A metacognitive contextual approach for facilitating return to work following acquired brain injury: Three descriptive case studies

A framework to support early team-based provision of vocational rehabilitation for adults with acquired brain injury

PURPOSE

Specialised vocational rehabilitation (VR) following acquired brain injury (ABI) positively impacts return to work, however access to this is limited globally. Providing VR as a component of standard ABI rehabilitation may improve access to VR and influence vocational outcomes. This study aimed to develop an evidence-based framework for the delivery of ABI VR during early transitional community rehabilitation.

MATERIALS AND METHODS

The development of the ABI VR framework utilised an emergent multi-phase design and was informed by models of evidence-based practice, national rehabilitation standards, guidelines for complex intervention development, model of care and framework development, and the knowledge-to-action framework. Four study phases were undertaken to identify and generate the evidence base, with findings synthesised to develop the ABI VR framework in phase five.

RESULTS

The framework provides a structure for the systematic delivery of VR as a component of team-based ABI rehabilitation, through five phases of rehabilitation: assessment; goal setting and rehabilitation planning; intervention; monitoring and evaluation; and discharge. It details the activities to be undertaken across the phases using a hybrid model of ABI VR (involving program-based VR and case coordination) and contains service delivery features.

CONCLUSION

The framework has the potential to translate to other similar service contexts.

Stroke rehabilitation adaptive approaches: A theory-focused scoping review

BACKGROUND

Stroke rehabilitation consists of restorative and adaptive approaches. Multiple adaptive approaches exist.

AIMS/OBJECTIVES

The objective of this study was to develop a framework for categorising adaptive stroke rehabilitation interventions, based on underlying theory.

MATERIAL AND METHODS

We searched multiple databases to April 2020 to identify studies of interventions designed to improve participation in valued activities. We extracted the name of the intervention, underlying explicit or implicit theory, intervention elements, and anticipated outcomes. Using this information, we proposed distinct groups of interventions based on theoretical drivers.

RESULTS

Twenty-nine adaptive interventions were examined in at least one of 77 studies. Underlying theories included Cognitive Learning Theory, Self-determination Theory, Social Cognitive Theory, adult learning theories, and Psychological Stress and Coping Theory. Three overarching theoretical drivers were identified: learning, motivation, and coping.

CONCLUSIONS

At least 29 adaptive approaches exist, but each appear to be based on one of three underlying theoretical drivers. Consideration of effectiveness of these approaches by theoretical driver could help indicate underlying mechanisms and essential elements of effective adaptive approaches.

SIGNIFICANCE

Our framework is an important advance in understanding and evaluating adaptive approaches to stroke rehabilitation.

Return to work for adults following stroke: a scoping review of interventions, factors, barriers, and facilitators

OBJECTIVE

This scoping review aimed to map the literature on interventions, factors, barriers, and facilitators for return to work for adults post-stroke with or without communication disorders.

INTRODUCTION

Difficulties in returning to work can significantly impact individuals following a stroke (eg, their sense of purpose and self-esteem), not only financially, but also as they adjust to the change in their situation. Such difficulties may arise from communication disorders as well as physical impairments. Previous reviews on return to work post-stroke have focused on specific aspects, such as interventions, or barriers and facilitators, but have not provided a comprehensive map of the field. Further, no systematic or scoping reviews to date have focused on literature addressing return to work for people with communication disorders post-stroke.

INCLUSION CRITERIA

This review considered literature that reported on interventions, barriers, and facilitators for return to work for adults (aged 16 years or older) following an ischemic or hemorrhagic stroke. Records focusing on transient ischemic attacks or acquired brain injury were excluded, as were those in which a comorbidity or disability (eg, learning disability, dementia, respiratory disorder) had a significant impact on the individual's ability to work.

METHODS

This review followed the JBI scoping review methodology. Primary research of any type, systematic and non-systematic reviews, and gray literature from developed countries written in English from 2010 to the present day were identified from 7 databases, 2 gray literature repositories, JBI Evidence Synthesis , and an internet search. Records were screened for relevance to the review topic by 2 independent reviewers, and data relevant to the review questions were extracted. Findings were presented as narrative supported by tables.

RESULTS

Of the 106 sources included, 61 addressed demographic-based, socioeconomic-based, impairment-based, or recovery-based factors related to return to work. One of these 61 sources, a narrative review, focused on communication disorders. Thirty-eight sources explored barriers and facilitators for return to work from different stakeholders' perspectives; 3 of these 38 sources, including 2 qualitative studies and 1 narrative review, focused on post-stroke communication disorders. Eleven sources focused on interventions, including 7 studies (reported across 9 sources) that developed or tested return-to-work interventions. Of these primary studies, 1 randomized controlled trial and 1 retrospective cohort study were identified. The remaining intervention studies were case studies or case series. None of these intervention studies addressed communication disorders.

CONCLUSIONS

While there has been extensive research on factors, barriers, and facilitators for return to work post-stroke, there is a lack of research on interventions supporting return to work. There is also a significant gap in the evidence base on returning to work with a post-stroke communication disorder, highlighting the need for further research in this important area.

Exploring the experiences of women with acquired brain injury on return to work and entrepreneurial skills development in the Western Cape Metropolitan, South Africa

BACKGROUND

Acquired brain injury (ABI) is an important public health problem. Individuals with ABI experience greater challenges with community reintegration and successful return to work (RTW) due to both personal and environmental factors. Empirical evidence has shown that women with brain injury are vulnerable to poorer functional outcomes and have demonstrated lower RTW rates post-injury. Therefore, further research is needed to gain greater insight on women with acquired brain injury's functional and work abilities as well as their experiences of RTW and entrepreneurial skills development.

OBJECTIVE

This study aimed to explore and describe women with acquired brain injury's experiences during their rehabilitation process, their resumption of their worker role, and entrepreneurial skills development. This qualitative exploration formed part of a study that resulted in an occupational therapy practice model to enhance the entrepreneurial skills of women with acquired brain injury living in the Cape Metropolitan, Western Cape, South Africa.

METHODS

Semi-structured interviews were conducted with ten females with acquired brain injury. A qualitative approach was employed to thematically analyse the data.

RESULTS

Three themes emerged from the study: (1) Barriers within the rehabilitation process, 2) ABI causes loss of a sense of self and financial strain, 3) Entrepreneurship and education as a strategy to empowerment.

CONCLUSION

Unmet individual needs related to occupational engagement results in RTW challenges for women with ABI. ABI sequelae cause activity limitations and hinder gainful occupational participation. A holistic client-centred entrepreneurial skills development approach is a viable and needed strategy to facilitate economic empowerment for women with ABI.

Identifying models, processes, and components of vocational rehabilitation following acquired brain injury: a systematic scoping review

PURPOSE

Acquired brain injury (ABI) is a complex injury which impacts engagement with worker roles. Return to work (RTW) rates for individuals with brain injury are low and those who do RTW often report job instability. Vocational rehabilitation (VR) can improve RTW rates and job stability; however, service provision is varied, and no gold standard has been identified.

METHODS

A systematic scoping review of the literature was completed to explore research activity in VR for individuals with ABI to address the following three questions: what models have been identified to underpin VR in ABI? What clinical processes have been identified to guide provision of VR in ABI? What components of VR have been described and/or recommended in the ABI literature?

RESULTS

The number of included articles was 57. From these articles, 16 models, nine process steps, eight components, and four service delivery components were identified that were utilised in provision of ABI VR. Implications for practice are discussed.

CONCLUSIONS

Key processes and components of ABI VR have been identified across a range of models and apply to clients at all phases post-injury. Findings may be used to inform service provision across a range of time points and support clinicians in their delivery of VR to adults with brain injury.Implications for RehabilitationPeople with acquired brain injury (ABI), even severe injury, can be successful with return to work (RTW) when provided appropriate supports.A wide range of models, interventions, and service components have been identified in the literature which can be used to guide clinical and policy development in ABI vocational rehabilitation.Vocational rehabilitation for individuals with brain injury involves a complex interaction of factors, and consideration should be paid to not only the person and their abilities but also job demands and the environment (physical, social, cultural).Vocational rehabilitation services should be accessible and timed to maximise chances of a successful RTW, provided by a coordinated interdisciplinary team and should involve active stakeholder engagement.

Consumer perspectives of vocational rehabilitation and return to work following acquired brain injury

Introduction:

Following acquired brain injury, the goal of return to work is common. While return to work is supported through different rehabilitation models and services, access to vocational rehabilitation varies within and between countries, and global rates of employment post-injury remain low. The literature identifies outcomes from vocational programs and experiences with return to work, yet little is known about individuals’ perceptions and experiences regarding rehabilitation to support their vocational goals and experiences in attempting to return to work.

Method:

This qualitative study investigated the experiences of community-living adults with acquired brain injury (n = 8; mean age 45 years; mean time post-injury of 5.5 years) regarding their vocational rehabilitation and return to work. Focus groups and semi-structured interviews were conducted, with data analyzed via thematic analysis.

Results:

Participants identified negative and positive experiences with vocational rehabilitation and return to work. Five overarching themes were identified: addressing vocational rehabilitation in rehabilitation; facilitators of recovery and return to work; the importance and experience of working again; acquired brain injury and identity; and services, systems and policies. Participants also identified five key areas for early vocational rehabilitation services: education; service provision; employer liaison; workplace supports; and peer mentors. Study findings inform current and future practice and service delivery, at a clinical, service and system level.

Evidence-Based Interventions for Increasing Work Participation for Persons With Various Disabilities

Title I of the Americans With Disabilities Act prohibits discrimination in employment; however, 26 years later, employment rates for persons with disabilities hover at 34%. This systematic review investigates the effectiveness of evidence-based interventions to increase employment for people with various disabilities. Forty-six articles met the inclusion criteria for evidence-based interventions. The majority of studies assessed interventions for persons with mental health disabilities. Strong evidence was found for ongoing support and work-related social skills training prior to and during competitive employment for persons with mental health disabilities. Moderate evidence supported simulation and use of assistive technology, especially apps for cueing and peer support to increase work participation for persons with intellectual disabilities, neurological/cognitive disabilities, and autism spectrum disorder. Many of the strategies to increase work participation were appropriate for occupational therapy intervention. Suggestions were made for research, specifically looking at more rigorous evaluation of strategies in the long term.

Level of agreement of occupational titles between persons with traumatic brain injury and their informants

BACKGROUND

Returning to work is one of the most important goals cited by individuals with traumatic brain injury (TBI). However, they may have difficulty evoking past work history. The ability to recall work history is integral to the rehabilitation process of return to work.

OBJECTIVE

The aim of this study was to determine 1) the level of agreement on the reporting of occupations and 2) if agreement is affected when specific occupational details are required in recall between adults with traumatic brain injury and their informants.

METHODS

This is a retrospective cohort study of 259 individuals, with moderate to severe traumatic brain injury, and their selected informants (e.g. spouse, parent). Interviews were conducted separately for the individual and respective informant to gather information on type of occupation at time of injury and at time of interview. Reported occupations were coded using a standard classification system. Level of agreement was analyzed by interclass correlation coefficients and percent agreement, and the significance of bias was calculated.

RESULTS

Participants were a mean age of 44.5 at time of study with 40% employed compared to 77% at time of injury. Agreement between participants and their informants for occupational title was high for both time periods though more so at the time of injury compared to current status. Level of agreement for specificity was moderate to high however, decreased as need for specificity of detail increased.

CONCLUSION

While participant-informant responses appear to be reliable for occupational classification, when detailed information is required corroborating information is likely needed.

Metacognitive function poststroke: a review of definition and assessment

Metacognition is the conscious knowledge individuals have about their own cognitive capacities and the regulation of these activities through self-monitoring. The aim of this review was to identify the definitions and assessment tools used to examine metacognition in relation to stroke studies. A computer database search was conducted using MEDLINE, CINAHL, PsycINFO, Cochrane Reviews, Scopus and Web of Science. A total of 1412 publications were retrieved from the initial database search. Following the removal of unrelated articles, 34 articles remained eligible. 5 studies examined metacognition in relation to cognitive and/or emotional functioning, 4 examined the concept in relation to memory, while others investigated its relationship to driving, employment or restrictions in daily living. 12 studies examined metacognitive function exclusively in stroke. Only 1 study examined metacognition in the acute phase of stroke. 7 studies adhered to the standard definition of metacognition in line with the neuropsychological literature. The main assessment tools utilised included the Self-Regulation and Skills Interview (SRSI), the Self-Awareness of Deficits Interview (SADI), the Awareness Questionnaire (AQ) and the Patient Competency Rating Scale (PCRS). Assessment of metacognition has tended to focus on traumatic and other acquired brain injury in comparison to stroke. The majority of the studies that examined metacognition in stroke did not assess patients in the acute phase. The heterogeneity of assessment tools was in keeping with the variation in the definition of metacognition. The emergence of a standard metacognitive assessment tool may have important implications for future rehabilitative programmes.

Cognitive training for improving executive function in chemotherapy-treated breast cancer survivors

BACKGROUND

A majority of breast cancer (BC) survivors, particularly those treated with chemotherapy, experience long-term cognitive deficits that significantly reduce quality of life. Among the cognitive domains most commonly affected include executive functions (EF), such as working memory, cognitive flexibility, multitasking, planning, and attention. Previous studies in other populations have shown that cognitive training, a behavioral method for treating cognitive deficits, can result in significant improvements in a number of cognitive skills, including EF.

MATERIALS AND METHODS

In this study, we conducted a randomized controlled trial to investigate the feasibility and preliminary effectiveness of a novel, online EF training program in long-term BC survivors. A total of 41 BC survivors (21 active, 20 wait list) completed the 48 session training program over 12 weeks. The participants were, on average, 6 years after therapy.

RESULTS

Cognitive training led to significant improvements in cognitive flexibility, verbal fluency and processing speed, with marginally significant downstream improvements in verbal memory as assessed via standardized measures. Self-ratings of EF skills, including planning, organizing, and task monitoring, also were improved in the active group compared with the wait list group.

CONCLUSIONS

Our findings suggest that EF skills may be improved even in long-term survivors by using a computerized, home-based intervention program. These improvements may potentially include subjective EF skills, which suggest a transfer of the training program to real-world behaviors.