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Strategies for Successful Integration
into Work following ABI
Nicole Beauchesne, OT Reg. (MB)
Owner/Manager
Block Building Therapies &
Concussion Care Community Clinic
Prevalence
• TBI’s result in 200-300 hospital admissions per 100,000
• The majority of TBI’s are mild-moderate (GCS > 8)
• Workplace injuries and MVA are primary cause
• Many more TBI patients surviving than before with more severe impairments
( Reference : Traumatic Brain Injury & Return to Work; Scollon. J, 1998)
Research on RTW after ABI
• Rates of RTW following TBI range from 10%-70%
• Highest rates of RTW following TBI have been found to occur in the first 6 months post-injury
• RTW is an important end point in terms of measuring effectiveness of rehabilitation among TBI patients
• RTW is determined by demographics, severity of injury, access to rehab and work assistance, modes of verifying work status.
( Reference : Traumatic Brain Injury & Return to Work;
Scollon. J, 1998)
Best Practice Recommendations
• Most predictors/indicators are only weakly correlated with RTW therefore caution is required.
• Assessment/Evaluation of employment outcome should be a minimum of 2 years, if not more.
• Emotional/Functional impairments are greater barriers to success (than cognitive), therefore thorough assessment is required.
• Stabilize neurological/psychiatric/affective conditions first.
• Chronic Pain and TBI symptoms overlap so co-treatment is required.
• Always consider pre-injury status in relation to IQ.
• Interventions should be multidisciplinary to address all areas of function.
• Severe TBI functional status was stable at 1 year, but shown to improve at 3 year follow up. ( Reference : Traumatic Brain Injury & Return to Work; Scollon. J, 1998)
Symptoms• Somatic – headaches, fatigue, nausea, light or
noise sensitivity
• Physical – strength, ROM, activity tolerance, impaired balance, vertigo
• Cognitive- memory, speed of processing, distractibility, attention/concentration, executive dysfunction
• Affective – anxiety, depression, agitation, labile
• Visual – acuity, diplopia, visual field cuts, ocular pursuits
Risk Factors (Red Flags)
Risk factors associated with poor outcome:
• Prior brain injury/concussion
• Increased age
• Pre-existing psychiatric illness (anxiety/depression)
• Existence of chronic pain (pre or post)
• Psychosocial factors
Case Study
SH Case Study
Barriers to Return to Work in mTBI
Avoiders
• Associated fear and anxiety about increased symptoms
• Medical clearance is a huge challenge!
• Slow to recover!
Over-Achievers
• Type A students, workers, parents
• High risk of persistent symptoms
• Slow to recover!
Your client has a brain injury….Now what??
Early intervention
• Make connections and build rapport with client, family and even the employer
• Educate the client and employer about brain injury, recovery and rehabilitation
• Reassurance is of the essence to both the client and the employer!
EVIDENCE SUPPORTS THAT REASSURANCE AND EDUCATION ABOUT
SYMPTOMS IS MOST EFFECTIVE FOR LOWERING RISK OF PERSISTENT
SYMPTOMS.
(SOURCE: MACCIOCCHI, A.W., 1993).
The key to successful case management of
the brain injured client is hiring the right clinical team!
Return to Work Team• Client and family
• Case Manager
• PT, OT, SLP, SW
• Neuropsychologist, Psychologist, Psychiatry
• Vocational Consultant
• Employer – Supervisor, Union, Occupational Health Nurse
Assessments
•Cognitive/Behavioral Assessment
•Physical Assessment
•Worksite Assessments
•Vocational Assessments
Understanding Symptoms• Critical areas to review include:
• Sleep• Levels of Fatigue• Headaches• Vertigo• Sensitivity to light/noise• Changes in auditory processing,
concentration, attention• Tolerance for physical activity
Barriers to Returning to Work
• Person has greater desire than actual readiness
• Lack of supports in work environment
• Lack of Opportunities to demonstrate capabilities
• Poor emotional control
• Fatigue
• Lack of self confidence
• Poor initiation (interpreted as poor motivation)
Determining Readiness for
GRTW
Work Readiness is….
• Managing headaches and fatigue
• Adequate self care (grooming, good sleep, diet)
• Able to tolerate adequate physical task (1-2 hours)
• Managing social/emotional status
• Independence with appointments, daily activities(finance/medication), rehabilitation program/exercise
• Ability to use strategies for memory, social skills, etc.
• Adequate decision making, planning and judgement
• Being motivated and positive about the plan!
Return to Work Options
• Return to previous place of employment
• Start new job (casual, part time of full time)
• Adult Ed or Vocational Training
• Start own business
• Volunteer (especially when unemployable)
Best to consult with Vocational Rehabilitation Consultant with brain injury experience!
Work place Exposure
• Simulate work related tasks at home
• Increase activity levels in the home first then in community
• Consider volunteer work first
• Early integration in the work environment (as an extra, just a presence..)
• Make goal rehabilitative versus vocational
Key to success…..is to decrease anxiety and fear of failure!
GRTW program
• Working supernumary….always as an extra.
• Consider other appointments and rest required (cognitive and physical)
• Sample GRTW:• Week 1-2 = M/W/F : 8 -10 am• Week 3-4 = M/W/F : 8 – 12 pm• Week 5-6 = M/W/F: 8-2 pm• Week 7-8 = Monday-Friday 8 - 12 pm• Week 9-10 = Monday-Friday 8 – 2 pm• Week 11-12= Resume FTE with ongoing monitoring
Goal is rehabilitation not vocational!
Intervention Strategies
Options for Managing
Impairments•Remediation
•Substitution
•Accommodation
•Assimilation
Physical Accommodations
• Physical – environmental modifications, adaptive computer equipment and accessibility
• Visual – Font, large print, lighting
• Tolerance – flexible scheduling and frequent breaks, GRTW program increase every 2 weeks
Assistive Technology for Physical Deficits
1. Alternative Input Devices
2. Pointing Devices
3. Sip and Puff System
4. Keyboard Filters
5. On-screen Keyboards
6. Voice Recognition Programs
Addressing Cognitive Deficits
• Many clients may have difficulties with focus, concentration, memory, organization and word-finding.• Large monitor• Task Oriented Software• Word prediction software• Calender programs, alarms and timers• Task lists, checklists• Background music and earplugs
Cognitive Accommodations
• Executive Functioning– give frequent direct feedback, use watch and timer
• Memory - verbal and written instructions, mentors/work partner
• Social/Emotional – frequent meetings, open to feedback, organize time to decrease anxiety, take breaks as needed, relaxation/meditation, counselling
Assistive Devices For Cognitive Deficits
• Memory: contact lists, alarms, timers, reminder systems, screen saver
• Organization: calendar programs with auditory reminders, Outlook/iCalender, To-Do lists; color coded priorities
• Visual: larger screen, magnifiers, oversized keyboards, screen reader, glare guard, text to speech
• Emotional: instant messaging, connections with webcam, email, support groups
Facilitate Computer Access
• Accessories • Workstations, sit/stand station, headsets
• Compensatory Strategies• Favorites, address book, auto complete/Correct,
templates
• Accessibility Options• Icon Size, magnifier, on screen keyboard, high contrast,
trackpad sensitivity, sticky keys, toggle keys, voice over
• Iphone/Ipad• Apps, calendar, social media, memo, alarms
JB Case Study• 52 year old woman slipped on ice at work. Co-workers
drove her home, sat in ER, went home and describes the following symptoms:• Sleeping 14 hours a day for almost 3 weeks• Headaches, confusion, labile, irritability• Hiding in a dark room (noise, lights)• Inability to read, write, work on computer, etc
• Saw doctor, advised to stay off work as a manager
• Attempts to go back to work 3 times
• Attends physiotherapy for WAD and referred to CCCC
Plan, Pace & Prioritize!
Pacing Points System
The Toolkit
• Biweekly meetings with ongoing review
• Tools/strategies included:• Ongoing education and reassurance• Increasing activity tolerance (physical and cognitive)• Gradual Return to work Program• Tedtalks/Websites on mindfulness• Meeting other clients with concussion• Regular reports to case manager
Summary• Early intervention : Rapport, Education and
Reassurance
• Employer Education
• Consider volunteering first or as option when unemployable
• Modifications:• Hours • Tasks• Physical Workplace• Cognitive Strategies• Social/Emotional Accommodations
• Make goal rehabilitative, not vocational in early stages
• Active Management
Resources
• www.brainstreams.ca
• www.apple.com/accessibility
• www.microsoft.com/accessibility
• www.synapse.org.au
• G.F. Strong Rehabilitation Centre, BC
• Parkwood Institute: St. Josephs Health Care
• Ontario NeuroTrauma Foundation, 2013
• Scollon, J, Traumatic Brain Injury and Return to Work (WCB), 1998
Forcem.co.uk
Questions
Nicole BeauchesneOT Reg. (MB), BSc O.T.Owner/ManagerBlock Building Therapies &Concussion Care Community [email protected]
Mynamesnotmommy.com