An effective community-based mentoring program for return to work and school after brain and spinal cord injury

Authors: 
Kowalske, K., Plenger, P. M., Lusby, B., & Hayden, M., E.
Year Published: 
2012
Publication: 
NeuroRehabilitation
Volume: 
31
Number: 
1
Pages: 
63-73
Publisher: 
IOS Press
Background: 

Individuals with traumatic brain injury (TBI), spinal cord injury (SCI), and other neurological disorders often have severe disabilities impacting their ability to return to previous activities and return to work is limited. There is an ongoing need for education and vocational rehabilitation systems to work together to improve outcomes for youth and young adults with disabilities.

Purpose: 

The purpose of this article was to present information on a community-based mentoring program for young adults, ages 16 - 26 years with a recently acquired TBI, SCI, and other neurological disorders. The two objectives of this study were to 1) to demonstrate continuing increased in standardized measures of community integration from the time of enrollment in the program to the time of exit, and 2) improve the percentage of youth and adults who successfully access post-secondary education or employment opportunities.

Setting: 

The setting was various community sites in California.

Sample: 

The study sample included 131 individuals with TBI, SCI, or other neurologic disabilities recruited between 2005 and 2010. The majority were individuals with TBI or SCI with one individuals dually diagnosed with TBI and SCI (0.8%) and 8.4% with other disabilities to include other neurological disabilities. The majority were male (67.9%). The mean age was 20.3 years. Participants were primarily Hispanic (42%) or Caucasian (36.3%) with the remaining Asians (10.7%) or African American (4.6%). In addition, there were 121 trained "mentors" who were a minimum of two years post injury and had "a high level of acceptance and successful integration into the community". This included working or post-secondary education. Most were working (57%) while 30% were attending school, and 13% were retired.

Data Collection: 

Assessment was conducted a minimum number of four times: at enrollment, three months after entry, and every three months thereafter until attempted entry to post-secondary education or employment. In addition, each mentor and mentee completed a questionnaire which documented satisfaction with the relationship. Finally, the program used standardized assessments to include the Disability Rating Scale to include Employability and Level of Functioning, the Participation Index of the Mayo-Portland Adaptability Inventory, version 4, the Supervision Rating Scale, the Craig Handicap Assessment and Reporting Technique Short Form, and the Diener Satisfaction with Life Scale. A successful transition was as the individual remained in the post-secondary education or employment environment.

Data were collected by mentors and project staff. Formal assessments were collected by trained research assistants. Mentors submitted meeting logs documenting when, where, and topics discussed. Data were stored in an Access database and descriptive and inferential analyses were conducted using SPSS. Pre and post test program scores on standardized outcome measures were compared by paired T-tests.

Intervention: 

A mentoring program was developed called the "Back on Track to Success Mentoring Program." The goal of the program was to improve the ability of youth/young adults with disabilities to navigate through the services and programs available to individuals with disabilities. In addition, the goal was to increase the rate of return to work and post-secondary education. Each of the program participants were matched with a "mentor" who had training on a specific curriculum and refresher sessions throughout the entire program. Mentor/mentee relationships were required to have a minimum of three contacts per month in-person, telephone, or electronic mail methods.

Control: 

No comparison condition.

Findings: 

A total of 89 mentees were successfully matched with community-based mentors and participated in the program through to completion. Of this number 77 completed the entire program. Of this number 42 (54.5%) were considered program successes and 35 (45.5%) were considered program failures. Of the 42, 69% returned to school and 13 became employed (31%). For program successes, significant CHART subscale increases were seen for Cognitive Independence and Mobility. For program "failures" no statistically significant changes were seen in CHART subscale scores. For program successes, there were also significant improvements seen in the M2PI, the DRS, and SRS. For failures there were improvements seen in DRS but these were not statistically significant.

Conclusions: 

Overall, findings suggest that mentoring can be beneficial toward achieving the goals of post-secondary education, employment and community independence for individuals with disabilities; specifically those with traumatic brain injury, spinal cord injury and other neurological disorders.

URL: 
http://content.iospress.com/articles/neurorehabilitation/nre00775
NIDILRR Funded: 
Research Design: 
Peer Reviewed: 
Yes

The relationship of cognitive retraining to neurological patients' work and school status

Authors: 
Kolakowsky-Hayner, S. A., Wright, J., Shem, K., Medel, R., & Duong, T.
Year Published: 
2007
Publication: 
Brain Injury
Volume: 
21
Number: 
11
Pages: 
1097-1107
Publisher: 
Informa Healthcare
Background: 

The goals of cognitive retraining are to help patients: ameliorate difficulties in cognitive functioning, develop ways to compensate for those problems and improve their awareness and appreciation of how neurobehavioural strengths and difficulties impact and generalize to the home and community. Cognitive training has been viewed as a holistic
milieu-oriented approach for people with brain injuries. However, there is considerable scepticism about the benefits of this approach from both healthcare workers and insurance companies. High quality research is needed to on how the effectiveness of cognitive retraining.

Purpose: 

The purpose of the study was to explore the relationship of cognitive retraining performance to discharge productivity status. The hypotheses were:
1)Work/school status at discharge will be related to Working Alliance ratings, Cognitive Retraining scores and CRBC ratings;
2) Better Working Alliance scores will be associated with better scores on the CRBC with regard to Use of Compensatory Strategies, Seeing the Big Picture and Independence in Scoring and Record Keeping

Setting: 

The study took place in a neurorehabilitation therapy department in a large healthcare center located in Arizona.

Sample: 

The study examined scores on Cognitive Retraining tasks and variables associated with those task and return to work or school outcomes for 101 patients who had participated in neurotherapies at a large medical center in Arizona within a seven year time span. This included patients who had participated in either or both the Work or School Re-entry programmes and by the time of discharge had completed 4 study Cognitive Retraining tasks. The majority of participants were male (63%). The mean age of participants was 35 years with an average of 14 years of education. Around 64% had sustained traumatic brain injury, 22% had cerebrovascular accident and the remaining 14% had other causes of brain injury. Around 59% of the sample had Glasgow Coma Scale data. The majority or 71% had severe brain injuries.

The majority or 86% of the participants had a primary goal of return to work and the remaining had the goal of return to school. Among those with the return to work goal the majority or 71% had been in both the Work Re-entry and Home Independence programmes. Of those who planned to return to school, the majority or 79% attended the School Re-entry and Home Independence programmes.

Data Collection: 

Cognitive retraining data was taken from participants' Cognitive Retraining charts. More specific, this included: initial, last, best and mean scores for each of the four study tasks. Data on process variables associated with the tasks came from the Cognitive Retraining Behaviour Checklist completed by the person's primary therapist. Scores on Working Alliance came from patient charts. Information on participant's employment and/or school status also came from the chart.

Intervention: 

The intervention included several types of combination of programmes designed to assist individuals with returning to work or school post brain injury and/or improve independent living.

Control: 

No comparison condition.

Findings: 

The majority or (82.2%) of the sample returned to paid work or school. Better performance on two cognitive retraining tasks related to information processing speed, visual scanning, visuospatial skills and memory were associated with return to the same level of work/school with and without modifications. Selected process variables related to the patients' behavioural approach to cognitive retraining tasks were associated with better work/school outcomes. Positive working alliance ratings related to their behavioural approach to cognitive retraining tasks.

Conclusions: 

The information provided should help clinicians fine-tune Cognitive Retraining interventions to help patients achieve their maximal level of functioning.

URL: 
http://www.ncbi.nlm.nih.gov/pubmed/17952711
Populations: 
NIDILRR Funded: 
Research Design: 
Peer Reviewed: 
Yes

Improved occupational performance of young adults with a physical disability after a vocational rehabilitation intervention.

Authors: 
Vlasveld, M. C., Anema, J. R , Beekman, A. T. F., van Mechelen, W., Hoedeman, R., van Marwijk, H. W. J., Rutten, F. F., Hakkaart-van Roijen, L., & van der Feltz-Cornelis, C. M.
Year Published: 
2014
Publication: 
Journal of Occupational Rehabilitation
Volume: 
24
Number: 
1
Pages: 
42-51
Publisher: 
Springer Science+Business Media New York
Background: 

Employment leads to more independence as an adult. Many youth with physical disabilities have difficulty gaining and maintaining employment. This may result in a reduced quality of life.

Purpose: 

The purpose of the study was to examine how occupational performance of participants of a vocational rehabilitation intervention changed over time. More specifically, it looked at work, self care and leisure. The researchers also looked at the differences between individuals who were employed and those who remained unemployed after the vocational rehabilitation intervention.

Setting: 

The setting was an outpatient rehabilitation clinic for young adults located in Rotterdam, the Netherlands.

Sample: 

Participants include eleven young adults with physical disabilities; six male and five females. Their mean age was 22 years prior to the intervention. Three individuals had cerebral palsy, 2 had muscular disease, 2 had traumatic brain injury and the remainder had other types of physical disabilities. The amount time participants had spent looking for work ranged from Five of the participants had not yet looked for work while 2 had been looking for more than 2 years.

Data Collection: 

Demographic data was collected. Severity of physical limitations was categorized using scores on the Physical Functioning scale of the MOS Short-Form General Health Survey. Occupational performance was explored at baseline and one year later using semi structured interviews. The Canadian Occupational Performance Measure (COPM), an interview, was used to assess self perception of work performance in the areas of self care, productivity and leisure over time. The Occupational Performance History Interview II (OPHI-II) was used to assess aspects of occupational adaptation: occupational identity, competence and setting. Results were summarized using descriptive statistics. Sores on the COPM subscales and the OPHI-II scales were calculated. Qualitative data from the COPM and audio taped OPHI-II were summarized and categorized into the 3 occupational performance categories: self care, leisure and work productivity. Narrative were classified as regressive, stable or progressive. Differences between pre and post intervention scores on COPM and OPHI-II were tested using Wilcoxon signed rank test. Demographics between the employed and unemployed groups were compared using the Mann-Whitney U test. Non-parametric test were used. Data was analyzed using SPSS 16.0.

Intervention: 

The intervention was "At Work?! This is a multidisciplinary vocational rehabilitation intervention that was designed for young adults with physical disabilities, who are entering the labor market, and is geared towards improving abilities to achieve employment. The year long intervention brought rehabilitation and vocational services into a group program that included individuals assessments and coaching.

Control: 

There was no control group. The participants served as their own controls.

Findings: 

The participants expressed fewer problems after the intervention. Additionally, they showed improved in work performance, self care and leisure. An increase in satisfaction with these improvements was also reported. Occupational identify, competence and overall scores on the OPHI II also increased. The demographic characteristics of the individuals who did not gain employment were not difference from the group that was employed. The unemployed experienced difficulties in all three areas of occupational performance prior to the intervention and more difficulty in the work setting. Post-intervention, their levels of occupational identity, competence and settings were like those of employed persons. Participants showed improved occupational performance post intervention. The unemployed participants appeared to catch up during the intervention but had not achieved employment within one year.

Conclusions: 

Young adults with physical disabilities, showed improved occupational performance in work, self care and leisure and were more satisfied with their performance after participating in a one year multidisciplinary vocational rehabilitation intervention. Those who did not go to work faced problems in all three areas at pre-intervention. The goal of employment and the intervention appeared to motivate participants to solve problems related to work, self care and leisure. There is a need for interventions aimed at improving work participation by address problem across the three areas. Young adults who go to work may benefit from ongoing coaching to help address new problems.

URL: 
http://link.springer.com/article/10.1007%2Fs10926-013-9446-9
NIDILRR Funded: 
Peer Reviewed: 
Yes

Occupational categories and return to work after traumatic brain injury: A multicenter study

Authors: 
Wallace, C. J., & Tauber, R.
Year Published: 
2006
Publication: 
Archives of Physical Medicine and Rehabilitation
Volume: 
87
Number: 
12
Pages: 
1576-1582
Publisher: 
Elsevier
Background: 

A number of researchers have indicated that postinjury return to work rates are a function of pre-injury job classifications. However, these and other job category studies have conflicting findings, differing methodology and small sample sizes. This makes it difficult to determine if this is a significant and unique predictor that impacts return to work rates. Due to poor post injury employment rates for individuals with TBI knowing the relation between pre-injury occupational category and return to work could improve employment outcomes.

Purpose: 

The purpose of the study was to find out if pre-employment occupation was a significant and unique predictor of return to work for individuals with TBI.

Setting: 

The setting was 17 NIDILRR funded TBI Model Systems Projects (TBIMS) located across the United States.

Sample: 

The sample size was 1,341 individuals with TBI who had data in the TBIMS national database including one year follow up data. The majority of the sample were males (77%) and white (69%). Most had sustained an injury that would be considered moderate to severe.

Data Collection: 

Data was collected at TBIMS rehabilitation centers that include a wide array of services. Hospital records and admission and discharge FIM instrument used to evaluate level of independence were used to collect medical information. Annual telephone interviews were attempted to collect follow up information at month 10 and 14 post-injury. If this was not successful, a questionnaire via mail and/or an interview with significant other was completed.

Intervention: 

The intervention included an array of return-to-work services.

Control: 

There was no control or comparison condition.

Findings: 

Individuals who held professional and managerial jobs were more likely to be working during the one year follow up. Approximately, 33% of those who had worked in manual labor jobs were working at follow up with a slightly improved rate among those in skilled labor positions.Severity of injury was not predictive. However, the following variables: preinjury job category, education level, hospital LOS and discharge FIM total score were predictors. Additional analysis, clearly supported that job category predicts return to work outcomes beyond using educational level obtained prior to injury alone.

Conclusions: 

Preinjury occupational factors influence return to work post injury for individuals with TBI. Given that individuals, who were worked as manual laborers prior to injury had the poorest return to work rate, this group may have a greater need for vocational services. More research is needed to better understand return to work rates and evaluate possible strategies to improve employment outcomes.

URL: 
http://www.msktc.org/publications/detail/1732
Populations: 
Outcomes: 
NIDILRR Funded: 
Peer Reviewed: 
Yes

Traumatic brain injury and employment outcomes: Integration of the working alliance model

Authors: 
Kitchiner, N. J.
Year Published: 
2008
Publication: 
Work
Volume: 
31
Number: 
3
Pages: 
309-317
Publisher: 
IOS Press
Background: 

Polytrauma includes a complex constellation of symptoms that may involve an array of interrelated cognitive, physical, and psychological symptoms. According to the United States Veteran Health Administration, polytrauma is an injury to the brain in addition to other body parts or systems resulting in physical, cognitive, psychological, or psychosocial impairments and functional disability. Although problems post traumatic brain injury (TBI) can be challenging many of these individuals remain employable. Rehabilitation specialists assisting persons with TBI with return to work need to understand treatment protocols that could enhance the relationship with the individuals and thereby enhance their employment outcomes.

Purpose: 

This paper provided a brief review of the return to work literature and presented Bordin's working alliance model. A case example was used to illustrate the model.

Setting: 

The setting for the study was an In/Outpatient Rehabilitation Center.

Sample: 

The paper presents one case study.

Data Collection: 

The case study provides a brief overview of the meetings between the client and his rehabilitation counselor.

Intervention: 

The intervention was the Working Alliance Model of Rehabilitation. Some limited research has highlighted the working alliance model‚ benefit in working with participants for whom issues of inclusion, empowerment, and promotion of autonomy have become central to the definition of a healthy counseling relationship. One of the main benefits of the model is its dynamic, collaborative orientation. In essence, the sense of ownership a participant gains given the model‚ central tenet of shared power and decision making within the professional relationship provides a solid rationale for using this model in rehabilitation settings.

Control: 

No comparison condition.

Findings: 

A treatment and rehabilitation program was developed for the individual with TBI using the Work Alliance model. This included: obtaining a neuropsychological evaluation, transitioning level of care to a day treatment program, continuing to work with his rehabilitation counselor using the Work Alliance model to construct realistic return to work plan and refer him to case manager to monitor his behavioral and psychological needs.

Conclusions: 

The model may be able to strengthen the relationship between a person with TBI and a rehabilitation specialist.

URL: 
http://content.iospress.com/articles/work/wor00785
Populations: 
Outcomes: 
NIDILRR Funded: 
Research Design: 
Peer Reviewed: 
Yes

Supported employment for persons with traumatic brain injury: A preliminary investigation of long-term follow-up costs and program efficiency.

Authors: 
Wehman, P., Lau, S., Molinelli, A., Brooke, V., Thompson, K., Moore, C., & West, M.
Year Published: 
2003
Publication: 
Archives of Physical Medicine and Rehabilitation
Volume: 
84
Number: 
2
Pages: 
192-196
Publisher: 
Elsevier
Background: 

Research shows that individuals with traumatic brain injury (TBI) often experience great difficulty returning to competitive employment postinjury. Challenges arise from cognitive, physical, sensory and/or psychosocial problems. Supported employment is one approach in vocational rehabilitation that has been used to assist individuals with significant disabilities, including TBI, with returning to preinjury work or securing and maintaining new employment.In the individual placement approach typically a vocational professional known as an employment specialist or job coach, works one to one with the individual. The specialist assist the person with locating employment by developing job opportunities. Then, once the individual is hired the specialist provides and facilitates on-the-job supports such as: skills training and/or identifying various types of supports (ie. compensatory memory strategies, assistive technology) to help the new hire learn how to perform the job and meet the employer‚ performance standards. Furthermore, long-term follow-up services are offered throughout the duration of a person‚ employment. During this time, additional on-the-job assistance is available, and, as indicated, select case management services related to resolving off-the-job-site issues that if left unattended would impact job retention, are provided. Information on cost and benefits is needed to determine the efficacy of this approach for individuals with TBI.

Purpose: 

The purpose of this study was to investigate the long-term follow-up costs associated with supported employment. It also examined wage and employment characteristics for individuals with moderate to severe traumatic brain injury (TBI) received supported employment services over a 14-year time span.Specifically, this research sought to answer the following questions:(1) What is the average cost of supported employment services for individuals with TBI? (2) What is the average length of employment for individuals with TBI who have received supported employment services? and (3) How do benefits (ie, participant income) compare with costs of supported employment during a 14-year time period (from 1985 to 1999)?

Setting: 

The setting was multiple employment sites where individuals worked.

Sample: 

The sample size included 59 individuals with moderate to severe TBI who were consecutively referred for supported employment services. The sample was restricted those who were employed in at least one job during the study period. The eligibility criteria for receiving supported employment services included the following: the person was between the ages of 18 and 64 years, and had sustained a moderate to severe TBI, as indicated by length of coma greater than 24 hours or a Glasgow Coma Scale score of less than 13 on admission to the hospital. In addition, individuals had to present clear indications of the need for ongoing vocational intervention to return to preinjury employment or to obtain and maintain new employment. These indications came from the individual‚ post injury employment history or from reports from his/her family, physician, or vocational rehabilitation counselor. The demographics of the group were as follows. The majority (81%) were males; (75%) were white. The average age was 33 years. The majority (64%) had a high school diploma or less education. The majority (71%) were working prior to injury.

Data Collection: 

Data were collected on individuals who used supported employment services to assist them with gaining and maintaining work anytime between 1985 to 1999.Data about each participant's length of employment, wages, and costs associated with service delivery were collected by the employment specialist assigned to serve the person. For those individuals who had been employed in more than one job over the years, data on length of employment and cost of service delivery were combined. Analyses were performed to examine the costs of supported employment, employment characteristics (e.g., wages, length of employment), and benefit-cost ratios of supported employment for individuals with TBI. Descriptive statistics were calculated for length of employment, costs associated with supported employment services, and wages earned. Subgroup comparisons were also performed to examine the influence of length of employment on wages and supported employment costs. Calculations were based on individual clients, not job placements. Therefore, employment and billing data were combined and averaged for individuals who worked in more than 1 job over the study period.

Intervention: 

The intervention was individualized supported employment services.

Control: 

Subgroup comparisons were performed to take a look at the influence of length of employment on wages (less than and greater than 2 years) and cost of services.

Findings: 

Participants worked an average of 30 hours per week. and earned between $3.35 (minimum wage at the time) and 11.99 an hour. The average length of employment was 43 months. Average earnings were cited as $633.63 per month. Average gross earnings was $26,129.74. The majority of the sample worked over 2 years and approximately 25% had worked 7 years or more.The average hourly billing cost associated with the provision of supported employment services was $10,349.37; with a mean cost of $8614.00. This resulted in a mean monthly cost of $202.00 per participant.The subgroup cost-earning comparison revealed that cost were substantially less for those who maintained employment for 2 or more years. Individuals earned an average of $17,515.00 more than the cost associated with service implementation.

Conclusions: 

Supported employment is a cost effective way to assist individuals with TBI with gaining and maintaining employment. Over time the cost associated with long term services (ie. follow along) decreases.

URL: 
http://www.ncbi.nlm.nih.gov/pubmed/12601649
NIDILRR Funded: 
Peer Reviewed: 
Yes

Return to work for individuals with TBI and a history of substance abuse.

Authors: 
Wehmeyer, M. L., Palmer, S. B., Smith, S. J., Davies, D., & Stock, S.
Year Published: 
2000
Publication: 
NeuroRehabilitation
Volume: 
15
Number: 
1
Pages: 
71-77
Publisher: 
IOS Press
Background: 

Substance abuse can be a problem for any person. However, it is more prevalent among individuals with disabilities than society in general. Individuals with substance abuse problems often have trouble gaining and maintaining work. Among those disability groups demonstrating a prevalence of substance abuse are individuals who survive traumatic brain injury (TBI).When individuals have a dual diagnosis of substance abuse and disability like TBI the treatment of both conditions becomes more complex. This may increase the possibility of medical complications and heighten the the symptoms of the disability for the person. It can also decrease the effectiveness of interventions designed to assist a person with employment post TBI. Research that specifically examines strategies or models that enhance employment rates of persons with TBI and substance problems is scant. Supported Employment is one return to work strategy for individuals with severe TBI and substance abuse problems

Purpose: 

The purpose of this paper is to describe how substance abuse can be addressed within the context of a vocational rehabilitation program that provides supported employment services to individuals with severe TBI and substance abuse problems.

Setting: 

The setting was a place of employment in Virginia.

Sample: 

A case study illustrate how a man with a long history of substance abuse and a TBI gained and maintained work using a supported employment approach.

Data Collection: 

Information was collected from the employment specialist who worked with individual described in the case study through face to face interview. In addition, case file information including daily notes were reviewed.

Intervention: 

The individualized model of supported employment. In this approach a vocational rehabilitation professional known as an employment specialist or job coach analyzes the jobseeker's personal vocational strengths and
support needs; meets with employer's to develop jobs; provides on the job support to help the new hire learn the job and offers ongoing follow up services and case management throughout the person's job tenure.

Control: 

There was no control or comparison condition.

Findings: 

The individual described in the case study remained employed for over one year at the time of publication. The employment specialist took on a variety of roles in response to his needs. Roles included: providing feedback and encouragement, on the job site new skills training including designing and implementing compensatory strategies, ongoing support and case management.Employment specialists will need training and ongoing education to effectively support individuals with TBI and substance abuse histories. Lack of transportation remains a barrier to work and impacts the ability to get to substance abuse treatment (ie. AA meetings). Repeated efforts may be needed to assist individuals with successfully returning to work. Furthermore, many programs do not serve individuals with active substance abuse, so these people do not get help.

Conclusions: 

Substance abuse further complicates TBI and return to work. Supported employment providers need to provide a mix of services that are career oriented and unique to a person‚ specific needs and circumstances.Individualized support should include assisting a person with issues outside of work, particularly those that may negatively impact employment or substance abuse treatment.

URL: 
https://www.ncbi.nlm.nih.gov/pubmed/11455083
Populations: 
Outcomes: 
NIDILRR Funded: 
Research Design: 
Peer Reviewed: 
Yes

Vocational rehabilitation following traumatic brain injury: A quantitative synthesis of outcome studies

Authors: 
Khan, F., Ng, L., & Turner-Stokes, L.
Year Published: 
2008
Publication: 
Journal of Vocational Rehabilitation
Volume: 
25
Number: 
3
Pages: 
149-160
Publisher: 
IOS Press
Background: 

Return to work following traumatic brain injury can range from 20% to 90%. Rehabilitation professionals need to sound research to guide best practices in service delivery. For years there has been a call for using evidenced based approaches to medical care and rehabilitation. Despite this fact, evidence related to the efficacy of vocational rehabilitation remains inconclusive. To further complicate the issue the wide range of outcomes and interventions makes it difficult to determine employment outcomes for individuals with TBI. A synthesis of the existing literature should help identify effective vocational rehabilitation practices to assist individuals with TBI with employment.

Purpose: 

The purpose of the study was to consolidate findings from existing studies in order to classify return to work outcomes for individuals with traumatic brain injury.

Setting: 

This study is a systematic review. The included studies were undertaken in various locations and settings. The quantitative synthesis took place at the Centre of National Research on Disability and Rehabilitation Medicine and Griffith University in Australia.

Sample: 

The sample included 26 studies involving individuals with traumatic brain injury. Among these the number of participants ranged from 9 to 1170 with a total of 3792.

Data Collection: 

A multimethod search strategy was used to find all possible studies related to vocational rehabilitation and traumatic brain injury between the years of 1993 and 2000. Twenty six studies were included. Data extracted from each of the studies included baseline employment percentages for the sample where reported (i.e., pre-injury employment rate), post-injury employment percentages, definitions of return-to-work (i.e., restricted definition pertaining to full-time competitive employment only or inclusive definition pertaining to any employment or productive activity including any competitive work, study, or other functional activity), and follow-up time(s) post-injury. The traditional meta-analytic approach was not applied in this study, as the assumptions of parametric analysis were violated. Specifically, both return-to-work and intervention are intrinsically linked to time, producing non-linear effects and non-independent observations. Rather than employing a single aggregate method as in meta-analysis, quantitative synthesis was conducted using non-linear exponential modeling through the SAS PROC NLIN1 module. To confirm the validity of the non-linear analysis, the results were checked using an approximate permutation test (also through SAS PROC NLIN). The analysis was conducted using follow-up time, return-to-work patterns, and the return-to-work definition (restricted or inclusive) to develop an overall model of unemployment following injury. Non-linear models were constructed to predict unemployment at a given time from all available data points. Comparisons were made by comparing the parameters obtained against parameters computed by random permutation of the relevant covariates thus producing an approximate permutation test of the original estimates. Degrees of freedom were based on the number of studies included in the analysis rather than the number of participants variance estimates could not be derived as a result of biased means and standard deviations (caused by possible right censoring in the data).

Intervention: 

Interventions included a variety of vocational rehabilitation programs including supported employment, work/school programs, other post-acute rehabilitation or a combination of these.

Control: 

There were no comparison or control conditions.

Findings: 

The selected studies (n = 26) were combined to produce 37 separate observations or data points. In terms of return-to-work, the 17 intervention studies generally appeared to produce higher percentages of successful adjusted return-to-work using an inclusive definition across all follow-up time points than did the 20 non-intervention studies. Using an inclusive definition increased the apparent rate of return to work by an average of 17% (SD = 12.5%). When the rate using the restricted definition for these 11 data points was aggregated and compared against the rate using the inclusive definition for the remaining 26 data points a similar finding emerged, with average return to work at 68% for the inclusive definition values and 48% for the restricted definition values. This finding approached significance. There was a negative correlation between unemployment and follow up time where the longer duration following injury led to a return to workplace or productive activity.

Conclusions: 

The research seems to indicate that rehabilitation interventions may be a major determinant in return to work regardless of severity of injury or other injury variables. Standardized terminology and methods for reporting return to work outcomes over the long term are needed. Synthesis of the literature that fail to do so will likely reach wrong conclusions.

URL: 
http://content.iospress.com/articles/journal-of-vocational-rehabilitation/jvr00352
Populations: 
NIDILRR Funded: 
Peer Reviewed: 
Yes

Predictors of success for state vocational rehabilitation for clients with traumatic brain injury

Authors: 
Jones, C. J., Perkins, D. V., & Born, D. L.
Year Published: 
2003
Publication: 
Archives of Physical Medicine and Rehabilitation
Volume: 
84
Number: 
2
Pages: 
161-167
Publisher: 
Elsevier
Background: 

Return to work after a Traumatic Brain Injury (TBI) is an important outcome and often considered a primary measure to evaluate the effectiveness of rehabilitation. Research in Traumatic Brain Injury is disjointed and most related to vocational rehabilitation includes small sample sizes and other weaknesses. A more complete investigation of the relationship between vocational rehabilitation services and outcomes of individuals with TBI may help determine determine predictors of vocational success.

Purpose: 

Find what descriptive characteristics of vocational rehabilitation clients with TBI contribute to the prediction of successful vocational outcomes.

Setting: 

This study included individuals with TBI served by the Missouri vocational rehabilitation agency in various settings.

Sample: 

Seventy eight individuals with Traumatic Brain Injury who were served by the Missouri DVR were selected from a sample of 220 individuals. The majority of the participants were single, white (82%) males (71%). The average length of time from injury to referral to DVR was 9.2 years and the average age was 36.7 years. The majority had a high school education or less(76%). Twenty five percent reported a history of substance abuse and 17 indicated a history of a learning disability.

Control: 

A neuropsychological evaluation to measure a range of skills was given to each participant. Additional information was obtained from DVR and included: type of services provided, work status variables at the time the person was referred to DVR, work status variable at the time the person's case was closed by DVR, and cost of services. Demographic information was obtained from the client and psychologist.

Findings: 

Seventeen percent of the individuals in the sample had a successful DVR case closure; however 2 of these people were working in a sheltered workshop. Services such as vocational guidance and counseling, and on the job training predicted vocational outcome.
Other variables such as severity of injury, neuropsychological evaluation findings, and demographics did not.

Conclusions: 

The study can not be generalized to all individuals with TBI, as it focused only on those served by DVR. Larger sample sizes are needed that follow the person for longer periods of time after VR case closure. Future research should focus more on the environmental factors such as the provision of VR services, increasing access to transportation etc...that impact community participation and less on medical and psychosocial variables.

URL: 
http://www.ncbi.nlm.nih.gov/pubmed/12601645
NIDILRR Funded: 
Research Design: 
Peer Reviewed: 
Yes

"Rural/urban differences in vocational outcomes for state vocational rehabilitation clients with TBI"

Authors: 
Johnstone, B., Vessell, R. Bounds, T., Hoskins, S., & Sherman, A.
Year Published: 
2003
Publication: 
NeuroRehabilitation
Volume: 
18
Number: 
3
Pages: 
197-203
Publisher: 
IOS Press
Background: 

After TBI many individuals experience difficulties with returning to work and if financially eligible turn to federally funded state vocational rehabilitation (VR) programs for services. Although billions of taxpayer dollars are spent on VR services each year, little is known about their effectiveness. Few studies have been published on the vocational outcomes of persons with TBI who utilize
state VR programs. More research is needed about individuals with TBI who receive state VR services in order to identify problems, develop appropriate services, and improve vocational outcomes. There are few published studies regarding persons with TBI in rural areas. Furthermore, the published research specifically on the vocational outcomes of persons with TBI in rural areas is essentially non existent with only one study identified on this topic.

Purpose: 

The purpose of the study was to evaluate differences in demographics, injury severity, and vocational outcomes for individuals with TBI based on whether that resided in a rural vs. urban environment. It was hypothesized that individuals from rural and urban areas would not differ in demographics, that rural individuals would have greater injury severity based on previous studies, and that rural individuals would receive fewer VR services and have a lower rate of successful employment.

Setting: 

The setting for the study was vocational rehabilitation agencies in Missouri.

Sample: 

The study included 78 individuals with TBI who had completed services from the Missouri Division of Vocational
Rehabilitation (VR). The majority or 71% were male. Eighty percent were Caucasian.
Demographic and injury severity data was reported by rural (N=28) and urban status (N=50). For the rural group, the mean age was 37; mean years of education was 12, and mean years post injury was 8 for the rural group. Mean number of hours in coma was 241 hours, mean days of post traumatic amnesia was 53 and mean days of hospitalization was 53 days. For the urban group, the mean age was 36; mean years of education was 12, and mean years post injury was 11 for the rural group. Mean number of hours in coma was 96 hours, mean days of post traumatic amnesia was 25 and mean days of hospitalization was 33 days.

Data Collection: 

Each participant was administered a standard neuropsychological evaluation used as part of a statewide VR protocol. Information about demographic and psychosocial variables was obtained by the evaluating psychologist. Self-report information regarding duration of loss of consciousness (LOC), posttraumatic amnesia (PTA), and hospitalization was obtained from most clients because medical records were not routinely available for review.

Information from Missouri DVR was obtained on each participant, including the specific services provided, the vocational status of the participant at case closure, and the financial cost of the case to DVR. Vocational outcome was determined using standard DVR categories, including: 1) successfully closed, 2) closed, no services provided, 3) closed, services interrupted, and 4) unsuccessfully closed. Rural and urban status was determined by definitions used by the US Office of Management and Budget (OMB). Data analysis included Chi-squares, Fisher‚ Exact tests, Wilcoxon Rank Sums test, and MANOVAs.

Intervention: 

The intervention was vocational rehabilitation services.

Control: 

A comparison was made between two groups of individuals with TBI; those living in rural versus urban settings.

Findings: 

There were no remarkable differences between the groups in terms of demographics. People residing in urban areas received significantly more maintenance funds, transportation services, and on-the-job training, than those living in rural settings. Additionally these individuals had more case service dollars expended on them. Finally, although statistically non-significant, individuals from urban areas were successfully employed at VR case closure, compared to those from rural areas.

Conclusions: 

The results suggest that rehabilitation professionals and vocational counselors should focus on possible environmental factors that limit the successful vocational outcomes of individuals with TBI in rural areas. VR counselors need to focus on environment factors that limit vocational outcomes for those living in rural areas. They need to find creative ways to address difficulties associated with limited resources in rural environments like transportation , locating vocational training settings, and developing job opportunities. VR counselors also need to better determine why many of their rural clients with TBI discontinue services after they are deemed eligible to receive them. This information can help them develop strategies to increase their client retention.

URL: 
http://www.ncbi.nlm.nih.gov/pubmed/14530584
NIDILRR Funded: 
Research Design: 
Peer Reviewed: 
Yes