How can you best get patients with a brain injury back to work?
Stroke and traumatic brain injury are major causes of death and disability, impacting millions of individuals annually in the United States alone. Survivors of brain injury (BI) are often left with severe deficits that impact daily functioning and, in the long run, their ability to return to gainful employment. An emphasis on returning to work is beneficial in the rehabilitation process.
The majority of BI survivors cite returning to their jobs as a main priority during recovery. Overall, achieving the highest possible level of function and quality of life (QOL) is the primary goal and returning to work is a critical aspect. Return to work (RTW) ultimately reduces the stress of financial burdens, provides focus, allows for a sense of productivity, and gives structure to the day. Additionally, the overarching cost of BI is high. When we consider the costs of hospitalization and rehab, lost wages, decreases in productivity, and dependence on government assistance, the cost estimates for BI can exceed $1 billion annually.1 RTW not only contributes to overall increases in subjective QOL but also reduces financial burdens to the patient, society, and employer costs related to decreases in productivity secondary to unfulfilled positions and hiring, training, and retraining staff.
Factors Influencing Return to Work
Post BI, a number of factors can influence an individual’s ability to RTW, including physical functioning, psychosocial interactions, visual/perceptual skills, and cognitive abilities.2-4
Physical functioning. Physical functioning tends to be the deficit that is most obvious for RTW ability. In many situations, BI survivors have physical limitations that require time, focus, and patience to improve. Physical deficits are easier for the majority of others to understand, given that these problems are visible. We can generally tell if someone is having trouble reaching, balancing, walking, etc. Common complaints related to physical functioning postinjury include, but are not limited to, spasticity, ambulation, fatigue, endurance, and coordination.
Invisible deficits. In addition to physical deficits, BI survivors are often left with subtle, invisible impairments that may be long-lasting, such as problems with psychosocial interactions, visual/perceptual skills, and cognitive function. These invisible impairments will have a negative impact on RTW and the ability to manage household and family tasks effectively, especially if they are not properly and systematically addressed in a rehabilitative setting.
Psychosocial interactions. Psychosocial interactions refer to the ways in which we interact and relate to those around us. Deficits in psychosocial interactions are common post-BI and may include some of the following problems: difficulty perceiving their role in the workplace, such as not understanding the supervisor/supervisee relationship, being prone to social errors (not picking up on body language, etc), as well as potentially perceiving their role as less valued.
Visual/perceptual skills. Deficits in visual perceptual skills may also have a significant impact on RTW ability. These skills refer to the processing of visual information. Rather than an inability to visually see something, it is related to how the brain processes that information to make sense of it. In the workplace, this can lead to physical injury (walking into a doorframe rather than through the door opening) or even misunderstanding written instructions.
Cognitive abilities. Cognitive abilities are considered the most impacted after BI and are crucial for RTW. Common cognitive deficits post-BI include issues with memory, processing speed, problem solving, and multi-tasking. Deficits in these areas make it particularly difficult to perform daily tasks in most workplaces. Survivors with cognitive deficits may lack the ability to plan and execute processes without structure, support, or guidance; may be unable to remember to return phone calls or follow up on tasks; may be distracted easily by stimuli in their environment; and may be unable to attend to or focus on more than one thing at a time. Cognitive skills specifically have been cited as the strongest predictors for RTW and are also considered the most affected after BI.
Predictors of Return to Work
The ability to make predictions about vocational outcomes allows for the delivery of realistic prognoses and may contribute to goal setting and establishment of targeted interventions.5,6 Predictors can be grouped into categories: preinjury demographics (ie, age, sex, education, marital status, etc), preinjury productivity/occupation (ie, employed versus unemployed, professional versus manual labor), injury-related variables (ie, injury severity, length of hospital stay, duration of coma, initial level of disability, etc), and postinjury variables (ie, comorbidities, psychiatric diagnoses, time since injury, access to care, etc). In general, literature pertaining to these predictors is variable but promising in establishing guidelines for use in the rehabilitative setting. Understanding these predictors can assist in identifying high risk [for RTW difficulties] patients early in the continuum, allowing clinical staff to direct and redirect necessary resources to maximize outcome potential.
Rehab and Return to Work
With a high correlation between RTW and QOL, RTW tends to be a fundamental objective for post-acute rehabilitation. Post-acute rehabilitation offers a level of rehabilitation outside the immediate needs of the patient, allowing for a focus on factors that will contribute to RTW goals. Cognitive/speech rehabilitation, counseling, occupational, educational, and physical therapy can work together in the post-acute setting to assess difficulties and coordinate treatment. Coordinated treatment plans between a variety of disciplines allows teams to track progress across time and plan accordingly to hone job-related skills. Ultimately, inadequate treatment and/or therapy is a primary cause of unsuccessful attempts at RTW. Early and repeated job failures can be detrimental for BI survivors, leading to lower subjective QOL, as well as an increased risk of hospital readmissions and sick days.
Successful Strategies for Return to Work
The types of therapy and strategies used can, and should, vary between patients.7 No BI is exactly alike, so the treatment strategies should be as unique as the injury itself. Generally speaking, a combination of cognitive remediation (restorative) and strategy training (compensatory) has been successful. Worksite evaluations are invaluable, as clinical staff can see the work environment themselves, offer suggestions on external aids and employer compensatory strategies, as well as bring plans back to the clinic for context-based training before the employment start date. Phased approaches to RTW have also been successful in allowing a partial return to the workplace while still attending therapy sessions. By using phased approaches, patients can address concerns and difficulties they have experienced at work with therapy staff and work through them in the clinic before returning full-time to their job site.
Reentry to Employment Rates
When analyzing post-BI RTW rates, there is a wide variation in statistics.2-6 Reentry to employment rates can be found between 40% to 80% 1-year post-TBI and between 40% to 60% 1-year post-stroke. This variation can be attributed to severity of the injury, the time since injury, the age of the survivor, and the definition of successful RTW. The definition of successful RTW (full-time versus any meaningful employment; return to preinjury occupation versus new employment, etc) varies between studies and must be considered when interpreting the results. RTW rates are also influenced by the predictors mentioned previously.
In summary, BI remains a substantial problem in the United States and worldwide. With such a high incidence of injury, as well as high numbers of survivors, thinking ahead to ways in which we can encourage and support survivors in their journey to RTW is critical. Understanding factors that influence RTW and how we may capitalize on that during the rehabilitative process will help maximize outcome potential.
Dr Howell is a senior neuroscientist at the Centre for Neuro Skills. She is a specialist in brain injury rehabilitation, neurodegenerative disease, and clinical research.
1. Humphreys I, Wood RL, Phillips CJ, Macey S. The costs of traumatic brain injury: a literature review. Clinicoecon Outcomes Res. 2013;5:281-287.
2. Bloom B, Thomas S, Ahrensberg JM, et al. A systematic review and meta-analysis of return to work after mild traumatic brain injury. Brain Injury. 2018;32(13-14):1623-1636.
3. Edwards J, Kapoor A, Linkewich E. Return to work after young stroke: a systematic review. Int J Stroke. 2018;13(3):243-256.
4. Mani K, Cater B, Hudlikar A, et al. Cognition and return to work after mild/moderate traumatic brain injury: a systematic review. Work. 2017;58(1):51-62.
5. Van Deynse H, Kazadi CI, Kimpe E, et al. Predictors of return to work after moderate to severe traumatic brain injury: a systematic review of current literature and recommendations for future research. Disabil Rehabil. 2022;44(20):5750-5757.
6. Van der Kemp J, Kruithof W, Nijober T, et al. Return to work after mild-to-moderate stroke: work satisfaction and predictive factors. Neuropsychol Rehabil. 2019;29(4):638-653.
7. Donker-Kools B, Dams JG, Wind H, et al. Effective return-to-work interventions after acquired brain injury: a systematic review. Brain Inj. 2016;30(2):113-131.