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- How Big of a Problem is Post-TBI Failure to RTW?
- What Do We Know from Current Research About RTW After TBI?
- What Can We Conclude From Current Research?
- What are the Implications of Current Research?
How Often Does TBI Happen?
Returning to work, school or being a homemaker is a major problem for many people with traumatic brain injury (TBI). (This TBI Research Review does not distinguish between those who did not work at the time of injury and those who did, although important differences characterize these two groups.) The failure to return to productive roles comes at great economic and personal costs to people with TBI, to their families and to society. The costs are great because the number of people with TBI is huge, estimated at more than five million individuals in the U.S.1
TBI is often an injury of youth, as incidence rates peak between ages 16 and 255, leading to many years of living with disability. This adds to the tremendous cost, which Thurman6 estimates at $56 billion yearly in the United States. Much of this is due to lost economic productivity. Failure to return to work (RTW) after TBI is the focus of this issue of TBI Research Review.
How Big of a Problem is Post-TBI Failure to RTW
Whiteneck and colleagues7, analyzing data from the Colorado TBI registry, which includes all people hospitalized with TBI in that state, found that about 50 percent of those who were severely injured failed to RTW at one-year post injury. Twenty percent of those with so-called mild injuries were unemployed. Other studies vary in their estimates. This variation is due to differing definitions of "successful" RTW, how long after injury the outcomes are studied and the severity of injury.
Despite study differences, all evidence points to many people with TBI being unable to return to the vocational roles they had established before injury. This has strong implications at the personal level, where research shows lower subjective well-being8 in people who fail to RTW after TBI compared to those who succeed in RTW. Research also shows many people feel they have strong unmet needs in connection with working9. At the societal level, lost wages and increased dependence on governmental and other financial support contributes to the huge yearly cost of TBI. Further, employers face the cost of lowered productivity due to unfilled positions and the cost of hiring and training replacement staff.
What Do We Know from Current Research About RTW After TBI?
A few studies are available that evaluate the effectiveness of efforts to maximize RTW; however, there are many more studies that document the factors associated with, but not necessarily promoting, RTW. The results of systematic reviews and other substantive reviews of this literature on RTW10-13 are summarized in this TBI Research Review. Then we review policy implications for researchers, clinicians and policy makers.
Prognostic Studies
Most reports of research on post-TBI vocational outcomes seek to identify the personal (and, occasionally, the environmental) characteristics that hinder RTW. These research results are potentially useful in pinpointing who needs the most help, but the results seldom demonstrate the specific nature of the needs.
Many studies reviewed10-13 suggest what is obvious: that, other things being equal, people with more challenges in functioning after TBI will have more difficulty in RTW. For example, studies find poorer outcomes for those persons who have more severe injuries, experience fatigue, are dependent on others in their activities of daily living, have transportation challenges, who evidence significant emotional issues and poor neuropsychological functioning, such as problems with memory, sequencing and judgment. Other studies that focus on demographics (such as age, gender and minority status) have generated variable results. In both types of study, however, the correlations between characteristics of the person with TBI (for example, severity of injury or gender) and RTW are quite modest.
In short, while existing research tells us general characteristics of people who are less likely to return to productivity, the research does not tell us whether any specific person with TBI will succeed or fail. At best, the results of prognostic research can define the conditions/ characteristics that should be attended to in developing an array of services to aid RTW. The research results do not, and should not, imply that the person on the negative side of these "predictors" is destined (or even likely) to fail.
Studies Evaluating Service Effectiveness
Effectiveness studies in the past often grossly focused on whether better outcomes were associated with receiving services or not. These "Yes/No" global assessments typically showed that vocational rehabilitation (VR) services help some clients – a not-surprising result. Recent studies that hone in on specific elements or characteristics of service programs have proved to be somewhat more useful.
Before reviewing these findings, some research weaknesses in this area need highlighting, as these weaknesses often undermine the validity of study findings and hinder the comparison of studies focused on the same topic to learn if evidence is consistent across studies:
- While randomized controlled trials (RCT)* comprise the gold standard for judging cause and effect, studies of this type have not been undertaken to evaluate VR services. Thus, because of the weak methodology of most of the studies done (non-RCT), one cannot conclude that a service is effective (or ineffective). For example, any positive results could be due to clients simply receiving a service (any service), due to receiving more attention than they would otherwise or due to being selected from the most capable people with TBI.
- Comparing studies is difficult when "success" is not uniformly defined from study to study. For example, some studies define success as return to "competitive full-time work;" other studies define it as return to "any productive role at any level." Alternatively, success is defined as "maintaining work status" for a specified period.
- Research reports often fail to describe adequately the treatment or service being evaluated, so that, if successful, the service is not easily duplicated elsewhere, for lack of program detail that others can "run with."
From Mount Sinai School of Medicine. www.mssm.edu.
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Excellent case discussion of influential factors for TBI survivors for life after injury. I suffered my injury when I was a young adult at the age of 21, which is a peak age of TBI, so I can relate to the hardships of survivors returning to work. I personally feel that there are some unmet needs that survivors may face with returning to work, such as transportation, and being given that initial opportunity to prove yourself. One fact that must not be overlooked, is that every injury is unique to that individual, and with it the recovery process. Speaking as a survivor who still is navigating the recovery path, I feel that both good family and self confidence can aid in recovery.
Aug 12th, 2009 2:35pm