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Annalisa Stoddart Manager Brain Injury Vocational Rehabilitation Services Glasgow. Rehab Scotland – Brain Injury Vocational Rehabilitation Services Aim: To enable people with acquired brain injury to participate in further education/further training and/or employment opportunities.

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Annalisa Stoddart Manager Brain Injury Vocational Rehabilitation Services Glasgow

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Annalisa Stoddart

Manager

Brain Injury Vocational Rehabilitation Services

Glasgow


  • Rehab Scotland – Brain Injury Vocational Rehabilitation Services

  • Aim:

  • To enable people with acquired brain injury to participate in further education/further training and/or employment opportunities.

  • This is achieved by working with clients using a multi-disciplinary team approach in order to enable clients to address brain injury related problems which might present barriers and to clarify and test out training/employment goals.


  • Introduction

  • Brain Injury – the facts

  • Brain Injury – the effects

  • Case study 1

  • Vocational rehabilitation and supported employment

  • Case study 2

  • Conclusion


  • Brain Injury – the facts

  • Approximately 1 million in Britain each year

  • Per year, per 100,000 of the population

    • *10 – 15 severe

    • *15 – 20 moderate

    • *250 – 300 mild

  • One family in every 300 will be affected by the long term effects


  • Brain Injury – the causes

  • Road traffic accidents (including bicycles)

  • Assaults

  • Falls

  • Sports/industrial accidents

  • Alcohol


  • Brain Injury – prevalence

  • 3:1 male/female ratio

  • 2/3 of head injuries are aged under 30 years old

  • Residence in urban areas where social inclusion predominates

  • Income poverty

  • Unemployment

  • Lack of educational attainment

  • High levels of crime

  • Substance misuse


  • Brain Injury – types of injury

  • Primary injury occurs at the moment of impact, being caused by the blow

  • Secondary injury occurs as a result of systemic complications, which are potentially treatable

  • Primary: skull fracture, cerebral contusions, diffuse axonal injury

  • Secondary: intracranial haematoma, brain swelling, infection, raised intracranial pressure, respiratory failure, hypotension, ischaemic brain damage


  • Brain Injury – delayed complications

  • Post traumatic epilepsy

  • Hydrocephalus


  • Brain Injury – severity

  • Mild head injury (75%): loss consciousness <15 minutes/no loss of consciousness

  • Moderate head injury: loss of consciousness between 15 minutes and 6 hours/post traumatic amnesia up to 24 hours

  • Severe head injury: loss of consciousness >48 hours/post traumatic amnesia>24 hours


  • Brain Injury- disability

  • Thornhill and Teasdale – 2000

  • Study of 3000 people admitted to hospital with head injury

  • Follow up of 1000 at one year post injury

  • 78% of severe head injuries experienced disability

  • 54% of moderate head injuries experienced disability

  • 51% of mild head injuries experienced disability


  • Brain Injury – lack of follow up

  • Most head injured receive no follow up after discharge

  • Less than 50% were seen in hospital after discharge

  • Only 28% received any form of rehabilitation

  • Only 15% had contact with Social Work

  • Most common service was physiotherapy


  • Brain Injury – physical effects

  • Headaches

  • Paralysis/mobility problems

  • Balance problems

  • Dizziness

  • Epilepsy

  • Reduced stamina

  • Problems with co-ordination

  • Ataxia (shakiness)

  • Dyspraxia (message from brain to limb is blocked)

  • Problems with continence

  • Reduced/increased libido


  • Brain Injury: physical effects

  • Visual impairment

  • Loss of sense of smell

  • Loss of sense of taste

  • Impaired hearing

  • Swallowing problems

  • Dysarthria ( difficulties forming words )


  • Brain Injury – cognitive/executive/communication effects

  • Impaired memory

  • Impaired concentration

  • Increased sensitivity to noise/stimuli

  • Reduced speed of information processing

  • Perseveration

  • Confusion/disorientation

  • Lack of insight

  • Difficulties with visual - spatial judgment


  • Rigidity of thought

  • Problems with initiation/motivation

  • Problems with planning/organising

  • Difficulties with problem solving and decision making

  • Word finding problems

  • Difficulties understanding language

  • Dyslexia and literacy problems


  • Brain Injury – emotional effects

  • Agitation

  • Anger and frustration

  • Anxiety

  • Depression

  • Mood swings

  • Reduced tolerance/increased irritability

  • Loss of feeling/empathy

  • Loss of confidence


  • Brain Injury – behavioural effects

  • Agitation/aggression

  • Impulsivity

  • Disinhibition

  • Withdrawal


  • Brain Injury – social effects

  • Reduced ability to understand and cope with social interactions

  • Interpersonal/relationship difficulties

  • Impaired communication/social skills

  • Family/relationship breakdown

  • Social isolation

  • Reduced work/educational performance

  • Loss of role/identity

  • Loss of employment/loss of income

  • (less than 30%of head injured people will return to work without specialist rehabilitation and support)


Case Study 1 - Injury Details

  • Injury sustained in 1996

  • Male aged 28 years

  • Fall ( 70 Feet )

  • Alcohol

  • Orthopaedic injuries/respiratory and renal complications

  • Diffuse head injury

  • PTA: approximately 6 weeks

  • Length of hospitalisation: 8 weeks


CASE STUDY 1 – EFFECTS OF BRAIN INJURY

  • Sleep disturbance and low levels of stamina

  • Visuospatial impairment

  • Word finding problems

  • Disorientation

  • Memory impairment

  • Poor Concentration

  • Executive Dysfunction

  • Slowed information processing

  • Emotional and behavioural problems


CASE STUDY 1 –REINTEGRATION

  • Effects of trauma

  • Effects of head injury

  • No information or support

  • Stress of adjustment

  • Stress of reintegration into family,social life, education and work


CASE STUDY 1: SECONDARY PROBLEMS

  • Reduced ability to self monitor

  • Impaired social skills and relationship difficulties

  • Increased stress and and loss of self confidence

  • Difficulties balancing work and leisure

  • Impaired work performance

  • Reduction in earnings

  • Housing problems

  • Anger/frustration

  • Loss of social/work identity/status

  • Alcohol dependency


CASE STUDY 1: OUTCOME

  • Exhaustion

  • Psychiatric admission

  • Loss of employment/income

  • Loss of home/independence

  • Loss of role and achievement

  • Family and relationship breakdown

  • Alcohol dependency

  • Increasingly chaotic lifestyle

  • Academic failure


CASE STUDY 1: Implications for Vocational Rehabilitation

  • Loss of confidence in services and lack of trust

  • Programme had to be reactive rather than proactive initially

  • Vocational re-evaluation rather than retention

  • Need to address secondary psycho-social problems before vocational rehabilitation was possible

  • Lack of insight

  • Family denial


  • Case Study 1 – vocational rehabilitation: a multi disciplinary team approach

  • Manager

  • Clinical Neuropsychologist

  • Assistant Psychologist

  • Work Related Social Skills Tutor

  • Employment Liaison Officer

  • Job Coach

  • Occupational Therapist/Job Coach


CASE STUDY 1: INDIVIDUAL PROGRAMME PLANNING

  • Assessment

  • Induction

  • Introduction to structured environment and activity

  • Brain Injury Awareness Training

  • Training cognitive and executive skills

  • Stress, anxiety and relaxation training

  • Social reintegration and leisure activities

  • Work Related Social Skills Training

  • Individual psychological support and Liaison with Community Psychologist

  • Family information and support

  • Referral to Housing Department

  • Welfare rights advice


CASE STUDY 1: INDIVIDUAL PROGRAMME PLANNING

  • Vocational profiling

  • Vocational exploration

  • Job Seeking Skills Training

  • Liaison with university

  • Liaison with an architects’ business

  • Setting educational/vocational goals

  • Supported study for diploma thesis in Architecture

  • Study Skills Training

  • Work Placement in an architects’ office, supported by a specialist job coach


CASE STUDY 1: OUTCOME

  • Passed Diploma Thesis in Architecture: June 2001

  • Employed by Architects Office: September 2001


  • Vocational rehabilitation and supported employment – ideal model

  • Information, advice and support to client and family

  • Early intervention

  • Employer liaison

  • Community integration

  • Holistic assessment with other agencies, family and client input

  • Neuropsychological/occupational therapy assessment as required

  • Individual programme planning (multi disciplinary approach)


  • Vocational rehabilitation and supported employment – ideal model

  • Psychosocial rehabilitation

  • Training in compensatory strategies for physical problems/ stamina building

  • Flexible and realistic vocational profiling and exploration

  • Information technology training

  • Graded work experience placements with job coaches as transitional specialists

  • (place and train model)


  • Vocational rehabilitation and supported employment

  • Regular review of work goals

  • Specific vocational training as required/study skills training

  • Job seeking skills training and intensive job search

  • Marketing to employers

  • Ideal job match

  • Back to work benefits advice

  • Transitional/through care support in employment

  • Optimal use of natural supports in the workplace

  • Independence in the workplace/supported employment


CASE STUDY 2 - INJURY DETAILS

  • Injury sustained in May 1998

  • Male aged 34 years old

  • Fall down stairs, circumstances unclear

  • Admitted to Glasgow Royal Infirmary.

  • CT brain scan: left subdural haemorrhage with significant mass effect and oedema

  • 2 small intracerebral haematomas in the right and left frontal lobes

  • Transferred to The Southern General Hospital( no surgery – conservative treatment

  • Returned to GRI

  • PTA 2-3 days. Length of hospitalisation, 2 weeks


CASE STUDY 2: EFFECTS OF HEAD INJURY

  • Headaches

  • Sleep disturbance and low levels of stamina

  • Dizziness and positional vertigo

  • Impaired memory and poor concentration

  • Slowed information processing

  • Difficulties in initiating, planning and organising tasks

  • Word finding problems

  • Low mood and irritability

  • Increased sensitivity to noise

  • Low levels of motivation

  • High levels of anxiety/panic attacks

  • Low confidence and social isolation


CASE STUDY 2: SUPPORT PROVIDED PRIOR TO REFERRAL TO VRP

  • Information regarding head injury and its effects

  • Regular home support visits

  • Allocation of a support worker to assist community integration activities, including travel management

  • Liaison with employer/negotiation of medical retirement

  • Benefits advice and assistance

  • Anxiety management

  • Information about/support to implement compensatory strategies for memory impairment

  • Carer support/information

  • Referral to and assistance to attend The Head Injuries Trust for Scotland

  • Referral to Rehab Scotland, Brain Injury Vocational Rehabilitation Programme


CASE STUDY 2: Assessment of needs at referral

  • Dizziness/balance problems

  • Headaches

  • Poor stamina

  • Memory impairment

  • Difficulties with concentration( especially divided attention)

  • Difficulties initiating, planning and organising tasks

  • Anxiety

  • Low mood

  • Low levels of motivation

  • Lack of hope/goals in relation to returning to work


CASE STUDY 2: INDIVIDUAL PROGRAMME PLANNING

  • Induction

  • Gradual introduction to a structured, simulated work routine/environment

  • Neuropsychological assessment

  • Brain Injury Awareness Training

  • Cognitive training for memory/concentration problems

  • Rehabilitation strategies for executive problems

  • Stress,anxiety and relaxation training

  • Individual psychology support re anxiety and low mood

  • Work Related Social Skills Training


CASE STUDY 2: INDIVIDUAL PROGRAMME PLANNING

  • Social Re-integration and leisure activities

  • Individual Resource Project: Teaching others to play guitar

  • Family information and support (e.g childcare)

  • Client representative training

  • Information Technology Training ( Certificate)

  • Vocational profiling and exploration

  • Specific vocational training in Lifting and Handling

  • 2 Work Experience Placements ( Support Worker)

  • Review of work goal and Job Seeking Skills Training. (Cert)

  • Intensive Job search

  • Outcome: Employment, August 2000 as a concierge with Glasgow City Council, Housing Department


The benefits of early intervention, facilitated by an integrated pathway approach which promotes joint working:

  • Case Study 1: Significant gap between brain injury and return to employment (5 years)

  • Case Study 2: Reduced gap between brain injury and employment

  • (2 years)

  • Case Study 1: Significant secondary problems affecting mental health, family relationships and readiness/willingness of client/family for specialist intervention

  • Case Study 2 : Information and support at an early stage facilitated effective intervention, trust in service providers and family involvement/commitment


  • Range of employment outcomes

  • Architect – City centre practice

  • Concierge – Glasgow City Council

  • Support worker – Turning Point

  • Support worker – Care Line

  • Warehouse assistant – Index

  • Project Co-ordinator – Glasgow Play Scheme Association

  • Support worker – Key Housing

  • Warehouse assistant – Clothing factory

  • Sports centre assistant – National Sports Centre - Largs


  • Vocational rehabilitation – benefits

  • Cost effective (80% employment/15% further education/training)

  • Addresses specialist problems

  • Empowers

  • Feedback mechanism which captures performance targets

  • Promotes personal/professional development

  • Reduces psychosocial problems

  • Promotes social and economic inclusion


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