Predicting return to work after brain injury using occupational therapy assessments

Purpose: The aim of this study was to evaluate the value of occupational therapy assessments used in an outreach rehabilitation programme to predict return to work after brain injury. The assessments represent the ICIDH-2 levels of body function and activity. Method: Fifty-six persons in a late phase after brain injury who had been admitted to the rehabilitation programme during 2 years were followed up according to work status. The follow up was made at a minimum of 2 years after injury. Demographic data and scores from the occupational therapy assessments were compared for the two groups who were back to work or studies (BTW) and not back to work or studies (NBTW). Results: Assessments of memory, visual perception and apraxia separated between the two groups BTW and NBTW. Logistic regression showed that memory score in combination with data on PADL made up the best predictive model. In a subgroup with 21 persons where data on IADL were added to memory and PADL the predictive value was even stronger. Conclusions: In this study we found that occupational therapy assessments were valuable in predicting failure to return to work or studies after brain injury.     

Predicting return to work after brain injury using occupational therapy assessments

Purpose: The aim of this study was to evaluate the value of occupational therapy assessments used in an outreach rehabilitation programme to predict return to work after brain injury. The assessments represent the ICIDH-2 levels of body function and activity. Method: Fifty-six persons in a late phase after brain injury who had been admitted to the rehabilitation programme during 2 years were followed up according to work status. The follow up was made at a minimum of 2 years after injury. Demographic data and scores from the occupational therapy assessments were compared for the two groups who were back to work or studies (BTW) and not back to work or studies (NBTW). Results: Assessments of memory, visual perception and apraxia separated between the two groups BTW and NBTW. Logistic regression showed that memory score in combination with data on PADL made up the best predictive model. In a subgroup with 21 persons where data on IADL were added to memory and PADL the predictive value was even stronger. Conclusions: In this study we found that occupational therapy assessments were valuable in predicting failure to return to work or studies after brain injury.     

Working with a brain injury: personal experiences of returning to work following a mild or moderate brain injury.

OBJECTIVE: Most brain injuries occur in people of working age. Individuals with mild or moderate injuries may have unrecognized problems affecting return to work. Previous studies have focused on factors that predict return to work after brain injury. There is limited information about the experiences of individuals returning to work. DESIGN: Individual interviews explored the work-related expectations and experiences of workers who had sustained mild to moderate brain injury. A sampling frame ensured a spread of participants by age, injury severity and work type. METHODS: Thirty-three interviews were conducted 4-6 months post-injury. Most participants had returned to work. Interviews were transcribed verbatim for thematic analysis. RESULTS: Key emerging issues for participants were the invisibility of their injury, continuing symptoms affecting their ability to do their job and lack of advice and guidance on returning to work. Return to work support systems were considered to be poorly coordinated and managed. CONCLUSION: It is important that healthcare professionals anticipate the vocational rehabilitation needs of patients who have sustained mild to moderate brain injury. These patients may require additional coordinated interventions and specific person-centred information to ensure a successful and, most importantly, a sustained return to work.     

Acute predictors of return to employment after traumatic brain injury: a longitudinal follow-up

OBJECTIVE: To investigate the relation between selected acute injury and patient characteristics and subsequent return to work 1 to 5 years postinjury. DESIGN: Longitudinal design with prospectively collected data. Data were collected on patients at the time of injury and each year postinjury for up to 5 years. SETTING: Four medical centers in the federally sponsored Traumatic Brain Injury Model Systems project that provide emergency medical services, intensive and acute medical care, inpatient rehabilitation, and a spectrum of community rehabilitation services. PARTICIPANTS: Patients were selected from a national database of 538 rehabilitation inpatients admitted to acute care within 8 hours of traumatic brain injury (TBI) and seen at 1 to 5 years follow-up. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Employment status (employed vs not employed) at 1 to 5 years postinjury. Logistic regression analyses were performed to determine the extent to which selected variables predicted employment status at years 1 to 5 postinjury. RESULTS: At year 1 postinjury, preinjury productivity, age, education, and rehabilitation length of stay were all significantly associated with postinjury employment. Preinjury employment and productivity and age significantly predicted employment at postinjury year 2. At year 3 postinjury, preinjury productivity, age, and FIMtrade mark instrument discharge score significantly predicted employment status. Age was significantly associated with employment status at year 4 postinjury. Preinjury employment and productivity and Disability Rating Scale discharge score were found to be significant predictors of postinjury employment at year 5 follow-up. CONCLUSIONS: The relationship between certain acute injury and patient variables (eg, age, preinjury productivity, education, discharge FIM) and subsequent return to work may provide rehabilitation professionals with useful information regarding the intensity and types of services needed for individuals in the vocational rehabilitation planning process.     

Employment after spinal cord injury.

The purpose of this study was to compare preinjury and postinjury employment rates in a diverse sample of persons with spinal cord injuries. Several employment variables were compared in individuals grouped into cohorts based on injury level, chronologic age, age at injury, time since injury, and years of education. The study sample (N = 286) was highly educated (mean = 14.2 years of education) and was an average of 18.6 years postinjury. Forty-eight percent of the participants were working at the time of the study, and 75% had worked at some time since injury. Only 12% of the persons who were employed at the time of injury returned to the same job after injury. Several noteworthy findings among the groups were: (1) participants with paraplegia were more likely than those with quadriplegia to return to their preinjury jobs; (2) employment rates were dramatically lower in the 51- to 60-year group; (3) more than 85% of persons in the cohorts who were at least 21 years postinjury had worked at some time since injury; (4) younger age at injury was associated with higher current employment rates; and (5) nearly 95% of all participants with 16 or more years of education had worked at some point since injury. The study results reaffirmed the need for comprehensive rehabilitation, identified the need for retraining several years after injury, and pointed to the role of higher education in producing high employment rates.     

Returning to work after spinal cord injury: exploring young adults' early expectations and experience

Purpose.?The study sought to explore experience and expectations about paid work among young adults on sick leave after spinal cord injury (SCI).

Method.?Eight participants with traumatic SCI, who were 20–34 years of age, and had not yet returned to work 1–5 years post-injury, were interviewed. Selection was made with purposive sampling. Data were analysed using a constant comparative method.

Results.?Four main themes emerged as relevant: ‘finding your way to an everyday life where work is possible’, ‘at the crossroads, expectations of work through education’, ‘expectations of paid work as part of a desired future life’ and ‘expectations of finding a solution within oneself or with help from others’. The findings reveal high expectations of work ability but at the same time difficulties to plan for return to work and lack of support in this process.

Conclusions.?The participants represent a vulnerable group in vocational rehabilitation due to their young age and recent injury. Without formal training or suitable work experience, they need tailored work support as part of their general rehabilitation.     

Return to work after low voltage electrical injury

Low voltage electrical injury is associated with minor or no cutaneous burns and its symptoms rarely appear on initial examination. The purpose of this study was to determine the ability to return to work among patients with low voltage electrical injury. A retrospective hospital chart review was conducted among patients with low voltage electrical injury admitted to the outpatient burn clinic of a rehabilitation hospital between January 1, 2002 and March 21, 2006. Symptoms at follow-up visits and return to work status were compared between patients with electrical contact injuries and those with electrical flash injuries using Student's t-test and chi analysis with a P < 0.05 considered significant. Values are presented as mean +/- SD. Forty patients were treated for low voltage electrical injury, and all injuries occurred at work. There were 34 men (85%) and 6 women (15%) with a mean age of 37.3 +/- 11.2 years and a mean total body surface area burned of 13.0% +/- 17.6%. Most patients had neurological (92.5%), psychological (90.0%), and musculoskeletal (72.5%) symptoms, which were documented on average 303.7 days after injury. Twenty-five (62.5%) patients had electrical contact injury and 15 (37.5%) patients had electrical flash injuries. Patients with electrical contact injuries were younger (34.2 +/- 9.9 years vs 42.4 +/- 11.6 years, P = 0.030), complained of more psychological symptoms (25 vs 11, P = 0.006), more neurological symptoms (25 vs 12, P = 0.020), and more fatigue (10 vs 1, P = 0.022) than patients with electrical flash injuries. Twenty-three patients (57.5%, 14 electrical contact and 9 electrical flash) attempted to return to work on average 107.7 days after injury, but only 13 patients (32.5%, six electrical contact and seven electrical flash) successfully returned to work 59.38 days after injury. Of them 7 (53.8%) return to the same job, 5 (38.5%) returned to a modified job, and 1 (7.7%) to a new job. Low voltage electrical injury can significantly impact a patient's ability to return to work because of the psychological, neurological, and musculoskeletal symptoms, which are observed. Recognition of low voltage injury as a potentially permanent source of symptoms is important and has to date not been well established. More effective preventive measures should be implemented at work to reduce the risk of these injuries.     

Return to work in the context of everyday life 7–11 years after spinal cord injury – a follow-up study

Abstract

Purpose: The aim of this follow-up study was to explore experiences of return to work in the context of everyday life among adults 7–11 years after spinal cord injury (SCI).

Methods: This study used in-depth interviews and observations in a qualitative design with eight persons who had previously been interviewed in 2008. A narrative approach was used during data gathering and analysis.

Results: Return to work was experienced as something constantly needing to be negotiated in the context of everyday life. Several years after SCI expectations for work and perceptions of possibilities for meaningful work had changed. Five main themes were identified through the analysis, (1) negotiating the possibilities of working, (2) hope for future work tempered with concern, (3) education as a possible path to employment, (4) paths toward return to work in light of unmet support, and (5) unpaid occupations grounded in interest and competence.

Conclusions: Persons who have no higher education or lack viable employment to return to after SCI seem to be vulnerable in return to work. Early and timely interventions tailored to the person’s interests and competencies, in which the rehabilitation team has a distinct coordinating role, are thus critical in return to work.

• Implications for Rehabilitation

• Tensions between hope and expectations for work and unmet needs of support can lead to barriers in return to work, particularly for those who have no higher education or lack employment to return to after spinal cord injury.

• Rehabilitation after spinal cord injury can benefit from focus on how the balance of work fits into routines in the context of everyday life.

• Early and timely interventions integrating the person’s interests and competencies in return to work after spinal cord injury in combination with having a health care provider who has a distinct coordinating role are critical.

     

Occupational rehabilitation of neurological patients - long-term outcome data

Occupational rehabilitation in Germany is done in specialized centres (so-called "Phase II" centres). In the present study, long-term outcome data of 237 neurological rehabilitation patients (mean age 38.3 years) were analyzed. Most of the patients had suffered brain injuries. The examination took place some 7 years after the end of occupational rehabilitation and approximately 10 years after the injury. About 60% of patients returned to work (35% worked, 9.3% were seeking a job, 13.5% underwent training). Positive predictors for return to work were lower age and high educational level. The results from this study suggest that occupational rehabilitation is effective. Controlled and multi-centre studies should be carried out.     

Assessing the work-role quality and its significance in predicting return to work

Non-medical factors such as age, years of schooling, and job satisfaction play an important role in determining whether patients resume their work after rehabilitation treatment. One element is the way the work situation is perceived by the patient. Usually, aspects of strain or job concerns are assessed. But employment does also include positive and rewarding aspects, though, such as meaning or social contact. According to the concept of work-role quality, theoretically these are independent constructs: someone may perceive job concerns and job rewards at the same time. In this study a short questionnaire (FRQ-B), broadly adapted from Barnett, Davidson and Marshall (1991), measuring job concerns and job rewards was developed and administered to a sample of cardiac rehabilitation patients. Psychometric analysis shows the factorial validity, consistency and construct validity of the instrument. Prediction of the return to work status three months after discharge from rehabilitation could be achieved on the item and subscale level. The effect sizes were comparable to other significant variables (e. g. psychological status, NYHA-status, wish to work). Specificities vary from 30 to 60 percent. The best predictor seems to be the Fear Avoidance Belief Questionnaire (FABQ), assuming a causal relationship be-tween work and illness. An analysis of subgroups using the FRQ-B reveals patients who experience little job rewards as well as many job concerns as a group with a high risk of not returning to work. The results of this study demonstrate the importance of assessing work related variables when dealing with return to work after rehabilitation treatment. Interventions to change the perception of the working place situation should be initialized and focussed early in rehabilitation treatment. The need for further research integrating the concept of work-role quality is discussed.     

Including children in family-focused acquired brain injury rehabilitation: a national survey of rehabilitation staff practice

OBJECTIVE: To establish whether rehabilitation staff work regularly with child relatives of adults with acquired brain injury to involve them in their family member's rehabilitation. To explore factors influencing rehabilitation staff's decisions about involving child relatives. DESIGN: A cross-sectional postal survey design was used for the main study. Questionnaire packs were sent to rehabilitation staff, followed by a reminder letter one week later. Non-responders received a follow-up pack after three weeks.A prospective design was used with a subsample of participants who re-completed the questionnaire one month later. SUBJECTS: Participants were 393 multidisciplinary staff working in rehabilitation services for adults with acquired brain injury throughout the UK. MAIN MEASURES: A questionnaire based on the theory of planned behaviour was designed specially for the purposes of the study. RESULTS: A response rate of 67% (n=263) was obtained. Few respondents (19%, n=50) reported carrying out work with child relatives. Perceived behavioural control (e.g. access to training, resources and support) significantly predicted staff's intention to work with child relatives, and whether they carried this out. Staff's attitudes towards work with child relatives also significantly predicted intentions. Other influential factors were anxiety, training, work setting and perceptions of colleagues' attitudes. CONCLUSIONS: Little work is carried out with child relatives by acquired brain injury rehabilitation staff, influenced by several factors. A priority in addressing this is to provide staff training.     

不同病程创伤性颅脑损伤患者运动功能康复效果的回顾性分析

目的：探讨创伤性颅脑损伤后不同时期介入康复治疗对患者运动功能及日常生活活动能力的疗效影响。方法：对163例创伤性颅脑损伤患者的临床资料进行回顾性分析。根据康复治疗介入的时间（〈3个月、3-6个月、6-12个月、1-2年、〉2年）将患者分为5组，于治疗前及治疗2个月后评定患肢的运动功能、ADL能力及步行能力。结果：康复治疗介入时间〈3个月组和3—6个月组的患者上下肢及手的运动功能、步行能力和ADL均有显著提高（P〈0．05）；6-12个月组的患者除步行能力无明显改善外，其余功能均有显著提高（P〈0．05）；1-2年组的患者其上肢功能和ADL能力均有显著提高（P〈0．05），但其余功能均无提高；而〉2年组的患者只有ADL能力有显著提高（P〈0．05）．结论：系统正规的康复治疗有利于创伤性颅脑损伤后不同时期康复的患者。康复医师应根据康复介入的时间，确定康复治疗的重点。     

Quality of life and maintenance of improvements after early multimodal rehabilitation: A 5-year follow-up

Purpose.?There is a paucity of long-term evaluations on rehabilitation of musculoskeletal disorders, e.g., neck, shoulder or back pain. The aim of this study was to assess quality of life and the effect of early multimodal rehabilitation on 91 patients with musculoskeletal pain and disability at a 5-year follow-up.

Method.?The follow-up assessment, which included questions on pain, function, quality of life, perceived health, sick leave and psychosomatic symptoms, was performed 5 years after the assessment of baseline status.

Results.?Improvements in pain, perceived health and psychosomatic symptoms were maintained at the 5-year follow-up. In addition, improvements in function, quality of life, and level of acceptable pain were significant in comparison to baseline. At the time of the baseline assessment all patients were on sick leave (13% were on partial sick leave). At the 5-year follow-up, 58% of the patients were at work part or full time. The results show that those working differed significantly from those not working at the 5-year follow-up on almost all variables, indicating that those working enjoy better health. The most salient prognostic factors for return to work were perceived health and educational level at the time of the baseline evaluation.

Conclusions.?These results show that treatment improved quality of life and the effects were basically maintained at 5 years. Work capacity as reflected in return to work increased greatly (81%) at a 1-year follow-up and was substantial (58%) at the 5-year follow-up. Moreover, perceived health and educational levels were important prognostic factors. Finally, the fact that patients working reported better health underscores the probable importance of return to work. Our results imply that it may be feasible to obtain long-term benefits from such a primary care-based intervention.     

Quality of life and maintenance of improvements after early multimodal rehabilitation: a 5-year follow-up

Purpose. There is a paucity of long-term evaluations on rehabilitation of musculoskeletal disorders, e.g., neck, shoulder or back pain. The aim of this study was to assess quality of life and the effect of early multimodal rehabilitation on 91 patients with musculoskeletal pain and disability at a 5-year follow-up.

Method. The follow-up assessment, which included questions on pain, function, quality of life, perceived health, sick leave and psychosomatic symptoms, was performed 5 years after the assessment of baseline status.

Results. Improvements in pain, perceived health and psychosomatic symptoms were maintained at the 5-year follow-up. In addition, improvements in function, quality of life, and level of acceptable pain were significant in comparison to baseline. At the time of the baseline assessment all patients were on sick leave (13% were on partial sick leave). At the 5-year follow-up, 58% of the patients were at work part or full time. The results show that those working differed significantly from those not working at the 5-year follow-up on almost all variables, indicating that those working enjoy better health. The most salient prognostic factors for return to work were perceived health and educational level at the time of the baseline evaluation.

Conclusions. These results show that treatment improved quality of life and the effects were basically maintained at 5 years. Work capacity as reflected in return to work increased greatly (81%) at a 1-year follow-up and was substantial (58%) at the 5-year follow-up. Moreover, perceived health and educational levels were important prognostic factors. Finally, the fact that patients working reported better health underscores the probable importance of return to work. Our results imply that it may be feasible to obtain long-term benefits from such a primary care-based intervention.     

A comparison of acute and postdischarge predictors of employment 2 years after traumatic brain injury

OBJECTIVE: To examine whether adding postdischarge psychosocial predictors to premorbid and injury-related variables improved the capacity to predict employment 2 years after rehabilitation for traumatic brain injury (TBI). DESIGN: Data were collected prospectively at 6 and 24 months after discharge from rehabilitation. Logistic regression analyses examined predictors of employment status. SETTING: Inpatient and community TBI rehabilitation service attached to a major Australian teaching hospital. PARTICIPANTS: Fifty-five patients with TBI, aged 16 or older, who were consecutively admitted to a brain injury unit with complete longitudinal data and who agreed to participate in the study. INTERVENTION: Measured injury severity (Glasgow Coma Scale scores, posttraumatic amnesia); functional independence (Functional Assessment Measure cognitive subscale) at admission and discharge from rehabilitation; self-report of employment (premorbid, postdischarge); postdischarge psychosocial status at 6 months and 2 years (Community Integration Questionnaire, General Health Questionnaire, Trauma Complaints List, Overt Aggression Scale, Alcohol Use Disorders Inventory Test, Satisfaction with Life Scale). MAIN OUTCOME MEASURES: Employment status (employed, unemployed) was used to reflect vocational outcome. Predictor variables comprised premorbid work status, injury-related variables (age, injury severity), and postdischarge variables (employment, community integration, psychologic, cognitive status). RESULTS: Adding postdischarge predictors to premorbid and acute variables significantly improved the ability to predict work status 2 years after rehabilitation. Age at the time of injury, premorbid employment status, work status, and psychologic distress 6 months postdischarge were significant predictors of employment. CONCLUSIONS: It is important to consider postdischarge psychologic well-being, in conjunction with premorbid and acute factors, in vocational interventions after TBI.     

Predictors for return to work after spinal cord injury: a 3-year multicenter analysis

OBJECTIVE: To examine the ability of the Motor Index Score (MIS), in combination with demographic variables, to predict return to work during a 3-year period for individuals with spinal cord injury (SCI). METHODS: Prospectively collected data, between 1986 and 1995, submitted to the National Spinal Cord Injury Statistical Center were analyzed to determine the prediction of return to work utilizing variables of education, ethnicity, age, marital status, gender, and MIS. Individuals, aged 18 to 65 yrs, employed at the time of their injury, were evaluated at discharge from rehabilitation and at 1 (YR1), 2 (YR2), and 3 (YR3) years postinjury (sample sizes of 1,857, 1,486, and 1,177, respectively). RESULTS: The most important predictors of return to work were education, MIS, ethnicity, and age at onset of SCI. These variables resulted in a high rate of accuracy for predicting across all 3 yrs (YR1, 81%; YR2, 82%; YR3, 77%). CONCLUSIONS: The ability to predict return to work after SCI was shown utilizing MIS and demographic variables, with nearly 80% accuracy. This suggests that return to work after SCI is a dynamic process, with the level of importance of each variable changing with time postinjury.     

The prevalence and characteristics of shoulder pain after traumatic brain injury

OBJECTIVE: To determine the prevalence and characteristics of shoulder pain in people with traumatic brain injury participating in inpatient rehabilitation and to compare the clinical presentation with that of people with stroke. DESIGN: A prospective comparative study. SETTING: Six metropolitan rehabilitation units. SUBJECTS: Eighty-seven people with traumatic brain injury and 52 people with stroke took part in the study. MAIN MEASURES: Assessment of shoulder pain, range of motion, strength and function was conducted on admission and, for the subjects with traumatic brain injury, at discharge if rehabilitation exceeded two weeks. RESULTS: The prevalence of shoulder pain in people with traumatic brain injury was 62%, which was comparable with the 69% of subjects with stroke that experienced shoulder pain (odds ratio 0.72, 95% confidence interval 0.34 -1.5). Fracture in the shoulder complex and passive shoulder external rotation range of motion were the best predictors for shoulder pain after traumatic brain injury. This was different from the subjects with stroke for which the best predictors were passive shoulder flexion range of motion and length of acute hospital stay. CONCLUSION: There is a relatively high prevalence of shoulder pain after traumatic brain injury. Trauma to the shoulder complex contributes to shoulder pain after traumatic brain injury, making clinical presentation different from people with stroke. The findings support the need for greater attention in the management of shoulder pain after traumatic brain injury.     

Peripheral plasma amino acid abnormalities in rehabilitation patients with severe brain injury

OBJECTIVE: Acute severe brain injury causes an increased mobilization of amino acids from tissue. The plasma amino acid profile of patients undergoing rehabilitation after brain injury is unknown. This study was aimed at delineating the plasma amino acid profile of rehabilitation patients with brain injury. DESIGN: Peripheral plasma aminogram, lactate, pyruvate, glycerol, ketone body, and carnitine concentrations were determined in 11 patients with brain injury (34.6+/-15 years old, 60+/-16.8 days after injury) and in 8 controls. Resting energy expenditure and nitrogen balance were also determined. RESULTS: (1) All essential amino acids and about 50% of nonessential amino acids were significantly lower in brain injury patients than in controls (p < .05). (2) Plasma amino acids were lower irrespective of either energy and protein intake or nitrogen balance. (3) Total carnitine concentration and esterified/free carnitine ratio were higher in brain injury patients than in controls (p < .05). CONCLUSIONS: Rehabilitation patients with brain injury may have an important reduction of their plasma aminogram. Muscle tissue depletion and the persistence of a hypercatabolic state caused by subclinical infections, pressure sores, and immobility may contribute to this reduction.     

Able or unable to work? Life trajectory after severe occupational injury

Purpose: To study the probabilities and permanence of return to work, inability to work and rehabilitation, and to explore the connection between these life situations and later working after a severe occupational injury.

Materials and methods: A historical cohort of Finnish workers with a severe occupational injury during 2008 (N?=?11,585) were followed up annually on the outcomes of return to work over a 5-year observation period. We examined transition probabilities from one life situation to another with Markov chain analysis, and applied logistic regression with generalized estimating equations to assess the effect of register-based determinants on return to work.

Results: Within the five anniversaries, 85% of the injured were working, 9% were unable to work (fully or partly) and 2% received rehabilitation. Age, gross annual income, type of work, injured body part, injury type and the injured’s annual condition subsequent to the work injury were significant determinants of return to work.

Conclusions: The probability of return to work decreased with time, but, on average, one-fifth of the injured workers succeeded in return to work after being unable to work on the previous anniversary, which indicates that it is worthwhile to conduct efforts for this target group in order to promote return to work.

• Implications for Rehabilitation

• The current life situation of the injured should be taken into account when promoting return to work, as it is a strong predictor of later working after a serious occupational injury.

• Rehabilitation and return to work programs should start in time due to declining return to work rates as the disability continues.

• Return to work on a part-time basis could be a good option during the early phases of recovery, since a notable proportion of those partly unable to work on the first anniversary returned later to full-time workers.

• The probability of recovery is relatively high even for those with long-term disabilities, so the promotion of return to work is highly recommended also for this target group.