Investigation of factors related to employment outcome following traumatic brain injury: A critical review and conceptual model

Authors: 
O'Brien, L.
Year Published: 
2004
Publication: 
Disability and Rehabilitation
Volume: 
26
Number: 
13
Pages: 
765-783
Publisher: 
Taylor & Francis Ltd
Background: 

Employment outcomes post traumatic brain injury (TBI) result in a financial and social burden. In addition, unemployment may impact the individual's quality of life and emotional well being. The ability to predict vocational outcome using evidenced based guidelines can assist with rehabilitation planning, development of vocational support services and the role adjustment of the individual with a TBI and his or her family members.

Purpose: 

A review of the literature to identify key variables associated with positive employment outcomes post TBI can pave the way for future research and the development of rehabilitation practices.

Data Collection: 

Eighty five studies were identified between 1980 and 2003 that reported on factors associated with employment outcomes post TBI. Among those fifty studies met the inclusion criteria for the second stage review. The criteria used to evaluate and rate the quality of methodology for each study was adapted on guidelines by Sherer 2002 and Pengel et. al. 2003.

Intervention: 

The review highlights demographic, injury and neuropsychological factors associated with return to work. It also examines interventions that focus on modifying the social environment in addition to emotional and metacognitive factors. A conceptual model is presented that outlines the factors associated with employment outcomes.

Control: 

No control or comparison

Findings: 

The most consistent predictors and indicators of employment outcomes included premorbid occupational status, functional status at discharge, global cognitive functioning, perceptual functioning, executive functioning, involvement in vocational rehabilitation services and emotional status. The authors note that although the presence of specific characteristics may be a predictor for failure to return to work the absence of a factor does not guarantee return to work.
There is little evidence to support cognitive rehabilitation. The most successful programs target problems with motivation and emotional disturbance. Interventions to modify the social environment need to occur on multiple levels. A person's preferences for employment impact job retention. Supported employment has been described however, further evaluation of outcomes is needed. At a policy level a major barrier exists in the current service delivery system in which individuals do not have access to long term rehabilitation or specialized vocational support. Changes in public policy and funding could improve service delivery. Developing disability management programs may also assist those at risk for chronic unemployment post TBI.

Conclusions: 

The review of literature reported that the level of empirical support for employment outcome was greatest for: premorbid occupational status, functional status at discharge, global cognitive functioning, perceptual functioning, executive functioning, involvement in vocational rehabilitation services and emotional status. Future research is needed to determine the role of metacognitive, emotional and social environment factors that can be modified with various interventions. Interventions need to be evaluated to determine evidenced based practices.

URL: 
http://www.ncbi.nlm.nih.gov/pubmed/15371049
NIDILRR Funded: 
Peer Reviewed: 
Yes

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

Authors: 
Phillips, V. L., Temkin, A., Vesmarovich, S., Burns, R., & Idleman, L.
Year Published: 
2007
Publication: 
Brain Injury
Volume: 
21
Number: 
5
Pages: 
465-478
Publisher: 
Informa Healthcare
Background: 

Acquired brain injury (ABI) can be caused by cerebrovascular accident, trauma (such as assault or motor vehicle accident), tumors, hypoxia, infection or degenerative conditions and is a common occurrence [1]. It may result in significant disability and, in people of working age, limit their ability to join or return to the workforce.

Purpose: 

The aim of this study was to describe the services provided (including assessments, interventions and post-job placement support) and outcomes achieved by CRS Australia‚ Victorian ABI team and compare and contrast this with other models.

Setting: 

The study setting was a rehabilitation service organization in Australia.

Sample: 

The study sample consisted of 27 individuals with ABI who had received rehabilitation services at CRS Australia. The sample was randomly selected from cases that had been closed in the previous year with an employment outcome. Additional characteristics of the sample are not provided.

Data Collection: 

A data extraction method was used to audit patient information relevant to the study. Team members were also asked to indicate which of 17 vocational rehabilitation strategies they used with their clients and to rate each in terms of effectiveness in achieving a successful job placement. which of five post job-placement strategies (email to client, weekly or fortnightly phone calls to client, weekly or fortnightly phone calls to employer, support/counseling outside client‚ work hours and regular scheduled workplace visits) they used and to evaluate their perceived effectiveness.

Intervention: 

The intervention is described as client-centered practice. Each client is allocated to a Rehabilitation Consultant (RC) with whom they work one-to-one, wherever possible, throughout the duration of services. Active client involvement in the negotiation of individual rehabilitation plans is standard practice in all cases and clients are informed of their rights, responsibilities and the complaints handling mechanism at the earliest opportunity. Specific interventions are tailored to the individual and can include vocational counseling, skills training, cognitive retraining, job seeking, interview preparation, work behavior coaching, and post-employment services.

Control: 

There was no control or comparison condition. Outcomes for the study group were compared to those of other models.

Findings: 

Of the patient files audited, 42% were placed in professional, managerial, office or administrative work, two were placed in a trade-qualified job, eight were placed in semi-skilled positions, and four were placed in unskilled labor. Of the clients who had jobs to return to (n=10) all returned to their previous role or a similar job following a graded return with professional/clerical jobs figuring highly (50%; n=5). Those clients who did not have a job to return to (n=17) were placed in similar roles to their pre-injury employment, with seven placed in a professional role, six placed in semi-skilled work and four placed in unskilled labor positions. Half were employed more than 13 weeks.

Conclusions: 

The CRS Australia model resulted in higher than average employment outcome rates for this population (50% working at award wage for more than 13 weeks, compared to Australian ABI population estimates of 28–46.5%). This study shows that the CRS Australia model has been successful with people with mild, moderate and severe impairment following an ABI and significantly less time-intensive and therefore less costly than other models.

URL: 
http://www.ncbi.nlm.nih.gov/pubmed/17522986
Populations: 
NIDILRR Funded: 
Research Design: 
Peer Reviewed: 
Yes

The program without walls: Innovative approach to state agency vocational rehabilitation of persons with traumatic brain injury

Authors: 
Ottomanelli, L., & Lind, L.
Year Published: 
2004
Publication: 
Archives of Physical Medicine and Rehabilitation
Volume: 
85
Number: 
2
Pages: 
68-72
Publisher: 
Elsevier
Background: 

Employment is compromised for individuals with traumatic brain injury (TBI). Rates after TBI range from 10% to 70% .The literature reports on successful work outcomes for some with the use of specialized or intensive rehabilitation intervention. In spite of a number of intensive demonstration projects focusing on vocational rehabilitation (VR) and some research showing the effectiveness of certain program components, many persons with TBI remain unserved or underserved within the VR system. Individuals with TBI access VR services at rates that are much lower than other consumers relative to their prevalence in the general population. In addition to being underrepresented in counselor caseloads, people with TBI are less successful than other consumers in obtaining and maintaining competitive employment.

Purpose: 

The purpose of the paper was to describe the Program Without Walls (PWW), a person-centered, community-based approach for state rehabilitation counselors to provide vocational rehabilitation (VR) services to individuals with traumatic brain injury (TBI). The PWW includes many of the best practices suggested by previous research such as: functional cognitive remediation, job coaching, psychosocial counseling, job development and placement services, and fostering a strong relationship with the counselor via person-centered planning.

Setting: 

The setting included communities and two district vocational rehabilitation offices in the state of New York.

Sample: 

The study sample was made up of 42 individuals who had been accepted by New York State's VR program for services. The majority or (34)were men. Half of the group (21) received traditional services and the other half participated in the PWW. In terms of ethnicity, the majority of participants were nonwhite (i.e.. black and Asian). Related to education, close to half (48%) had not completed high school.

Data Collection: 

The following data were gathered from VESID central files for fiscal years 2001 (October 1, 2000–September 30, 2001) and 2002 (October 1, 2001–September 30, 2002): case status (26 successfully placed for 90 days, 28 closed after IPE-initiated, 30 closed before IPE initiated, 8 closed before IPE developed), weekly earnings at closure, hours worked per week at closure, cost of case services provided to each consumer, consumer demographic characteristics (gender, level of education, employment status at application, ethnicity, age), and name of the state VR counselor serving the consumer. By using case status, the proportion of successful closures (i.e., case status 26) were compared with unsuccessful closures (i.e., case status 8, 28, and 30) for the PWW counselors and other counselors in the catchment areas served by using Pearson chi-square analyses. One-tailed t tests were used to compare weekly earnings at closure, hours worked per week at closure, and cost of services for PWW consumers versus the matched consumers.

Intervention: 

All participants went through the initial VR procedures for eligibility determination and development of an individualized employment plan. Individuals in the receiving traditional services were referred to various outside organizations for services and followed by the vocational rehabilitation counselor. Individuals in the PWW group received person centered, community based services from consultants who were recruited, trained and supervised by a VR counselor.

Control: 

Each PWW participant was matched to a VR client receiving traditional services on gender, age, ethnicity, and education at referral.

Findings: 

Fifty-seven percent of the PWW consumers were successfully closed compared to only 24% of the matched consumers who received traditional services. The proportion of successful closures for PWW versus unsuccessful closures was significantly greater for this group. PWW participants earned 204 dollars more a week and worked an average of 14 hours more than the other group. The cost of services for the PWW participants was 260 dollars more than the group who received traditional services.

Conclusions: 

The PWW approach seems promising. More research is needed to determine its utility in assisting individuals with TBI with employment.

URL: 
http://www.ncbi.nlm.nih.gov/pubmed/15083424
Outcomes: 
NIDILRR Funded: 
Research Design: 
Peer Reviewed: 
Yes

Effectiveness of vocational rehabilitation following acquired brain injury: Preliminary evaluation of a UK specialist rehabilitation programme

Authors: 
Nachreiner, N. M., Dagher, R. K., McGovern, P. M., Baker, B. A., Alexander, B. H., & Gerberich, S. G.
Year Published: 
2006
Publication: 
Brain Injury
Volume: 
20
Number: 
11
Pages: 
1119-1129
Publisher: 
Informa Healthcare
Background: 

Individuals with Acquired Brain Injury have difficulties with returning to work. Studies show only around 30% returning to work.

Purpose: 

The purpose of the study is to determine the effectiveness of a vocational rehabilitation programme in assisting individuals with Acquired Brain Injury with returning to work or other meaningful activity.

Setting: 

Three Brain Injury Centres based across the United Kingdom.

Sample: 

Participants included 232 individuals with ABI who were discharged from the program between January 2000 and December 2002. The majority were males (82%) and 12% were females. The mean age was 33 years with a range from 17 to 62 years. The majority of injuries were TBI (62%). The date of a person's' injury and enrollment in the programme. ranged from 7 months to 35.5 years. And at the time of injury the majority of individuals has been employed (70%). At the time of entry into the program 92% of the participants were receiving an Incapacity Benefit and regarded as unemployable.

Data Collection: 

Data was gathered using administrative databases and other records located at the three centres. Job roles were classified using the UK standard occupational classification system. Data on outcomes was classified into one of the following: paid competitive work, education and training, voluntary work, discharge to other services, client withdrew and discharged for other reasons.

Intervention: 

Participants engaged in a vocational programme that included a per-vocational rehabilitation phase that provided intensive basic cognitive rehabilitation and in-site vocational trails phase. Afterwards, a supported job search and job coaching was offered to assist individuals with gaining work along with follow up support for up to 5 years.

Control: 

There was no control or comparison condition.

Findings: 

Upon exiting the programme, 41% of the participants had secured paid competitive employment; 16% were volunteering and 15% had entered a training or education. Among the remaining 28%, 15 % were discharged due to medical or rehabilitation programmes to deal with other issues and 13% withdrew. There was no formal cost analysis of the effectiveness of the intervention.

Conclusions: 

A total of 72% of those enrolled in the programme left to start a meaningful activity with 41% securing work. Vocational rehabilitation seems effective in assisting individuals with ABI with returning to work.

URL: 
http://www.ncbi.nlm.nih.gov/pubmed/17123928
NIDILRR Funded: 
Research Design: 
Peer Reviewed: 
Yes

Cognitive and emotional consequences of TBI: Intervention strategies for vocational rehabilitation

Authors: 
McDonnall, M. C., & Cmar, J.
Year Published: 
2006
Publication: 
NeuroRehabilitation
Volume: 
21
Number: 
4
Pages: 
315-326
Publisher: 
IOS Press
Background: 

Traumatic Brain Injury (TBI) negatively impacts successful return to work for many individuals. Training individuals to use effective interventions to compensate for common deficits like attention, memory and executive functioning post injury should improve return to work outcomes.

Purpose: 

The purpose of this study was to describe examples of effective cognitive rehabilitation strategies through the use of 3 case studies and a review of literature. Professionals in the field need this type of information to better serve individuals with TBI who are returning to work.

Sample: 

The study sample included three people with TBI.

Data Collection: 

Various scales were used to measure improvements specifically related to the cognitive ability that was being treated (i.e.. attention deficits, memory problems, executive deficits) in each of the 3 case studies.

Intervention: 

The intervention was individualized cognitive rehabilitation interventions for four individuals with traumatic brain injury.

Findings: 

There are numerous strategies that can be taught to individuals after TBI to help them compensate for common cognitive deficits (ie. attention, memory, executive functioning). Therapists must understand the possibilities and be able to implement specific interventions for each person and be able to use effective teaching strategies to train the individual. It is also important to be aware of ways to support a person who is particularly "challenging" by becoming aware of ways to improve social behaviors and self awareness.

Conclusions: 

Intervention strategies must be individualized. Other considerations include considering the nature and degree of the disability and environmental context. Therapist must be able to think outside the box and use creative problem solving to assist individuals with TBI with using strategies to improve employment outcomes.

URL: 
http://content.iospress.com/articles/neurorehabilitation/nre00329
Populations: 
Outcomes: 
NIDILRR Funded: 
Research Design: 
Peer Reviewed: 
Yes

The effectiveness of artificial intelligent 3-D virtual reality vocational problem-solving training in enhancing employment opportunities for people with traumatic brain injury

Authors: 
Marini, I., Lee, G. K., Chan, F., Chapin, M. H., & Romero, M. G.
Year Published: 
2013
Publication: 
Brain Injury
Volume: 
27
Number: 
9
Pages: 
1016-1025
Publisher: 
Informa Healthcare
Background: 

Individuals who sustain traumatic brain injuries face a myriad of cognitive and other disabilities post injury. Deficits in executive functioning are one of the major problems that impact work. Psychosocial educational interventions and computer assisted training have helped some individuals learn to problem solve. Virtual reality may also be a useful tool.

Purpose: 

This study explored whether or not participants with artificially intelligent VR based vocational problem solving skill training would show better problem solving skills and employment outcomes, than those who received conventional psychosocial program.

Setting: 

The training modules were developed at a University lab in Hong Kong. Where the study took place was not clear.

Sample: 

The study sample included 40 people from Hong Kong with mild (N=20)and moderate (N=20) traumatic brain injury. Participants were randomly assigned to one of the two study groups.

Data Collection: 

The Wisconsin Card Sorting Test and the Tower of London Test were administered to participants. In addition, the Vocational Cognitive Rating Scale was completed by the participant's case manager or supervisor of a rehabilitation facility or center. After the pretest each participant started either the virtual or psychosocial training. The content and structure of the two programs were similar. Each included an introduction to training objectives, training in specific vocational skills and practice and a review of those skills. The virtual program was interactive in nature. The psycho educational vocational training system included a training manual and was delivered under the guidance of a trainer. Post test were also conducted on the previously cited measures. Information about the participants employment status was collected at one, three and six month intervals. Statistical analysis were performed using SPSS for Windows Version 17.

Intervention: 

The intervention was an artificial intelligent virtual reality-based vocational problem solving training program. Participants took part in 12 sessions that lasted 20 to 25 minutes each.

Control: 

The control condition was traditional psycho-educational training.

Findings: 

There was no significant differences in the participants in screening criteria or baseline of outcomes between the virtual training and psycho education program. Those who participated in the virtual training showed improvements in selective cognitive functioning. However, the training did not transfer to functional real world outcomes, as indicated by limited success in vocational outcomes. The virtual training was more cost effective than workshop based training.

Conclusions: 

Virtual reality training may improve memory functioning and have other applications for vocational rehabilitation. More research is needed.

URL: 
http://www.ncbi.nlm.nih.gov/pubmed/23662639
Populations: 
NIDILRR Funded: 
Peer Reviewed: 
Yes

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

Authors: 
Man, D. W. K., Poon, W. S., & Lam, C.
Year Published: 
2000
Publication: 
Archives of Physical Medicine and Rehabilitation
Volume: 
81
Number: 
8
Pages: 
1007-1015
Publisher: 
Elsevier
Background: 

The present study tested a Medical/Vocational Case Coordination System (MVCCS) designed for persons with brain injury. The MVCSS, which was based on knowledge gained from the research literature and from clinical experience in medical and vocational rehabilitation for persons with BI, emphasize early intervention and coordinated service delivery through integrated medical center based and community-based services. Early intervention was emphasized to reduce the time between injury and community reintegration and to reduce the associated psychosocial complications that may result from lack of early intervention. The MVCCS was expected to maximize participants vocational and independent living outcomes and to minimize the use of medical and community resources.

The researchers review of previous research supported the belief that an intervention system for improving vocational outcomes of persons with BI must include these features: (1) early case identification and coordination, (2) appropriate medical and vocational rehabilitation interventions, (3) work trials, and (4) temporary or long-term supported employment in appropriate cases. To be viable, the system must significantly improve on the benchmark of 60% unemployment with results at least equivalent to those of earlier intervention studies; that is, approximately 75% of participants in community-based employment: approximately 50% working without long-term supports and approximately 25% in long-term, community-based, supported employment or in educational or training programs. They studied vocational outcomes of the MVCCS over a 4-year period.

Purpose: 

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. The study design evaluated 2 hypotheses. The first hypothesis was that vocational outcomes will meet or exceed those reported previously, that is, (1) 75% of participants in community-based independent or supported community-based employment or education/training programs (Vocational Independence Scale [VIS] levels 3 to 5); and (2) 50% of participants in independent community-based employment (VIS level 5). The second hypothesis was that vocational outcomes will be related to (1) severity of injury, (2) severity of impairment/disability, (3) ISA, (4) time since injury, (5) presence of additional non-brain injuries, and (6) preinjury educational/vocational status.

Setting: 

The setting was a large urban medical center.

Sample: 

One hundred fourteen Minnesota residents with traumatic or other acquired brain injury between the ages of 18 and 65 years. The majority (or 64%) had TBI followed by CVA (26%) and other (10%). The largest portion (36%) of the sample was referred for vocational services through outpatient rehabilitation evaluations. Severity of injury was classified only in TBI cases, based on results of available initial Glasgow Coma Scale (GCS) score and duration of loss of consciousness (LOC) at the time of injury; 56% were classified as severe TBI. Among all participants N=114, the majority (61%) were male. Mean age was 37.4. Preinjury education was less than 12 (22 %); 12 to 15 years (61%) and greater than 16 years (17%). Sixty nine percent were working prior to injury and 77% had an independent living status. The mean time since injury for the group was 65.5 months with a median of 12.7 months.

Data Collection: 

Vocational outcome at time of initial placement and at 1-year follow-up was measured using the Vocational Integration Scale. The Mayo-Portland Adaptability Inventory (MPAI), a scale based on the Portland Adaptability Inventory was used for rating the range of physical, cognitive, emotional, and social impairments and disabilities resulting from BI. It was completed by rehabilitation staff, the patient and a significant other. Rating scale (Rasch) analyses of the Staff MPAI based on 305 assessments led to a reduction in the number of items from 30 to 22 by eliminating non-contributing items. An indicator of Impaired self-awareness ISA was item 24 from the Staff MPAI, which rates level of indifference or lack of awareness of deficits. The second indicator of ISA used was the difference between the Rasch-converted score for 22-item Staff MPAI and the Rasch-converted score for the 22-item Survivor MPAI. Preinjury vocational status, the presence of other non-brain injuries, time since injury, and the Rasch-transformed Staff MPAI appeared to have some value in predicting the level of initial vocational placement. At 1-year follow-up, vocational status was predicted by time since injury and Rasch Staff MPAI. The VIS at initial placement also significantly predicted VIS at follow-up (Spearman coefficient 5 .75, n 5 101, p, .0001). The efficiency of services (i.e., months to placement) was significantly predicted by preinjury education, injury severity, time since injury, Rasch Staff MPAI, Rasch Survivor MPAI, and the difference between the Rasch Staff MPAI and Rasch Survivor MPAI. To control for experiment-wise error, potential predictor variables were further scrutinized using regression analyses.

Intervention: 

The MVCCS interfaced a medical center based BI Nurse Case Coordinator (NCC) with a medical-center based BI Vocational Case Coordinator (VCC) who served as a liaison to community-based services. This interface provided: (1) early identification by the NCC of individuals needing medical
services, medical rehabilitation, vocational rehabilitation, and social services; (2) late identification of other persons with chronic impairments after BI and their service needs by either the NCC or the VCC; (3) personal vocational counseling, consumer advocacy, and on-site consultation to other vocational services provided by the VCC; (4) access to community-based vocational services through the VCC that included: vocational evaluations, supported work trials, long-term community- based supported employment, job coaching, job development, and job placement; (5) access to other community based services that support employment, such as independent living services, community-based social services and mental health services, and traumatic brain injury (TBI) waivered services, including behavioral aide services; and (6) access to medical center services that enhance vocational re-entry for persons with BI, such as a CI day rehabilitation program; a 3-hour weekly community reintegration group; individual cognitive rehabilitation; medical rehabilitation services such as standard rehabilitation therapies, work hardening, and physical work assessments; neuropsychological and psychiatric services, including psychotherapy, family therapy, behavioral medicine, and substance abuse treatment; and other medical diagnostic and therapeutic services, including psychiatric and behavioral neurology services.

In the day-to-day operation of the MVCCS, the NCC, working with emergency room staff, identified all brain-injured
persons admitted to the hospital each working day and served as case coordinator for these cases. She reviewed the medical record, met with the patient, recommended additional services to the primary medical service, obtained consent, and entered participants into the clinical database. The NCC followed the patient after dismissal from acute care. If the patient left from acute care to home, she followed up by telephone within 1 month to identify potential BI sequelae and service needs and to assist in scheduling required services. If the patient left acute service to the rehabilitation unit, the NCC turned medical case coordination over to the rehabilitation social worker. In all cases referred, the VCC met with study participants and obtained consent for study participation, provided all appropriate vocational evaluations and counseling, completed the Staff MPAI with input from other involved rehabilitation staff, obtained the Survivor MPAI, and referred appropriate participants to community-based vocational services. The VCC followed up on each participant 1 year after the person was placed or left the project.

Control: 

There was no comparison condition. Participants served as their own controls.

Findings: 

he MVCCS evaluated in this study appeared to substantially improve employment outcome for persons with BI without interventions. Results were better than projections based on the previous literature 80% of those served were placed in community-based work with 46% in independent community-based employment. Employment outcomes for persons who received vocational services through this project approached or exceeded outcomes reported previously for intensive rehabilitation interventions. Just as importantly, initial vocational placements were maintained at 1-year follow-up. At the follow-up interview, 81% were working in the community and 53% were employed independently without job supports. Although the results were equivalent to those of other rehabilitation programs that are based on best practices the authors could not make direct comparisons with those programs because we did not investigate specific interventions. Primary predictors of initial placement in the present study were time since injury and overall impairment/disability as measured by the Staff MPAI. Return to previous work should be considered especially for the more recently injured who have retained ties to their previous employer. Results indicate that more severe impairments and disabilities, as measured by the MPAI, are significant barriers to employment in the general population of persons with BI. However, for persons with TBI, the presence of additional non-brain injuries appears to be a more important factor.

The best predictor of employment level at 1-year follow-up was the level of initial placement. ISA (as measured by the difference between Rasch Staff MPAI and Rasch Survivor MPAI) did not contribute to the prediction of either initial placement or job maintenance. This finding is inconsistent with some other studies reporting an association between ISA and long-term employment after BI. The results suggest that ISA may be a barrier to employment that can be overcome through rehabilitation, through education and support for employers, and by discriminating placement of those persons with ISA in work environments that are more tolerant of limitations in self-awareness. Overall level of impairment and disability also appears to be a factor in time required for placement. In some cases, more intensive rehabilitation efforts, such as a CI day rehabilitation program, were required for more severely disabled persons so they could develop cognitive compensation, communication, behavioral self-management, social, and other pre-vocational skills required for eventual placement. Because of the time required for participation in such an intensive rehabilitation program, most individuals who participated in CI day rehabilitation required 6 to 12 months from the time they were admitted to services to their eventual placement. Our data suggest that most placements (92%) can be made within 1 year of admission to services. Preinjury years of education also contributed slightly to prediction of time to placement, with more highly educated individuals being placed more quickly.

Conclusions: 

Introducing a VCC into an MVCCS program appears to optimize participants vocational outcome after BI, resulting in community-based employment for 81% of persons served with 53% working independently in the community 1 year after placement. Time since injury and overall level of impairment/ disability were the most significant factors in predicting vocational outcomes. Beyond its association with overall level of disability and chronicity, ISA did not contribute to the prediction of initial placement or job maintenance. The best predictor of employment status at 1 year follow-up was the level of initial placement. Persons with greater overall disability required more extended time and more extensive rehabilitation services before job placement.

URL: 
http://www.ncbi.nlm.nih.gov/pubmed/10943747
NIDILRR Funded: 
Research Design: 
Peer Reviewed: 
Yes

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

Authors: 
Malec, J. F., Buffington, A. L. H., Moessner, A. M., & Degiorgio, L.
Year Published: 
2001
Publication: 
Archives of Physical Medicine and Rehabilitation
Volume: 
82
Number: 
7
Pages: 
885-895
Publisher: 
Elsevier
Background: 

Employment rates for individuals with disabilities are poor and contribute to the ongoing high poverty rates for this group. Although overall employment rates have risen over the years, work outcomes for young adults with disabilities still lag behind those without disabilities. Career development takes place overtime and is influenced by multiple variables such as individual, family, school, and community factors. However, for individuals with disabilities, career development is often complex, nonlinear, and chaotic. High school and post-school services can have a positive impact on employment for youth with disabilities. Students with disabilities who participate in vocational courses and community based work experiences are more likely to obtain and maintain employment after high school. Additionally, participation in adult services like vocational rehabilitation or post secondary education or training can lead to better job opportunities. Research studying patterns of career development for successfully employed adults with disabilities may be able inform clinical practices through the identification of common themes that influence employment in living wage occupations.

Purpose: 

There were 2 hypotheses. The first was that vocational outcomes will meet or exceed those cited in prior research. Specifically, 75% of participants in community-based independent or supported community-based employment or education/training programs; and (b) 50% of individuals in independent community-based employment. The other hypothesis was vocational outcomes will be related to (1) severity of injury, (2) severity of impairment/disability, (3) ISA, (4) time since injury, (5) presence of additional injuries not related to the brain injury, and (6) preinjury educational/vocational status.

Setting: 

The setting was a Rehabilitation Center.

Sample: 

One hundred and thirteen individuals with brain injury, who were consecutively admitted to the CDT program from 1988 to 1998. This included 96 individuals who completed the program and 17 who did not. Traumatic brain injury accounted for the majority or 72% of the participants who completed the program and 71% of the drop outs. The severity of the TBI sample was 82% and 92% respectively. The mean time since injury (TBI, CVA or other) among those who completed the program was 4.6 years.
The subjects had myriad of problems in the following areas post injury: self awareness, cognitive, communication, social skills and emotional/behavioral.
They were also either unemployed or facing failure at work. Participants had mobility, functional communication skills and exhibited some capacity for applying new knowledge. The average length of stay among participants in the CDT program was 189.5.

Data Collection: 

Evaluation and outcome data were analyzed for each participant. For those who completed the program, work outcomes was measured using the 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. Data was collected from the Independent Living Scale, VIS, GAS and MPAI-22 when participants entered and exited the program to measure this factor. Logistic regression analysis was conducted for the ILS and VIS were for those who completed the program one year post completion with potential outcome predictors that included: age, education, severity of injury, type of injury, time post injury, degree of impairment prior to program participation.

Intervention: 

Participants attended a CDT that followed guidelines developed by prior research for post acute brain injury rehabilitation programs, along with the following changes: combination of physical therapy and recreation therapy into a Life Skills Group, family education and use of a vocational counselor to provide employer education and support.

Control: 

There was no control or comparison condition.

Findings: 

Significant goal achievement on GAS and improvement on MPAI-22; increased societal participation at 1-year follow-up for those treated post acutely 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: 

Community Day Treatment program improves participation in society for individuals with brain injury. Next steps needed are 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 individuals with severe brain injury.

URL: 
https://www.archives-pmr.org/article/S0003-9993(01)74722-3/fulltext
NIDILRR Funded: 
Research Design: 
Peer Reviewed: 
Yes

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

Authors: 
Lidz, V., Sorrentino, D. M., Robison, L., & Bunz, S.
Year Published: 
2004
Publication: 
Disability and Rehabilitation
Volume: 
26
Number: 
5
Pages: 
290-298
Publisher: 
Informa Healthcare
Background: 

Vocational outcome is one of the most important indicators of rehabilitation following a traumatic brain injury. Specifically, types of paid vocations, especially full-time work, are often viewed most favorably as a sign of success. The factors related to this perception of success are vast.

Purpose: 

This study aims at evaluating whether or not the common perceptions of success are in line with those factors that those individuals undergoing rehabilitation for traumatic brain injury (TBI) view as most indicative of progress following an injury.

Sample: 

The study sample included 4 males and 3 females between the ages of 26-51. Six were Europeans and one was of Maori descent. Participants had memory loss of one day to months. All were one year post injury.

Data Collection: 

Open-ended interviews with minimal prompting were taped and transcribed. They were then read and coded with comparisons to other interviews taking place at the same time. The transcripts were then sent to the participants for verification of accuracy.

Intervention: 

The effects of returning to full-time paid employment on the feeling of success, impact on non-working lives, feelings of productivity and ability to sustain employment.

Control: 

There was no control or comparison condition.

Findings: 

The results indicated that while participants view return to work as an important goal of rehabilitation following TBI, they also valued other means of feeling successful , not having a stressful work life affect their personal life, and feeling successful without full time pay (previously considered the goal) to be of near equal importance.

Conclusions: 

While paid employment is important, the work must also provide feelings of productivity and success. The researchers also feel evaluation of these individuals should take more subjective factors into consideration of their "success" of rehabilitation.

URL: 
http://www.worksupport.com/kter/documents/pdf/LevackRTWafterTBI.pdf
Populations: 
NIDILRR Funded: 
Research Design: 
Peer Reviewed: 
Yes

Vocational reentry following TBI: An enablement model

Authors: 
Kramer, S. E.
Year Published: 
2000
Publication: 
The Journal of Head Trauma Rehabilitation
Volume: 
15
Number: 
4
Pages: 
989-999
Publisher: 
Lippincott Williams & Wilkins, Inc.
Background: 

Environmental factors are at the heart of many performance problems after traumatic brain injury (TBI). This vulnerability negatively affects the ability of the patient to generalize treatment gains made in an artificial clinic environment to more naturalistic settings like home and work. It also impacts the rehabilitation professional's ability to predict the performance of a patient in these and other real world settings. Rehabilitation efforts that make patient environmental interactions part of the treatment plan will increase generalization and predictability. Rehabilitation efforts should include data-based definitions of the environment(s) within which each individual can best function. Also important is a focus on the tasks that he or she can perform within those environment(s). When a discharge goal is to return to work, rehabilitation efforts must include: identifying job settings where enabling environments can be established and providing ongoing support to the individual in the job situation should the environment change. More research is needed on the use and benefits of an environmentally focused treatment model.

Purpose: 

The purpose of this paper was twofold. First it described a treatment program for individuals with brain injury that focuses heavily on patient-environment interactions, both during treatment and after discharge and provide illustrative case examples.

Setting: 

The interventions took place in the clinical setting and the individuals' places of employment.

Sample: 

The study examined the experiences of three individuals with TBI who received varying levels of support to return to work. More specific, they demonstrate how treatment environments were initially configured and then modified during treatment as the patients returned to work. The case studies were selected from an overall sample of 57 individuals with TBI. All three patients had extremely severe neurocognitive dysfunction.

Data Collection: 

No specific data was collected or analyzed. Three case studies illustrated three interventions to help individuals with TBI with returning to work.

Intervention: 

The three interventions were part of an environmentally focused treatment model. Preliminary steps for each involved a) contacting an employer about a patients return to work for those employed at the time of injury or if the person was not employed or does not want to return to work a job developer gets involved to develop work options in an environment where the person is most likely to optimally perform and b) a rehab staff member conducts a job site visit in order to gain an understanding of environmental factors that may impact success on the job.

The first intervention teaches a patient to structure environments. Clinic staff make an initial job site visit and may have some ongoing contact with the employer, but the patient has primary responsibility for structuring the work environment. The second intervention is reserved for a patient who is incapable of assuming primary responsibility for structuring his own environments. Therefore, the rehabilitation staff play a major role in developing an enabling environment. This makes vocational placement easier. The third intervention involves creating a highly structured work environment for a extremely compromised patient, by educating the family throughout the rehabilitation process. The family then supplies the ongoing structure and limits distractions, as necessary, to maximize the person's performance.

Control: 

No comparison condition.

Findings: 

It is clear that the successful vocational re-entry depicted in these cases required close attention to each patient's specific strengths and weaknesses as they related to specific environmental factors, especially the levels and types of structure and distraction that were inherent in the environment. It seems that specialized, individualized treatment that focuses on the patients' strengths and weaknesses and on environmental factors, like the degree of structure and distractions, can enable return to work for individuals with severe TBI.

Conclusions: 

Environmental factors impact the ability of individuals with TBI to return to work. Individualized treatment that focuses on how structure and/or distractions impact work performance can be used to help individuals with TBI return to work.

URL: 
http://www.ncbi.nlm.nih.gov/pubmed/10876171
Populations: 
NIDILRR Funded: 
Research Design: 
Peer Reviewed: 
Yes