Traumatic brain injury (TBI)

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.