Employment After Traumatic Brain Injury: Predictors, Challenges, and Interventions Lynne C. Davis, Ph.D. Brain Injury Research Center TIRR Memorial Hermann

Employment After Employment After Traumatic Brain Injury: Traumatic Brain Injury: Predictors, Challenges, Predictors, Challenges,

and Interventionsand Interventions

Lynne C. Davis, Ph.D.Lynne C. Davis, Ph.D.Brain Injury Research CenterBrain Injury Research Center

TIRR Memorial HermannTIRR Memorial HermannHouston, TXHouston, TX

SponsorSponsor

Grant #:Grant #:H133B090023H133B090023, National , National Institute on Disability and Institute on Disability and Rehabilitation Research (NIDRR), U.S. Rehabilitation Research (NIDRR), U.S. Dept. of EducationDept. of Education

Learning ObjectivesLearning Objectives

Increase awareness about Increase awareness about traumatic brain injury (TBI):traumatic brain injury (TBI):– Define TBIDefine TBI– Incidence/prevalenceIncidence/prevalence– Common sequelaeCommon sequelae

Identify challenges and predictors Identify challenges and predictors of returning to work after TBIof returning to work after TBI

Identify 3 types of interventions to Identify 3 types of interventions to help persons with TBI return to help persons with TBI return to workwork

Overview of TBIOverview of TBI

What is a traumatic brain injury What is a traumatic brain injury (TBI)?(TBI)?

a mechanical force applied to the a mechanical force applied to the head that affects brain functioninghead that affects brain functioning

Common causes:Common causes:– falls falls – motor vehicle accidents motor vehicle accidents – struck by/against an object struck by/against an object – assaults assaults

Overview of TBI (cont’d)Overview of TBI (cont’d)

Types of TBI:Types of TBI:

Closed TBIClosed TBI: brain is injured without : brain is injured without penetration of the skullpenetration of the skull

Open TBIOpen TBI: brain is injured with : brain is injured with penetration of the skullpenetration of the skull


How common is TBI?How common is TBI?– 1.4 million TBIs annually in U.S. 1.4 million TBIs annually in U.S. – 75,000 to 80,000 new cases of 75,000 to 80,000 new cases of

disability each yeardisability each year– 5.3 million living with significant 5.3 million living with significant

disability as a result of TBIdisability as a result of TBI


Injury SeverityInjury Severity Refers to initial injury – not Refers to initial injury – not

outcomeoutcome Classification:Classification:

– Loss of consciousnessLoss of consciousness– Length of post-traumatic amnesiaLength of post-traumatic amnesia– Glasgow Coma Scale (GCS)Glasgow Coma Scale (GCS)


Mild TBIMild TBI– LOC<30 minLOC<30 min– GCS 13-15GCS 13-15

Moderate to SevereModerate to Severe– LOC > 30 min - hours, days, weeksLOC > 30 min - hours, days, weeks– GCS 9-12 = GCS 9-12 = ModerateModerate– GCS 3-8 = GCS 3-8 = SevereSevere


Recovery CourseRecovery Course Every injury differentEvery injury different Every recovery can be different as Every recovery can be different as

wellwell Mild TBI:Mild TBI:

– Most rapid in first few weeksMost rapid in first few weeks– At 3 months most feel “back to normal”At 3 months most feel “back to normal”– If continued problems, likely to improve If continued problems, likely to improve

over the first yearover the first year


Moderate/Severe TBI:Moderate/Severe TBI:– Most rapid changes seen in first 6 Most rapid changes seen in first 6

monthsmonths– Continue to see changes in first 1-2 Continue to see changes in first 1-2

years, with changes slowing down years, with changes slowing down over timeover time

– Functional improvements possible at Functional improvements possible at any time after injury: use of any time after injury: use of compensatory strategies and supportscompensatory strategies and supports


Common problemsCommon problems:: SensorySensory MotorMotor CognitiveCognitive Emotional/BehavioralEmotional/Behavioral


SensorySensory – Headaches Headaches – Fatigue Fatigue – DizzinessDizziness– Blurred or double vision Blurred or double vision – Sensitivity to noise/light Sensitivity to noise/light – Trouble with taste or smell Trouble with taste or smell


MotorMotor– Weakness/paralysis and spasticity Weakness/paralysis and spasticity – Slowed performance Slowed performance – Poor coordination/balance Poor coordination/balance – Slurred speech Slurred speech


CognitiveCognitive– Attention/concentration Attention/concentration – Memory Memory – Slowed information processing speed Slowed information processing speed – Problem-solving difficulties Problem-solving difficulties – Organizational difficulties Organizational difficulties


Emotional/BehavioralEmotional/Behavioral– Decreased initiation Decreased initiation – Lack of awareness Lack of awareness – Impulsivity Impulsivity – Depression Depression – Irritability/anger Irritability/anger – Emotional lability Emotional lability

Return to Work (RTW): Return to Work (RTW): Facts, Challenges and Facts, Challenges and

PredictorsPredictors TBI is one of the leading causes of TBI is one of the leading causes of

disability among young persons of disability among young persons of working age in the U.S.working age in the U.S.

Total lifetime productivity losses Total lifetime productivity losses are estimated at $51.2 billion.are estimated at $51.2 billion.11

Only about 30-40% of persons Only about 30-40% of persons with moderate to severe TBI with moderate to severe TBI return to work after injury.return to work after injury.22


Predictors (cont’d)Predictors (cont’d)

Persons with TBI identify RTW as a Persons with TBI identify RTW as a primary need after injury.primary need after injury.

Employment provides economic and Employment provides economic and social benefits after TBI.social benefits after TBI.

Rates of depression are lower for Rates of depression are lower for employed than unemployed persons employed than unemployed persons with TBI.with TBI.33

Satisfaction with life rated as higher in Satisfaction with life rated as higher in employed vs. unemployed persons with employed vs. unemployed persons with TBI.TBI.44



ChallengesChallenges– physical physical – cognitivecognitive– emotional/behavioralemotional/behavioral– support system support system – disincentives disincentives


Predictors (cont’d)Predictors (cont’d) Physical challengesPhysical challenges

– Headaches Headaches – Fatigue Fatigue – DizzinessDizziness– Blurred or double vision Blurred or double vision – Sensitivity to noise/light Sensitivity to noise/light – Trouble with taste or smellTrouble with taste or smell– Weakness/paralysis and spasticity Weakness/paralysis and spasticity – Slowed performance Slowed performance – Poor coordination/balance Poor coordination/balance – Slurred speech Slurred speech



Cognitive challengesCognitive challenges– Attention/concentration Attention/concentration – Memory Memory – Slowed information processing speed Slowed information processing speed – Problem-solving difficulties Problem-solving difficulties – Organizational difficultiesOrganizational difficulties



Emotional/behavioral challengesEmotional/behavioral challenges– Decreased initiation Decreased initiation – Lack of awareness Lack of awareness – Impulsivity Impulsivity – Depression Depression – Irritability/anger Irritability/anger – Emotional labilityEmotional lability



Support system challengesSupport system challenges– Lack of social support can interact Lack of social support can interact

with physical, cognitive, and with physical, cognitive, and emotional/behavioral challenges to emotional/behavioral challenges to make it even more difficult to return make it even more difficult to return to work.to work.



DisincentivesDisincentives– Fear of losing disability compensationFear of losing disability compensation– Inability to return to same type of jobInability to return to same type of job– Psychological disincentivesPsychological disincentives



Predictors of RTW after TBIPredictors of RTW after TBI– Predicting RTW is difficult, depends on:Predicting RTW is difficult, depends on:

DemographicsDemographics Pre-injury variablesPre-injury variables Injury-related variablesInjury-related variables Environmental variablesEnvironmental variables Other variables (personality features, Other variables (personality features,

economic variables, cultural influences)economic variables, cultural influences)



Predictors of RTW after TBIPredictors of RTW after TBI– Demographic variables:Demographic variables:

Age – inverse relationship between age and Age – inverse relationship between age and RTW.RTW.55

Education – mixed findings, but most Education – mixed findings, but most studies show a positive association between studies show a positive association between pre-injury education and RTW.pre-injury education and RTW.66



Predictors of RTW after TBIPredictors of RTW after TBI– Pre-injury variables:Pre-injury variables:

Pre-injury employment – mixed findings, but Pre-injury employment – mixed findings, but there appears to be a positive relationship there appears to be a positive relationship between pre- and post-TBI employment.between pre- and post-TBI employment.

Psychiatric history appears related to Psychiatric history appears related to employment after moderate to severe TBI,employment after moderate to severe TBI,77 as does pre-injury drug/alcohol abuse.as does pre-injury drug/alcohol abuse.



Predictors of RTW after TBIPredictors of RTW after TBI– Injury-related variables:Injury-related variables:

Greater TBI severity is associated with Greater TBI severity is associated with lower rates of RTW in many, but not all, lower rates of RTW in many, but not all, studies.studies.

Level of impairment/disability predicts Level of impairment/disability predicts vocational outcome: those with less vocational outcome: those with less impairment/disability have better impairment/disability have better vocational outcomes.vocational outcomes.88



Predictors of RTW after TBIPredictors of RTW after TBI– Injury-related variables:Injury-related variables:

Time since injury – early intervention is Time since injury – early intervention is associated with better vocational associated with better vocational outcomes.outcomes.99

Impaired awareness – mixed findingsImpaired awareness – mixed findings



Predictors of RTW after TBIPredictors of RTW after TBI– Environmental variables:Environmental variables:

Family/social support promotes Family/social support promotes employabilityemployability

– Identifying jobsIdentifying jobs– Helping with transportationHelping with transportation– Identifying other needs that have Identifying other needs that have

implications for employment (e.g., implications for employment (e.g., psychotherapy)psychotherapy)



Predictors of RTW after TBIPredictors of RTW after TBI– Variables that have received less attention, Variables that have received less attention,

but that are also important in RTW:but that are also important in RTW: Personality featuresPersonality features Economic variablesEconomic variables Cultural influencesCultural influences

Return to Work (RTW) Return to Work (RTW) InterventionsInterventions

Vocational interventions lead toVocational interventions lead to improved RTW rates.improved RTW rates.1010

Return to Work (RTW) Return to Work (RTW) Interventions (cont’d)Interventions (cont’d)

3 major RTW intervention 3 major RTW intervention approaches:approaches:1111

– Program-based vocational Program-based vocational rehabilitation modelrehabilitation model

– Supported employment modelSupported employment model– Case coordination modelCase coordination model


Program-based vocational Program-based vocational rehabilitation modelrehabilitation model– First described by Ben-Yishay et al.First described by Ben-Yishay et al.1212

– Consists of 3 sequential modulesConsists of 3 sequential modules Module 1: individualized, intensive work Module 1: individualized, intensive work

skills interventionskills intervention Module 2: guided work trialsModule 2: guided work trials Module 3: assisted job placement with Module 3: assisted job placement with

supportsupport


Program-based vocational Program-based vocational rehabilitation modelrehabilitation model– Involves interdisciplinary, group-based Involves interdisciplinary, group-based

interventions targeting cognitive interventions targeting cognitive deficits, awareness, acceptance, and deficits, awareness, acceptance, and social skills. social skills.

– This approach may be most effective for This approach may be most effective for those with severely impaired awareness, those with severely impaired awareness, cognition, and social functioning.cognition, and social functioning.


Program-based vocational Program-based vocational rehabilitation modelrehabilitation model– Post-treatment employment rates Post-treatment employment rates

are high, ranging from 75-85%.are high, ranging from 75-85%.1313

– Weaknesses: high intensity of Weaknesses: high intensity of program, elevated costs, poor fit for program, elevated costs, poor fit for those with less severe impairments.those with less severe impairments.


Supported employment modelSupported employment model– Is an “individual placement model” Is an “individual placement model”

adapted for persons with brain injury by adapted for persons with brain injury by Wehman et al. in late 1980sWehman et al. in late 1980s1414

– Involves limited pre-employment Involves limited pre-employment training, quick job placement, training, quick job placement, individualized on-the-job training from individualized on-the-job training from job coach, and long-term monitoring. job coach, and long-term monitoring.


Supported employment modelSupported employment model– Job coaches help with: contacting potential Job coaches help with: contacting potential

employers, providing additional training, employers, providing additional training, helping perform some job duties while helping perform some job duties while employee is learning, obtaining assistive employee is learning, obtaining assistive technology, teaching problem-solving and technology, teaching problem-solving and compensatory strategies, and modeling compensatory strategies, and modeling social skills.social skills.

– Approach designed for persons with severe Approach designed for persons with severe deficits who could not maintain employment deficits who could not maintain employment without on-site, ongoing assistance.without on-site, ongoing assistance.


Supported employment modelSupported employment model– Has been shown to be effective, Has been shown to be effective,

achieving a 71% employment rate.achieving a 71% employment rate.1515 – Weaknesses: extensive resources Weaknesses: extensive resources

may be required for adequate job may be required for adequate job retention (i.e., high number of retention (i.e., high number of intervention hours), poor fit for those intervention hours), poor fit for those with less severe impairments. with less severe impairments.


Case coordination modelCase coordination model– Is a holistic, flexible, individualized Is a holistic, flexible, individualized

approach.approach.– Case coordinator works with person Case coordinator works with person

with TBI to assess for needed services with TBI to assess for needed services and then makes referrals.and then makes referrals.

– Common referrals include vocational Common referrals include vocational counseling, pre-employment training, counseling, pre-employment training, and job placement assistance.and job placement assistance.


Case coordination modelCase coordination model– Emphasizes integration of vocational Emphasizes integration of vocational

services with other rehabilitation services with other rehabilitation services.services.

– Key components: early intervention, Key components: early intervention, continuity of care, and identification continuity of care, and identification of impairments that could interfere of impairments that could interfere with vocational success.with vocational success.


Case coordination modelCase coordination model– has been shown effective for persons has been shown effective for persons

with mild to severe TBI, with 70% with mild to severe TBI, with 70% employment rate achieved within 12 employment rate achieved within 12 months.months.1616

– Weaknesses: success depends on Weaknesses: success depends on the skill of the specific staff members the skill of the specific staff members and on availability of services in and on availability of services in clients’ areas.clients’ areas.


Which approach is best?Which approach is best?– Depends on the needs, resources, Depends on the needs, resources,

and characteristics of the injured and characteristics of the injured person.person.

– Is no clear “best practice” approach, Is no clear “best practice” approach, but overall the case coordination but overall the case coordination approach appears to have the approach appears to have the strongest outcome evidence.strongest outcome evidence.1111

Application of the Case Application of the Case Coordination ModelCoordination Model

Randomized controlled trial (RCT) Randomized controlled trial (RCT) at the Brain Injury Research at the Brain Injury Research Center of TIRR Memorial Center of TIRR Memorial HermannHermann– part of our Rehabilitation Research and part of our Rehabilitation Research and

Training Center on Developing Strategies Training Center on Developing Strategies to Foster Community Integration and to Foster Community Integration and Participation for Individuals with Participation for Individuals with Traumatic Brain Injury funded by NIDRRTraumatic Brain Injury funded by NIDRR

Application of the Case Application of the Case Coordination Model Coordination Model

(cont’d)(cont’d) Recruit from Level I trauma center acute Recruit from Level I trauma center acute

care, emphasis on early intervention.care, emphasis on early intervention. Inclusion criteria: complicated mild Inclusion criteria: complicated mild

through severe TBI, age 18-65, fluent in through severe TBI, age 18-65, fluent in English/Spanish, English/Spanish, ≥ 6 mos. continuous ≥ 6 mos. continuous employment in 2 yrs before injury, employment in 2 yrs before injury, wants to return to work, legal resident wants to return to work, legal resident of TX or has valid work visa, resides of TX or has valid work visa, resides within 100-mile radius.within 100-mile radius.


(cont’d)(cont’d)

Potential participants administered Potential participants administered a readiness evaluation.a readiness evaluation.

Those who are ready are Those who are ready are randomized to case coordination randomized to case coordination intervention or standard of care.intervention or standard of care.

Both groups receive referrals for Both groups receive referrals for state vocational rehabilitation state vocational rehabilitation services.services.


(cont’d)(cont’d)

Those in the case coordination Those in the case coordination group receive biweekly phone group receive biweekly phone calls from case coordinator for calls from case coordinator for ≤ 1 ≤ 1 yearyear, who assesses for referral , who assesses for referral needs.needs.

Case coordinator also contacts Case coordinator also contacts assigned vocational counselor to assigned vocational counselor to help participants through process.help participants through process.


(cont’d)(cont’d) Employment and community Employment and community

integration outcomes assessed in both integration outcomes assessed in both groups at 6, 9, 12, and 18 months groups at 6, 9, 12, and 18 months following enrollment.following enrollment.

Observations so far: Observations so far: – Participants confused about state Participants confused about state

vocational rehabilitation process.vocational rehabilitation process.– Participants appear to value case Participants appear to value case

coordinators’ assistance.coordinators’ assistance.

Work Readiness after Work Readiness after TBITBI

Stergiou-Kita et al.Stergiou-Kita et al.15 15 identified identified critical personal variables when critical personal variables when assessing RTW readiness:assessing RTW readiness:– motivationmotivation– physical and functional independencephysical and functional independence– cognition (attention, memory, cognition (attention, memory,

judgment, self-awareness)judgment, self-awareness)– use of compensatory strategiesuse of compensatory strategies

Future DirectionsFuture Directions

Develop standardized Develop standardized procedures/measures to match persons procedures/measures to match persons with TBI to RTW intervention best with TBI to RTW intervention best suited for them based on their needs.suited for them based on their needs.

Comparative outcome studies of RTW Comparative outcome studies of RTW interventions.interventions.

Identify ways to implement RTW Identify ways to implement RTW interventions within state vocational interventions within state vocational rehabilitation systems.rehabilitation systems.

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Documents

Employment After Traumatic Brain Injury: Predictors, Challenges, and Interventions Lynne C. Davis, Ph.D. Brain Injury Research Center TIRR Memorial Hermann