Employment after traumatic brain injury predictors challenges and interventions
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Employment After Traumatic Brain Injury: Predictors, Challenges, and Interventions. Lynne C. Davis, Ph.D. Brain Injury Research Center TIRR Memorial Hermann Houston, TX. Sponsor.

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Employment after traumatic brain injury predictors challenges and interventions

Employment After Traumatic Brain Injury: Predictors, Challenges, and Interventions

Lynne C. Davis, Ph.D.

Brain Injury Research Center

TIRR Memorial Hermann

Houston, TX


Sponsor

Sponsor

  • Grant #:H133B090023, National Institute on Disability and Rehabilitation Research (NIDRR), U.S. Dept. of Education


Learning objectives

Learning Objectives

  • Increase awareness about traumatic brain injury (TBI):

    • Define TBI

    • Incidence/prevalence

    • Common sequelae

  • Identify challenges and predictors of returning to work after TBI

  • Identify 3 types of interventions to help persons with TBI return to work


Overview of tbi

Overview of TBI

  • What is a traumatic brain injury (TBI)?

    a mechanical force applied to the head that affects brain functioning

  • Common causes:

    • falls

    • motor vehicle accidents

    • struck by/against an object

    • assaults


Overview of tbi cont d

Overview of TBI (cont’d)

  • Types of TBI:

    Closed TBI: brain is injured without penetration of the skull

    Open TBI: brain is injured with penetration of the skull


Overview of tbi cont d1

Overview of TBI (cont’d)

  • How common is TBI?

    • 1.4 million TBIs annually in U.S.

    • 75,000 to 80,000 new cases of disability each year

    • 5.3 million living with significant disability as a result of TBI


Overview of tbi cont d2

Overview of TBI (cont’d)

Injury Severity

  • Refers to initial injury – not outcome

  • Classification:

    • Loss of consciousness

    • Length of post-traumatic amnesia

    • Glasgow Coma Scale (GCS)


Overview of tbi cont d3

Overview of TBI (cont’d)

  • Mild TBI

    • LOC<30 min

    • GCS 13-15

  • Moderate to Severe

    • LOC > 30 min - hours, days, weeks

    • GCS 9-12 = Moderate

    • GCS 3-8 = Severe


Overview of tbi cont d4

Overview of TBI (cont’d)

Recovery Course

  • Every injury different

  • Every recovery can be different as well

  • Mild TBI:

    • Most rapid in first few weeks

    • At 3 months most feel “back to normal”

    • If continued problems, likely to improve over the first year


Overview of tbi cont d5

Overview of TBI (cont’d)

  • Moderate/Severe TBI:

    • Most rapid changes seen in first 6 months

    • Continue to see changes in first 1-2 years, with changes slowing down over time

    • Functional improvements possible at any time after injury: use of compensatory strategies and supports


Overview of tbi cont d6

Overview of TBI (cont’d)

Common problems:

  • Sensory

  • Motor

  • Cognitive

  • Emotional/Behavioral


Overview of tbi cont d7

Overview of TBI (cont’d)

  • Sensory

    • Headaches

    • Fatigue

    • Dizziness

    • Blurred or double vision

    • Sensitivity to noise/light

    • Trouble with taste or smell


Overview of tbi cont d8

Overview of TBI (cont’d)

  • Motor

    • Weakness/paralysis and spasticity

    • Slowed performance

    • Poor coordination/balance

    • Slurred speech


Overview of tbi cont d9

Overview of TBI (cont’d)

  • Cognitive

    • Attention/concentration

    • Memory

    • Slowed information processing speed

    • Problem-solving difficulties

    • Organizational difficulties


Overview of tbi cont d10

Overview of TBI (cont’d)

  • Emotional/Behavioral

    • Decreased initiation

    • Lack of awareness

    • Impulsivity

    • Depression

    • Irritability/anger

    • Emotional lability


Return to work rtw facts challenges and predictors

Return to Work (RTW): Facts, Challenges and Predictors

  • TBI is one of the leading causes of disability among young persons of working age in the U.S.

  • Total lifetime productivity losses are estimated at $51.2 billion.1

  • Only about 30-40% of persons with moderate to severe TBI return to work after injury.2


Return to work rtw facts challenges and predictors cont d

Return to Work (RTW): Facts, Challenges and Predictors (cont’d)

  • Persons with TBI identify RTW as a primary need after injury.

  • Employment provides economic and social benefits after TBI.

  • Rates of depression are lower for employed than unemployed persons with TBI.3

  • Satisfaction with life rated as higher in employed vs. unemployed persons with TBI.4


Return to work rtw facts challenges and predictors cont d1

Return to Work (RTW): Facts, Challenges and Predictors (cont’d)

  • Challenges

    • physical

    • cognitive

    • emotional/behavioral

    • support system

    • disincentives


Return to work rtw facts challenges and predictors cont d2

Return to Work (RTW): Facts, Challenges and Predictors (cont’d)

  • Physical challenges

    • Headaches

    • Fatigue

    • Dizziness

    • Blurred or double vision

    • Sensitivity to noise/light

    • Trouble with taste or smell

    • Weakness/paralysis and spasticity

    • Slowed performance

    • Poor coordination/balance

    • Slurred speech


Return to work rtw facts challenges and predictors cont d3

Return to Work (RTW): Facts, Challenges and Predictors (cont’d)

  • Cognitive challenges

    • Attention/concentration

    • Memory

    • Slowed information processing speed

    • Problem-solving difficulties

    • Organizational difficulties


Return to work rtw facts challenges and predictors cont d4

Return to Work (RTW): Facts, Challenges and Predictors (cont’d)

  • Emotional/behavioral challenges

    • Decreased initiation

    • Lack of awareness

    • Impulsivity

    • Depression

    • Irritability/anger

    • Emotional lability


Return to work rtw facts challenges and predictors cont d5

Return to Work (RTW): Facts, Challenges and Predictors (cont’d)

  • Support system challenges

    • Lack of social support can interact with physical, cognitive, and emotional/behavioral challenges to make it even more difficult to return to work.


Return to work rtw facts challenges and predictors cont d6

Return to Work (RTW): Facts, Challenges and Predictors (cont’d)

  • Disincentives

    • Fear of losing disability compensation

    • Inability to return to same type of job

    • Psychological disincentives


Return to work rtw facts challenges and predictors cont d7

Return to Work (RTW): Facts, Challenges and Predictors (cont’d)

  • Predictors of RTW after TBI

    • Predicting RTW is difficult, depends on:

      • Demographics

      • Pre-injury variables

      • Injury-related variables

      • Environmental variables

      • Other variables (personality features, economic variables, cultural influences)


Return to work rtw facts challenges and predictors cont d8

Return to Work (RTW): Facts, Challenges and Predictors (cont’d)

  • Predictors of RTW after TBI

    • Demographic variables:

      • Age – inverse relationship between age and RTW.5

      • Education – mixed findings, but most studies show a positive association between pre-injury education and RTW.6


Return to work rtw facts challenges and predictors cont d9

Return to Work (RTW): Facts, Challenges and Predictors (cont’d)

  • Predictors of RTW after TBI

    • Pre-injury variables:

      • Pre-injury employment – mixed findings, but there appears to be a positive relationship between pre- and post-TBI employment.

      • Psychiatric history appears related to employment after moderate to severe TBI,7 as does pre-injury drug/alcohol abuse.


Return to work rtw facts challenges and predictors cont d10

Return to Work (RTW): Facts, Challenges and Predictors (cont’d)

  • Predictors of RTW after TBI

    • Injury-related variables:

      • Greater TBI severity is associated with lower rates of RTW in many, but not all, studies.

      • Level of impairment/disability predicts vocational outcome: those with less impairment/disability have better vocational outcomes.8


Return to work rtw facts challenges and predictors cont d11

Return to Work (RTW): Facts, Challenges and Predictors (cont’d)

  • Predictors of RTW after TBI

    • Injury-related variables:

      • Time since injury – early intervention is associated with better vocational outcomes.9

      • Impaired awareness – mixed findings


Return to work rtw facts challenges and predictors cont d12

Return to Work (RTW): Facts, Challenges and Predictors (cont’d)

  • Predictors of RTW after TBI

    • Environmental variables:

      • Family/social support promotes employability

        • Identifying jobs

        • Helping with transportation

        • Identifying other needs that have implications for employment (e.g., psychotherapy)


Return to work rtw facts challenges and predictors cont d13

Return to Work (RTW): Facts, Challenges and Predictors (cont’d)

  • Predictors of RTW after TBI

    • Variables that have received less attention, but that are also important in RTW:

      • Personality features

      • Economic variables

      • Cultural influences


Return to work rtw interventions

Return to Work (RTW) Interventions

  • Vocational interventions lead toimproved RTW rates.10


Return to work rtw interventions cont d

Return to Work (RTW) Interventions (cont’d)

  • 3 major RTW intervention approaches:11

    • Program-based vocational rehabilitation model

    • Supported employment model

    • Case coordination model


Return to work rtw interventions cont d1

Return to Work (RTW) Interventions (cont’d)

  • Program-based vocational rehabilitation model

    • First described by Ben-Yishay et al.12

    • Consists of 3 sequential modules

      • Module 1: individualized, intensive work skills intervention

      • Module 2: guided work trials

      • Module 3: assisted job placement with support


Return to work rtw interventions cont d2

Return to Work (RTW) Interventions (cont’d)

  • Program-based vocational rehabilitation model

    • Involves interdisciplinary, group-based interventions targeting cognitive deficits, awareness, acceptance, and social skills.

    • This approach may be most effective for those with severely impaired awareness, cognition, and social functioning.


Return to work rtw interventions cont d3

Return to Work (RTW) Interventions (cont’d)

  • Program-based vocational rehabilitation model

    • Post-treatment employment rates are high, ranging from 75-85%.13

    • Weaknesses: high intensity of program, elevated costs, poor fit for those with less severe impairments.


Return to work rtw interventions cont d4

Return to Work (RTW) Interventions (cont’d)

  • Supported employment model

    • Is an “individual placement model” adapted for persons with brain injury by Wehman et al. in late 1980s14

    • Involves limited pre-employment training, quick job placement, individualized on-the-job training from job coach, and long-term monitoring.


Return to work rtw interventions cont d5

Return to Work (RTW) Interventions (cont’d)

  • Supported employment model

    • Job coaches help with: contacting potential employers, providing additional training, helping perform some job duties while employee is learning, obtaining assistive technology, teaching problem-solving and compensatory strategies, and modeling social skills.

    • Approach designed for persons with severe deficits who could not maintain employment without on-site, ongoing assistance.


Return to work rtw interventions cont d6

Return to Work (RTW) Interventions (cont’d)

  • Supported employment model

    • Has been shown to be effective, achieving a 71% employment rate.15

    • Weaknesses: extensive resources may be required for adequate job retention (i.e., high number of intervention hours), poor fit for those with less severe impairments.


Return to work rtw interventions cont d7

Return to Work (RTW) Interventions (cont’d)

  • Case coordination model

    • Is a holistic, flexible, individualized approach.

    • Case coordinator works with person with TBI to assess for needed services and then makes referrals.

    • Common referrals include vocational counseling, pre-employment training, and job placement assistance.


Return to work rtw interventions cont d8

Return to Work (RTW) Interventions (cont’d)

  • Case coordination model

    • Emphasizes integration of vocational services with other rehabilitation services.

    • Key components: early intervention, continuity of care, and identification of impairments that could interfere with vocational success.


Return to work rtw interventions cont d9

Return to Work (RTW) Interventions (cont’d)

  • Case coordination model

    • has been shown effective for persons with mild to severe TBI, with 70% employment rate achieved within 12 months.16

    • Weaknesses: success depends on the skill of the specific staff members and on availability of services in clients’ areas.


Return to work rtw interventions cont d10

Return to Work (RTW) Interventions (cont’d)

  • Which approach is best?

    • Depends on the needs, resources, and characteristics of the injured person.

    • Is no clear “best practice” approach, but overall the case coordination approach appears to have the strongest outcome evidence.11


Application of the case coordination model

Application of the Case Coordination Model

  • Randomized controlled trial (RCT) at the Brain Injury Research Center of TIRR Memorial Hermann

    • part of our Rehabilitation Research and Training Center on Developing Strategies to Foster Community Integration and Participation for Individuals with Traumatic Brain Injury funded by NIDRR


Application of the case coordination model cont d

Application of the Case Coordination Model (cont’d)

  • Recruit from Level I trauma center acute care, emphasis on early intervention.

  • Inclusion criteria: complicated mild through severe TBI, age 18-65, fluent in English/Spanish, ≥ 6 mos. continuous employment in 2 yrs before injury, wants to return to work, legal resident of TX or has valid work visa, resides within 100-mile radius.


Application of the case coordination model cont d1

Application of the Case Coordination Model (cont’d)

  • Potential participants administered a readiness evaluation.

  • Those who are ready are randomized to case coordination intervention or standard of care.

  • Both groups receive referrals for state vocational rehabilitation services.


Application of the case coordination model cont d2

Application of the Case Coordination Model (cont’d)

  • Those in the case coordination group receive biweekly phone calls from case coordinator for ≤ 1 year, who assesses for referral needs.

  • Case coordinator also contacts assigned vocational counselor to help participants through process.


Application of the case coordination model cont d3

Application of the Case Coordination Model (cont’d)

  • Employment and community integration outcomes assessed in both groups at 6, 9, 12, and 18 months following enrollment.

  • Observations so far:

    • Participants confused about state vocational rehabilitation process.

    • Participants appear to value case coordinators’ assistance.


Work readiness after tbi

Work Readiness after TBI

  • Stergiou-Kita et al.15 identified critical personal variables when assessing RTW readiness:

    • motivation

    • physical and functional independence

    • cognition (attention, memory, judgment, self-awareness)

    • use of compensatory strategies


Future directions

Future Directions

  • Develop standardized procedures/measures to match persons with TBI to RTW intervention best suited for them based on their needs.

  • Comparative outcome studies of RTW interventions.

  • Identify ways to implement RTW interventions within state vocational rehabilitation systems.


References

References

1. Finkelstein EA, Corso PC, Miller TR, Fiebelkorn IA, Zaloshnja E, Lawrence BA.

Incidence and economic burden of injuries in the United States. New York, NY: Oxford

University Press; 2006.

2. van Velzen JM, van Bennekom CAM, Edelaar MJA, Sluiter JK, Frings-Dresen MHW.

Prognostic factors of return to work after acquired brain injury: A systematic review.

Brain Injury 2009;23:385-395.

3. Dawson D, Schwarts M, Winocur G, Stuss D. Return to productivity following brain

injury: Cognitive, psychological, physical, spiritual and environmental correlates. Disability

And Rehabilitation 2007;29:301-313.

4. Corrigan JD, Bogner J, Mysiw WJ, Clinchot D, Fugate L. Life satisfaction after traumatic

brain injury. Journal of Head Trauma Rehabilitation 2001;16:543-555.

5. Keyser-Marcus LA, Bricout JC, Wehman P, Campbell LR, Cifu DX, Englander J, High W,

Zafonte RD. Acute predictors of return to employment after traumatic brain injury: A

longitudinal follow-up. Archives of Physical Medicine and Rehabilitation 2002;85:635-641.


References1

References

6. Stergiou-Kita M, Dawson DR, Rappolt SG. An integrated review of the processes and

factors relevant to vocational evaluation following traumatic brain injury. Journal of

Occupational Rehabilitation 2011;Jan 22 [Epub ahead of print].

7. MacMillan PJ, Hart RP, Martelli MF, Zasler ND. Pre-injury status and adaptation

following traumatic brain injury. Brain Injury 2002;16:41-49.

8. Malec JF. Impact of comprehensive day treatment on societal participation for persons

with acquired brain injury. Archives of Physical Medicine and Rehabilitation 2001;82:885-

894.

9. Malec JF, Degiorgio L. Characteristics of successful and unsuccessful completers of

three postacute brain injury rehabilitation pathways. Archives of Physical Medicine and

Rehabilitation 2002;83:1759-1764.

10. Kendall E, Muenchberger H, Gee T. Vocational rehabilitation following traumatic brain

injury: A quantitative symthesis of outcome studies. Journal of Vocational Rehabilitation

2006;25:149-160.


References2

References

11. Fadyl JK, McPherson KM. Approaches to vocational rehabilitation after traumatic brain

injury: A review of the evidence. Journal of Head Trauma Rehabilitation 2009;24:195-

212.

12. Ben-Yishay Y, Silver SM, Piasetsky E, Rattock J. Relationship between employability

and vocational outcome after intensive holistic cognitive rehabilitation. Journal of Head

Trauma Rehabilitation 1987;2:35-48.

13. Prigatano GP, Klonoff P, O’Brien KP, et al. Productivity after neuropsychological

oriented milieu rehabilitation. Journal of Head Trauma Rehabilitation 1994;9:91-102.

14. Wehman P, Bricout J, Targett P. Supported employment for persons with traumatic

brain injury: A guide for implementation. In: Fraser R, Clemmens D, eds. Traumatic Brain

Injury Rehabilitation: Practical Vocational, Neuropsychological, and Psychotherapy

Interventions. Boca Raton, FL: CRC Press; 2000:201-240.

15. Wehman P, West M, Sherron P, Roah C, Kreutzer J. Return to work: Supported

employment strategies, costs, and outcome data. In: Thomas DF, Menz FE, McAlees DC,

eds. Community-Based Employment Following Traumatic Brain Injury. Menomonie:

University of Wisconsin-Stout; 1993.


References3

References

16. Buffington ALH, Malec JF. The vocational rehabilitation continuum: Maximizing

outcomes through bridging the gap from hospital to community-based services. Journal

of Head Trauma Rehabilitation 1997;12:1-13.

17. Stergiou-Kita M, Yantzi A, Wan J. The personal and workplace factors relevant to

work readiness evaluation following acquired brain injury: Occupational therapists’

perceptions. Brain Injury 2010;24:948-958.


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