The meaning of work after acquired brain injury.

PURPOSE: Research in the field of brain injury rehabilitation has tended to regard return to work as a measure of outcome. Researchers have not paid particular attention to the experiences of people living with a brain injury. The aim of the phenomenological study reported here was to identify and describe what characterizes the meaning of work to those with acquired brain injury. METHODS: Ten participants of working age were interviewed about the meaning of work 1-5 years after being inflicted with a brain injury. Data were analyzed and interpreted using the Empirical Phenomenological Psychological method. RESULTS: The findings revealed a meaning structure consisting of four main characteristics. Work was no longer experienced as the primary event in life and the social dimension had become more important. The perceived competence and work identity were threatened after the injury. A common theme across all interviews was the struggle to return to a state of normality, and working was considered to be evidence of success. CONCLUSION: The findings described the altered meaning of work 1-5 years after brain injury. This knowledge should lead to an increased understanding among occupational therapists engaged in work rehabilitation after brain injury and can serve as a basis for individualized intervention strategies.     

Returning to school after a spinal cord injury: perspectives from four adolescents.

A phenomenological approach was used to explore the experience of returning to school following a spinal cord injury. Four adolescents who sustained spinal cord injuries and returned to premorbid school environments were interviewed concerning their perceptions, feelings, and experiences of returning to school. The responses were coded into six themes: people, role change, self-image, coping strategies, accessibility, and feelings. The themes were discussed as to their relevance on returning to school following a spinal cord injury. The research participants' suggestions on ways to ease the transition from the rehabilitation environment to the school environment and implications of the study are included.     

Fitting back in: adolescents returning to school after severe acquired brain injury

Purpose. To explore the experiences of Australian adolescents with severe acquired brain injury (ABI) and their families as the adolescent returned to school. In particular, to understand the influence of services and support on the school return.

Method. In-depth interviews conducted over a two-year period with families who had an adolescent with a recent severe ABI (mean age 15 years, 11 months) analysed using a grounded theory approach.

Results. Two critical phases for adolescents returning to school post ABI were identified: organizing the school return and being back at school.Experience in these phases was influenced by length of school absence, extent of noticeable and hidden problems and school response to the students' return post injury. The central concept characterizing experience was the challenge of fitting back in. Some adolescents fitted back in adequately and continued school participation. Those that did not fit in tried again by revisiting the organizing phase, re-evaluated their school experience and either continued or left school.

Conclusions. Adolescents with ABI faced the challenge of fitting back in when they returned to school. This was either facilitated or hindered by the extent and quality of organization, communication and support from parents, schoolteachers and the rehabilitation team.     

Traumatic brain injury is under-diagnosed in patients with spinal cord injury.

OBJECTIVE: To investigate the occurrence and severity of traumatic brain injury in patients with traumatic spinal cord injury. DESIGN: Cross-sectional study with prospective neurological, neuropsychological and neuroradiological examinations and retrospective medical record review. PATIENTS: Thirty-one consecutive, traumatic spinal cord injury patients on their first post-acute rehabilitation period in a national rehabilitation centre. METHODS: The American Congress of Rehabilitation Medicine diagnostic criteria for mild traumatic brain injury were applied. Assessments were performed with neurological and neuropsychological examinations and magnetic resonance imaging 1.5T. RESULTS: Twenty-three of the 31 patients with spinal cord injury (74%) met the diagnostic criteria for traumatic brain injury. Nineteen patients had sustained a loss of consciousness or post-traumatic amnesia. Four patients had a focal neurological finding and 21 had neuropsychological findings apparently due to traumatic brain injury. Trauma-related magnetic resonance imaging abnormalities were detected in 10 patients. Traumatic brain injury was classified as moderate or severe in 17 patients and mild in 6 patients. CONCLUSION: The results suggest a high frequency of traumatic brain injury in patients with traumatic spinal cord injury, and stress a special diagnostic issue to be considered in this patient group.     

The relationship between post-traumatic growth and return to work following mild traumatic brain injury

Abstract

Purpose: To investigate the prevalence of post-traumatic growth (PTG) following mild traumatic brain injury (mTBI) and to examine whether PTG is associated with vocational status.

Materials and methods: Archival data from a random sample of 74 individuals who sustained mTBI (mean age: 43.23; male, 55%) were obtained from a larger sample of litigating patients who were referred for a neuropsychological examination. Factors associated with return to work were ascertained using a multiple regression analysis. The demographic variables age, sex, and education were added to the first block, whilst relating to others, new possibilities, personal strength, spiritual change, and appreciation of life, as measured by the Posttraumatic Growth Inventory (PTGI), were added in the second block.

Results: Approximately 31% of the sample exhibited moderate levels of PTG, as defined by endorsing a 3 or more on each item of the PTGI, with the most common aspects of PTG being appreciation of life, relating to others, and personal strength. The multiple regression analysis revealed that new possibilities and personal strength were independently associated with return to work.

Conclusions: Results of this study suggest that there is evidence for the development of PTG among individuals with mTBI. These findings have important implications for rehabilitation planning, individual and family adjustment, and the prediction of long-term outcome as it pertains to return to work in particular.

• Implications for Rehabilitation

• Return to work is an integral component of rehabilitation following mild traumatic brain injury (mTBI) and should not be overlooked.

• Results of this study indicate that post-traumatic growth (PTG) can be used to inform intervention approaches that seek to promote growth and resiliency post-injury.

• Informing patients about the prospects of a positive post-injury recovery trajectory could help manage the individual’s expectations of recovery.

     

Return to work after spinal cord injury in Taiwan: the contribution of functional independence

OBJECTIVE: To study the employment rate and determinants of return to work for persons with traumatic spinal cord injury (SCI) in Taiwan. DESIGN: Cross-sectional. SETTING: Taiwan community. PARTICIPANTS: One hundred sixty-nine people who had sustained traumatic SCI, had been completely rehabilitated in a university hospital between 1989 and 2002, and who were between 18 and 60 years of age at the time of interview in 2003. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: A structured questionnaire was used to identify demographic and injury-related status, functional status, and pre- and postinjury work-related information. RESULTS: At the time of survey, only 47% of the participants were engaged in remunerative employment. Cox regression analysis, with time elapsed between injury and survey as the underlying time axis, showed that education and functional independence were associated with employment. Subjects with a high school education had a 2.2-fold higher chance (95% confidence interval [CI], 1.3-3.8) of returning to work than those without. Subjects with higher scores on the Barthel Index and ability to use public or private transport independently had a 2.7-fold higher chance (95% CI, 1.5-4.9) of returning to work than those unable to travel independently. Other factors significantly associated with employment included marital status, with marriage having a favorable influence; age at injury, with age below 25 years being favorable; preinjury occupation; and vocational training after injury. The importance of functional independence training in rehabilitation is stressed. CONCLUSIONS: Functional independence was a strong factor predicting return to work. Rehabilitation focused on education, vocational training, self-care ability, community mobility, and environmental modifications could improve employability after SCI.     

In the line of fire: traumatic brain injury among Iraq War veterans

Soldiers returning home from Iraq are experiencing an increased number of head injuries related to blasts and explosions compared to soldiers of previous conflicts. These injuries are often undetected until the soldiers return home and have difficulty functioning as they did prior to the war. It is therefore important for occupational health nurses to understand blast injury, its pathophysiology, methods for detecting traumatic brain injury, and how these soldiers can be treated.     

Adapting multiple-family group treatment for brain and spinal cord injury intervention development and preliminary outcomes

OBJECTIVE: There is a need for interventions that assist in managing the multiple adjustments of persons with spinal cord and brain injuries and their families. The purpose of the present field-initiated development project was to adapt a family psychoeducation model, multiple-family group treatment (MFGT), for persons with brain and spinal cord injury and their families. DESIGN: The experiences of survivors and caregivers in MFGT were evaluated using quantitative and qualitative methods. Twenty-seven survivors and 28 caregivers participated in MFGT for 12-18 mos. Reliable and valid quantitative measures were used to assess a variety of target outcomes. Additionally, semistructured interviews and focus groups were conducted with participants. RESULTS: Survivors reported a decrease in depressive symptoms and anger expression toward others as well as an increase in life satisfaction. Caregivers reported a significant reduction in burden. The themes derived from the qualitative analysis addressed the normalization of the caregiving experience, importance of socialization, improvement in a variety of coping skills, and education about the injuries. CONCLUSIONS: The findings support the adaptation of MFGT for brain and spinal cord injuries.     

Fitting back in: Adolescents returning to school after severe acquired brain injury

Purpose.?To explore the experiences of Australian adolescents with severe acquired brain injury (ABI) and their families as the adolescent returned to school. In particular, to understand the influence of services and support on the school return.

Method.?In-depth interviews conducted over a two-year period with families who had an adolescent with a recent severe ABI (mean age 15 years, 11 months) analysed using a grounded theory approach.

Results.?Two critical phases for adolescents returning to school post ABI were identified: organizing the school return and being back at school.Experience in these phases was influenced by length of school absence, extent of noticeable and hidden problems and school response to the students' return post injury. The central concept characterizing experience was the challenge of fitting back in. Some adolescents fitted back in adequately and continued school participation. Those that did not fit in tried again by revisiting the organizing phase, re-evaluated their school experience and either continued or left school.

Conclusions.?Adolescents with ABI faced the challenge of fitting back in when they returned to school. This was either facilitated or hindered by the extent and quality of organization, communication and support from parents, schoolteachers and the rehabilitation team.     

Return to work following traumatic brain injury: Trends and challenges

Purpose. The aim of this paper is to present the current knowledge regarding return to work (RTW) following traumatic brain injury (TBI).

Method. Based on a Medline search, the authors reviewed the current TBI rehabilitation literature regarding (a) predictive factors for successful RTW, and (b) current concepts in rehabilitative strategies for successful RTW.

Results. The functional consequences to the victim of traumatic brain injury (TBI) can be severe. Intensive rehabilitative efforts typically emphasize the early phase and address mainly the accompanying functional deficits in the realm of basic activities of daily living and mobility. An otherwise successful medical rehabilitation may end unsuccessfully because of the failure to return to work, with profound consequences to the individual and family, both economic and psychosocial. Even mild TBI may cause lasting problems in tasks calling for sustained attention. There appears to be a complex interaction between pre-morbid characteristics, injury factors, post injury impairments, personal and environmental factors in TBI patients, which influences RTW outcomes in ways that make prediction difficult. Injury severity and lack of self-awareness appear to be the most significant indicators of failure to RTW. Several medical, psychosocial and rehabilitative therapies are currently being implemented in rehabilitation settings which improve the chances of returning to work.

Conclusion. Accurate prediction of whether a particular TBI patient will successfully return to work is not feasible, with RTW rates in the 12 – 70% range. A significant proportion of TBI patients, including those who are severely injured, are able to return to productive employment if sufficient and appropriate effort is invested. A comprehensive approach – medical and psychosocial – eventually entailing adequate vocational rehabilitation with supported employment can improve outcomes.     

Spinal cord injury and concomitant traumatic brain injury. Results of a longitudinal investigation

One-hundred fifty persons with traumatic onset spinal cord injury (SCI) were administered a comprehensive neuropsychologic test battery an average of 7 weeks after SCI, and 67 were retested using the same battery an average of 38 weeks after initial testing. It was hypothesized that if traumatic brain injury were a significant sequela of SCI, retesting would reveal evidence of cognitive recovery over time and would further enable a clearer separation of preinjury cognitive capacity from the effects of injury. Significant improvement in test performance occurred across time to the degree and in a pattern similar to that noted in persons who have sustained mild to moderate traumatic brain injury. Hypothesized relationships between level and extent of SCI, etiology of injury and presence/absence of loss of consciousness and neuropsychologic test scores were not observed. Implications for the rehabilitation process are discussed.     

Outcome after mild to moderate traumatic brain injury: the role of dizziness

OBJECTIVE: To assess the specific effect of dizziness on psychosocial outcome after mild to moderate traumatic brain injury (TBI). DESIGN: Six-month cross-sectional study. Setting An outpatient TBI clinic in a tertiary care referral center. Participants A consecutive sample of 207 adults with mild to moderate TBI, 138 (66.7%) of whom had subjective complaint of posttraumatic dizziness. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Psychosocial indices (Glasgow Outcome Scale [GOS], General Health Questionnaire [GHQ], Rivermead Head Injury Follow-Up Questionnaire [RHFUQ], return to work status) were collected from dizzy and nondizzy patients. RESULTS: Despite similar demographic, TBI, and global disability (GOS) profiles of both groups, psychosocial functioning (GHQ, RHFUQ, return to work) was significantly worse in dizzy subjects ( P <.01 for all indices). A logistic regression analysis identified dizziness ( P =.006), total GHQ ( P =.001), and psychotropic and analgesic use ( P =.05) as significant independent predictors of reemployment. CONCLUSIONS: Although dizziness was closely linked to psychologic distress at 6 months after head injury, it also emerged as an independent predictor of failure to return to work, suggesting that not all its adverse effects on outcome are psychologically mediated. Clinicians need to be alert to the presence of dizziness as an adverse prognostic indicator after mild to moderate TBI.     

Interest of workplace support for returning to work after a traumatic brain injury: A retrospective study

ObjectiveTo analyse usefulness of the SPASE programme, a coordinated facility programme to assist traumatic brain injury (TBI) persons in returning to work and retaining their job in the ordinary work environment.DesignA retrospective study including 100 subjects aged over 18 who had suffered traumatic brain injury (GOS 1 or 2). The criterion for return to work (RTW) success was the ability to return to the job he/she had before the accident or to a new professional activity.ResultsFactors associated with RTW success were at short-term (2–3 years): the presence of significant workplace support OR = 15.1 [3.7–61.7], the presence of physical disabilities OR = 0.32 [0.12–0.87] or serious traumatic brain injury OR = 0.22 [0.07–0.66]. At medium-term (over 3 years) these factors were: significant workplace support OR = 3.9 [1.3–11.3] and presence of mental illness OR = 0.15 [0.03–0.7].ConclusionThis study suggests that a case coordination vocational programme may facilitate the return and maintain to work of TBI persons. It reveals that the workplace support is a key factor for job retention in the medium-term.     

The complexity of participation in daily life: a qualitative study of the experiences of persons with acquired brain injury

OBJECTIVE: To describe and enhance the understanding of how adults with acquired brain injury experience participation in daily life. PATIENTS AND METHODS: Qualitative interviews with 11 persons of working age with acquired brain injuries were analysed using qualitative content analysis. RESULTS: The informants' experiences formed 5 categories: "Performing tasks"; "Making decisions and exerting influence"; "Being engaged in meaningful activities"; "Doing things for others"; and "Belonging". The categories that needed to be present for the informants to experience a feeling of participation varied according to their individual daily life situations. In addition, their experiences showed that a variety of conditions, related to each of the 5 categories, influenced their participation. Individuals adopted a variety of strategies to enhance their experience of participation. CONCLUSION: The meaning of participation and the conditions and strategies influencing participation are complex. Many of the categories identified for participation can be understood only through subjective experience and cannot be captured by professionals' observation of the performance of activities. These results emphasize the importance of considering clients' unique experiences of participation when designing individually tailored rehabilitation programmes intended to enhance participation.     

Participation in the workforce after a traumatic brain injury: a matter of control

Purpose: This study sought to explore individual experience in developing a mastery of daily activities and roles after a traumatic brain injury (TBI) with the objective of returning to work. Method: Eight 30–60-year-old men, employed at the time of injury, were each interviewed three times over a 6-month period. Ten to 21 months after the injuries, four participants had returned to work at least part time. Grounded theory was adapted for analyses. Results: A single core category emerged: a desire for control: focusing on high-priority issues. Still, 2 years after injury, the participants were uncertain about their abilities with respect to what was expected of them at work. They felt they would do better as time progressed. Conclusions: The participants’ uncertainty about their efficacy cast doubt on their beliefs in improving their skills, balancing daily activities and work. They wondered about the sustainability of their health and efficacy at work. Wanting to control their own improvement, the participants asked for counselling in strategies and techniques to help with their progress. This issue could be taken into account in follow-up rehabilitation programmes. Additionally, the workplace might be the ideal context in which to develop the structures and routines necessary to master life in general.

• Implications for Rehabilitation

• Two years after injury, the participants remained uncertain about their abilities with respect to what was expected of them at work. The participants felt they would do better as time progressed.

• The participants, wanting to control their own improvement, sought counselling to help sort out their priorities and found it could contribute to help with their progress in finding a suitable balance between daily activities and work.

• A consequence of our main finding, in a multidisciplinary context, is that counselling in structures and routines with respect to work-related tasks should be considered to be an integral part of any rehabilitation programme after TBI.

     

Outcome after traumatic brain injury: effects of aging on recovery

OBJECTIVE: To identify differences in outcome after traumatic brain injury (TBI) compared with orthopedic injuries as a function of age. DESIGN: Longitudinal data analyses from an inception cohort. SETTING: Outpatient rehabilitation program. PARTICIPANTS: Eighty-two orthopedic injury patients and 195 TBI patients. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Independent living, employment, and level of functioning 1 to 2 years after injury. RESULTS: Older patients and those with TBI were more likely to have increased dependence postinjury. Older TBI patients were more likely to have changes in employment status compared with orthopedic injury patients younger or TBI. The Mayo-Portland Adaptability Inventory and Disability Rating Scale were moderately predictive of level of functioning, return to employment, and independent living status 1 to 2 years postinjury. Injury severity was only mildly predictive of outcome. CONCLUSIONS: The effect of age on outcome affects recovery from neurologic injuries and, to a lesser extent, orthopedic injuries. Outcome after TBI is best predicted by patients' age and estimates of level of function at discharge. Findings suggest that older patients and those with TBI have a greater likelihood of becoming physically and financially dependent on others. Rehabilitation efforts should focus on maximizing levels of independence to limit financial and emotional costs to patients and their families.     

Training in brain injury rehabilitation

Purpose: To evaluate our current training programme for professionals involved in brain injury rehabilitation, which involves disability simulation, and to consider the ethics and consequences of such programmes. Method: Seventy-two professionals took part in a brain injury disability simulation exercise and completed questionnaires pre and post the workshop. Results: Results suggest that participants have increased insight into the challenges faced by people with brain injuries. Conclusions: We believe that brain injury simulation exercises help professionals increase their understanding of the impairments and disabilities that may follow brain injury and can therefore form an important part of a training programme for rehabilitation staff.     

The meaning of living with traumatic brain injury in people with moderate or severe traumatic brain injury.

A traumatic brain injury (TBI) extensively affects the injured person's daily life. Research based on the perspectives of people with TBI can increase understanding of the challenges they face and the possibility of supporting them in managing their lives. The aim of this study was to elucidate the meaning of living with TBI as narrated by the people with moderate or severe TBI. The data were collected by means of qualitative research interviews with 12 participants who had lived with TBI for 4-13 years. A phenomenological hermeneutic method was used to interpret the transcribed interviews. The study showed that people with TBI had lost their way and struggled to achieve a new normalcy. Losing one's way included experiences of waking up to unknown, missing relationships and experiencing the body as an enemy. Participants' struggles to attain a new normalcy included searching for an explanation, recovering the self, wishing to be met with respect, and finding a new way of living. Living with TBI seems to mean living with a perpetually altered body that changed the whole life and caused deep suffering, where feelings of shame and dignity competed with each other. Participants seem to be quite alone in their suffering and need more support from healthcare professionals.