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Table 16 Multimodal Interventions for Vocational Rehabilitation and Productivity Post ABI

Author Year Country Study Design Sample Size Methods Outcome
Trexler et al. (2016) USA RCT PEDro=8 Ninitial=44, Nfinal=42 Population: ABI. Treatment Group (TG, n=22): Mean Age=33.0yr; Mean Time Post Injury=63.2d. Control Group (CG, n=22): Mean Age=39.5yr; Mean Time Post Injury=64.4d. Intervention: Participants were randomized to receive services from an outpatient multidisciplinary resource facilitation team (TG) or standard outpatient care (CG). Outcomes were assessed at baseline and after 15mo of treatment. Outcome Measures: Return to Work (RTW), Vocational Independence Scale (VIS), Mayo-Portland Adaptability Inventory (MPAI). 1.        RTW was 69% in TG and 50% in CG. 2.        Both groups improved on VIS at follow-up, but TG showed significantly greater improvement than CG (p=0.027). 3.        Both groups returned to productive activity (VIS>2) at follow-up, but TG was significantly more likely than CG (p=0.027). 4.        There was no statistically significant effect of time (p=0.139) or group (p=0.813) on MPAI Participation Index, nor interaction between group and time (p=0.735).
Cogne et al. (2017) USA Cohort N=57   Population: TBI=39, Other=18; Mean Age=34.7yr; Gender: Male=38, Female=19; Mean Time Post Injury=9-247mo. Intervention: Patients were recruited from those who completed the 2008 French evaluation, retraining, social and vocational unit (UEROS) program for 5yr follow-up to assess family and vocational status, autonomy and life satisfaction. Outcome Measures: Health, return to work, life satisfaction, activities of daily living, psychosocial and community integration. 1.        At 5yr follow-up, 56% reported having a health problem, mainly pain, epilepsy, and asthenia. 2.        Participants were 33% more independent when completing activities of daily living than at inclusion. 3.        At 5yr follow-up, 47% were working compared with 11% when the cohort first entered the program. 4.        Approximately half of those surveyed reported being satisfied or very satisfied with their quality of life. 5.        More persons lived with a partner (+23%) or in their own home (+21%) at 5yr follow-up compared with when they entered the program.
Bonneterre et al. (2013) France Pre-Post N=100 Population: TBI; Gender: Male=80, Female=20. Intervention: Patients attended a personalized service of accompaniment and follow-up to employment (SPASE) program. Two interviews were conducted: one over the phone and one with a vocational rehabilitation specialist from the SPASE workplace reintegration programme. Outcome Measures: Return to work. 1.       Compared to pre-intervention, significantly more individuals were at work after treatment (p=0.001). 2.       Workplace support was a highly significant factor in returning to work in the short term (<3 yr; p<0.001) and in the medium term (>3 yr; p=0.01). 3.       Regularity of assistance (p=0.05) and physical disabilities (p=0.05) both affected workplace reintegration in the short term.
Watanabe (2013) Japan Pre-Post N=300 Population: TBI; Mean Age=36.7yr; Gender: Male=247, Female=53; Severity: Moderate=48, Severe=247, Unavailable=5. Intervention: Patients attended an inpatient rehabilitation program with supported employment. Participants were grouped based on their Barthel Index (BI) score. Outcome Measures: Employment status, Activities of Daily Living (ADL). 1.       Group A (BI score <20) and Group B (20<BI score<80) displayed significant gains in ADL (p>0.05), but Group A was not fully independent in ADL. 2.       No members of Group A returned to work, but 35.7% of Group C (BI score of >80) and 10.7% of Group B did return to work.
Bergquist et al. (2012) USA Pre-Post N=154 Population: TBI=96, Stroke=15, Other=43; Mean Age=35.5yr; Gender: Male=108, Female=46. Intervention: Participants attended the Mayo Clinic Comprehensive Day Treatment Program and identified goals at three levels: personal, short-term, and graduation. Goals consisted of social awareness, cognitive, and communication improvements. Goal attainment was recorded, and follow-up was completed at 1 yr. Outcome Measures: Goal Attainment Scale (GAS), Independent Living Scale (ILS), Vocational Independence Scale (VIS). 1.        Patients living independently (ILS) in the community were significantly more likely to meet their graduation goals (GAS, p<0.02). 2.        At 1yr, more of the ‘goals met’ group were living independently compared to the ‘goals unmet’ group (72% vs. 56%, p<0.05). 3.       At discharge, 62% of the ‘goals met’ group were in community-based employment (VIS) compared to 46% of the ‘goals unmet’ group (p<0.05); at 1yr follow-up the rates were 73% and 51%, respectively (p<0.01).
Geurtsen et al. (2008) Netherlands Pre-Post N=24 Population: TBI=18, Stroke=3, Other=3; Mean Age=28.5yr; Gender: Male=18, Female=6; Mean Time Post Injury=5.4yr; Mean GCS=5.9. Intervention: Patients attended the Brain Integration Program with 3 educational modules: independent living, work, and social-emotional. Outcomes were assessed before and after treatment, with follow-up at 1yr and 3 yr. Outcome Measures: Community Integration Questionnaire (CIQ), Centre for Epidemiological Studies-Depression (CES-D), Quality of Life, Employability Rating Scale (ERS), Employment status. 1.       There was an increase in community integration (p=0.001), a decrease in depression (p=0.004), and improvement in their quality of life (p=0.000) from pre- to post-intervention. 2.       The increase in employability was only significant between discharge and 1yr (p=0.03). 3.       Following the program, patients felt a greater sense of independence, with those living independently rising (41.6% to 71%). 4.       Patients working increased from 38% to 58% from pre- to post-intervention, with mean hours worked per week increasing from 8 to 15.5. 5.       There were no significant improvements from 1-3yr for community integration (CIQ), employability (ERS), work hours (ERS), emotional well-being (CES-D), or QoL. 6.       From 1-3yr, the number of patients working slightly increased (33 vs. 41) but the number of patients living independently decreased (42 vs. 37).
Walker et al. (2006) USA Cohort N=1341 Population: TBI; Mean Age=35yr; Gender: Male=1033, Female=308; Mean GCS=8. Intervention: Individuals participated in an individualized comprehensive inpatient rehabilitation program. Outcome Measures: Category of Productive Activity, Census Occupational Category, Occupation Group, Functional Independence Measure, Duration of Unconsciousness. 1.       Fifty-five percent held skilled positions pre-injury. 2.       Overall 39% returned to competitive employment in any occupation 1yr post injury, 9% were students/retired/or homemakers, and roughly half were unemployed. 3.       Participants in professional/managerial jobs pre-injury showed 56% return to work compared to those in skilled trades (40%) and manual labour (32%). 4.       Those scoring at the 75% level on the FIM were 3.33 times more likely to return to work than those at the 25% level.
O’Neill et al. (2004) USA Case Control N=42 Population: TBI; Gender: Male=34, Female=8. Intervention: Patients who attended the Program Without Walls (PWW; n=21) were compared to those receiving traditional vocational rehabilitation services (n=21). Outcome Measures: Case status at closure, weekly earnings at closure, hours working at closure, cost of case services. 1.        More cases in the PWW group were successfully closed (57% vs. 24%; p=0.03), had higher mean earnings ($328.70 vs. $124.00; p=0.03), and worked more hours on average (32.08 vs. 17.8; p=0.04) compared to controls. 2.        The average cost of case services per PWW consumer was $3586.10 vs. $3326.00 for non-PWW consumers, although this difference was not statistically significant (p=0.43).
De Kort et al. (2002) Netherlands Post-Test NInitial=25, NFinal=20   Population: ABI; Mean Age=29 yr. Intervention: Patients attended the Come Back Program (CBP) aimed at regaining maximal independence in work and leisure activities. Participants received aid from social workers, a neuropsychologist, and a physician. Outcomes were assessed by chart review and at a mean of 3yr after the program. Outcome Measures: Employment status, Living situation. 1.       At the start of the study, 11 patients lived independently, and at the end of the program 13 patients were living independently. 2.       Fourteen patients had a job pre injury, and 4 patients within 3mo before CBP. 3.       For those with a pre-injury job, 10 of 14 achieved employment after CBP, but only 7 were paid and only 3 did the same work as pre-injury. 4.       Ten patients were in a relationship pre injury, all of which were terminated post injury. 5 patients were in a relationship within 3mo before CBP and 10 after CBP. 5.       There were no significant changes to the number of patients having friends at any point in the study. 6.       The two main goals expressed by patients were solving problems in living and work-related problems, 9 of 11 were satisfied with their result of the first goal, and 12 of 15 were satisfied with the second goal.
Malec and Degiorgio (2002) USA Cohort N=114 Population: TBI=73, ABI=41; Mean Age=37.4yr; Gender: Male=70, Female=44; Mean Time Post Injury=65.5mo. Intervention: Patients in 3 different rehabilitation pathways were compared at 1yr: (1) Specialized vocational services (SVS); (2) SVS and community reintegration (1 hr/day, 3 days/wk); and (3) SVS and comprehensive day treatment (6 hr/day, 5 days/wk). Outcome Measures: Mayo-Portland Adaptability Inventory-4 (MPAI-4), Vocational-Independence Scale (VIS), Community-Based Employment (CBE). 1.       VIS outcomes differed significantly between groups at placement (p=0.01) but not at 1yr (p=0.06). 2.       CBE success rates for group 1, 2, and 3 were 77%, 85%, and 84%, respectively (p>0.10). 3.       The number of individuals returning to work for a pre-injury employer did not differ significantly between groups. 4.       In group 3, MPAI-4 scores did not significantly differ between those who were successful and those who were not.
Foy (2014) UK Case Series NInitial=119, NFinal=97 Population: ABI=119; Age Range: 16-36yr; Gender: Male=73, Female=24; Time Post Injury: >1yr; Severity: Severe-to-Very-Severe=119. Intervention: Participants attended QEF Neuro Rehabilitation Services (QEF Neuro Rehab), a program that provides residential intensive neurorehabilitation, education, and vocational rehabilitation for young adults with ABI. Participants received interventions for up to 5h/d tailored to their needs. Outcome measures were assessed at least 1-yr after the completion of the program via postal questionnaire or telephone. Outcome Measures: Vocational outcome (employment status or return to school). 1.        Over half (53 %) of the clients attained a positive vocational outcome.
Geurtsen, Van Heugten, Martina, & Geurts (2012) Netherlands Pre-Post NInitial=70, NFinal=67 Population: TBI=47, stroke=7, brain tumor=10, encephalitis=4, hypoxia=2; Mean Age: 25.1±7.9yr; Gender: Male=46, Female=24; Mean Time Post Injury=5.2y; Severity: Mean GCS=7.5 Intervention: Participants attended a structured residential treatment program consisting of three modules: the independent living module (100h per person), the social-emotional module (110h per person), and the vocational module (44h per person). Outcome measures were assessed at inclusion (T0), the start of the treatment 3mo later (T1), the end of the treatment (T2) and 1yr follow-up after the end of treatment (T3). Outcome Measures: Community Integration Questionnaire (CIQ), Employability Rating Scale (ERS), living situation, school, work situation, work hours, Center for Epidemiological Studies Depression Scale (CES-D), EuroQOL quality of life scale (EQ-5D), World Health Organization Quality of Life Scale Abbreviated (WHOQOL-BREF; 5 scales), Global Assessment of Functioning (GAF) scale 1.        Participants showed significant improvement in employability immediately after treatment (ERS; p<.001). 2.        No significant change in work hours was observed immediately after treatment (p>.05). 3.        At follow-up, 57.3% of the patients were working, compared to 17.9% before treatment.
Geurtsen, Van Heugten, Martina, Rietveld, et al. (2012) Netherlands Post-Test NInitial=67, NFinal=63   *Follow-up study of Geurtsen, Van Heugten, Martina, & Geurts (2012)   Population: TBI=42, Mean Age= 24.7±7.2yr, Gender: Male=42, Female=21, Mean Time Post Injury=5.1±5.3yr, Severity: Mean GCS=7.8 Intervention: Participants attended a structured residential treatment program consisting of three modules: the independent living module (100h per person), the social-emotional module (110h per person), and the vocational module (44h per person). Outcome measures were assessed 1 and 3yr post treatment. Outcome Measures: Community Integration Questionnaire (CIQ), Employability Rating Scale (ERS), living situation, school, work situation, work hours, Center for Epidemiological Studies Depression Scale (CES-D), World Health Organization Quality of Life Scale Abbreviated (WHOQOL-BREF; 5 scales) 1.        There were no significant differences for any of the outcome measures between the 1yr and 3yr follow-up assessments (p>.05).
Haffey & Abrams (1991) USA Cohort NInitial=241, NFinal=199 Population: TBI=241, WRP Group (n=130): Mean Age=32yr, Gender: Male=72%, Female=28%, Time Post Injury=Not reported; Severity: Mild=0, Moderate-to-Severe=130, Day Treatment Group (n=35): Mean Age=31yr; Gender: Male=81%, Female=19%; Time Post Injury=Not reported; Severity: Mild=0, Moderate-to-Severe=35, Comparison Group (n=76): Mean Age=33yr; Gender: Male=65%, Female=35%; Mean Time Post Injury=not reported; Severity: Mild=0, Moderate-to-Severe=76 Intervention: Participants were clients who received one of the following interventions: 1)       The Work Re-Entry Program (WRP; with approx. 60h of staff assistance) that consisted of the following components: ·         Intake ·         Vocational Assessment ·         Work Hardening ·         Job Development ·         Job Analysis ·         Transitional Employment Program ·         Job Placement ·         Short-Term Support and Long-Term Follow-Up 2)       A Day Treatment Program where return-to-work was not one of the treatment goals 3)       No formal postacute rehabilitation services following discharge from in-patient rehabilitation (Comparison Group). Outcome measures were assessed every 6mo following discharge from the WRP, the day treatment program, or in-patient rehabilitation. Outcome Measures: Employment status, hours worked, wages, functional performance on the job, activity patterns (living circumstances, household relationship, daily living supports etc.), Preliminary Diagnostic Questionnaire (PDQ), a self-assessment questionnaire measuring perceived interpersonal and community survival skill competency, emotional status, and life satisfaction, a family/caregiver assessment, and a personality profile 1.        For the WRP group, there was a 68% placement rate in paid employment, a 71% employment retention rate, and a 75% employment stability rate. 2.        Engagement in paid employment was less than 40% for a group of graduates of the Day Treatment Group and the Comparison Group who only received inpatient rehabilitation.
Malec (2001) USA Pre-Post NInitial=113, NFinal=96 Population: ABI=113, Program Graduates (n=96): TBI=72%, CVA=19%, Other (e.g., anoxia)=9%; Mean Age=34.2±12.2yr; Gender: Male=73%, Female=27%; Mean Time Post Injury=4.6±6.6yr; Severity: Mild=7%, Moderate=7%, Severe=82%, Undetermined=4%, Dropouts (n=17): TBI=71%, CVA=6%, Other (e.g., anoxia)=23%; Mean Age=29.4±12.4yr; Gender: Male=71%, Female=29%; Mean Time Post Injury=1.3±1.5yr; Severity: Mild=8%, Severe=92% Intervention: Participants attended a comprehensive day treatment (CTD) program involving daily group sessions and individual therapy as needed, for an average of 189.5d. The CTD program utilized a transdisciplinary approach, supportive feedback, and a variety of therapeutic modalities (peer, staff, videotape). The program sessions aimed to improve: ·         Self-awareness of strengths and weaknesses ·         Coping and compensation skills ·         Personal organization ·         Social skills and effectiveness; ·         Emotional and behavioral self-management participation in social, work, and leisure activities ·         Health maintenance Outcome measures were assessed before and after the program, and at 1yr follow-up Outcome Measures: Independent living status, vocational independence scale, Mayo-Portland Adaptability Inventory (MPAI-22), Goal Attainment Scaling (GAS) 1.        At 1yr follow-up, 39% of program graduates were working independently, 10% were in transitional placements, and 18% were in supported or volunteer work.
Malec et al. (1995) USA Post-Test NInitial=67, NFinal=51 Population: TBI=67; Age Range=18-55yr; Gender: Not reported; Mean Time Post Injury=Not Reported; Severity: Mild=0, Moderate=0, Severe=67 Intervention:  Participants received integrative medical center- and community-based services that targeted barriers to employment identified by the research team. The medical and vocational services were integrated through the collaboration between a nurse case coordinator (NCC) and a vocational case coordinator (VCC) within the medical centre. Vocational services were individualized for each participant based on his/her medical history, needs, and goals. The intervention program was still ongoing as of the writing of the article. Outcome measures were assessed 1yr after the implementation of the intervention program. Outcome Measures: Mayo-Portland Adaptability Inventory, a vocational rating scale that uses a 5-point rating system to identify the level of vocational functioning, additional measures of vocational success (level of independent living, job type and setting, rate of pay, types and costs of vocational supports being used). 1.        Following the first year of the implementation of the program, 34% of the participants were able to participate in full- or part-time community-based work or training programs.
Perumparaichallai et al. (2020) USA Pre-Post NInitial=107, NFinal=107 Population: TBI=62, CVA=27, Other (Anoxia, Tumor, & infection)=14; Mean Age=35.81yr; Gender: Male=62, Female=45; Mean Time Post Injury=3.02yr; Severity: Mild=3, Moderate-to-Severe=36, Severe=18, Unknown=3 Intervention: Participants attended holistic milieu-oriented neurorehabilitation between 1986 and 2016. Participant completed one or more of the intervention programs that aimed to facilitate: ·         Home and community independence ·         Social relationships and quality of life ·         Work and/or school re-entry The intervention programs incorporated individual and group therapies (intervention length=3-5d/wk, 4-6h/d). Primary outcome measures were assessed at program admission, discharge, and follow-up in 2016. Secondary outcome measures were assessed at follow-up in 2016. Outcome Measures: Primary Outcome measures: Productivity status (e.g., return-to-work/school), driving status. Secondary Outcome Measures: Mayo-Portland Adaptability Inventory-4 (MPAI-4) and a long-term outcome questionnaire (LOQ) specifically developed for this study. 1.        Eighty-nine percent of the participants were productive at up to 30yr post-discharge (73% engaged in competitive work and/or school) after excluding the retired participants. 2.        At the follow-up in 2016, 70% of participants were had an annual income of $20,000 or more.
Rumrill (2019) USA Pre-Post NInitial=146, NFinal=125 Population: TBI=146; Mean Age=26yr; Male=80, Female=66; Mean Time Post Injury=Not reported Severity: Mild=24%, Moderate=27.2%, Severe=47.9%, Unknown=6.8% Intervention: Participants took part in Project Career, an individualized support program, over the course of 5yr. The program merged Cognitive Support Technology (CST) and Vocational Rehabilitation practices and was designed to improve the career readiness and employment outcomes of undergraduate students with TBI. Project Career students who graduated from their degree programs during the five-year program received post-graduation follow-up services for 1yr.  Outcome measures were assessed at baseline and at 6mo intervals for the duration of the program. Outcome Measures: Career Maturity Inventory—Form C (CMI), a scale measuring acceptance of disability, perception and usage of technology rated on a reverse-scored scale from 5 to 15 with lower scores indicating more positive experiences, ratings of interpersonal/emotional, cognitive, and daily activity proficiencies, academic performance (measured by GPA), engagement in career preparatory activities (e.g., preparing for a resume, completing internships), employment status. 1.        The CMI Curiosity subscale score decreased significantly from baseline to 6mo follow up (p=.032), indicating more concrete and definitive career plans. 2.        Acceptance of disability increased significantly from baseline to 12mo (p=.005). 3.        Both cognitive (p=.029) and daily activity proficiencies (p=.022) increased significantly from baseline to 6mo. 4.        Participants’ mean GPA increased from 2.87 at baseline to 3.02 at 12mo follow-up 5.        The majority of the participants engaged in one or more career preparatory activities during their participation with the program. 6.        Of the participants who were currently pursuing their degrees, 71% reported being employed full or part-time as of the writing of the article, which was higher than the baseline employment rate (44.4%). 7.        Of those who have graduated from their degree programs as of the writing of the article, 80.5% were employed full or part-time. 8.        Participants’ improvement in experiences with technology was not significant across the three time periods (p>.05).