Angelle M. Sander

Moderating factors in return to work and job stability after traumatic brain injury

Objective:To examine job stability moderating variables and develop a postinjury work stability prediction model. Design:Multicenter analysis of individuals with traumatic brain injury (TBI) who returned for follow-up at 1, 2, and 3, or 4 years postinjury, were of working age (between 18 and 62 years of age at injury), and were working preinjury. Setting:Six National Institute on Disability and Rehabilitation Research TBI Model System centers for coordinated acute and rehabilitation care. Participants:A total of 186 adults with TBI were included in the study. Main outcome measures:Job stability was categorized as stably employed (employed at all 3 follow-up intervals); unstably employed (employed at one or two of all three follow-up intervals); and unemployed (unemployed at all three follow-up intervals). Results:After injury, 34% were stably employed, 27% were unstably employed, and 39% were unemployed at all three follow-up intervals. Minority group members, people who did not complete high school, and unmarried people were more likely to be unemployed. Driving independence was highly influential and significantly related to employment stability. A discriminant function analysis, which included age, length of unconsciousness and Disability Rating Scale scores at 1 year postinjury, accurately predicted job stability groupings. ConclusionData analysis provided evidence that employment stability is predictable with a combination of functional, demographic, and injury severity variables. Identification of people at risk for poor employment outcomes early on can facilitate rehabilitation planning and intervention.

The community integration questionnaire revisited: An assessment of factor structure and validity

OBJECTIVE To investigate the factor structure and concurrent validity of the Community Integration Questionnaire (CIQ), using a large sample of persons with traumatic brain injury (TBI). DESIGN Principal components analysis with varimax rotation was performed on CIQ items completed through interview with patients at 1 year after injury. Correlational analyses compared CIQ scores to scores on other widely used outcome measures. SETTING Outpatient clinics affiliated with four TBI Model System rehabilitation centers funded by the National Institute on Disability and Rehabilitation Research. PARTICIPANTS Three hundred twelve patients with medically documented TBI who were enrolled in the TBI Model Systems Project. The majority of patients were Caucasian males with severe TBI. MAIN OUTCOME MEASURES CIQ; Functional Independence Measure (FIM); Functional Assessment Measure (FAM); Disability Rating Scale (DRS). RESULTS Three factors emerged: Home Competency, Social Integration, and Productive Activity. The financial management item was moved from Social Integration to Home Competency, and the travel item was moved from Productive Activity to Social Integration. Each CIQ scale score showed significant correlations in the expected direction with the FIM+FAM and DRS items. CONCLUSIONS The results provide further evidence for the validity of the CIQ and improve the scoring system. The factor structure is clinically and theoretically meaningful. The subscale and total scores show significant relationships with other widely used measures of outcome. Future research should focus on increasing the range of questions, accounting for changes from preinjury functioning, and obtaining normative data on the new factors.

A multicenter longitudinal investigation of return to work and community integration following traumatic brain injury.

Objectives:To characterize changes in employment status and community integration following traumatic brain injury and to investigate relationships among outcome, sociodemographic, and injury-related variables. Design:Longitudinal analyses of employment (n=42) and community Integration (n=53) were conducted, with data examined at three follow-up periods. Chi-square (x2) and analysis of variance (ANOVA) were used to investigate the relationship between employment, time since injury, and demographic and injury-related variables. Repeated measures ANOVA and multiple regression analyses were utilized to investigate similar relationships for the community integration sample. Setting:Outpatient clinics affiliated with the TBI Model Systems programs. Participants:Patients with traumatic brain injury who received acute medical care at a Level I Trauma Center and received inpaticnt rehabilitation. Mean age of subjects was 33.9 years. The full range of injury severity was represented. Main Outcome Measures:Employment status determined through structured interview and scores on the Community Integration Questionnaire. Results:Less than 40% of persons employed before injury were employed at any follow-up interval. Fewer persons were employed at year 2 than at year 1 and years 3 or 4. Seventy-five percent of persons employed at year 1 were also employed at year 3 or 4. Fifty percent of persons unemployed at year 1 were either employed or otherwise productively engaged at year 3 or 4. Unemployed persons had longer acute hospital stays than employed persons at all follow-up intervals. Conclusions:Till has an adverse, long-term impact on employment and productivity. Findings highlight the need for postacute rehabilitation programs with particular emphasis on vocational rehabilitation. Uncertainties remain about the impact of brain injury on socialization and home activity patterns, partly because of limitations in measurement of community integration

Neuropsychological Assessment and Employment Outcome After Traumatic Brain Injury: A Review

While there may be many reasons for obtaining neuropsychological assessment after traumatic brain injury (TBI), prediction of real world functioning is generally a key goal. The present paper reviews 23 studies concerning the relationship between neuropsychological test results and employment outcome after TBI. The review was conducted in accordance with guidelines developed by the Committee on Empirically Supported Practice of Division 40 (Neuropsychology) of the American Psychological Association. Results of the review support a Category A (strongly supported) recommendation for the use of early neuropsychological assessment to predict late employment outcome. Studies of late neuropsychological assessment and subsequent employment outcome and studies of concurrent neuropsychological assessment and employment outcome were inconclusive regarding either support or contraindication for neuropsychological assessment to predict employment outcome. Almost all studies conducted at these late or concurrent time points had significant limitations with regard to study type or adequacy of methodology. However, there is no conceptual basis for believing that neuropsychological findings obtained closer in time to assessment of employment outcome should be less predictive of this outcome than neuropsychological findings obtained at an earlier time.

Race and productivity outcome after traumatic brain injury: influence of confounding factors.

Objective:Investigate the impact of race on productivity outcome after traumatic brain injury (TBI) and evaluate the influence of confounding factors on this relationship. Design:Inception cohort of 1083 adults with TBI for whom 1-year productivity follow-up data were available. Results:Univariable logistic regression indicated that race was a significant predictor of productivity outcome after TBI. African Americans were 2.76 times more likely to be nonproductive than whites and other racial minorities were 1.92 times more likely to be nonproductive than whites. Multivariable logistic regression analyses revealed that the effect of race on employability was influenced by confounds with preinjury productivity, education level, and cause of injury. After adjustment for other predictors, African Americans were 2.00 times more likely to be nonproductive than whites and other racial minorities were 2.08 times more likely to be nonproductive than whites. The multivariable logistic regression model with all predictors except race accounted for 39% of the variability in productivity outcome (R2-Nagelkerke = 0.39), whereas the full logistic regression model including race accounted for 41% of the variability in productivity outcome (R2-Nagelkerke = 0.41); a difference of only 2%. Conclusion:Any effect of race on productivity is significantly influenced by confounding with preinjury productivity, education level, and cause of injury.

What Is Community Integration Anyway?: Defining Meaning Following Traumatic Brain Injury

Full community integration, or participation in society, is the ultimate goal of rehabilitation and of research conducted in the field of rehabilitation for persons with traumatic brain injury (TBI). Community integration has been traditionally defined by 3 main areas: employment or other productive activity, independent living, and social activity. However, these have not always received equal weighting and attention in clinical or research efforts. Significant gaps remain in our understanding of factors that impact community integration and in our ability to intervene to improve participation for persons with TBI. This article describes 3 main challenges for researchers and rehabilitation professionals. First, a comprehensive meaning of community integration is needed, which includes the viewpoints and preferences of persons with TBI. Second, cultural competence in measurement and intervention is needed. Third, a thorough assessment of environmental factors impacting participation is needed and should be incorporated into research and treatment planning.

Examining the contribution of social communication abilities and affective/behavioral functioning to social integration outcomes for adults with traumatic brain injury

Objective:To evaluate the contribution of social communication abilities and affective/behavioral functioning to socialintegration outcomes for persons with traumatic brain injury (TBI). Design:Prospective cohort study. Participants:A total of 184 adults with TBI (72.8% men) evaluated at least 6 months postdischarge from acute care orinpatient rehabilitation hospitals and after living at least 3 months in the community postdischarge (Mean = 7.84 monthspostinjury). Measures:La Trobe Communication Questionnaire (LCQ), Assessment of Interpersonal Problem-Solving Skills(AIPSS), Affective Behavioral subscale From the Problem Checklist of the Head Injury Family Interview (AB-HIFI), Craig HandicapAssessment and Reporting Technique–Short Form Social Integration subscale (CHART-SF-SI), Community Integration QuestionnaireSocial Integration subscale (CIQ-SI). Results:Social communication measures (LCQ, AIPSS) and self-reported behavioralfunctioning (AB-HIFI) contributed significantly to concurrently measured social integration outcomes after controlling for demographicand injury-related variables. Separate hierarchical multiple regression analyses revealed that social communication and behavioralvariables accounted for 11.3% of variance in CIQ-SI and 16.3% of variance in CHART-SF-SI. Conclusions:Social communication abilities and affective/behavioral functioning make a substantial contribution to social integration outcomes after TBI. The implications of such evidence for clinical assessment and intervention are discussed.

Exploring experiences of intimacy from the viewpoint of individuals with traumatic brain injury and their partners.

Objective:To explore qualitatively the experience of intimacy from the viewpoint of persons with traumatic brain injury (TBI) and their intimate partners. Design:Qualitative interview study. Setting:Outpatient community. Participants:Eighteen persons with TBI and their intimate partners at a mean length of 4.78 years postinjury. Main measures:Open-ended, semistructured, in-depth interviews regarding participants’ experience of intimacy, factors impacting intimacy, and need for services. Results:Factors that were perceived as helping relationships remain strong included unconditional commitment, spending time together, open communication, a strong preinjury relationship, bonding through surviving the injury together, social support, family bonds, spirituality, experience with overcoming hardship, and coping skills. Factors that were perceived as barriers to intimacy included injury-related changes, emotional reactions to changes, sexual difficulties, role conflict and strain, family issues, social isolation, and communication issues. Conclusions and Implications:Education regarding the impact of TBI on intimacy should be integrated into rehabilitation. Health professionals should be sensitized as to the needs that persons with TBI and their partners have regarding intimacy and how to make appropriate referrals to assist them.

A multidimensional measure of caregiving appraisal: validation of the Caregiver Appraisal Scale in traumatic brain injury.

Objective:To investigate the factor structure and concurrent validity of the Caregiver Appraisal Scale (CAS) in a sample of caregivers of adults with traumatic brain injury (TBI). Design:Prospective cohort study. Setting:Two sites: (1) Outpatient clinics associated with a comprehensive inpatient brain injury rehabilitation program and (2) a comprehensive residential postacute rehabilitation program in the Southern United States. Participants:One hundred forty-nine caregivers of adults with TBI enrolled in the TBI Model Systems Project and 92 caregivers of adults with TBI admitted to a residential postacute rehabilitation program. Most caregivers were women and either parents or spouses of the injured person. Main Outcome Measures:Caregiver Appraisal Scale (CAS); Subjective Burden Scale (SBS); Objective Burden Scale (OBS); General Health Questionnaire (GHQ). Results:Principal components analysis with varimax rotation yielded four factors: perceived burden (PB), caregiver relationship satisfaction (CRS), caregiving ideology (CI), and caregiving mastery (CM), which were found to be fairly stable across treatment settings. Adequate concurrent validity was demonstrated for the perceived burden factor, and adequate internal consistency was found for three of four scales. Conclusions:Preliminary support for the use of the CAS in caregivers of adults with TBI was obtained. However, further scale development, particularly for the CM factor, will likely improve the stability and usefulness of this instrument.

Long-term maintenance of gains obtained in postacute rehabilitation by persons with traumatic brain injury.

Objective:To investigate maintenance of gains after discharge from a postacute rehabilitation program. Design:Longitudinal cohort study, with inclusion based on availability of subjects at three time points. Setting:Comprehensive postacute rehabilitation program in the Southern United States. Participants:Thirty-four persons with medically documented complicated mild to severe traumatic brain injury; primarily male Caucasians with some college. Main Outcome Measures:Disability Rating Scale and the Community Integration Questionnaire completed at admission, discharge, and two follow-up time points. Results:Repeated measures analyses, using time from injury to discharge as a covariate, revealed significant improvements on all measures from admission to discharge, with no significant change from discharge to either of the follow-up periods. However, substantial changes were noted in individual cases. Conclusions:The results indicate that gains made by persons with traumatic brain injury during postacute rehabilitation are generally maintained at long-term follow-up, but changes occur in individual cases. Long-term services may help prevent decline in individual cases.