METHODS

Between-groups comparisons were conducted with 20 participants who had RTW and 13 who had not. Participants were well matched for age, pre-morbid intellectual functioning, years of education, injury severity and time since injury.

OUTCOMES AND RESULTS

The unemployed group reported significantly higher levels of fatigue and depression and significantly more problems on self-report questionnaires. A significantly higher proportion of this group was seeking compensation. No significant differences were obtained on neuropsychological measures of cognitive functioning.

CONCLUSIONS

Mood, fatigue and behavioural problems may impede a person's ability to RTW. Subjective measures may be more superior to objective measures in predicting RTW. The litigation process may affect people's motivation to RTW.

Functional outcome 10 years after traumatic brain injury: its relationship with demographic, injury severity, and cognitive and emotional status

Previous investigations of long-term outcome following traumatic brain injury (TBI) have yielded mixed results regarding the predictive power of injury severity and demographic factors. Furthermore, there has been limited investigation of the association between long-term outcome and current cognitive functioning and psychiatric state. The aim of this study was to investigate the association of injury severity, demographic factors, and concurrent cognitive and psychiatric functioning with functional outcome 10 years following mild to severe TBI. Outcome was rated using the Extended Glasgow Outcome Scale (GOSE) for 60 participants, who also completed neuropsychological measures of attention, speed of processing, memory and executive function and the Hospital Anxiety and Depression Scale (HADS). Outcome on the GOSE ranged from upper good recovery (32%) to lower severe disability (2%). Participants showing poorer outcome on the GOSE had significantly longer posttraumatic amnesia duration; less education; performed more poorly on cognitive measures of information processing speed, attention, memory, and executive function; and showed higher levels of anxiety on the HADS.

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

PRIMARY OBJECTIVE

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

METHOD AND PROCEDURES

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

MAIN OUTCOMES AND RESULTS

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

CONCLUSIONS

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

Psychosocial and emotional outcomes 10 years following traumatic brain injury

OBJECTIVES

To investigate the association of psychosocial outcome 10 years following traumatic brain injury (TBI) with demographic variables, injury severity, current cognitive functioning, emotional state, aggression, alcohol use, and fatigue.

SETTING

Community-based follow-up.

PARTICIPANTS

Fifty-three participants with mild to very severe TBI sustained 10 years previously and significant others.

MEASURES

Sydney Psychosocial Reintegration Scale, Extended Glasgow Outcome Scale, Hospital Anxiety and Depression Scale, NFI Aggression scale, Fatigue Severity Scale, Alcohol Use Disorders Identification Test, neuropsychological tests of attention/processing speed, memory, and executive function.

RESULTS

Psychosocial functioning was lowest in the occupational activity domain and highest in the living skills domains. Variables including education, posttraumatic amnesia duration, numerous cognitive measures, concurrent fatigue, aggression, anxiety, and depression were all significantly associated with psychosocial outcome, although the strength of correlations varied between ratings of participants with TBI and relatives. Posttraumatic amnesia duration was most strongly associated with psychosocial outcome measured by relatives; anxiety, aggression, and depression were the strongest predictors when ratings were assigned by participants with TBI. Self-reported fatigue, depression, and alcohol use were the strongest predictors of aggression.

CONCLUSIONS

It is important to address problems with anxiety, depression, fatigue, and alcohol use as a possible means of improving long-term psychosocial outcome following TBI.

Prediction of long-term occupational performance outcomes for adults after moderate to severe traumatic brain injury

PURPOSE

To examine predictors of long-term occupational performance outcomes for adults after moderate to severe traumatic brain injury (TBI).

METHOD

This study involved analysis of data from a retrospective cohort of adults (N = 306) with moderate to severe TBI discharged from a Pennsylvania rehabilitation treatment facility. Extensive pre-injury sociodemographic, injury-severity, post-injury personal (cognitive, physical, affective), post-injury environmental (social, institutional, physical), and post-injury occupational performance (participation in self-care, productivity, leisure activities) data were gathered from hospital records and using in-person interviews. Interviews occurred at a mean time of 14 (range, 7-24) years post-injury. Hierarchical multiple regression analysis was used to investigate determinants of long-term occupational performance outcomes.

RESULTS

Pre-injury behavioural problems, male gender, post-injury cognitive and physical deficits, and lack of access to transportation were significant independent predictors of worse occupational performance outcomes.

CONCLUSIONS

The study supports the use of a comprehensive model for long-term outcomes after TBI where pre-injury characteristics and post-injury cognitive and physical characteristics account for the greatest proportion of explained variance.

Stability of employment after traumatic brain injury

Although substantial information exists about factors related to who returns to work and time taken to return to work after traumatic brain injury (TBI), less is known about the stability of the work experience after the injury. One hundred sixty-five workers with complicated mild to severe traumatic brain injury were followed for 3 to 5 years postinjury. Work stability definitions included amount of time worked (amount of time worked divided by time observed postinjury) and maintenance of uninterrupted employment once a person returned to work. Amount of time worked was significantly and systematically related to brain injury severity, neuropsychological functioning at l-month postinjury, and preinjury characteristics such as prior work stability and earnings. However, once persons returned to work, the ability to maintain uninterrupted employment was largely related to premorbid characteristics such as being older, higher income before the injury, or a preinjury job with benefits. It was also related to higher neuropsychological functioning at 1-month postinjury (reflecting the combined effects of premorbid functioning and traumatic brain injury severity), but not related to neurologic indices of severity.

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.

Long-term employment outcomes in a rural area following traumatic brain injury

One of the major sequelae following traumatic brain injury is a change in employment status. This poses significant challenges for rehabilitation services. Several studies have investigated the longer-term outcome after traumatic brain injury. Longer-term outcome in an economically disadvantaged rural environment with limited rehabilitation services has not been studied extensively. A group of individuals (n = 65) who sustained a traumatic brain injury were compared regarding pre- and post-employment status. The moderate and severely injured sub-groups showed a significant change in employment status. Ideally rehabilitation programs should target re-employment as an outcome. Limited employment opportunities in rural areas may make this more difficult to achieve.

Predictors and Indicators of Return to Work following Traumatic Brain Injury in South Africa: Findings from a Preliminary Experimental Database

Traumatic brain injury (TBI) affects a substantial portion of the South African population every year. However, there is little empirical evidence available regarding eventual outcome after injury in South Africa. In particular, there is little information regarding the ability of head injured individuals to return to their places of employment following injury, or what factors are most closely related to a successful return to work. This study explored the return to work of a specific group of individuals with TBI, in relation to a number of domains, including: rate and nature of return to work, pre-morbid and accident variables that appeared to be related to return to work, and the relationship between return to work and other aspects of outcome, specifically communicative, cognitive, physical and emotional outcome. The study took the form of a detailed record review of a group of subjects seeking medico-legal compensation, using a specially designed data recording form and computerised database. Results indicated a poor rate of return to work in this sample (32%), with significant changes in work status post-injury. The strongest pre-morbid predictors of outcome were found to be first language and pre-injury educational level, with African language speakers and those with an educational level of matriculation or less being at a significant disadvantage. Numerous communicative and cognitive difficulties were significantly related to a failure to RTW, including difficulties in: motor speech, comprehension, expression, attention, speed of processing, incidental visual memory, cognitive flexibility and insight. These results indicate the multi-factorial nature of outcome following head injury in the sample.