Return to Work Following Traumatic Brain Injury

Theodore Tsaousides

BACKGROUND

Importance

Traumatic brain injury (TBI) results in cognitive, physical, and psychosocial impairments that present barriers to return to work (RTW) [1]. The importance of successful RTW after a TBI cannot be overstated. Survivors who RTW report an improved sense of well-being and identity, better health status, greater community involvement, less usage of healthcare services, decreased social isolation, and better quality of life [2]. With supportive legislation in place and the improvement of medical and rehabilitation interventions, increasing numbers of TBI survivors have had opportunities to RTW [1].

Incidence

It has been estimated that among patients who were employed prior to injury, 40.4% RTW at 1 year, and 40.8% at 2 years, with a range reported from 0% to 84% across studies [3,4]. Several factors contribute to the wide range of RTW rates, including varied classification of severity of TBI, differing definitions of RTW, financial incentives that promote or discourage RTW in different countries, and availability of vocational rehabilitation services [5]. RTW rates are higher for individuals with mild TBI of whom approximately 75% report full RTW at 6 months postinjury [6].

Durability

Review of U.S. TBI model systems (TBIMS) data collected on patients with moderate to severe TBI who required a course of inpatient rehabilitation postinjury revealed that 34% of survivors were stably employed (i.e., employed at 1-, 2-, and 3- or 4-year follow-up), 27% were unstably employed (employed at one or two of the three follow-up visits), and 39% were unemployed at all three follow-up intervals [7]. More recent data from the TBIMS suggest that the odds of RTW are higher within the first years from injury, while the probabilities decline between years 5 and 10 [8]. The majority of individuals with mild TBIs are expected to return to work within 3 and 6 months postinjury [6].

Changes in Occupational Status Post-RTW

While RTW rates are relatively low, what is often overlooked in the RTW literature is the consistency in occupational status between preinjury and postinjury jobs for those who successfully RTW. Consistency rates are higher for those in managerial and professional jobs compared to those in manual labor jobs [9]. Nevertheless, approximately 20% of those who are steadily employed postinjury (working 3–5 years after the injury) return to jobs for which they are overqualified in terms of education and vocational training requirements [10]. RTW is more positive for those returning to more supportive and nurturing work environments than more competitive and high risk work environments [11].

Rehabilitation Continuum of Care

The full spectrum of TBI rehabilitative services includes acute inpatient rehabilitation, postacute rehabilitation, and community reentry and RTW with assistance as indicated. Vocational assistance may range from instruction on gaining employment to intensive on-the-job training, and outpatient follow-up to help adapt to new challenges and access community resources [5,12].

Primary Treatment Models

These include comprehensive/holistic programs that feature work readiness training and work trials [13], case coordination [14,15], and supported employment [16–18]. All treatments are “individualized” to some degree; more research is needed to determine unique effects of different treatment approaches on long-term outcomes [12].

Effectiveness

The evidence supporting interventions to improve RTW is weak, consisting mostly of observational and uncontrolled studies [19]. Supported employment can improve outcomes for individuals with severe TBI [14,20]. Those who go to work also seem to improve in nonvocational areas. Work has therapeutic benefits including social interaction, providing structure and purpose in life, enhancing perception of quality life, and positively impacting self-concept.

Funding Sources for Vocational Interventions

These may include:

• State vocational rehabilitation agency

• Insurance carrier

• Out of pocket

ASSESSMENT

Factors

A systematic review of the literature (1992–2008) for prognostic and nonprognostic factors impacting RTW in non-TBI and TBI indicates the following: greater injury severity (Glasgow Coma Scale) and presence of depression or anxiety are negatively associated with RTW; longer inpatient stay, functional status on admission and/or discharge, residual physical impairments, number/extent of injuries, and limitations in activities of daily living performance also appear to correlate with a reduced chance of RTW (Table 69.1) [3].

Note that RTW involves a complex interaction between premorbid characteristics, injury factors, postinjury impairments, and personal and environmental factors, making predicting outcomes only moderately accurate [5].

Physical Examination

A thorough physical examination and diagnostic workup including neuroimaging and neuropsychological testing is necessary for accurate diagnosis of the physical, cognitive, behavioral, and emotional sequelae of TBI. If returning to previous work, some type of release to return to duty may be required. Having a member of the team conduct a thorough job analysis can be very helpful.

Vocational Assessment

• Traditional vocational assessment, that is, a “place once and done” approach, has not been effective for individuals with more significant support needs [1,18].

• Functional vocational assessment: This assessment is designed to determine RTW options and support needs. It may involve examining the individual’s ability to return to preinjury employment; a new job that capitalizes on use of the person’s residual skills either with preinjury or new employer; or a different type of job with new employer [1]. Assessment includes interviewing the individual and/or caregivers as well as a vocational situational assessment in a real (not simulated) work setting.

TABLE 69.1 Some of the Risk Factors Associated With Unsuccessful RTW for TBI

Age more than 40 years at time of injury

Unemployment preinjury

Low-preinjury education level

Unskilled manual laborer preinjury

Greater number of neuropsychological deficits

Length of inpatient rehabilitation stay

Length of coma

Lack of awareness of available work incentives

Lack of job placement assistance

Inability to return to preinjury job or employer

Lack of self-awareness

Poor social support network

Psychiatric history and prior drug or EtOH use

Greater level of physical disability

Source: Adapted from Refs. [1, 4].

VOCATIONAL REHABILITATION INTERVENTION

Team Approach

This may include physiatry, vocational rehabilitation (including job coach if severe disability), social work, physical therapy, occupational therapy, vision therapy, speech therapy, and neuropsychology. Each discipline can offer unique insight that can be integrated into the survivor’s RTW plan. It is also important to solicit input from the family and patient.

Client Instruction and Advisement

Client instruction and advisement involves providing the client with information and instruction to assist with conducting a job search and, once employed, use of compensatory strategies at work. Many individuals with TBI will not be able to profit from this office-based intervention because of cognitive impairments.

Selective Placement

This involves job placement assistance followed by minimal interaction and intervention. This approach assumes that neither intensive on-the-job assistance nor ongoing support is necessary. Ongoing contact with the individual may be maintained more closely than with the employer.

Supported Employment

Supported employment is effective in increasing employment among those with TBI [18], with a job retention rate of more than 70% [21]. This approach is characterized by individualized employment support, provided and/or facilitated by a vocational rehabilitation specialist sometimes referred to as a job coach [1]. These services are specifically tailored to assist an individual with severe TBI with gaining and maintaining competitive employment. This approach begins with a functional vocational assessment, followed by an immediate job search (in place of prolonged pre-employment training or treatment) that is aligned with the information gathered during client assessment and review of the employer’s business needs. Once the job seeker is hired, the job coach facilitates on and off job-site supports. On-the-job training is often provided, including assisting the new hire with developing and learning to use various supports like compensatory memory strategies. The job coach gauges how the new hire is progressing toward meeting the employer’s standards and expectations and adjusts instructional strategies accordingly. Ongoing long-term follow-up or job retention services are also provided throughout the individual’s tenure. This could include assisting the employee with resolving novel challenges as they arise or new skills training if indicated [1,3,5,18,20].

Workplace Supports

Some common physical, cognitive, and emotional impairments and possible workplace supports are described as follows:

• Physical impairments (e.g., seizures, heterotopic ossification, spasticity) [22]: Some ways to help circumvent difficulties arising from physical sequelae of TBI include [23]

Developing a job that will utilize residual strengths versus merely avoiding points of weakness

Selecting or modifying the work environment to ensure safety in the event of the recurrence of a seizure or in the setting of balance dysfunction and dizziness; teaching the client to recognize symptoms and take steps to “be safe”; educating the employer on reaction to occurrence if appropriate

Rearranging the workspace to help accommodate decreased range of motion and strength

Considering ergonomic modifications

Considering how pattern or sequencing of activities impacts speed and accuracy, endurance and fatigue; making modifications where feasible

Utilizing assistive technology and/or adaptive equipment if necessary

• Cognitive and emotional impairments (e.g., memory impairment, impaired attention/concentration, lack of self-awareness, disinhibited behaviors). Some ways to help ameliorate cognitive, emotional, and behavioral dysfunction at work include

Cognitive rehabilitation [5]