Return to work after traumatic brain injury.

It can be expected that ability to resume some form of employment is important to many persons with traumatic brain impairment, especially the youthful group most commonly affected. Many studies consist of youthful males, many of whom had been employed prior to injury, but who have experienced problems of vocational and social re-integration since injury.

Analyses of these problems in the literature have not always been conclusive. Early post-war research was confounded by varying standards of clinical severity of impairment and social outcome (Humphrey & Oddy, 1980). There was also a tendency to present occupational re-settlement in broad outline, and as the major criteria of rehabilitation outcome. Later studies presented a more detailed analysis whereby return to work was treated as one aspect of psycho-social outcome, and as not necessarily indicating absence of sequelae after onset of traumatic brain impairment. They have also reflected the now generally accepted view that employment status is determined by both the individual's residual deficits and environmental factors.

Recent studies have also included a greater proportion of persons with severe injuries who survived trauma due to improvements in medical technology, and who often experienced social and vocational dislocation following injury. Most of the earlier studies (reviewed by Humphrey and Oddy, 1980) sampled persons with less severe disabilities, and reported very high rates of return to work.

This review presents a broad perspective of the information available from empirical studies of the past 15 years. Studies were included if they provided descriptive, correlational or multivariate analyses of vocational outcome. Those factors commonly identified in the literature were: (a) severity of injury measured, for example, by post-traumatic amnesia; (b) cognitive deficits; (c) personality change; (d) psycho-social adaptation; (e) physical disability; (f) age; (g) pre-injury work/education history; and (h) access to rehabilitation. The studies that focused on these factors are listed in Table 1.

Severity of Injury

Severity of injury has often been measured by post-traumatic amnesia (PTA). Concerning the relationship of PTA to occupational re-settlement, Brown (1975) stated that in most instances where PTA exceeded 24 hours, 20 to 30 percent of the individuals required less taxing employment than before injury and 10 percent were unemployable. Oddy, Humphrey and Uttley (1978) TABULAR DATA OMITTED found that persons with less severe disabilities (e.g., PTA 1-7 days) returned to work more quickly than those with more severe disability (PTA 7 days). Kaplan (1988) reported that longer PTA (i.e., PTA 14 days) was associated with a lower probability of returning to pre-disability activity levels (i.e., work and school). Similar results were evident in other studies (Fraser, Dikmen, McLean, Miller & Temkin, 1988; Klonoff, Costa & Snow, 1986; McMordie, Barker & Paolos, 1990; Rao, Rosenthal, Cronin-Stubbs, Lambert, Barnes & Swanson, 1990; Van Zomeren & Van Den Berg, 1985).

Prospects for return to work appear better for persons with mild injuries, i.e., PTA 36 hours (Fraser et al., 1988; Wrightson & Gronwall, 1980). However, statistically viable generalizations conceal individual variations; difficulties in social and vocational adjustment do not necessarily decrease among individuals with mild deficits who attempt to cope in demanding work environments (Brown, 1975; Burke, Wesolowski & Guth, 1988; Jennett, Snoek, Bond & Brooks, 1981; McMordie et al., 1990; Newcombe, 1982; Ranseen, 1990; Tate, Lulham & Strettles, 1982; Wehman, Kreutzer, Wood et al., 1989b).

Cognitive Deficits and Personality Change

The long-term process of psycho-social adaptation to residual disability has been the focus of many studies, whereas discussion concerning the influence of pre-morbid personality upon vocational outcome has been largely speculative (Haas, Cope & Hall, 1987, theoretical (Cohen, 1985; Long, Gouvier & Cole, 1984) and lacking in empirical support (Brooks, McKinlay, Symington, Beattie & Campsie, 1987).

In their study of 44 adults with severe brain impairment who were followed-up 2 years after onset of injury, Weddell, Oddy and Jenkins (1980) found that non-workers had greater memory and personality disturbances than those who had returned to work.

When re-assessed 5 years later (Oddy, Coughlan, Tyerman & Jenkins, 1985) there was no change in their cognitive status. Difficulties in memory and concentration, and personality problems, were still commonly reported. Those unemployed at two years post-injury had remained out of work 5 years later. Those employed at two years post-injury had maintained employment 5 years later, but usually by a process of trial and error with a few persons still in "precarious positions" (Oddy et al., 1985, p.566).

Other studies have reported cognitive deficits and personality change to be related to employment status. They differed in terms of the specific nature of cognitive deficits and personality change which they reported. These discrepancies are largely due to differences in the populations and research methods that were used.

In numerous studies, a range of neuropsychological scales have discriminated between those who returned to work and those who did not. Some examples are:

* performance on the Wechsler Digit Symbol sub-scale that measures ability to learn with practice and speed of new learning (Prigatano, Fordyce, Zeiner, Roueche, Pepping & Wood, 1984);

* the Wechsler Performance IQ score (Fraser et al., 1988) and other tests of current adaptive abilities as opposed to tests of pre-injury learning and level of education, e.g., the Wechsler Verbal IQ score (Heaton, Chelune & Lehman, 1978;

* immediate logical (verbal) memory measured by the Wechsler Memory Scale and verbal attention measured by the Paced Auditory Serial Addition Test (Brooks et al., 1987;

* gross intellectual deficits measured by the Standard Progressive Matrices Test (Weddell et al., 1980);

* and, a battery of neuropsychological scales to measure particular aspects of learning, memory, language and attention skills (Heaton et al., 1978; Newnan, Heaton & Lehman, 1978; Stapleton, Parente & Bennett, 1989).

In other studies, post-injury employment was related to ability to use feedback from others and respond to the needs or demands of the immediate environment (Ainsley & Gliner, 1989); and, to awareness and acceptance of cognitive deficits (Haffey & Lewis, 1989; Kay, 1989; McMordie et al., 1990; Prigatano et al., 1984) and "their existential situation" (Ben-Yishay, Silver, Piasetsky & Rattok, 1987).

Psycho-Social Adaptation

Many studies have reported long-term psycho-social difficulties, e.g., social isolation, especially among those who are unemployed and have few leisure activities (Oddy et al., 1985; Tate, Lulham, Broe, Strettles & Pfaff, 1989); lack of social contact outside the immediate family (Jacobs, 1988; Lezak & O'Brien, 1988; Thomsen, 1984); inability to engage in appropriate social interaction (Kaplan, 1988; Newton & Johnson, 1985; Wehman, Kreutzer, West et al., 1990); and, inability to find a companion or spouse, and dependency within the family (Rappaport, Herrero-Backe, Rappaport & Winterfield, 1989).

Notwithstanding the frequency of these reports, not all individuals are adversely affected by their injury Ranseen, 1990). Further, long-term psycho-social adjustment may be mediated by the extent of independence in basic functional life skills (Jellinek, Torkelson & Harvey, 1982) and by different types of coping strategies (Moore, Stambrook & Peters, 1989). Moore et al. (1989) examined the coping strategies utilized by 69 persons at one to eight years post-injury. They found that persons with greater psycho-social difficulties were those who made a wide and indiscriminate use of coping strategies. Those persons who experienced least difficulties had either made little use of coping strategies or had relied upon a relatively specific strategy, i.e., they had re-appraised their altered situation in a positive light and had sought social support.

Two important issues are raised. First, it is debatable whether some individuals who used few coping strategies or who saw their situation in a positive way actually lacked insight; and, if so, whether that was a dysfunctional act of denial or a useful reality "buffer" against the stress of living with head injury (Moore et al. 1989; McKinlay & Brooks, 1984). Second, those persons with brain impairment who appear to have adjusted better had sought social support. In the study by Moore et al. (1989) it is not clear how well they obtained and maintained the support they sought. Perhaps they were socially skilled and not emotionally distressed and, therefore, able to attract social support and achieve a positive vocational outcome (Kaplan, 1990).

Family members are often the major source of social contact, especially for those who are unemployed (Oddy et al., 1985; Weddell et al., 1980). Family life may also play an important part in an individual's post-disability vocational adjustment. Kaplan (1988) found an association between pre- and postdisability family adjustment and return to work or school. Persons with low levels of personal and vocational adjustment tended to live in families with poor inter-personal relationships before and after the onset of injury.

Physical Disability

A review of the literature suggests that cognitive deficits and psycho-social difficulties have a greater impact upon adjustment to disability than physical impairment (Brooks et al., 1987; Humphrey & Oddy, 1980; Jennett et al., 1981; Lezak & O'Brien, 1988). However, other studies (Dikmen, McLean & Temkin, 1986; Fraser et al., 1988; Klonoff et al., 1986; Matheson, 1982; McMordie et al., 1990; Oakeshott, 1982; Thomsen, 1984 presented physical disabilities as variables which influenced vocational and psycho-social adjustment.

Clearly, differences in sampling and methodology accounted for this discrepancy in the literature. Klonoff et al. (1986) contrasted their methodology with some other studies and concluded that their study consisted of a greater proportion of participants with multiple injuries. Likewise, in Thomsen's (1984) study, 11 persons had severe brainstem lesions, 7 used wheelchairs, 6 had severe ataxia and/or poor balance, and 9 reported late onset of epilepsy. An extremely low postinjury employment rate (12.5%) was reported for this group.

Age

Persons with severe injuries who return to work tend to be younger rather than older (Brooks et al., 1987; McMordie et al., 1990; Najenson et al., 1974; Oddy et al., 1985; Rao et al. 1990). In general, persons over age 40 years have greater difficulty in returning to work. Time off work after minor head injury also tends to be longer for those over the age of 40 years (Wrightson & Gronwall, 1980). Older persons seem to be handicapped by reduced powers of adaptation and the reluctance of employers to re-employ injured workers with a limited working life span. But, they may adjust better to being unemployed than younger persons if they have a lower risk of behavioral (e.g., immaturity) and emotional sequelae. Issues related to aging with brain impairment have been largely unexplored and require further investigation.

Work/Education History

Oddy et al. (1978) found that failure to return to work six months after injury was greatest among semi- or unskilled manual workers. Higher education and professional training prior to injury was associated with successful occupational re-settlement. Similar findings were reported by Brooks et al. (1987, Najenson et al. (1974) and Rao et al. (1987, but not by Ainsley and Gliner (1989) and Rappaport et al. (1989).

Prigatano et al. (1984, p.512) concluded that a "good work history" prior to injury, but not necessarily "a great deal of formal education" may be an advantage for some individuals attempting to return to work. Like Ainsley and Gliner (1989) and Wehman, Kreutzer, Sale et al. (1989a), they also argued that the quality of professional intervention may be a crucial factor in vocational rehabilitation for both skilled and unskilled workers.

Access to Rehabilitation Services

The respondents of some studies have undergone intensive rehabilitation (Rao et al., 1990, or hardly any at all (Brooks et al., 1987). The latter study had a lower rate of return to work or school (i.e., 29%) compared to the former (58%) which also included respondents with a higher level of pre-morbid educational and vocational success. This may suggest that they are more responsive to vocational rehabilitation than those with less flattering pre-injury work/education histories. However, it has been too frequently observed that the supply of rehabilitation services does not adequately meet demand. Many persons with brain impairment who would benefit from long-term rehabilitation have not received any Jacobs, 1988; McMordie & Barker, 1988; Ostwald, 1989; Rappaport et al., 1989; Thomsen, 1989).

Following onset of injury, people who have sustained closed head injuries may be best served by an early admission to an intensive hospital rehabilitation program (Cope & Hall, 1982; Rappaport et al., 1989). Early access to vocational rehabilitation during early hospitalization is also recommended by Jellinek and Harvey (1982) who found that those persons who had access to a vocational rehabilitation counselor throughout the hospital phase of rehabilitation were more likely to be employed or at school 3 years after injury than those who received counseling at a later stage of rehabilitation.

However, it is unclear in their study whether successful vocational outcome was also significantly related to other variables, e.g., severity of and type of disability.

Other studies, discussed below, have placed greater emphasis upon the provision of intensive vocational rehabilitation programs that deal with specific individual and environmental barriers to employment.

Wehman, Kreutzer, West et al. (1990) reported a higher than usual job retention rate of 71 percent, which they attributed to job coaching. This group underwent a mean of 291 hours of job coaching in which they learned compensatory strategies in the work place. These strategies are arguably better learned there than in a pre-vocational or treatment setting where learning is less effectively generalized to the work place. However, there were some persons who were not placed in supported employment, i.e., those with greater cognitive and neurophysical deficits; and, there were others who discontinued work because of problems of psycho-social adjustment (as in the study by Stapleton et al., 1989).

Johnson (1987) also found that successful return to work was significantly related to the provision of special support at work. Unlike Wehman et al. (1990), job coaching was not utilized. Instead, a number of special conditions were set in place, e.g., flexible hours and payments, liaison with rehabilitation workers, training to assist with specific problems (e.g., memory), extra support and tolerance from co-workers. In most cases, these conditions were in operation over a period of months rather than weeks.

Ben-Yishay et al. (1987) reported successful outcomes for persons who received 20 weeks of neuropsychological remediation, guided occupational trials for 3-9 months, and job placement and follow-up. Up to 3 years after the guided occupational trials, 50 percent had retained competitive employment and 22 percent were in sheltered employment. This is impressive given that all respondents had not obtained or held a job post-injury before entering the program. Those who did not benefit from the program had psycho-social, substance abuse or other behavioral problems.

Employer Attitudes

There have been few studies of employer attitudes to persons with traumatic brain injury. However, in an extensive review of the literature related to employers' attitudes towards persons with disabilities in general, Greenwood and Johnson (1987) concluded that many employers have doubts about workers with emotional and mental disabilities. They recommended intensive advocacy, education, and job development and placement initiatives by rehabilitation agencies.

Vocational placement may be best directed towards agricultural/forestry and manufacturing/construction occupations. These occupations were perceived by 48 employers surveyed by Blair and Spellacy 1989) as more suitable for persons with brain impairment (without physical injuries) than service occupations.

The chances of successful return to work may be greater among professional and managerial workers (Humphrey & Oddy, 1980). Their ability to retain high skill levels which were learned prior to injury may allow them to compensate for post-trauma deficits better than the less educated/trained person. It has also been suggested that they may be able to work at a reduced capacity and be "covered" by colleagues (Brooks et al., 1987). Downgrading in less skilled occupations may be more acceptable to employers than to persons with injuries and theft families (Najenson et al., 1974).

Conclusion

The literature on vocational re-settlement after traumatic brain injury is dominated by medical and clinical neuropsychological studies, which focused mostly upon these factors: cognitive deficits, personality change, psycho-social adaptation, and access to rehabilitation services.

In their review of the literature just over ten years ago, Humphrey and Oddy (1980) predicted that improved methods of research

would be unlikely to challenge the importance of age and length of post-traumatic amnesia....but should lead to a better understanding of other factors such as previous occupational status, cognitive deficits and personality changes. (p. 107)

This prediction has been confirmed by much of the research of the past decade. There has especially been a more sophisticated analysis of cognitive deficits: the precise nature of deficits is regarded as an important predictor of vocational re-settlement. However, there continues to be a variety of clinical measures and outcomes reported in the literature.

A major difference between this review and Humphrey and Oddy's (1980) is the greater emphasis in this review upon the importance of providing intensive rehabilitation to persons with traumatic brain impairment. Lower rates of employment were often reported in studies that consisted of persons with severe injuries who had received little rehabilitation. Higher rates of employment were evident in groups with "mild to severe" injuries and greater access to neuropsychological and vocational rehabilitation programs.

Although people with less severe injuries may receive more encouragement to undergo vocational rehabilitation than those with severe injuries, there is evidence (e.g., Ben-Yishay et al, 1987; Wehman et al, 1990) that some persons with severe injuries do benefit from specialized and intensive vocational assistance. Given the relative recency and scarcity of such programs, further research is required to ascertain the conditions under which individuals may respond to, and benefit from, different types of programs.

This review has not yielded a formula to enable predictions of vocational outcome after onset of injury. However, the literature does provide rehabilitation professionals with an understanding of the difficulties faced by persons with brain impairment, i.e., an appreciation of the relationship between an individual's functional limitations and the environmental demands (both physical and social) he or she may face. How this relationship can be evaluated by rehabilitation professionals has been described largely in terms of modifying the environment so that it interacts with the client's strengths (Moore & Bartlow, 1990; Ostwald, 1989).

Most of the studies reviewed have been retrospective and have focused upon groups and relatively small sets of clinical problems. There have been few analyses of individual responses to living with brain impairment, and their interaction with particular demographic, economic and psycho-social factors. Future research that focuses upon individual experiences over different time periods can complement the findings of the many retrospective group studies.

Further, the individual's own perceptions must be taken into account. Many researchers continue to rely on relatives' reports, and to discount the perceptions of injured persons; and, others (Prigatano & Altman, 1990) still search for better neuropsychological methods of measuring impaired awareness of deficits. Notwithstanding the importance of these efforts, further research that includes a social psychological framework is needed (Fordyce & Roueche, 1986; McKinlay & Brooks, 1984). Researchers should acknowledge that living with a disability usually carries different meanings in different social situations for different persons. This type of qualitative analysis has been missing in much of the research literature.

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