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

1. Employment After Traumatic Brain Injury: Predictors, Challenges, and Interventions Lynne C. Davis, Ph.D. Brain Injury Research Center TIRR Memorial Hermann Houston, TX

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

3. Learning Objectives • Increase awareness about traumatic brain injury (TBI): • Define TBI • Incidence/prevalence • Common sequelae • Identify challenges and predictors of returning to work after TBI • Identify 3 types of interventions to help persons with TBI return to work

4. Overview of TBI • What is a traumatic brain injury (TBI)? a mechanical force applied to the head that affects brain functioning • Common causes: • falls • motor vehicle accidents • struck by/against an object • assaults

5. Overview of TBI (cont’d) • Types of TBI: Closed TBI: brain is injured without penetration of the skull Open TBI: brain is injured with penetration of the skull

6. Overview of TBI (cont’d) • How common is TBI? • 1.4 million TBIs annually in U.S. • 75,000 to 80,000 new cases of disability each year • 5.3 million living with significant disability as a result of TBI

7. Overview of TBI (cont’d) Injury Severity • Refers to initial injury – not outcome • Classification: • Loss of consciousness • Length of post-traumatic amnesia • Glasgow Coma Scale (GCS)

8. Overview of TBI (cont’d) • Mild TBI • LOC<30 min • GCS 13-15 • Moderate to Severe • LOC > 30 min - hours, days, weeks • GCS 9-12 = Moderate • GCS 3-8 = Severe

9. Overview of TBI (cont’d) Recovery Course • Every injury different • Every recovery can be different as well • Mild TBI: • Most rapid in first few weeks • At 3 months most feel “back to normal” • If continued problems, likely to improve over the first year

10. Overview of TBI (cont’d) • Moderate/Severe TBI: • Most rapid changes seen in first 6 months • Continue to see changes in first 1-2 years, with changes slowing down over time • Functional improvements possible at any time after injury: use of compensatory strategies and supports

11. Overview of TBI (cont’d) Common problems: • Sensory • Motor • Cognitive • Emotional/Behavioral

12. Overview of TBI (cont’d) • Sensory • Headaches • Fatigue • Dizziness • Blurred or double vision • Sensitivity to noise/light • Trouble with taste or smell

13. Overview of TBI (cont’d) • Motor • Weakness/paralysis and spasticity • Slowed performance • Poor coordination/balance • Slurred speech

14. Overview of TBI (cont’d) • Cognitive • Attention/concentration • Memory • Slowed information processing speed • Problem-solving difficulties • Organizational difficulties

15. Overview of TBI (cont’d) • Emotional/Behavioral • Decreased initiation • Lack of awareness • Impulsivity • Depression • Irritability/anger • Emotional lability

16. Return to Work (RTW): Facts, Challenges and Predictors • TBI is one of the leading causes of disability among young persons of working age in the U.S. • Total lifetime productivity losses are estimated at $51.2 billion.1 • Only about 30-40% of persons with moderate to severe TBI return to work after injury.2

17. Return to Work (RTW): Facts, Challenges and Predictors (cont’d) • Persons with TBI identify RTW as a primary need after injury. • Employment provides economic and social benefits after TBI. • Rates of depression are lower for employed than unemployed persons with TBI.3 • Satisfaction with life rated as higher in employed vs. unemployed persons with TBI.4

18. Return to Work (RTW): Facts, Challenges and Predictors (cont’d) • Challenges • physical • cognitive • emotional/behavioral • support system • disincentives

19. Return to Work (RTW): Facts, Challenges and Predictors (cont’d) • Physical challenges • Headaches • Fatigue • Dizziness • Blurred or double vision • Sensitivity to noise/light • Trouble with taste or smell • Weakness/paralysis and spasticity • Slowed performance • Poor coordination/balance • Slurred speech

20. Return to Work (RTW): Facts, Challenges and Predictors (cont’d) • Cognitive challenges • Attention/concentration • Memory • Slowed information processing speed • Problem-solving difficulties • Organizational difficulties

21. Return to Work (RTW): Facts, Challenges and Predictors (cont’d) • Emotional/behavioral challenges • Decreased initiation • Lack of awareness • Impulsivity • Depression • Irritability/anger • Emotional lability

22. Return to Work (RTW): Facts, Challenges and Predictors (cont’d) • Support system challenges • Lack of social support can interact with physical, cognitive, and emotional/behavioral challenges to make it even more difficult to return to work.

23. Return to Work (RTW): Facts, Challenges and Predictors (cont’d) • Disincentives • Fear of losing disability compensation • Inability to return to same type of job • Psychological disincentives

24. Return to Work (RTW): Facts, Challenges and Predictors (cont’d) • Predictors of RTW after TBI • Predicting RTW is difficult, depends on: • Demographics • Pre-injury variables • Injury-related variables • Environmental variables • Other variables (personality features, economic variables, cultural influences)

25. Return to Work (RTW): Facts, Challenges and Predictors (cont’d) • Predictors of RTW after TBI • Demographic variables: • Age – inverse relationship between age and RTW.5 • Education – mixed findings, but most studies show a positive association between pre-injury education and RTW.6

26. Return to Work (RTW): Facts, Challenges and Predictors (cont’d) • Predictors of RTW after TBI • Pre-injury variables: • Pre-injury employment – mixed findings, but there appears to be a positive relationship between pre- and post-TBI employment. • Psychiatric history appears related to employment after moderate to severe TBI,7 as does pre-injury drug/alcohol abuse.

27. Return to Work (RTW): Facts, Challenges and Predictors (cont’d) • Predictors of RTW after TBI • Injury-related variables: • Greater TBI severity is associated with lower rates of RTW in many, but not all, studies. • Level of impairment/disability predicts vocational outcome: those with less impairment/disability have better vocational outcomes.8

28. Return to Work (RTW): Facts, Challenges and Predictors (cont’d) • Predictors of RTW after TBI • Injury-related variables: • Time since injury – early intervention is associated with better vocational outcomes.9 • Impaired awareness – mixed findings

29. Return to Work (RTW): Facts, Challenges and Predictors (cont’d) • Predictors of RTW after TBI • Environmental variables: • Family/social support promotes employability • Identifying jobs • Helping with transportation • Identifying other needs that have implications for employment (e.g., psychotherapy)

30. Return to Work (RTW): Facts, Challenges and Predictors (cont’d) • Predictors of RTW after TBI • Variables that have received less attention, but that are also important in RTW: • Personality features • Economic variables • Cultural influences

31. Return to Work (RTW) Interventions • Vocational interventions lead toimproved RTW rates.10

32. Return to Work (RTW) Interventions (cont’d) • 3 major RTW intervention approaches:11 • Program-based vocational rehabilitation model • Supported employment model • Case coordination model

33. Return to Work (RTW) Interventions (cont’d) • Program-based vocational rehabilitation model • First described by Ben-Yishay et al.12 • Consists of 3 sequential modules • Module 1: individualized, intensive work skills intervention • Module 2: guided work trials • Module 3: assisted job placement with support

34. Return to Work (RTW) Interventions (cont’d) • Program-based vocational rehabilitation model • Involves interdisciplinary, group-based interventions targeting cognitive deficits, awareness, acceptance, and social skills. • This approach may be most effective for those with severely impaired awareness, cognition, and social functioning.

35. Return to Work (RTW) Interventions (cont’d) • Program-based vocational rehabilitation model • Post-treatment employment rates are high, ranging from 75-85%.13 • Weaknesses: high intensity of program, elevated costs, poor fit for those with less severe impairments.

36. Return to Work (RTW) Interventions (cont’d) • Supported employment model • Is an “individual placement model” adapted for persons with brain injury by Wehman et al. in late 1980s14 • Involves limited pre-employment training, quick job placement, individualized on-the-job training from job coach, and long-term monitoring.

37. Return to Work (RTW) Interventions (cont’d) • Supported employment model • Job coaches help with: contacting potential employers, providing additional training, helping perform some job duties while employee is learning, obtaining assistive technology, teaching problem-solving and compensatory strategies, and modeling social skills. • Approach designed for persons with severe deficits who could not maintain employment without on-site, ongoing assistance.

38. Return to Work (RTW) Interventions (cont’d) • Supported employment model • Has been shown to be effective, achieving a 71% employment rate.15 • Weaknesses: extensive resources may be required for adequate job retention (i.e., high number of intervention hours), poor fit for those with less severe impairments.

39. Return to Work (RTW) Interventions (cont’d) • Case coordination model • Is a holistic, flexible, individualized approach. • Case coordinator works with person with TBI to assess for needed services and then makes referrals. • Common referrals include vocational counseling, pre-employment training, and job placement assistance.

40. Return to Work (RTW) Interventions (cont’d) • Case coordination model • Emphasizes integration of vocational services with other rehabilitation services. • Key components: early intervention, continuity of care, and identification of impairments that could interfere with vocational success.

41. Return to Work (RTW) Interventions (cont’d) • Case coordination model • has been shown effective for persons with mild to severe TBI, with 70% employment rate achieved within 12 months.16 • Weaknesses: success depends on the skill of the specific staff members and on availability of services in clients’ areas.

42. Return to Work (RTW) Interventions (cont’d) • Which approach is best? • Depends on the needs, resources, and characteristics of the injured person. • Is no clear “best practice” approach, but overall the case coordination approach appears to have the strongest outcome evidence.11

43. Application of the Case Coordination Model • Randomized controlled trial (RCT) at the Brain Injury Research Center of TIRR Memorial Hermann • part of our Rehabilitation Research and Training Center on Developing Strategies to Foster Community Integration and Participation for Individuals with Traumatic Brain Injury funded by NIDRR

44. Application of the Case Coordination Model (cont’d) • Recruit from Level I trauma center acute care, emphasis on early intervention. • Inclusion criteria: complicated mild through severe TBI, age 18-65, fluent in English/Spanish, ≥ 6 mos. continuous employment in 2 yrs before injury, wants to return to work, legal resident of TX or has valid work visa, resides within 100-mile radius.

45. Application of the Case Coordination Model (cont’d) • Potential participants administered a readiness evaluation. • Those who are ready are randomized to case coordination intervention or standard of care. • Both groups receive referrals for state vocational rehabilitation services.

46. Application of the Case Coordination Model (cont’d) • Those in the case coordination group receive biweekly phone calls from case coordinator for ≤ 1 year, who assesses for referral needs. • Case coordinator also contacts assigned vocational counselor to help participants through process.

47. Application of the Case Coordination Model (cont’d) • Employment and community integration outcomes assessed in both groups at 6, 9, 12, and 18 months following enrollment. • Observations so far: • Participants confused about state vocational rehabilitation process. • Participants appear to value case coordinators’ assistance.

48. Work Readiness after TBI • Stergiou-Kita et al.15 identified critical personal variables when assessing RTW readiness: • motivation • physical and functional independence • cognition (attention, memory, judgment, self-awareness) • use of compensatory strategies

49. Future Directions • Develop standardized procedures/measures to match persons with TBI to RTW intervention best suited for them based on their needs. • Comparative outcome studies of RTW interventions. • Identify ways to implement RTW interventions within state vocational rehabilitation systems.

50. References 1. Finkelstein EA, Corso PC, Miller TR, Fiebelkorn IA, Zaloshnja E, Lawrence BA. Incidence and economic burden of injuries in the United States. New York, NY: Oxford University Press; 2006. 2. van Velzen JM, van Bennekom CAM, Edelaar MJA, Sluiter JK, Frings-Dresen MHW. Prognostic factors of return to work after acquired brain injury: A systematic review. Brain Injury 2009;23:385-395. 3. Dawson D, Schwarts M, Winocur G, Stuss D. Return to productivity following brain injury: Cognitive, psychological, physical, spiritual and environmental correlates. Disability And Rehabilitation 2007;29:301-313. 4. Corrigan JD, Bogner J, Mysiw WJ, Clinchot D, Fugate L. Life satisfaction after traumatic brain injury. Journal of Head Trauma Rehabilitation 2001;16:543-555. 5. Keyser-Marcus LA, Bricout JC, Wehman P, Campbell LR, Cifu DX, Englander J, High W, Zafonte RD. Acute predictors of return to employment after traumatic brain injury: A longitudinal follow-up. Archives of Physical Medicine and Rehabilitation 2002;85:635-641.