NeuroRehabilitation An Interdisciplinary Joumal

ELSEVIER

NeuroRehabiIitation 5 (1995) 39-48

Traumatic brain injury rehabilitation: Issues in vocational outcome Robert T. Fraser*a, Paul Wehman b a Departments

of Neurological Surgery and Rehabilitation Medicine, University of Washington, Harborview Medical Center, ZA-05 Seattle, WA 98104, USA bDepartments of Physical Medicine and Rehabilitation / Special Education, Medical College of Virginia, Virginia Commonwealth University, Richmond, VA 23284-2011, USA Accepted 10 September 1994

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Abstract Since the population with a traumatic brain injury is principally young with many years of potential future earning capacity, understanding the issues affecting the vocational outlook for this group is critical. This article overviews the research to date on vocational outcome, emphasizing newly developed multivariate prediction models and encouraging a focus on actually examining the effects of different vocational interventions. The reasons for the variability in current study findings are reviewed with a framework proposed for more meaningful future research on the vocational rehabilitation process for this disability group. It is only through utilization of more standard intake and outcome variables and manipulation of interventions within this more standardized context that efficient and effective vocational rehabilitation for these survivors will be understood. Keywords: Traumatic brain injury; Vocational rehabilitation outcome

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1. Introduction Although return to work studies for individuals with traumatic brain injury (TBI) have been replete in the literature for more than two decades [1], our understanding of this process and the actual long-term success of interventions deserve further clarity. From a historical perspective, individuals with traumatic brain injury have shown

* Corresponding author.

relatively high unemployment rates, varying between 50 and 80% [2-5], with poorer outcomes estimated between 70 and 80% for individuals with severe traumatic brain injury - Glasgow Coma Scale (GCS) score < 8, post-traumatic amnesia > 7 days, duration of coma ~ 24 h, etc. [6]. Wehman et al. [7] suggest that key barriers to employability relate to cognitive issues such as new learning and memory, impaired self-awareness, pre-existing and post-injury dysfunctional behavior to include substance abuse and other

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psychological problems. Fraser and Baarslag [8] utilized consensus data from a vocational rehabilitation team of rehabilitation psychologists, rehabilitation counselors, and job coaches to clarify work barriers for 52 clients having a severe traumatic brain injury. The team reviewed clinical notes, test data, and client work protocol information as completed by supervisors from initial job try-outs and actual work sites. Concerns or impairments were only identified as barriers if they affected the achievement of a defined vocational goal and job maintenance for a specific client. In other words, a client may have an impairment related to a traumatic brain injury which is not a work-related barrier or handicap to employment within the context of the identified job goal. A review of these actual barriers indicates that, among the 52 severely traumatic brain injured clients within this study, cognitive barriers were prominent (63%) followed by diverse concerns related to emotional functioning (35%), additional physical impairments such as a hemipariesis, physical stamina, or motor deficits (31%), and characterological/behavioral propensities that actually pre-existed the TBI (31 %). Lesser categories of concern included financial disincentives (15%), communication deficits (12%), transportation concerns (12%), and other psychosocial and medical concerns. The vast majority of these clients (86%) had two or more categories of work barrier which, in the cognitive category, could be multidimensional (i.e., a barrier identified as generally moderate to severe neuropsychological impairment involved a number of impaired neuropsychological capacities). These salient difficulties and the interaction of these work-related barriers result in the high unemployment and the challenges to employability for the TBI population. The Rehabilitation Services Administration, and its subsidiary the National Institute on Disability and Rehabilitation Research, among other federal and state agencies, have attempted to support new and specialized research demonstration projects in order to improve work access or return to work outcome for individuals with a traumatic brain injury. These projects [2,6,7,9-11], indicate that with specialized and intensive forms

of vocational intervention, achieved employment rates can range within the area of 50-80% for even severe TBI groups, with employment retention rates of 50-65% at follow-up periods varying from 6 to 36 months post-placement. It appears that most of these specialized and intensive programs are making a difference in achieving employment, but sustained job retention is less certain and understood. There remain a number of issues to be clarified in relation to both the functional success of the vocational rehabilitation effort and the processes involved in achieving this success. This article highlights trends from the existing vocational outcome research in this area, underscores salient reasons for the variability in study findings, and calls for more standardization and salient variable definition in future research efforts. 2. Reviews of the vocational outcome literature

2.1. Existing reviews For purposes of this article, it is timely that two recent analyses and reviews of the literature have been conducted by Crepeau and Scherzer [1] and Wehman et al. [7]. Prior reviews by Oddy and Humphrey [12] and Kay et al. [13] basically summarized return to work statistics without more comprehensively examining pre-injury predictors or injury severity indicators in relation to outcome. The Oddy and Humphrey review did suggest, however, that pre-injury employment status, personality, age at trauma, duration of coma, and post-traumatic amnesia are most consistently related to work return. They, however, do not specifically address cognitive deficits as part of their review. Crepeau and Scherzer present a very recent extensive and comprehensive effort, using metaanalysis, in order to combine and compare the results of the available independent studies so that they may be more easily understood. It is the most sophisticated assessment of research in this area to date and merits full discussion of its approach and findings. They identified 140 studies with only 41 meeting the criteria for their evaluation: the study had to be limited exclusively to individuals with traumatic brain injury, have at

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least one quantitative predictor or severity indicator measure and one measure of return to work, the predictors or indicators used in a study had to be generally understood concepts within the context of rehabilitation (e.g., derived summary deficit scores were not considered generally understood concepts), and the measure of work status generally meant competitive work vs. school return or homemaker status. These restrictive criteria reduced the review to 41 articles for purposes of reasonable comparison. It is of interest that this review differentiates between predictor variables (relevant pre-trauma and early post-trauma data) to include pre-trauma characteristics of the individual (acute medical and early recovery data) vs. indicator variables or post-injury measures of cognitive, emotional, and sensorimotor functioning of an individual. The predictor and indicator variables were also examined according to pre-, peri-, and post-trauma time frames. The authors used diffuse, combined, and focused statistical tests [14] in order to evaluate the reviewed studies. Among the pre-trauma predictors, these authors found that age was only related to work status in studies that included subjects over 60 while sex and number of years of education seemed to have a minimal relationship to employment outcome, and that there was a slight tendency for individuals with more skilled employment backgrounds to be more apt to return to work. Few studies were identified that relate neuroanatomical or neurophysiological damage to vocational outcome although neurosurgical intervention seems to be strongly associated with successful work return. In the area of level of consciousness and physical function predictors, the best Glasgow Coma Scale score on the first day of hospitalization seemed more related to work status than the initial Glasgow Coma Scale score at admission to the emergency room. Despite the fact that duration of coma was the most frequently used variable in the literature, the results of a diffuse test indicated the lack of precision of this measure. The predictive value of coma appeared to be higher in instances of less severe subject samples. The results of nine studies on post-traumatic amnesia were very heterogeneous. Early post-trauma

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global neurological sequelae or physical sequelae (summary sequelae) seemed to have a limited relationship to work status. Detailed evaluation of specific physical issues can have more consistent results. There are some emerging indications in the literature that early psychological and neuropsychological functioning deficits are both related to work return. Among neurological sequelae, complaints of slowness appeared to have a moderate correlation with work outcome. The relationship of other patient self-report neurological sequelae appear only weakly related or have conflicting findings. Level of post-coma activity had a moderate-tostrong association to vocational outcome. Global ratings of dependency have a moderate relation to work outcome with the results of a self-care ability questionnaire being one of the measures most related to vocational outcome. Self-care would, of course, be presumed as prerequisite to work capacity. Driving status also had a moderate association to work outcome. There was more attention in the 41 studies examined to the cognitive sequelae as indicators of later employment status than other variables. Global cognitive functioning measures seemed to have moderate correlations to work status within the studies evaluated. Language and visual-spatial abilities all appear to have moderate correlations to employment outcome. Measures of executive functioning and flexibility were also moderately homogeneous within the studies examined and were highly correlated to employment outcome. Ten studies involving memory had widely divergent results and the heterogeneity remained unexplained. Memory functions have so many nuances (e.g., verbal vs. visual-spatial, immediate vs. delayed, explicit vs. implicit, etc.) that require more discrete and consistent evaluation or baseline measures. Emotional and behavioral indicators as assessed on global scales reveal heterogeneous results although five of the eight studies when examined separately indicated homogeneous results with a moderate correlation to employment outcome. These and the memory indicators pose more difficulty in variability of measurement. Aggressiveness and depression, more

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specifically, revealed moderate correlations to work status. Crepeau and Scherzer also evaluated external indicators such as duration of rehabilitation, litigation involvement, and family relations. Three studies indicate that having received vocational rehabilitation and community reintegration services proved to be highly correlated to work status - although this can obviously involve a selffactor selection. Involvement in litigation resulted in contradictory results. There appeared to be a minimal relationship between being awarded financial compensation or family dissatisfaction and work status. Studies concerning quality of life post-trauma and related variables show considerable heterogeneity relative to vocational outcome. These authors state that, in general, pre-trauma and early recovery predictors are marginally associated with vocational outcome. This is because it may take several predictors to reflect global severity of the neurological damage according to these authors and they believe that damages are reflected poorly by existing measures such as coma duration, PTA, and other early post-trauma symptoms as complicated by age. These measures can also be difficult to record consistently. The meta-analysis suggested that the most promising of the predictor variables appeared to be postcoma activity level, post-trauma sequelae (such as neurological sequelae, motor sequelae, associated damage), and duration of hospitalization. Indicator measures seem to have better correlations with employment outcome than the marginal correlations afforded by predictors. Indicators that appeared to be most promising include a client's post-acute self-care activity level, level of dependency, and capacity to drive a car. Executive functioning and cognitive flexibility deficits also appear to be important in relation to work return. These authors also indicate that physical sequelae, family context and CT scan anomalies, although moderately correlated with work status, should have a stronger association as these variables are further refined. Duration of rehabilitation also appeared to have an important association with return to work. After review of both the traumatic brain injury predictor and indicator variables, these authors

suggest the testing of a theoretical construct of leturn to work which would include a rehabilitation program of adequate duration (ideal length unspecified at this time) which improves executive functioning and cognitive flexibility with a goal of maximizing personal autonomy and activities of daily living. Interpersonal functioning variables such as anger and impulsivity did not have a clear relationship to work return in the meta-analysis. As the authors indicate, there are a number of issues with this type of meta-analysis. They include the distribution of variables within and between samples, the time duration until vocational outcome follow-up, measurement concerns with certain variables, the necessity for empirical observation for inclusion in the analysis which can exclude important clinical considerations, the use of a dichotomous employed or unemployed outcome measure, aspects of different vocational rehabilitation approaches being merged, individuals' varying job goals, and the lack of inclusion of several variables such as fatigue (which have been valuable indices of general recovery in traumatic brain injury, but were simply not prevalent in vocational research studies). Despite the limitations of this meta-analysis, it is the most comprehensive review to date and provides a contextual reference for future research efforts. Wehman et al. [7] have also completed a recent review of the literature and further analysis of 87 individuals securing competitive employment through a specialized TBI supported employment program from 1987 to 1994. The study also discusses some of the injury severity, pre-injury variables, and types of impairments due to TBI, as related to work outcome, and describes some conflicting findings. This paper reviews the authors' post-injury services more comprehensively than their prior work. In the review section, they indicate that although post-injury rehabilitation service is a significant predictor of return to work, to date, these have been primarily physical and occupational therapy services vs. services with a specific vocational emphasis. The review by Wehman et al. also emphasizes that Kaplan [15] established no relationship between the receipt of cognitive retraining services and vocational outcome while Prigatano et al. [16] established that

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actual 'in vivo' work trials appeared to be a successful intervention in increasing productive vocational functioning as compared to a control group which did not receive such services. Prigatano et al. also established that vocational productivity appears to be linked to a supportive working relationship between the family and the rehabilitation team. Based upon findings through their supported employment program and analysis of the literature, Wehman et al. conclude that traumatic brain injury and its concomitant neuropsychological deficits have a strong influence on vocational functioning. Supported employment with individual job coaching appears to be a successful means of assisting individuals with severe TBI to re-enter the work force. Although supported employment can be effective in overriding some of the cognitive, physical, and social impairments that have been traditionally related to poor outcome, the success of supported employment is enhanced if it can meet some of the financial needs of consumers (exceeding the benefits of federal and state subsidies) and also provide a socially rewarding environment. They endorse the supported employment approach as very assistive for clients who due to the nature of the injury and its associated impairments will have difficulty with job stability - the cost of intervention ranging between $9000 and $10000. They also conclude that individuals with diverse, associated impairments make the vocational intervention more arduous and extend time lines. Alcohol and substance abuse further confound both the placement and job retention process. Wehman et al. also support the emphasis on improving a client's self-awareness as part of the vocational intervention effort and the use of community-based work experiences as a means of maintaining vocational momentum and improving a client's self-awareness of assets and deficits. Their work is highly consistent with the findings of Prigatano and his colleagues related to the critical nature of client.self-awareness [17]. The Americans With Disabilities Act (PLlOI-336) and the 1992 amendments to the Rehabilitation Act prevent discrimination in employment for individuals with severe disabilities and mandate for

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workplace accommodations to include supported employment [18]. It is important for researchers to understand that with a more consistent and prevalent-effort on reasonable accommodation in the workplace, future study findings relative to predictors and indicators of vocational outcome will become more incongruent depending upon which samples do and do not receive aggressive reasonable accommodation benefits (procedural changes to include short-term supported employment, physical modifications to the work site, adaptive equipment or several of these accommodations) as part of their work return effort.

2.2. Recent muitivariate prediction models of work return There have been several very recent efforts to establish multivariate prediction models utilizing salient predictor and indicator variables that could affect employment outcome. These studies have not been previously reviewed. Godfrey et al. [19] assessed in a New Zealand study, the effects of a range of cognitive and psychosocial variables on employment outcome for 66 patients. Multivariate regression analysis indicated that cognitive variables, specifically number of neuropsychological impairments on a neuropsychological impairment scale, was the strongest predictor of work return. Schwab et al. [20], after extensive testing of neurological, neuropsychological, and social functioning of 520 Vietnam veterans, provide a logistic regression model with seven systematically defined impairments contributing to an understanding of employment outcome. These impairments included post-traumatic epilepsy, paralysis, visual field loss, verbal memory loss, visual memory loss, psychological problems, and violent behavior. The authors suggest that a sum score of the number of these seven disabilities can yield a 'residual disabilities score' which may prove to be a practical tool for assessing work return or work access in a traumatic brain injured population. As a caveat, this is a follow-up study of the veterans' work status 15 years after a penetrating head injury and involved mostly focal brain injuries (generally low-velocity shrapnel wounds) involving no or brief loss of consciousness. Fifty-six percent of the veterans were work-

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ing at the time of follow-up, but their employment status can also be confounded by both GI Bill educational benefits and other opportunities available to them to include disability benefits. This study, however, involved one of the most comprehensive pools of independent variables to date that have been assessed in relation to outcome. Dikmen et al. [21] utilized a survival analysis methodology and regression models through which 366 hospitalized patients with traumatic head injuries were compared on a prospective basis with 95 comparison subjects who sustained traumatic injury to the body, but not to the head. Patients' time of work return was related to the pre-injury characteristics of the TBI patients (e.g., age, education, pre-entry work history), the severity of the head injury (e.g., assessed by the Glasgow Coma Scale score), associated neuropsychological status at one month post-injury (Halstead-Reitan Impairment Index), and the severity of other system injuries. The study provides substantially improved information about time of work return and its predictors in a population with traumatic brain injury. The survival analysis methodology provides an opportunity to assess through individual composite scores which patients may experience protracted post-injury unemployment and those with a higher probability for return to work with limited support. It lays a groundwork for differentiated planning and utilization of rehabilitation efforts within the context of the limited resources that are currently available. There are a number of cautions related to this work, however, since outcome was related solely to first return to work and the examination of job performance or retention was not considered. The study may also not have taken into account those who did and did not receive general rehabilitation or vocational services because the provision of treatment was neither random nor controlled. The results, however, still represent the best available information on employment outcome in representative civilians experiencing a TBI. The findings should also be helpful in planning vocational intervention studies, for example, to define groups with an equivalent

amount of unemployment risk. Clinically, the results can be helpful as a general guideline for the rehabilitation team, supplemented with an understanding of the clinical circumstances and work background / goals of each individual.

2.3. Post-injury services and intervention and vocational outcome: an overlooked area An obvious gap in the research to date has been some ignoring of rehabilitation process variables and rel~ting them to vocational outcome. There has been some work that shows that the Disability Rating Scale (DRS), a short economic scale which enables tracking of functional capacities from coma to community, may assist in predicting outcome. Novack et al. [22] found that DRS scores exceeding 15 on rehabilitation admission, exceeding 7 on discharge, and exceeding 4 at 3 months after community return are incompatible with return to work. Rao and Kilgore [23] found that DRS rehabilitation admission and discharge scores predicted return to work with an 80% accuracy in a sample of 57 patients with TBI. This represents some effort to globally assess the rehabilitation intervention process and relate progress or lack thereof to outcome. More specific to the vocational arena, there has been little work that tests the value of different types of interventions with different types of clients subjected to a traumatic brain injury. The available literature basically supports the global success of different specialized or intensive vocational rehabilitation programs, but does not discuss different program tracks or variances in approaches that might demonstrate the efficacy or efficiency of one program variant over another (e.g., [7,17,24]). Only Bennett [25] demonstrated that individuals with a severe traumatic brain injury receiving both the psychosocial group and job coaching service components with a medium length of intervention did better than other individuals in a Maryland State DVR demonstration project receiving other and more extended vocational services. This is an area that now deserves attention because although new programs demonstrate above average placement success, available retention rates still appear to gradually stabilize

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at slightly above 50%, as earlier described by Ben-Yishay et al. [2]. Vocational success for this population very obviously not only involves the securing of a job, but the ability to maintain a position on a consistent basis within the work force. Retention still seems somewhat tenuous and perhaps a comparison of interventions, combinations of interventions, and the services timing or time involved may have a greater positive influence on retention. In assessing the effectiveness of interventions, the study by Dikmen et al. [21] better enables controlling for severity across studies when comparing interventions' effectiveness. 3. Variability in study findings A review of the existing literature in TBI vocational rehabilitation indicates significant variability in vocational outcome relating to the varied measures used across studies. Recent studies are attempting to pay more attention to these methodological concerns [4,7], but some of the following issues have consistently emerged: a. There is a lack of uniformity in the severity of TBI disability variables utilized. This would include using different Glasgow Coma Scale scores (e.g., emergency room GCS vs. first day of hospitalization), including periods of disorientation as being part of the time in coma and not using a more standard 'time to follow' command as a guideline for coma termination, mixing levels of TBI severity in a study, or difficulties with indices such as post-traumatic amnesia (PTA) which is more subjective and difficult to accurately measure. b. Using neuropsychological test batteries that differ radically relative to baseline measures of cognitive impairment, or not using a uniform core of neuropsychological tests against which findings could be more reliably assessed, is a continuing problem. c. Lacking an operational definition of successful employment outcome is a prevalent issue. Some studies mix successful student, volunteer, and other work-related experiences into the category of 'competitive employment',

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lump part- and full-time work activity together, use subjective ratings of employability, and otherwise lack rigor in establishing vocational outcome measures. A very basic issue is that even 'competitive employment' can be separated into 'return to a prior job or company' vs. 'new or even first time work access.' Returning individuals to a prior job or company is often a less arduous challenge. d. In most studies, it is difficult to understand the role of pre- and post-injury emotional and behavioral functioning as related to employment outcome. This area needs more consistent and standard attention. e. Varying periods of follow-up and not being able to understand clients' patterns of job sustention, the number of jobs during followup, pre- vs. post-wage differentials, and supervisors' perspectives on functional job performance also present further difficulties. f. To date, there has been little attempt to relate different aspects of vocational intervention or services provision to more or less successful outcomes. Reviews of the newer demonstration projects reveal relative success, but there is little indication that manipulation of any aspect of an intervention could, in fact, increase the success of the outcomes presented or increase them for clients with a specific post-injury profile. 4. Toward a standardized protocol for assessing functional vocational outcomes After a review of the available literature and some of the issues that we have encountered in our own work, it would seem that at this juncture in vocational rehabilitation efforts, future research, and demonstration projects might be encouraged to follow a framework that utilizes more standard predictor, indicator, process, and outcome variables in order that the efficacy and efficiency of a project might be comparatively better understood, in addition to intra-project patterns of success that might be further refined and capitalized upon. The proposed framework would include the following variables:

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a.

h.

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Employment-related variables: Within each study participant educational level, employment status at project intake, last job with Dictionary of Occupational Titles [26] code and number of hours worked, hourly salary on last job and for the one year prior to entrance into the project, and monthly employment ratio (see description below) for the 12-month period prior to entrance into the vocational rehabilitation program. Indicators of severity: The Glasgow Coma Scale score obtained in the emergency room and time to follow command appear to be the best generally available measures of head injury severity [21]. The GCS evaluates depth of coma by responsiveness to eye opening, motor, and verbal measures. Time to follow command is used as a measure of length of coma and is operationally defined as the duration of time between the injury and the patient's regaining the ability to respond consistently to verbal commands as defined by the motor component of the GCS [21]. Although the GCS on first day of hospitalization may be a better measure, it is not as readily available as GCS at time of initial entrance into the hospital emergency room. The study by Dikmen et al. [21] used these measures and the Abbreviated Injury Scale (AIS) and a modified Injury Severity Score (ISS) for establishing the severity of other system injuries excluding the region of the head. The latter measures are helpful to consider when establishing a participant's more global severity of disability, although obviously requiring more detailed effort. It would be also very helpful to have a Halstead-Reitan Impairment Index and WAIS-R Full Scale, Verbal, and Performance IQ levels. Since the full Halstead-Reitan Battery or even parts thereof are not consistently given throughout the country, it would be relatively easy to administer a mini-battery to include Trails A and B, the Symbol-Digit Modalities Test, and Name Writing (all which can be administered within a few minutes) in order to have some baseline measures of cognitive efficiency, fiexibil-

ity, and motor speed against which outcome can be compared. Emotional status is perhaps best assessed by the MMPI I-II or the Millon Clinical Multiaxial Inventories I-III. c. Vocational rehabilitation process variables: As new projects develop around the country and do not adhere to one single model of vocational rehabilitation work access or return to work, specific placement models as utilized with each client (basic counseling and job search skills training, assistance with selective placement. or some form of supported employment, such as individualized job coaching or a co-worker as mentor) should be identified and recorded. Clients receiving additional services such as psychoeducational group, specific cognitive remediation training with a speech pathologist or neuropsychologist, or those receiving some form of reasonable accommodation on the job (a procedural change, physical modification of the work site, or provision of low- or high-cost assistive equipment) should have these services recorded and categorized for purposes of relating these service components to outcome. If the Disability Rating Scale scores are available on rehabilitation admission, discharge, or from a community-based rating, these also could be recorded and an effort made to relate them to outcome. d. Job procurement: Initial success of a project can be assessed by identifying whether a client secures employment, the time involved in securing employment, the employment status according to the Dictionary of Occupational Titles job code, annual salary level, and whether the individual returned to a prior job or company vs. being assisted to placement in a new position. This could also involve the direct measurement of job development hours which service personnel have to expend in order to have a placement occur. There needs to be a significant commitment involved with this last activity. e. Job support: Given the fact that job procurement may not be as difficult as job support and, ultimately, long-term retention, we must take a much closer look at what actually

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f.

occurs on the job site from the first day of employment. Protocols need to be established and standardized across programs to verify the specific interventions which job coaches and rehabilitation counselors do. More specifically, we must attempt to validate the nature and context of interventions associated with success for individuals with varying levels of TBI, and those with a second or third disability. Only when we provide more specificity in these protocols can we hope to replicate successes and communicate with greater clarity. Job retention: The use of monthly employment ratios (percentage of months in which an individual was available for work and worked more than half-time) or another measure which provides an ongoing picture of sustained outcome is desperately needed. With economic downturns, changes in health status, varying occupational aspirations, and so forth, clients with TBI may move in and out of the work force throughout their life. Looking only at the number or percentage of people employed at any given point in time is truly a distortion of the overall program.

Much of the above framework incorporates standard concerns about research in rehabilitation psychology. Meyerson and Kerr [27] called for finer grain analysis of a disability group's concerns (specifically the more severely impaired), moving away from too much emphasis on the study of static variables which cannot be manipulated to result in improved rehabilitation vs. more of a focus on interventions that can be modified and related to better vocational outcome. In sum, we are also endorsing a better understanding of what does occur through the rehabilitation process and more of an effort to 'fine tune' the benefits of different vocational rehabilitation interventions as appropriate to specific TBI subgroups. 5. Conclusion Significant success has been attained in the efforts to improve vocational outcome for a population of clients who, in the not too distant past,

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were considered lucky to have survived. Despite this process there is a great deal yet to be accomplished. We must reach a point where we can assess more quickly and more accurately which people are likely to work and through what level or type of intervention (if necessary). Consulting physicians need to know when to call for more specialized vocational help. Workmens compensation managers and insurance adjusters also need data providing a reasonable vocational outcome perspective. It will be difficult to establish viable critical pathways without reliable predictors and indicators of well delineated functional vocational outcome. The framework described in this article hopefully provides a good step in the right direction. References [1]

[2]

[3]

[4]

[5] [6]

[7]

[8]

[9]

[10]

Crepeau F, Scherzer P. Predictors and indicators of work status after traumatic brain injury: A meta-analyis. Neuropsychol Rehab 1993;3:5-35. Ben-Yishay Y, Silver SM, Piasetsky E, et al. Relationship between employability and vocational outcome after intensive holistic cognitive rehabilitation. J Head Trauma Rehab 1987;2:35-48. Fraser R, Dikmen S, McLean A, et al. Employability of head injury survivors: First year post-injury. Rehab Counsel Bull 1988;31:276-288. Jacobs JE. The Los Angeles head injury survey: Project rationale and design implications. J Head Trauma Rehab 1987;2:37-50. McMordie WR, Barker SL, Paolo TM. Return to work (RTW) after head injury. Brain Injury 1990;4:57-69. Haffey W, Abrams D. Employment outcomes for participants in a brain injury work re-entry program: Preliminary findings. Rehab Psychol 1989;2:147-158. Wehman P, West M, Kregel J, et al. Return to work for persons with severe traumatic brain injury. Submitted to J Head Trauma Rehab 1995; in press. Fraser R, Baarslag-Benson R. Crossdisciplinary collaboration in the removal of work barriers after traumatic brain injury. Top Language Disorders, 1994: 15:55--67. Ellerd D. Development of a work re-entry program. In Wehman P, Kreutzer J, eds. Vocational rehabilitation for persons with traumatic brain injury. Rockville, MD: Aspen, 1990;105-118. Fraser R, Clemmons D, Andrechak D, et al. Vocational re-entry of the traumatic brain injured. In: Fraser RT (chair), Summary of NIDRR studies in the vocational rehabilitation of individuals with traumatic brain injury. Symposium presented at the ninth annual symposium.

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[11] [12] [13]

[14] [15] [16]

[17] [18] [19]

R. T. Fraser et ai. / NeuroRehabilitation 5 (J995) 39-48

New Orleans, LA: National Head Injury Foundation, November 1990. Stapleton M, Parente R, Bennett P. Job coaching traumatically brain injured individuals: Lessons learned. Cogn Rehab 1989;7:18-2l. Oddy J, Humphrey M. Social recovery during the year following severe head injury. J Neurol Neurosurg Psychiatry 1980;43:798-802. Kay T, Ezrachi 0, Carvallo M. Annotated bibliography of research on vocational outcome. New York: New York University Medical Center, Research and Training Center on Head Trauma and Stroke 1984; Publication No. 185-I. Rosenthal R. Meta-analysis procedures for social research. London: Sage Publications, 1994. Kaplan SP. Social support, emotional distress, and vocational outcomes among persons with brain injuries. Rehab Counsel Bull 1990;34:16-23. Prigatano GP, Fordyce DJ, Zeiner HK, et al. Neuropsychological rehabilitation after closed head injury in young adults. J Neurol Neurosurg Psychiatry 1984;47:505-513. Prigatano G, Klonoff P, O'Brien K, et al. Productivity after ncuropsychologically oriented milieu rehabilitation. J Head Trauma Rehab 1994;9:91-92. Wehman P. ADA - A mandate for social change. Baltimore: Paul Brookes Publishing Co., 1992. Godfrey H, Bisharo S, Partridge F, et al. Neuropsychological impairment and return to work following severe closed head injury: Implementations for clinical management. NZ Med J 1993;106:301-393.

[20] Schwab K, Grafman J, Salazar A, et al. Residual impairments and work status 15 years after penetrating head injury: Report from the Vietnam Head Injury Study. Neurology 1993;43:96-103. [21] Dikmen SS, Temkin NR, Machamer JE, et al. Employment following traumatic head injuries. Arch Neurol 1994;51:177-186. [22] Novack TA, Kofoed BA, Bennett G. Disability Rating Scale scores during recovery from head injury. Paper presented at the 65th Annual Conference of the American Congress of Rehabilitation, Medicine, Seattle, WA, November 1988. [23] Rao N, Kilgore KM. Predicting return to work in traumatic brain injury using assessment scales. Arch Phys Med Rehab 1992;73:911-916. [24] Abrams D, Toms Barker L, Haffey W, et al. The economics of return to work for survivors of traumatic brain injury: Vocational services are worth the investment. J Head Trauma Rehab 1993;8:59-76. [25] Bennett P. Pathways to employment. In: Fraser RT (chair), Summary of NIDRR studies in the vocational rehabilitation of individuals with traumatic brain injury. Symposium presented at the Ninth Annual Symposium, National Head Injury Foundation, New Orleans, LA, November 1990. [26] US Department of Labor. Dictionary of Occupational Titles. Fourth Edition. Washington, DC: US Government Printing Office, 199I. [27] Meyerson L, Kerr N. Research strategies for meaningful rehabilitation research. Rehab PsychoI1979;26:228-238.