Returning to Work After Injury
By Lynn Brouwers, MS, CRC, CBIST
Rainbow Rehabilitation Centers
Editor’s Note: This is the first in a series of articles on vocational rehabilitation and returning to work.
The Bad News
The news is not good. The Bureau of Labor Statistics reports that less than 30 percent of working age people with a disability were employed in 2013, compared to 78 percent for people without a disability. And the bad news affects families, too. Families with an adult member with a disability earn almost 40 percent less than households without an adult member with a disability (2012 Disability Status Report).
So, what is the news for people with disability from brain injury? An analysis of Colorado’s registry showed that working people with severe brain injury (more than one day of coma) had a failure rate of 50 percent in their goal of returning to work at one year.
For working people with mild TBI, 20 percent failed at return to work at one year post injury, often because of difficulties with the cognitive skill of sustained attention (Shames, Treger, Ring, & Giaquinto, 2007). Moreover, job loss occurred in the next five to 10 years for those who were able to return to work (van Velzen, van Bennekom, Edelaar, Sluiter, & Frings-Dresen, June 2009) pointing to an additional problem: retention. (see Figure 1)
Too many people fail at returning to work after brain injury. And after failing, relatively few of the many people who attempt to return to work are referred to receive additional assistance in vocational rehabilitation.
The Centers for Disease Control and Prevention (CDC) estimates that of the working age people who are hospitalized with TBI each year, only five to six percent are served by the publicly funded vocational rehabilitation system (Langlois, Rutland-Brown, & Thomas, 2004). Thus, vocational rehabilitation specialists reach only a small group of people with TBI who might benefit. (Catalano, Pereira, Wu, Ho, Chan, 2006).
“Will ‘I’ go back to work?”
The literature gives us clues of which groups of people are more successful but no evidence to predict who individually will be successful in return to work.
An analysis of the scientific literature about return to work after brain injury and stroke continues to show that we cannot accurately predict who will be successful, with return to work rates of 12 percent to 70 percent (Shames, Treger, Ring, & Giaquinto, 2007) and 19 percent to 73 percent respectively. In stroke, the side of the brain injured or stroke location was not a factor (Shames, Treger, Ring, Giaquinto, 2007). Surprisingly, injury severity (classified by Glasgow Coma Scale), gender, depression/anxiety were not related to success or failure either (van Velzen, van Bennekom, Edelaar, Sluiter, Frings-Dresen, May 2009).
We do know that people with the following characteristics have more success (Walker, Marwitz, Kreutzer, Hart, Novak, 2006):
- More educated
- White collar professions (professional/managerial returned at 56 percent compared to manual labor at 32 percent)
- Shorter hospital stay
- Strong social and financial supports
People were more successful when they returned to work in the same occupational category grouping (van Velzen, van Bennekom, Edelaar, Sluiter, Frings-Dresen, May 2009) and support in the work environment seems to be the most important predictor of success (brainline.org).
So how do we change the bad news? A number of approaches have been studied. The literature is not conclusive, but best practice ideas are being promoted and the best are being incorporated into Rainbow’s vocational rehabilitation approach.
For the future, as part of its mission to advance research and appropriate treatment for people with brain injuries, the Brain Injury Association of America (BIAA) announced in July 2014 that it has awarded a grant to the Brain Injury Research Center at the Icahn School of Medicine at Mount Sinai. The grant funds a three-year investigation to develop Guidelines for the Rehabilitation and Disease Management of Adults with Moderate to Severe Traumatic Brain Injury (TBI). Fifty of the nation’s top researchers and clinicians, including Heidi Reyst, Ph.D., from Rainbow Rehabilitation Centers, as well as family members of people with brain injuries, were selected to review and assess evidence in functional, medical, cognitive, behavioral, and vocational/community.
Best Practice Idea #1: The value of early vocational rehabilitation; preserving a valued job/identity and keeping a supportive work environment
In research conducted by Jim Malec et al., people who received early vocational case coordination had better vocational return to work rates (80%), maintained employment at a better rate at one year post injury, and even had reductions in psychiatric comorbidity.
To keep the lines of communication open, Rainbow performs a vocational screen at the time of admission. With permission of the person served, we research early if they have an employer that is supportive. And we find out if there are opportunities for a return to work even while elements of medical rehabilitation continue. This is a different paradigm. Rehabilitation physicians and therapists often view vocational rehabilitation as the tail end of rehabilitation, but studies show value in early vocational interventions (Malec, Buffington, Moessner, & Degiorgio, 2008).
It is delicate timing to return a person to their own work setting or a similar work setting with the necessary supports and education. Brain injury education is vital so co-workers understand how brain injury can change a person’s abilities and that recovery takes place over months to years.
By tailoring the rehabilitation program to the work history, interests and skills of the worker, we also capitalize on opportunities for mutual goal setting and engagement. This helps to combat the problem of anosognosia where persons early in recovery may not recognize their own disabling conditions as a result of their brain injury. It also may help a person stay positive by holding onto their work identity and accomplishments of “who I am” while integrating the “new self.”
At Rainbow, we begin with the traditional medical rehabilitation treatment team: the occupational therapist, physical therapist and speech & language pathologist that will take work information and incorporate it into therapy. When tolerance for, or the goals of traditional therapy have been achieved, work conditioning is then built in.
Work conditioning can be incorporated into fitness, performed as a component of occupational therapy, or can happen on the work floor at a vocational program. A program of work conditioning along with participation in interesting activities helps the injured worker keep a stable activity pattern.
The reductions in psychiatric comorbidity seen in the literature when people return to work may relate to being surrounded by supportive people and by working in a supportive environment.
So, how can we keep people who are injured connected to their bosses, friends, and co-workers when they have strong relationships? How can we help maintain relationships…when their coworker hovers between life and death…coma or waking up? A car accident of a valued work team member is shocking and sudden and friends are often at the bedside supporting family and the injured person and will want to do everything in their power to help.
Education about recovery from brain injury can keep friends and co-workers engaged and supportive even when cognitive problems are more evident. We need to let them know that brain injury recovery is a marathon event, not a sprint. It can keep friends/co-workers rooting for the best recovery.
Research shows that even when the work environment is supportive, chances for success are increased when there is a working alliance between the injured worker and the vocational rehabilitation counselor. (Lustig et al, 2003). The alliance could be private (known only by the counselor and injured worker) or include open dialogue with the employer, based on the preference of the injured worker. Counseling, guidance, and problem solving are essential components of the alliance.
Best Practice Idea #2: On the job training works! Program-based vocational rehabilitation and supported employment
Program-based Vocational Rehabilitation may use all of the therapeutic services available. Established after a review of the individualized needs and desires of the persons served and their family, physical therapy, occupational therapy, speech & language pathology, mental health services and vocational rehabilitation are designed in a day program format.
At Rainbow, Young Adult Programs and Adult Programs offer job-coached, supported employment in facility-based and community employment settings coupled with therapeutic groups that support learning about the world of work, job seeking skills, social skills training, and work conditioning. This model showed evidence of success (Fadyl, & McPherson, 2009) and has the added benefit of addressing additional domains that affect independence.
On-the-job training works. This was the conclusion of a number of studies. It makes sense too, given that people with severe brain injury have trouble generalizing skills and strategies from artificial settings to real settings. A great example of this model is Project Search (mathematic-mpr.com) in which young people with severe cognitive/intellectual disabilities have successfully been employed through a unique work immersion model of employment that focuses on the needs of the employer and worker.
Supported employment, where all interventions are provided solely on the job and the extent of support is not time-limited, is a model that also showed evidence of success (Wehman, Bricout, & Targett, 2000).
About the Author
Lynn Brouwers, MS, CRC, CBIST
Director of Program Development
Lynn Brouwers holds a Master of Science in Rehabilitation Services from the University of Wisconsin. She has more than 25 years of leadership experience in medical rehabilitation with a specialty in programs for persons with traumatic brain injury and spinal cord injury. She has managed neurological rehabilitation programs in hospitals, skilled nursing facilities, residential facilities, and in the home and community.
2012 Disability Status Report http://www.disabilitystatistics.org/StatusReports/2012-PDF/2012-StatusReport
Bureau of Labor Statistics http://www.bls.gov/news.release/disabil.nr0.htm
Catalano D, Pereira AP, Wu MY, Ho H, Chan F. Service patterns related to successful employment outcomes of persons with traumatic brain injury in vocational rehabilitation. NeuroRehabilitation 2006;21 (4):279-93
Fadyl JK, and McPherson KM (2009) Approaches to Vocational Rehabilitation after Traumatic Brain Injury: A Review of the Evidence. Journal of Head Trauma Rehabilitation, 24, 195-212
Langlois JA, Rutland-Brown, W, and Thomas, KE (2004) Traumatic Brain Injury in the United States: Emergency Department Visits, Hospitalizations, and Deaths. Washington DC: Dept of Health and Human Services, Centers for Disease Control and Prevention, Division of Acute Care, Rehabilitation Research and Disability prevention, National Center for Injury Prevention and Control.
Lustig DC, Strauser DR, Weems GH et al (2003) Traumatic Brain Injury and Rehabilitation Outcomes: Does a Working Alliance Make a Difference? Journal of Applied Rehabilitation Counseling, 34, 30-37
Malec J.F., Buffington A, Moessner A., Degiorgio L., A medical/vocational case coordination system for persons with brain injury: an evaluation of employment outcomes. Arch Phys Med Rehabil. 2000; 81: 1007-1015
Project Search: Opening Doors to Employment for young people with Disabilities http://www.mathematica-mpr.com/~/media/publications/PDFs/disability/project_search_brief.pdf
Shames J, Treger I, Ring H, Giaquinto S, Return to work in stroke patients Disability Rehabilitation 2007 Sept 15; 29 (17): 1387-95
Shames J, Treger I, Ring H, Giaquinto S, Return to work following traumatic brain injury: trends and challenges. Disability Rehabilitation 2007 Sept 15; 29 (17): 1397-403
van Velzen JM, van Bennekom CA, Edelaar MJ, Sluiter JK, Frings-Dresen MH Prognostic factors of return to work after acquired brain injury: a systematic review Brain Inj 2009 May;23(5):385-95. Doi: 10. 1080/02699050902838165
van Velzen JM, van Bennekom CA, Edelaar MJ, Sluiter JK, Frings-Dresen MH: How many people return to work after acquired brain injury?: a systematic review: Brain Inj 2009 Jun; 23(6): 473-88. Doi: 10.1080/02699050902970737
Vocational Rehabilitation (VR) Research in Brief: Achieving Vocational Success after Traumatic Brain Injury. http://www2.ed.gov/rschstat/research/pubs/vrbriefs/tbi.html
Walker WC, Marwitz JH, Kreutzer JS, Hart T, Novak TA, Occupational categories and return to work after traumatic brain injury: a multicenter study. Arch Phys Med Rehabil 2006 Dec; 87 (12):1576-82
Wehman P, Bricout J, and Targett P (2000) Supported employment for persons with Traumatic Brain Injury: A Guide for Implementation. Traumatic Brain Injury Rehabilitation: Practical Vocational, Neuropsychological and Psychotherapy Interventions. Boca Raton, Fl. CRC Press 201-240