Case Study (continued)
As mentioned earlier, at 6 month follow-up the patient has not yet returned to work as an engineer in a large factory. He has been employed at this job for the past 4 years. He wants to return to work but is worried about fatigue and some anxiety. His wife still complains he has short-term memory problems and does not communicate as well as pre-accident. His employer is willing to consider a return to work plan and make appropriate adjustments or work modifications but wants medical clearance that he is in fact able to successfully return to work.
5.7.1 Impact of ABI on Work
What is the impact of an ABI on employment and productivity?
Individuals with an ABI suffer significant declines in employment and productivity.
- The more severe the ABI the less likely the patient will return to work.
Individuals who suffer an ABI experience significant declines in their employment and productivity rates following their injury.
One study looking at the expected rate of return to work found reported that 66.5% of all patients (regardless of severity) returned to work 1 year after TBI, while 72% return to work 2 years after the injury 7.
In those who sustained severe injuries, only 37% return to work 2 years after the injury 7.
Cifu et al.8reported that persons with better injury severity indicators (e.g., admission GCS) are more likely to return to the workforce; however findings also suggest of patients who were productive before the injury, only 37% were productive 1-2 years after injury.
For a more detailed discussion on employment and productivity post ABI please see ERABI/Community Reintegration Post ABI.
5.7.2 Impact of Work on Life Satisfaction Post ABI
What is the impact of return to employment on life satisfaction following ABI?
Successful return to work is associated with improved life satisfaction following ABI.
- Failure to achieve gainful and challenging employment is associated with decreased life satisfaction.
Vocational success has significant implications for life satisfaction following ABI.
Decreased life satisfaction has been associated with unemployment, and with passive uninvolved lifestyles following ABI 9.
Life satisfaction following ABI seems to be directly related to employment and social integration10;11.
In some Western societies, participation in employment starting in young adulthood is promoted as a means of achieving social and financial stability.
Brain injury often deprives individuals from participating in gainful and challenging employment, thus isolating brain injury survivors from the rest of society and fostering feelings of despair and worthlessness.
For more discussion on return to work post ABI please see ERABI/ Community Reintegration Post ABI.
5.7.3 The Type of Work ABI Patients Return To
After an ABI do patients eventually return to similar vocational activities?
- Following ABI, those patients who reintegrate into vocational activities return to lower levels of employment or schooling, and only a small number are able to return to vocational activities which are comparable to pre-morbid levels.
Oftentimes, following brain injury, those who resume vocational activities must return to lower levels of employment or academics.
Only a small number are able to return to their prior jobs or to school at levels comparable to their pre-morbid status.
- In a cohort study conducted by Walker et al. 12, the greatest success in returning to work following an ABI was found for those in the professional/managerial job category.
5.7.4 Vocational Rehabilitation Post ABI
Case Study (continued)
The specialist who is managing the patient is concerned that the patient is not yet ready to return to work and recommends vocational rehabilitation.
For ABI patients seeking to return to employment, what are the elements of vocational assessment?
Evaluation of individual vocational and educational needs.
Identification of barriers to successful return to work.
Direct liaison with employers to discuss the special needs of the ABI individual.
Evaluation of the workplace.
Determination of work modifications.
- Ongoing follow-up.
According to ABIKUS Recommendations 13
Patients seeking a return to employment, education or training should be assessed by a professional or team trained in vocational needs following brain injury. Assessment should include:
- Evaluation of their individual vocational and/or educational needs
- Identification of difficulties which are likely to limit the prospects of a successful return and appropriate intervention to minimize them
- Direct liaison with employers (including occupational health services when available), or education providers to discuss needs and the appropriate action in advance of any return
- Evaluation of environmental factors, workplace, psychosocial aspects including social environment and work culture
- Verbal and written advise about their return, including arrangements for review and follow-up (ABIKUS C, adapted from RCP, G159, p.50) (G93-p.32)
Clinicians involved in brain injury rehabilitation should consider vocational needs and put patients in touch with the relevant agencies as part of their routine planning, and refer where appropriate, to a specialist vocational rehabilitation program (ABIKUS C, adapted from RCP, G158, p.50) (G94-p.32)
In setting up placement into a long-term job, monitoring should be provided for at least six months or longer to respond to any emergent difficulties, with a follow-up thereafter to establish the long-term viability of the placement. (ABIKUS C, adapted from RCP, G164, p.51)
How effective is vocational rehabilitation post ABI?
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 3 evidence (from one Case-Control study) that supported employment strategies following brain injury cause improvements in competitive job placement and retention.
Participation within groups that provide cognitive strategies which can be applied to the work place seem to increase the proportion of brain injury survivors who successfully return to full time employment 14.
Cognitive strategies, such as the problem solving techniques, seem to improve the level of employment success once a person has obtained employment 15.
The model of supported employment emphasizes job development, job placement, on-site job training, and retention services to ensure the successful return to employment following brain injury.
The most important aspect of this vocational intervention seems to be on-site job training provided by vocational rehabilitation experts.
- Increased job success may be achieved through community based vocational training programs which combine the concepts of work adjustment and supported employment16.
How important is the timing of vocational rehabilitation post ABI?
- There is Level 4 evidence that vocational rehabilitation strategies are more effective when they are implemented earlier following the injury.
The timing of vocational interventions also seems to play a key role on the successful reintegration into vocational activities.
Buffington and Malec 17found that patients who received vocational services at 12 months or less following their injuries, had significantly faster and more independent job placements than those who received the same services > 12 months after their injuries.
These study results suggest that vocational rehabilitation strategies should be implemented as early as possible to improve the likelihood of successful vocational reintegration.
For more details please see ERABI/Community Reintegration Post ABI.