Return to work (RTW) after head injury

Association between the Wechsler Adult Intelligence Scale III and early return to work after traumatic brain injury

BACKGROUND

Residual capacity evaluation via neuropsychological testing can facilitate the development of a rehabilitation plan in patients following a traumatic brain injury (TBI).

OBJECTIVE

This study aimed to confirm the tasks that patients must perform well for early return to work (RTW) following TBI using the Wechsler Adult Intelligence Scale III (WAIS-III).

METHODS

In total, 40 male and 13 female patients who suffered from neurobehavioral disabilities following TBI were recruited and classified into two groups: the successfully returned to work group (SRTW-G; n = 22) and the unsuccessfully returned to work group (USRTW-G; n = 31). The outcomes assessed by WAIS-III and the time to RTW were compared between the SRTW-G and USRTW-G groups. Multiple logistic regression, multiple regression analysis, and Cox regression were employed to assess differences between the groups.

RESULTS

The Comprehension and Letter-Number Sequencing subtests of the WAIS-III were significantly correlated with early RTW more than the other subtests.

CONCLUSIONS

We found that, as reflected in the two subtests, patients with TBI must be able to perform well in the following tasks for early RTW: Retention of information for short time periods, information processing, and social judgment based on the knowledge of the patient's experience.

The effect of severe traumatic brain injury on social cognition, emotion regulation, and mood

This chapter provides a review of the emotional and psychosocial consequences of moderate to severe traumatic brain injury (TBI). Many of the disorders affecting socioemotional function arise from damage to frontotemporal systems, exacerbated by white matter injury. They include disorders of social cognition, such as the ability to recognize emotions in others, the ability to attribute mental states to others, and the ability to experience empathy. Patients with TBI also often have disorders of emotion regulation. Disorders of drive or apathy can manifest across cognitive, emotional, and behavioral domains. Likewise, disorders of control can lead to dysregulated emotions and behavior. Other disorders, such as loss of self-awareness, are also implicated in poor psychosocial recovery. Finally, this chapter overviews psychiatric disorders associated with TBI, especially anxiety and depression. For each kind of disorder, the nature of the disorder and its prevalence, as well as theoretical considerations and impact on every day functions, are reviewed.

Who among patients with acquired brain injury returned to work after occupational rehabilitation? The rapid-return-to-work-cohort-study

BACKGROUND

Acquired brain injury (ABI) is known to be severely disabling. On average, 40% of employees return to work (RTW) within two years after injury. There is, however, limited research on what might contribute to successful RTW.

AIM

To examine factors that might impact the time-to first RTW for patients with ABI, participating in a RTW-program.

METHODS

The study was designed as a cohort study of patients on sick leave due to mild or moderate ABI (n = 137). The mean age of the patients was 51 years, and 58% were men. The most common diagnoses were stroke (75%) and traumatic brain injury (12%). Data were collected through questionnaires, and combined with register data on sickness absence. Survival analyses were used to analyse the effect of different variables on time to first RTW (full or partial), at one- and two-year follow-up.

RESULTS

Generally, women (HR = 0.447; CI: 0.239-0.283) had higher RTW-rates than men, and patients with non-comorbid impairments returned to work earlier than patients with multiple impairments. Although not statistically significant, receiving individual consultations and participating in group-sessions were generally associated with a delayed RTW at both follow-up-times. The only service-related factor significantly associated with delayed RTW was meetings with the social insurance office (HR = 0.522; CI: 0.282-0.965), and only at one-year follow-up.

CONCLUSIONS

Women and patients with non-comorbid impairments returned to work earlier than men and patients with multiple impairments. There seems to be an association between intense and long-lasting participation in the RTW program and prolonged time-to first-RTW, even after controlling for level of cognitive impairments and comorbidity. Implications for Rehabilitation Acquired brain injury (ABI) is known to be severely disabling, and persons with ABI often experience difficulties in regard to returning to work. This study provides information on prognostic factors that might contribute to return to work (RTW) for patients with acquired brain injury, both at the individual level, but also in regard to service and timing characteristics. Knowledge about such factors provide rehabilitation professionals with information about effective service components that might help patients with ABI to RTW, and thus makes it possible to adapt and adjust the services to the patient's situation. Furthermore, having more knowledge on factors that contribute to RTW gives clinics the opportunity to select patients that might benefit the most from these services, thereby making them more effective.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

Are there cognitive and neurobehavioural correlates of hormonal neuroprotection for women after TBI?

This study examined possible cognitive correlates of hormonal neuroprotection following traumatic brain injury (TBI) using archival neuropsychological findings for 1563 individuals undergoing acute TBI rehabilitation between 1989 and 2002. Presumed age of menopause was based on the STRAW (Stages of Reproductive Aging) staging system (Soules, 2005; Soules et al., 2001) and general linear model (GLM) analysis of performance on neuropsychological testing by participants across gender and age groups (25-34, 35-44, 45-54, and 55-64) was performed. Hypotheses were (1) women with TBI in the oldest age group would have lower scores on neuropsychological tests and functional outcome measures than women in the younger groups, and (2) men in the oldest age group would have higher scores than women of the same age group. Analyses revealed that oldest females had significantly worse Trails B and SDMT written and oral scores than the youngest females. In addition, oldest females had significantly better Trails B, Rey AVLT and SDMT written scores than the oldest males. Possible cohort exposure to hormone replacement therapy, unknown hormonal status at time of testing, and sample-specific injury characteristics may have contributed to these findings.

Assessing Social Skills in People With Very Severe Traumatic Brain Injury: Validity of the Social Performance Survey Schedule (SPSS)

The current study was designed to determine whether the Social Performance Survey Schedule (SPSS; Lowe & Cautela, 1978) is a useful measure of social skills in people with traumatic brain injuries (TBI). Forty-nine adults with TBI were compared on the SPSS to 190 adults without injuries. The validity of the SPSS was also investigated in relation to another measure of social performance, the first scale of the Katz Adjustment Scale (KAS-R1; Katz & Lyerly, 1963) and a broad measure of social function (the SPRS; Tate, Hodgkinson, Veerabangsa, & Maggiotto, 1999). Individuals with TBI had significantly lower scores on the positive scale of the SPSS than nonbrain-injured individuals. They did not have lower scores on the SPSS negative scale relative to the normative sample. Significant correlations with the KAS-R1 and SPRS provided evidence for the construct and criterion validity of SPSS within this population. In conclusion, this study suggests that where an appropriate normative sample is used, the positive subscale of the SPSS is a sound measure for detecting the extent and nature of deficits in prosocial behaviour seen in TBI, but raises the question as to how we define negative behaviours in the 21st century on scales such as the SPSS.

A Systematic Review of Early Prognostic Factors for Return to Work After Traumatic Brain Injury

This article presents a systematic review identifying variables and their prognostic value for return to work (RTW) after traumatic brain injury (TBI). RTW has been identified as being a key goal following TBI, with estimates ranging from 10% to 70%. Prediction of postinjury employment is important for planning rehabilitation and structuring individualised vocational services. Studies examining prognostic factors were identified by searching four electronic databases, until June 2006. Searches yielded 1948 studies of which 55 met inclusion criteria and were subsequently rated for methodological quality. Mean methodological score for included studies was 3.9/6 (SD0.9, range 1–6). Analysis focused on a subset of 27 studies which provided sampling from all three domains of preinjury, injury and early postinjury variables. Few studies considered preinjury variables, apart from simple demographics. Only five studies considered preinjury employment, which was a significant predictor in each case. Severity of injury variables were invariably examined, but were significant predictors in only 8/27 studies (30%). For early postinjury variables, 14/27 studies entered cognitive variables with 12/14 (86%) identifying them as significant predictors; 3/27 studies examined neurophysical variables, with 2/3 (67%) studies finding them significant; and 12/27 studies examined multidimensional/participation variables which were statistically significant individual predictors in 8/12 (67%) cases. The results are discussed in the context of methodological issues encountered during the course of the review that require addressing in future studies.

Sex differences in outcome after mild traumatic brain injury

The objective of this study was to estimate the independent association of sex with outcome after mild traumatic brain injury (mTBI). We performed an analysis of a subset of an established cohort involving 1425 mTBI patients presenting to an academic emergency department (ED). The associations between sex and three outcomes determined 3 months after the initial ED visit were examined: post-concussive symptom (PCS) score (0, 1-5, 6-16, and >16), the number of days to return of normal activities (0, 1-7, and >7), and the number of days of work missed (0, 1-7,and >7). Logistic regression analyses were used to determine the relationship between sex and each outcome after controlling for 12 relevant subject-level variables. Of the 1425 subjects, 643 (45.1%) were female and 782 (54.9%) were male. Three months after mTBI, males had significantly lower odds of being in a higher PCS score category (odds ratio [OR] 0.62, 95% confidence interval [CI]: 0.50, 0.78); this association appeared to be more prominent during child-bearing years for females. Males and females did not significantly differ with respect to the odds of poorer outcome as defined by the number of days to return of normal activities or the number of days of work missed. Female sex is associated with significantly higher odds of poor outcome after mTBI, as measured by PCS score, after control for appropriate confounders. The observed pattern of peak disability for females during the child-bearing years suggests disruption of endogenous estrogen or progesterone production. Attempts to better understand how mTBI affects production of these hormones acutely after injury and during the recovery period may shed light on the mechanism behind poorer outcome among females and putative therapeutic interventions.

Return to work following traumatic brain injury: Trends and challenges

PURPOSE

The aim of this paper is to present the current knowledge regarding return to work (RTW) following traumatic brain injury (TBI).

METHOD

Based on a Medline search, the authors reviewed the current TBI rehabilitation literature regarding (a) predictive factors for successful RTW, and (b) current concepts in rehabilitative strategies for successful RTW.

RESULTS

The functional consequences to the victim of traumatic brain injury (TBI) can be severe. Intensive rehabilitative efforts typically emphasize the early phase and address mainly the accompanying functional deficits in the realm of basic activities of daily living and mobility. An otherwise successful medical rehabilitation may end unsuccessfully because of the failure to return to work, with profound consequences to the individual and family, both economic and psychosocial. Even mild TBI may cause lasting problems in tasks calling for sustained attention. There appears to be a complex interaction between pre-morbid characteristics, injury factors, post injury impairments, personal and environmental factors in TBI patients, which influences RTW outcomes in ways that make prediction difficult. Injury severity and lack of self-awareness appear to be the most significant indicators of failure to RTW. Several medical, psychosocial and rehabilitative therapies are currently being implemented in rehabilitation settings which improve the chances of returning to work.

CONCLUSION

Accurate prediction of whether a particular TBI patient will successfully return to work is not feasible, with RTW rates in the 12 - 70% range. A significant proportion of TBI patients, including those who are severely injured, are able to return to productive employment if sufficient and appropriate effort is invested. A comprehensive approach - medical and psychosocial - eventually entailing adequate vocational rehabilitation with supported employment can improve outcomes.

Success in the workplace following traumatic brain injury: are we evaluating what is most important?

PURPOSE

Vocational outcome, and in particular full-time paid work, is considered an important indicator of successful rehabilitation following traumatic brain injury (TBI). However it has not been established that these outcomes adequately or accurately represent the values of the people with TBI. This paper describes a study exploring the experiences of individuals who attempted returning to work following TBI, with emphasis on factors that related to perceptions of 'success' or 'failure'.

METHOD

A phenomenological study, interviewing seven people with moderate to severe TBI was conducted. The interview data were analysed for themes relating to experiences of success or failure in the workplace. Community consultation provided additional perspectives in the interpretation and validation of results.

RESULTS

The results of this study support in part the assumption that paid employment is indicative of success following TBI. Equally prevalent were findings that challenged this assumption, including situations where: (1) return to employment contributed to catastrophic personal events, (2) feelings of success were achieved even though paid employment was not, and (3) success in the workplace was associated with factors other than hours worked or pay earned.

CONCLUSIONS

This research suggests that the use of work placement as a measure of successful rehabilitation might misrepresent the perspective of individuals with TBI. A multifactorial approach to evaluating vocational rehabilitation is recommended, which incorporates the subjective experience of work.

Investigating gender differences in outcome following severe traumatic brain injury in a predominantly Asian population

The objective of this study was to investigate if there are possible gender differences in relation to outcome following closed severe traumatic brain injury (TBI) in a predominantly Asian population. A study was conducted using our prospectively maintained TBI database of 672 patients with severe TBI admitted into our neurosurgical intensive care unit. All patients were managed on a standardized protocol in accordance with the Guidelines to the management of severe traumatic brain injury. Glasgow Outcome Score was used to measure the outcome of patients 6 months postinjury. There were 525 males and 147 females, with the latter significantly older than their counterpart. Females had a significantly higher mortality and poorer outcome compared with males. However, this difference was no longer significant when variables (presence of multiple injuries, postresuscitation pupil abnormalities and Glasgow Coma Score) are controlled for. However, both crude and adjusted odd ratios revealed that females aged 60 and below were significantly more likely to have a poorer outcome.

Recognition of emotion from facial expression following traumatic brain injury

PRIMARY OBJECTIVE

To assess three domains of emotion recognition in people with traumatic brain injury (TBI).

RESEARCH DESIGN

A between group comparison.

PROCEDURES

Twenty-four participants with severe TBI and 15 matched participants without brain damage were asked to label and match facial expressions with and without context. The participants with TBI were also interviewed regarding changes in subjective experience of emotion.

MAIN OUTCOMES AND RESULTS

Participants with TBI were found to be significantly impaired on expression labelling and matching, but experienced some improvement when provided with context. Negative emotions were particularly affected. Affective semantic knowledge and face perception appeared to be relatively intact in this group. The majority of participants with TBI reported some change in the post-injury experience of everyday emotion, although the pattern of changes differed greatly between individuals. Reduced subjective experience, especially of sadness and fear, was associated with poor emotion matching but not emotion labelling.

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.

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.

Retorno à produtividade após reabilitação de pacientes deambuladores vítimas de trauma craniencefálico

Vítimas de trauma craniencefálico (TCE) freqüentemente alcançam independência nas atividades de vida diária, mas encontram limitações quanto à participação na comunidade ou no trabalho produtivo. Este estudo visou verificar o índice de retorno, após programa de reabilitação, à produtividade (estudo e/ou trabalho) de sujeitos que haviam tido TCE. Participaram 60 sujeitos deambuladores comunitários (média de idade 30,4 anos, mínima 18, máxima 53), selecionados dentre os prontuários de pacientes com diagnóstico de TCE que freqüentaram o programa de reabilitação entre 2002 a 2004 no Setor de Fisioterapia Adulto da Associação de Assistência à Criança Deficiente (AACD) em São Paulo, SP. Em entrevista, foi aplicado um questionário elaborado pela equipe da AACD. Os participantes - 51 homens e 9 mulheres - tinham sofrido em sua maioria (95%) trauma grave. Os resultados mostram que 71,7% dos participantes retomaram atividades ocupacionais ou escolares, mas apenas 38,3% estavam trabalhando por ocasião da entrevista. Embora sem significância estatística, o tempo decorrido entre o trauma e o início da reabilitação parece estar associado ao retorno à produtividade. O nível de escolaridade prévio ao trauma mostrou ter influência (p<0,01) no retorno à produtividade, alcançado por uma boa parte dos sujeitos que sofreram TCE.

Employment after traumatic brain injury: differences between men and women

OBJECTIVE

To determine whether there are sex differences in employment 1 year after traumatic brain injury.

DESIGN

Prospective cohort.

SETTING

Acute care hospitals in South Carolina and Traumatic Brain Injury Model Systems (TBIMS) rehabilitation centers.

PARTICIPANTS

Subjects in the TBIMS national dataset and the South Carolina Traumatic Brain Injury Follow-up Registry who were expected to be working before injury and followed at 1 year postinjury.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Change in employment from preinjury to 1 year postinjury.

RESULTS

When other measured influences on change in hours worked were held constant, there were significant interactions for sex by age and sex by marital status. Compared with men, women were more likely to decrease hours or stop working, except in the oldest age group (55-64y) in which men were more likely to stop working. For women, there was a pattern showing better employment outcomes as age increased. Decreased employment for women was most evident for married women, who were much more likely to reduce hours or stop working. There was also a tendency for divorced women to be more likely to stop working when compared with divorced men.

CONCLUSIONS

These findings run counter to the current literature. Although definitive explanations must await future studies, causal factors arising from differential societal behavior toward women as well as discriminatory attitudes about women and employment deserve further study.

Screening for job loss: development of a work instability scale for traumatic brain injury

OBJECTIVE

The objective of this study was to explore the concept of work instability (a mis-match between an individual's functional and cognitive abilities and the demands of their job) following traumatic brain injury (TBI) and develop a work instability scale specific to this population.

METHOD

Work instability (WI) following TBI was explored through qualitative interviews which were then used to generate items for a work instability scale (WIS). Rasch analysis was used to examine the scaling properties of the TBI-WIS which was then validated against a gold standard of expert vocational assessment by occupational psychologists.

RESULTS AND CONCLUSION

The resulting measure is a 36 item, self-administered scale which can be scored in three bands indicating low, medium and high risk of job retention problems. The scale meets modern psychometric requirements for measurement and presents an opportunity in routine clinical practice to take positive action to prevent job loss.

Return-to-work outcomes following work disability: stakeholder motivations, interests and concerns

INTRODUCTION

Satisfaction with return-to-work (RTW) outcomes is dependent on many factors, including a clear exposition of what people define as a "good outcome" and the information they use to determine if such an outcome has been achieved. This paper defines the key stakeholders involved in the RTW process and discusses the need to understand their motivations, interests, and concerns.

METHODS

A review of the literature and discussions with RTW researchers conducted by a multidisciplinary group of academic researchers.

RESULTS

Our analysis suggests that RTW stakeholders can share the goal of a successful RTW; however, this consensus has to be viewed in light of other, sometimes competing, goals and the environments in which stakeholders operate.

CONCLUSIONS

It is suggested that more clearly articulating and operationalizing stakeholders' perspectives will allow researchers to advance the understanding of RTW interventions and outcomes.

Outcome of a Comprehensive Neurorehabilitation Program for Patients With Traumatic Brain Injury

OBJECTIVE

To evaluate the outcome of a comprehensive neurorehabilitation program compared with that of conventional clinical care and rehabilitation for patients with traumatic brain injury (TBI).

DESIGN

Nonrandomized, controlled trial with a 2-year follow-up.

SETTING

Nationwide rehabilitation center and level I trauma center, both in Finland.

PARTICIPANTS

We studied 19 consecutive adults with a significant TBI who underwent a comprehensive neurorehabilitation program and 20 control patients who received conventional rehabilitation referred by physicians in the general health care system. The outcome of the control patients was not known before the selection. The groups were similar in age, sex, education, injury severity (assessed on the Glasgow Coma Scale, radiologic and neuropsychologic findings, neurosurgical interventions), time from the injury, and preinjury employment status.

INTERVENTIONS

A postacute, intensive, interdisciplinary, 6-week rehabilitation program for TBI patients who are considered to have adequate potential to achieve productivity by this means; focus on neuropsychologic rehabilitation and psychotherapy with vocational interventions and follow-up support.

MAIN OUTCOME MEASURE

Status of productivity, judged as productive (defined as working, studying, or participating in volunteer activities) or nonproductive, evaluated on questionnaires filled in by patients and their significant others at the time of follow-up evaluation.

RESULTS

At follow-up, 89% of the treated patients were productive compared with 55% of the controls. The rehabilitation program was significantly predictive of the productive status at follow-up (odds ratio=6.96; 95% confidence interval, 1.26-38.44; P=.017). Other factors did not explain the better productivity of the treatment group. Two neuropsychologist-evaluators, who were blind to the rehabilitation history of patients and to each other's evaluations, were perfectly consistent in their classification of patients' productivity statuses.

CONCLUSIONS

The findings support the proposition that comprehensive neuropsychologically oriented rehabilitation programs can improve psychosocial functioning in terms of productivity in postacute patients with moderate to severe TBI. Additional larger controlled studies are needed to establish the efficacy of TBI rehabilitation interventions.

Differential impairment in recognition of emotion across different media in people with severe traumatic brain injury

Recent evidence suggests that there may be dissociable systems for recognizing emotional expressions from different media including audio and visual channels, and still versus moving displays. In this study, 34 adults with severe traumatic brain injuries (TBI) and 28 adults without brain injuries were assessed for their capacity to recognize emotional expressions from dynamic audiovisual displays, conversational tone alone, moving facial displays, and still photographs. The TBI group were significantly impaired in their interpretation of both audio and audiovisual displays. In addition, eight of the 34 were significantly impaired in their capacity to recognize still facial expressions. In contrast, only one individual was impaired in the recognition of moving visual displays. Information processing speed was not found to play a significant role in producing problems with dynamic emotional expression. Instead the results suggest that visual moving displays may enlist different brain systems to those engaged with still displays, for example, the parietal cortices. Problems with the processing of affective prosody, while present, were not clearly related to other emotion processing problems. While this may attest to the independence of the auditory affective system, it may also reflect problems with the dual demands of listening to conversational meaning and affective tone.

Productive Work and Employment for Persons With Traumatic Brain Injury

This article describes return to work outcomes for individuals with traumatic brain injury (TBI) through a selective review of the published literature and an examination of TBI labor force participation from the Rehabilitation Services Administration 91l and the Social Security Administration Benefits Planning, Assistance and Outreach databases. Implications and recommendations to further our understanding about the different parts of the work outcome profile of individuals with TBI are offered.

Social Perception Deficits After Traumatic Brain Injury: Interaction Between Emotion Recognition, Mentalizing Ability, and Social Communication

Thirty-four adults with severe traumatic brain injuries (TBI) and 34 matched control participants were asked to interpret videotaped conversational exchanges. Study participants were asked to judge the speakers' emotions, the speakers' beliefs (first-order theory of mind), what the speakers intended their conversational partners to believe (second-order theory of mind), and what they meant by remarks that were sincere or literally untrue (i.e., a lie or sarcastic retort). The TBI group had marked difficulty judging most facets of social information. They could recognize speaker beliefs only when this information was explicitly provided. In general, emotion recognition and first-order theory of mind judgments were not related to the ability to understand social (conversational) inference, whereas second-order theory of mind judgments were related to that ability.

Return to work for a company president with traumatic brain injury

Return to work remains a central issue for many traumatic brain injury (TBI) patients. The present literature generally ignores the complex work issues involved for high-functioning individuals, in whose hands may lie the fate of many other workers. This case discusses return-to-work challenges facing a 64-year-old high-technology company founder and president. Following a bicycling accident, he sustained intracerebral hemorrhage with an initial Glasgow Coma Scale of score 12. Although postmorbidly he still maintained a relatively high level of cognitive functioning, his case highlights special challenges during workplace rehabilitation of patients with cognitively demanding jobs, including (a) a higher potential for patient frustration given the gap between function and job expectations and (b) confidentiality issues regarding business employees and competitors. Rehabilitation health care providers can benefit from lessons learned here, including tapping into these patients' strong motivation for return to work, accessing the likely higher remaining cognitive level, and drawing upon the likely strong social and professional networks available. Finally, the importance of the role of stress-management techniques in order to cope with high frustration levels is highlighted.

Acquired Brain Injury and Return to Work in Australia and New Zealand

The purpose of this paper is to review the return-to-work rates following acquired brain injury in Australia and New Zealand (ANZ). The reported return-to-work rates for the nine ANZ studies varied from 29% to 64% with a median of 46% and for 23 international studies the return-to-work rates varied from 19% to 88% (median also 46%). When the results of all ANZ studies were combined to form a total of 1010 subjects then the overall return-to-work rate was 44%. A number of methodological concerns were raised and it was estimated that only about 7–10% of persons with an acquired brain injury are likely to return to the same job.

The Determinants of Work Adjustment following Traumatic Brain Injury: A Focus for Career Counsellors

This longitudinal study examined the determinants of work adjustment in the traumatic brain injury (TBI) population, using the frameworks provided by Hershenson (1996) and Moos (2002) as a guide for selecting variables. Based on these frameworks, the predictive utility of a range of variables (i.e., self-esteem, perceived support, situational stressors, appraisal of stress and self-efficacy and coping responses) was examined. Eighty-one individuals with TBI provided data for the study. The prediction of work adjustment was improved beyond that accounted for by initial adjustment when these previously-mentioned variables were entered into regression equations. Specifically, short-term work adjustment was associated with high levels of social support and self-efficacy as well as the effective use of problem-solving. In the long-term, however, internal resources such as self-esteem became more important to work adjustment, as did the effects of lesion location and cognitive impairment. Greater focus on these determinants of work adjustment in the career counselling process could foster the development of a preventative approach to TBI vocational rehabilitation. In particular, it may be possible to identify individuals who are likely to experience work adjustment difficulties and assist them to maintain and develop the resources that will, in turn, improve their likelihood of vocational success.

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.

Return to work for persons with traumatic brain injury

Individuals with traumatic brain injuries experience an array of physical, cognitive, and emotional changes that often make return to preinjury employment unlikely and locating new employment difficult. The authors review the literature related to the return to work for persons with traumatic brain injuries. This includes return to work outcomes, factors influencing return to work, and vocational programs that enhance employment, including a supported employment approach. Guidelines for professionals engaged in supported employment practices are also provided.

Impact of comprehensive day treatment on societal participation for persons with acquired brain injury

OBJECTIVES

To evaluate comprehensive day treatment (CDT) for survivors of brain injury by time since injury and to identify outcome predictors.

DESIGN

Before and after.

SETTING

Rehabilitation center.

PARTICIPANTS

Ninety-six program graduates; 17 dropouts with acquired brain injury.

INTERVENTIONS

Comprehensive Day Treatment Program: daily group sessions to build cognitive and behavioral skills through a transdisciplinary approach, supportive feedback, and a variety of therapeutic modalities. Obtained outcome measures before and after the program, and at 1-year follow-up.

MAIN OUTCOME MEASURES

OUTCOME

Independent living status, vocational independence scale at program end and 1-year follow-up; and Rasch-analyzed Mayo-Portland Adaptability Inventory (MPAI-22) and goal attainment scaling (GAS) at program end.

PREDICTORS

age, education, severity of initial injury, time since injury, and preadmission MPAI-22.

RESULTS

Significant goal achievement on GAS and improvement on MPAI-22; increased societal participation at 1-year follow-up for those treated postacutely and many years after injury: 72% of graduates living independently; 39% working independently, 10% in transitional placements, and 18% in supported or volunteer work. Long-term outcomes were modestly related linearly to preadmission MPAI-22 and nonlinearly to time since injury.

CONCLUSIONS

CDT improves societal participation even among persons with a long history of limited participation after brain injury. This de facto extended baseline analysis indicates the effectiveness of CDT and paves the way for randomized control trials of active treatment components. Relationships of predictors to outcomes are not sufficiently strong for patient selection. More effective interventions for vocational reintegration are needed for those most severely disabled after brain injury.

Do women fare worse: a metaanalysis of gender differences in traumatic brain injury outcome

OBJECT

The purpose of this metaanalysis was to investigate possible gender differences in traumatic brain injury (TBI) sequelae. The case fatality rates in patients after TBI have previously been shown to be significantly higher in women as compared with men.

METHODS

A quantitative review of published studies of TBI outcome revealed eight studies (20 outcome variables) of TBI, in which outcome was reported separately for men and women.

CONCLUSIONS

Outcome was worse in women than in men for 85% of the measured variables, with an average effect size of -0.15. Although clinical opinion is often that women tend to experience better outcomes than men after TBI, the opposite pattern was suggested in the results of this metaanalysis. However, this conclusion is limited by the fact that, in only a small percentage of the total published reports on TBI outcome, was outcome described separately for each sex. A careful, prospective study of sex differences in TBI outcome is clearly needed.

A medical/vocational case coordination system for persons with brain injury: an evaluation of employment outcomes

OBJECTIVE

To evaluate initial placement and 1-year employment outcomes of a Medical/Vocational Case Coordination System (MVCCS) for persons with brain injury (BI) that provides: (1) early case identification and coordination, (2) appropriate medical and vocational rehabilitation interventions, (3) work trials, and (4) supported employment interventions including job coaching.

PARTICIPANTS

One hundred fourteen Minnesota residents, ages 18 to 65 years, with acquired BI.

MAIN OUTCOME MEASURES

OUTCOME

Five levels of Vocational Independence Scale (VIS).

PREDICTOR

Preinjury employment status (VIS) and years of education, severity of initial injury, time since injury, current impairment/disability as measured by the Rasch-analyzed Staff Mayo-Portland Adaptability Inventory (MPAI), and impaired self-awareness measured by staff rating and the difference between Staff MPAI and Survivor MPAI.

RESULTS

At placement, 46% in independent work; 25% in transitional placements; 9% in long-term supported employment; 10% in sheltered work; and 10% not placed. At 1-year follow-up (n = 101), 53% in independent work; 19% in transitional placement; 9% in supported work; 6% in sheltered work; and 13% unemployed. Regression analyses showed time since injury and Rasch Staff MPAI predicted VIS at placement; only VIS at placement independently predicted VIS at 1-year follow-up; Rasch Staff MPAI and preinjury education level predicted time to placement.

CONCLUSIONS

The MVCCS optimized vocational outcome after BI. Time since injury and impairment/disability best predicted vocational placement. Level of initial placement best predicted employment status at follow-up. Persons with greater disability required more extended time and more extensive rehabilitation services before placement.

Do women fare worse? A metaanalysis of gender differences in outcome after traumatic brain injury

The purpose of this metaanalysis was to investigate possible gender differences in TBI sequelae. The case fatality rates in patients after TBI have previously been shown to be significantly higher in women as compared with men. A quantitative review of published studies of TBI outcome revealed eight studies (20 outcome variables) of TBI in which outcome was reported separately for men and women. Outcome was worse in women than in men for 85% of the measured variables, with an average effect size of −0.15. Although clinical opinion is often that women tend to experience better outcomes than do men after TBI, the opposite pattern was suggested in the results of this metaanalysis. However, this conclusion is limited by the fact that in only a small percentage of the total published reports on TBI outcome was outcome described separately for each sex. A careful, prospective study of sex differences in TBI outcome is clearly needed.

Driving following traumatic brain injury: prevalence, exposure, advice and evaluations

Survivors of traumatic brain injury often have long-term sensory, cognitive and motor deficits that may impair vehicle operation. However, relatively little is known about the driving status and driving characteristics of brain injury survivors. To better understand driving following traumatic brain injury, a survey of driving status, driving exposure, advice received about driving and evaluations of driving competency was administered to a convenience sample of traumatic brain injury survivors (n = 83). The majority of survey participants had experienced either moderate or severe traumatic brain injuries based on the Glasgow Coma Scale. A total of 60% of the survey participants reported that they were currently active drivers. Most individuals (> 60%) who had returned to driving reported driving every day and more than 50 miles per week. Traumatic brain injury survivors frequently received advice about driving from family members, physicians or non-physician health care professionals, but over half (63%) had not been professionally evaluated for driving competency. The presence of high driving exposure, coupled with a lack of widespread driving fitness testing, suggests that some traumatic brain injury survivors have characteristics that may evaluate their risk for vehicle crashes. However, subsequent prospective studies that directly assess driver safety will be needed to confirm this possibility.

Outcome assessment after milieu-oriented rehabilitation: new considerations

OBJECTIVE

This study incorporated level of functional impairment ratings at program admission into rehabilitation outcome (return to work/school) at the time of program discharge.

HYPOTHESES

(1) Patients and families with better working alliance ratings will show better adjusted outcome; (2) patients seeking compensation will have poorer outcome than those not seeking compensation or receiving benefits; (3) speed of information processing and memory will relate to the level of adjusted outcome.

DESIGN

Consecutive neurorehabilitation admissions from March 1992 to May 1996.

SETTING

Outpatient milieu-based interdisciplinary day treatment program.

SUBJECTS

Sixty-four patients with heterogeneous brain injury etiologies.

MAIN OUTCOME MEASURES

Adjusted outcome, defined as level of discharge productivity adjusted by staff ratings of functional severity of impairment at program admission; work readiness and work eagerness, based on average staff ratings.

RESULTS

At discharge, 89.5% of patients showed fair or good adjusted outcome; 62% were gainfully employed/full-time students; 15.6% resumed preinjury status. Better working alliance predicted better adjusted outcome. Patients seeking compensation showed significantly lower work eagerness ratings. Poorer outcome was associated with better neuropsychological status.

CONCLUSIONS

Efficacy of neurorehabilitation was demonstrated for patients with better working alliance who were not seeking compensation. Adjusted outcome demonstrated greater sensitivity and utility by incorporating the variable of functional severity of impairment at program admission. Inclusion of "process" variables addressing working alliance, motivation, and capacity to work provide important contributions to understanding rehabilitation outcome.

Educational outcome for secondary and postsecondary students following traumatic brain injury

During the 12 month period of January-December 1991, 75 admissions were made to the Head Injury Unit at Bethesda Hospital, Melbourne, Australia. Approximately 26% (20) of these admissions were either secondary or postsecondary students. Thirteen of the 20 students were interviewed by telephone at approximately 3 years postinjury and demographic and medical information were obtained from their medical files. Outcome was documented in three areas: educational, medical and psychosocial status. At 3 years postinjury, 11 subjects (85%) had either completed a course or were still studying. The average time for students to return to study was approximately 11 months postinjury. The students reported a number of changes including: enrollment in different courses, a reduction in course load to part-time study, altered educational and vocational goals and an increased need to utilize study skill strategies, individual tuition and special consideration. In addition, students reported changes to their relationships with peers and their involvement in extracurricular activities. It is apparent from these results that a number of factors need to be considered when a student is planning to return to study following TBI and that a range of support services may be required. Future studies are needed to examine the factors which impede or enhance a student's progress following TBI.

Community-based training after acquired brain injury: preliminary findings

Persons entering or returning to the workforce after brain injury often require assistance to identify, locate, secure and maintain employment. This is especially true for workers from economically disadvantaged environments who may have limited pre-injury work experience. Supported employment, the use of natural supports, and community-based approaches are helpful for the process of identifying, securing and maintaining work. However, reports are limited as to how these approaches are helpful for economically disadvantaged persons, especially in identifying meaningful work. An approach is described here which combines work adjustment training and supported employment; which is helpful in identifying consumer interest, and in improving position attainment, job retention and work satisfaction. A sample of persons (n = 38) with brain injury were contacted after completing the programme. A total of 59% of these persons remained employed at follow-up, compared to 32% at time of injury. Additional outcome data are presented to describe the usefulness of this approach.

A review of mild head trauma. Part II: Clinical implications

In Binder et al. (1997) a metal-analytic review revealed a small effect size attributable to a history of mild head trauma (MHT). The results suggested a weak association between MHT and persistent neuropsychological deficits. In this paper, additional outcome data are summarized and the results are discussed. On a chronic basis, 7-8% of MHT patients remain symptomatic and 14% are disabled from work. Magnetic resonance studies of acutely injured persons may show lesions that are not detected in usual clinical practice. It is likely that the effects of these lesions dissipate with time, consistent with the neuropsychological data. The association between MHT and cognitive deficits, symptoms, and disability may not be casual; data suggest that MHT patients have more psychosocial problems prior to injury than do non-injured persons. The examiner of the MHT patient with chronic complaints must consider alternative medical and psychiatric explanations and perform a differential diagnosis. The possibility of a neurological basis for sustained neuropsychological problems cannot be completely dismissed. Presently, however, there is little evidence for neurological causation of most persisting complaints.

Acute predictors of successful return to work 1 year after traumatic brain injury: a multicenter analysis

OBJECTIVE

To investigate the influence of acute injury characteristics on subsequent return to work in traumatic brain injury (TBI) patients.

DESIGN

Descriptive statistics were performed in a comparative study of 49 TBI patients who were competitively employed at 1-year follow-up and 83 unemployed patients. Independent t tests were then performed to examine the differences between the two groups on specific measures including the Disability Rating Scale (DRS), Functional Assessment Measure (FIM), Rancho Los Amigos Scale (RLAS), Glasgow Coma Scale (GCS), Neurobehavioral Rating Scale (NRS), and neuropsychological test results.

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 245 rehabilitation inpatients admitted to acute care within 8 hours of TBI and seen at 1-year follow-up.

MAIN OUTCOME MEASURE

Return to work at 1-year follow-up.

RESULTS

Persons employed at 1-year follow-up obtained significantly better scores on specific acute measures of physical functioning (Admission FIM, Admission DRS, Discharge DRS), cognitive functioning (Logical Memory Delay), behavioral functioning (Admission RLAS, Discharge RLAS, NRS Excitement factor), and injury severity (Admission GCS, Highest GCS, Length of Coma, Length of PTA) than their unemployed counterparts.

CONCLUSIONS

Persons obtaining better scores on certain acute measures (e.g., Admission GCS) are more likely to return to the workforce. Future research should focus on developing a standardized tool to assess a patient's ability to return to work, as well as an operational definition for successful employment.

Persons with traumatic brain injuries and their families: living arrangements and well-being post injury

This article discusses an empirical study of 66 single, adult survivors of moderate to severe traumatic brain injury (TBI) who were either living alone or living with their parents. The researchers determined perceived levels of stress, life satisfaction, family satisfaction, and community integration within the two groups. Survivors, who were typically ten years or more post injury, and selected family members, responded to structured telephone interviews and standardized questionnaires. The findings of the study and their implications point to a need for practice interventions that will reestablish life cycle trajectories and meet developmental needs, as well as reintegrate affected individuals and their families into larger social systems.

Factors influencing failure to return to work due to traumatic brain injury

About 63% of all traumatic brain injuries (TBI) occur in teenagers and adults aged 15-64 years, the primary working population. Since reports of failure to return to work (FTRTW) vary, understanding the factors that influence FTRTW is key to improving work outcomes for this primarily working-age population. Our study sample consists of 343 previously employed persons who were hospitalized following TBI and had either returned to work at 1 year or had failed to return to work because of their injury (injury-related FTRTW). Medical records were reviewed and participants were interviewed by telephone at 1 year post-discharge. Individuals with injury-related FTRTW were far more likely to report dependence or modified independence on the Functional Independence Measure (FIM) than those who were employed at 1 year. The joint distribution of motor and cognitive items suggests that, for a given level of cognitive function, the addition of a motor limitation will result in greater injury-related FTRTW. In addition as motor function declines, FTRTW is further increased. Injury-related FTRTW is also associated with being unmarried and not completing high school. While the importance of behavioural, economic, and psychosocial factors should not be minimized, services aimed at improving function can be expected to have an impact on RTW after TBI.