Return to work following moderate-to-severe traumatic brain injury

Primary objective: To investigate the role of cognitive functioning, fatigue, mood and behaviour in return to work (RTW) following moderate-to-severe traumatic brain injury.

Design and methods: Between-groups comparisons were conducted with 20 participants who had RTW and 13 who had not. Participants were well matched for age, pre-morbid intellectual functioning, years of education, injury severity and time since injury.

Outcomes and results: The unemployed group reported significantly higher levels of fatigue and depression and significantly more problems on self-report questionnaires. A significantly higher proportion of this group was seeking compensation. No significant differences were obtained on neuropsychological measures of cognitive functioning.

Conclusions: Mood, fatigue and behavioural problems may impede a person's ability to RTW. Subjective measures may be more superior to objective measures in predicting RTW. The litigation process may affect people's motivation to RTW.     

Recovery and rehabilitation following traumatic brain injury

Although most patients are discharged following traumatic brain injury TBI with good recovery , recent reports indicate that many have persistent neuropsychological deficits. The purposes of this study were to 1 determine if functional, neuropsychological and social outcome at 3 and 6 months in patients hospitalized following TBI could be ascertained via telephone follow up, and 2 assess use of rehabilitation services in this population. Patients were identified through acute hospital admissions. A trained nurse practitioner abstracted data from acute charts. Using the Functional Independence Measure FIM , Neurobehavioral Rating Scale NRS , Telephone Interview for Cognitive Status TICS , and a social questionnaire she obtained follow up information at 3 and 6 months post injury. Of 74 patients initially identified, 51 and 48 were available at 3 and 6 months, respectively. Most experienced mild to moderate TBI. Physical disability was minimal at follow up as indicated by the FIM. Approximately half of the patients were rated cognitively impaired on the TICS at 3 months and over one third remained impaired at 6 months. At 6 months 60.5% remained unemployed. Only eight of the 67 discharged survivors received any rehabilitation services. A brief telephone follow up appears to be a cost effective way to ascertain functional and neuropsychological outcome in TBI survivors. Since few of these patients received rehabilitation, a telephone follow up may identify those who would potentially benefit from additional rehabilitation services.     

Return to work for a company president with traumatic brain injury

Return to work remains a central issue for many traumatic brain injury (TBI) patients. The present literature generally ignores the complex work issues involved for high-functioning individuals, in whose hands may lie the fate of many other workers. This case discusses return-to-work challenges facing a 64-year-old high-technology company founder and president. Following a bicycling accident, he sustained intracerebral hemorrhage with an initial Glasgow Coma Scale of score 12. Although postmorbidly he still maintained a relatively high level of cognitive functioning, his case highlights special challenges during workplace rehabilitation of patients with cognitively demanding jobs, including (a) a higher potential for patient frustration given the gap between function and job expectations and (b) confidentiality issues regarding business employees and competitors. Rehabilitation health care providers can benefit from lessons learned here, including tapping into these patients' strong motivation for return to work, accessing the likely higher remaining cognitive level, and drawing upon the likely strong social and professional networks available. Finally, the importance of the role of stress-management techniques in order to cope with high frustration levels is highlighted.     

Amantadine to enhance readiness for rehabilitation following severe traumatic brain injury

PRIMARY OBJECTIVE: To evaluate the association between amantadine and recovery of consciousness from prolonged traumatic coma. RESEARCH DESIGN: A retrospective cohort study. METHODS: Subjects included 123 adults with severe traumatic brain injury (TBI) admitted over a 10-year period who remained in coma despite becoming medically stable. EXPERIMENTAL INTERVENTIONS: Cases received 100-200 mg of amantadine twice daily. MAIN OUTCOMES AND RESULTS: 46.4% (13/28) of cases emerged from coma compared to 37.9% (36/95) of controls (p = 0.42). Somatosensory evoked potential (SSEP) was the only significant predictor of emergence from coma (p = 0.02), while SSEP, age and Glasgow Coma Score (GCS) significantly predicted time to emerge from coma (p < 0.05). CONCLUSIONS: Although the study and its design do not support the view that amantadine has an effect on recovery of consciousness; it remains safe, inexpensive and has few side effects. The lack of treatment alternatives and anecdotal support for its use may warrant further study. Prospective controlled trials would yield more definitive results.     

Community integration following multidisciplinary rehabilitation for traumatic brain injury

Primary objective : To determine the extent to which participation in a multidisciplinary rehabilitation programme and patient characteristics predict improvement in community integration following mild-to-moderate traumatic brain injury (TBI).

Research design : A non-randomized case-control study was conducted employing a pre-test-post-test multiple regression design.

Methods and procedures : Archival data for 42 patients with mild-to-moderate TBI who completed the Community Integration Questionnaire (CIQ) at intake and again 6-18 months later were analysed. Half the sample participated in an intensive outpatient rehabilitation programme that provided multi-modal interventions, while the other half received no rehabilitation. The two groups were matched on age, education and time since injury.

Results : On the CIQ Home Integration scale, participation in rehabilitation and female gender predicted better outcome. On the Productivity scale, patients with a lower age at injury had better outcome. Outcome on both of these scales, as well as on the Social Integration scale, was predicted by the baseline pre-test score (initial severity).

Conclusions : Overall, multidisciplinary rehabilitation appeared to increase personal independence. It is also concluded that: (1) multivariate analysis can reveal the relative importance of multiple predictors of outcome; (2) different predictors may predict different aspects of outcome; and (3) more sensitive and specific outcome measures are needed.     

Self-awareness following traumatic brain injury and implications for rehabilitation

Primary objective : Many studies investigating self-awareness following traumatic brain injury (TBI) have been conducted more than 2 years post-injury, thereby providing limited information regarding the implications of insight for rehabilitation. The present study aimed to investigate awareness of deficits in a group of patients who were less than 2 years post-injury and still involved in rehabilitation.

Research design : Thirty patients with a history of moderate or severe TBI and their significant other (SO) were studied in a cross-sectional analysis. A sub-group also participated in an interdisciplinary Memory Group at the Bethesda Rehabilitation Centre.

Methods and procedures : Level of insight was measured by the degree of agreement between self and significant other (SO) report on the Awareness of Deficit questionnaire (ADQ), assessing various domains of daily functioning.

Results : There was substantial agreement between patients and their SO, although the patients with TBI were less likely to acknowledge executive problems. Interestingly, both groups reported only low-to-moderate levels of difficulty.

Conclusions : The data indicate that SO's awareness may also be limited in the early recovery stages. A sub-group of the patients obtained benefit from participation in the Memory Group in a rehabilitation setting.     

Communication abilities and work re-entry following traumatic brain injury

This exploratory study was completed to determine if communication measures could discriminate employed from unemployed individuals with traumatic brain injury (TBI). Twenty adults with TBI participated, 10 employed and 10 unemployed; subjects in both groups were 1-4 years post-injury, with comparable severity of injury and type of work. Subjects were administered communication tests measuring auditory processing, effects of speaking under time pressure, production of oral language, and functional verbal reasoning ability. An aphasia test and a functional outcome measure were also administered. Results revealed that a combination of three tests, one test of functional verbal reasoning and two tests of auditory processing, correctly classified 85% of subjects as employed or unemployed. Tasks that were impairment- and disability-based appear to be more related to outcome than impairment-level tasks alone. Impairment and disability level communication tasks may provide functional and practical information, which could assist in work re-entry.     

Return to work after spinal cord injury

OBJECTIVE: To describe predictors of return to work after spinal cord injury (SCI), in particular the physical intensity of the pre-injury job. STUDY DESIGN: Survey. SETTING: Patients' home. METHODS: We interviewed 234 persons with a spinal cord injury (SCI) between 18 and 65 years of age and who were gainfully employed at the time of the injury. Possible predictors were tested with logistic regression analyses. RESULTS: After the SCI, only 37% of the persons were gainfully employed. People with heavy and strenuous physical work pre-injury regained work in only 25%, respectively 21%. Being male (Odds Ratio (OR) 3.70), light to moderate physical job pre-injury (OR 3.16), high Barthel Index (OR 2.76), high educational level (OR 2.12) and education post-injury (OR 2.14) were significant predictors for returning to gainful work after injury. Many unemployed persons thought they were capable of working. CONCLUSIONS: Only a minority returned to gainful employment after SCI even to a physically less demanding job. In addition to intensive inpatient re-education, long-term support in job seeking is very important, including switching to a less demanding job.     

Return to work after foot and ankle injury

A surgeon faces important issues when returning a patient to the workplace, including workers' compensation issues and the need for physician guidance. These patients deserve appropriate diagnosis and treatment protocols, and the other members of the workers compensation treatment team can help maximize the effects of careful guidance by a physician. The speediest possible return to the workplace is usually best for all concerned, the injured worker, the employer and the physician. The treatment team within the workers' compensation system assists in the facilitation and coordination of the medical care and assists in bringing the patient back to work. The team includes the nurse case manager, the insurer, and physical and occupational therapists. Appropriate use of work hardening programs or functional capacity evaluations can be valuable in the return-to-work effort. Physicians who make use of these resources may find it easier to guide this process efficiently to achieve the desired outcome of return to work of the injured worker.