Productivity

Productivity following ABI is inclusive of paid employment, educational pursuits, and volunteer work.  A large number of studies on community reintegration are concerned with productivity given that patients tend to be of employment age, the data is accessible, and the costs are tangible. A focus on vocational goals is usually desired by the participating individual, facilitated by the consulting clinicians in an attempt to promote autonomy, and promoted by the funding body/payer. Unlike several other indices of outcomes in the domain of community reintegration, vocational outcomes are clearly linked to financial indices and vulnerable to financial pressures.

Vocational success has significant implications for life satisfaction following ABI. Decreased life satisfaction has been associated with unemployment and passive uninvolved lifestyles following ABI (Melamed et al. 1992). Life satisfaction following ABI may be directly related to employment status and social integration (Corrigan et al. 2001; Tennant et al. 1995). Brain injury can deprive individuals from participating in gainful and challenging employment and achieving social and financial stability, thus fostering feelings of despair. Both depression and anxiety are more common among individuals who are unable to return to work or who cannot find work post ABI (McCrimmon & Oddy 2006; Ponsford & Spitz 2015).This section will address the studies dealing with vocational rehabilitation for individuals with ABI. 

Individual Studies

Table: Productivity Following ABI (Non-Intervention Studies)

Discussion

Following ABI, there are significant declines in rates of productivity, employment, and schooling. Rates of resuming education following ABI ranged from 44% to 75% (Avesani et al. 2005; Kennedy et al. 2008; Todis et al. 2011). Todis et al. (2011) found that 74.2% of individuals with ABI had received special education services while in school, and that those injured later in life were more likely to receive post-secondary education. Kennedy et al. (2008) found that many individuals needed to change their academic status (68%), their major (44%), and/or the college they attended (33%). For those that did return, 61% needed to review material more frequently than they needed to prior to their injury. Further, issues with understanding instructions, retaining information, and time management posed further challenges to returning students.

At one year post injury, employment rates ranged between 27.8% and 66.5% (Andelic et al. 2012; Avesani et al. 2005; Dikmen et al. 1994; Forslund et al. 2014; Forslundet al. 2013; Huebner et al. 2003; Johnson 1998; Jourdan et al. 2013; Ketchum et al. 2012; Klonoff et al. 2001; Klonoff et al. 1998; Ponsford & Spitz 2015; Rietdijk et al. 2013; Walker et al. 2006). At two years, there was slight increase in rates to a range between 37% and 72% (Cifu et al. 1997; Dikmen et al. 1994; Forslund et al. 2014; Forslund, Røe, et al. 2013; Ponsford & Spitz 2015). Subsequently, between 55% and 58.5% of individuals were found to be employed three years after injury (Grauwmeijer et al. 2012; Johnson 1998; Ponsford & Spitz 2015). Those who resume vocational activities often do so at a lesser capacity compared to their pre-injury levels of employment. Between 40% and 75% of the individuals resuming work went to the same employer, although 30% to 50% were in an adapted or lesser position (Grauwmeijer et al. 2012; Jourdan et al. 2013; Klonoff et al. 2001; Rietdijk et al. 2013).

The factors that influence return to productivity have been well-studied in individuals with ABI. Those with better injury severity indicators (e.g., admission Glasgow Coma Scale scores, Glasgow Outcome Scale scores, Injury Severity Scores) (Andelic et al. 2012; Avesani et al. 2005; Forslund et al. 2014; Forslund, Røe, et al. 2013; Jourdan et al. 2013; Lexell et al. 2016) and better functional recovery (Avesani et al. 2005; Grauwmeijer et al. 2012; Huebner et al. 2003; Ketchum et al. 2012; Klonoff et al. 1998) were more likely to return to the workforce. Additionally, those who returned to work were younger (Forslund et al. 2014; Jourdan et al. 2013; Klonoff et al. 2001; Lexell et al. 2016; Lustig et al. 2003), were in relationships (Forslund et al. 2014; Lexell et al. 2016), had shorter lengths of post traumatic amnesia (Avesani et al. 2005; Johnson 1998; Ketchum et al. 2012), had shorter lengths of stay in hospital (Avesani et al. 2005; Jourdan et al. 2013; Ketchum et al. 2012; McCrimmon & Oddy 2006), and had fewer cognitive deficits (Ponsford & Spitz 2015; Rietdijk et al. 2013). Pre-injury employment and education are also influential factors in return to work. Higher education and more professional positions prior to injury were associated with increased rates of employment post injury (Forslund et al. 2014; Ketchum et al. 2012; Ponsford & Spitz 2015). 

 

 

Following ABI, those who resume productive activities typically return to lower levels of employment or education, and only a small number are able to return to activities that are comparable to pre-injury levels.

Return to work is influenced by age, injury severity, relationship status, functional and cognitive abilities, and as well as pre-injury employment and education.

 

Intervention Studies Exploring Productivity Following ABI 

Table: Intervention Studies Exploring Productivity Following ABI 

Discussion

Various studies within this section have reported improvements in competitive job placement and retention because of supported employment strategies. The most important aspect of this vocational intervention seems to be on-site job training provided by vocational rehabilitation experts. As suggested by the findings of Wall et al. (1998), increased job success may be achieved through community based vocational training programs which combine the concepts of work adjustment and supported employment. Participants have shown to increase employment success and satisfaction when techniques that foster self-confidence were used, instruction and adjustments were given for specific work tasks, and a job coach was available to minimize interpersonal problems (Wall et al. 1998).

Numerous studies have reported improvements in return to work and competitive job placement as a result of vocational interventions, which are often in tandem with improved productivity, participation, independence, and integration. Programs such as vocational rehabilitation (Bonneterre et al. 2013; Buffington & Malec 1997; Radford et al. 2013), resource facilitation (Backhaus et al. 2010; Trexler et al. 2016), community reintegration  (De Kort et al. 2002; Geurtsen et al. 2008; Geurtsen et al. 2012; Malec & Moessner 2000), problem-solving (Man et al. 2013), goal-setting (Bergquist et al. 2012), and mentoring (Kolakowsky-Hayner et al. 2012) have all shown to be effective in improving vocation-related outcomes. Specialized programs that provide supported employment and on-site job training are particularly effective (Wall et al. 1998; Watanabe 2013). However, Malec and Degiorgio (2002) found that specialized vocational rehabilitation was not improved by the addition of community reintegration services or comprehensive day treatment, as each intervention yielded similar outcomes.

The timing of the interventions may play a role in returning to vocational activities as well.  Buffington and Malec (1997) found that patients who received vocational services within the first 12 months post injury had more opportunities and found independent job placements more quickly than those who received the same services more than 12 months post injury. This study suggests that vocational rehabilitation strategies should be implemented as early as possible to improve the likelihood of successful vocational reintegration.

Conclusions

There is Level 2 evidence that cognitive strategies increase the proportion of patients who successfully return to full time vocational activities following brain injury.

There is Level 1b evidence that resource facilitation programs improve vocational outcomes post ABI when compared to standard care.

There is Level 3 evidence that supported employment strategies post ABI result in improvements in competitive job placement and retention.           

There is Level 4 evidence that vocational rehabilitation strategies are more effective when they are implemented earlier following the injury.

There is Level 4 evidence the community reintegration programs post ABI result in increased employability, independence, and participation.

 

Vocational rehabilitation and resource facilitation programs increase the number of individuals that return to vocational activity.

Vocational rehabilitation is most effective when implemented earlier following injury.

Supported employment interventions improve job placement and retention post ABI.