Julie Phillips

Return to work after traumatic brain injury: Cohort comparison and economic evaluation

Background: Returning to work (RTW) in the UK is problematic following TBI. Vocational rehabilitation (VR) is limited and efficacy or costs seldom reported. This study aimed to determine whether a TBI specialist VR intervention (TBI VR) was more effective at work return and retention 12 months after injury than usual care (UC). Secondary aims were to explore the feasibility of collecting economic data to inform a definitive trial. Method: Work outcomes of TBI-VR were compared to UC. Ninety-four participants (40 TBI-VR) with TBI resulting in hospitalization ≥48 hours, who were working at injury were followed up by postal questionnaire at 3, 6 and 12 months post-hospital discharge. Primary outcome was RTW. Secondary outcomes were functional ability, mood and quality-of-life. Health resource use was measured by self-report. Results: At 12 months, 15% more TBI-VR participants (27% more with moderate/severe TBI) were working than UC (27/36, 75% vs. 27/45, 60%). Mean TBI-VR health costs per person (consultant, GP, therapy, medication) were only £75 greater at 1 year. Secondary outcomes showed no significant baseline differences between groups. Discussion: More TBI-VR participants returned to work than UC. People with moderate/severe TBI benefitted most. This positive trend was achieved without greatly increased health costs, suggesting cost-effectiveness. This study justifies the need for and can inform a definitive Randomized Controlled Trial (RCT).

Return to Work after Traumatic Brain Injury: Recording, Measuring and Describing Occupational Therapy Intervention

Low post-injury employment rates indicate that returning to work is difficult following traumatic brain injury (TBI). Occupational therapists assist people with TBI to return to work, but rarely is their intervention described. This has hindered research into vocational rehabilitation. As no existing tool was identified for recording intervention, a proforma was developed for this study. Using best practice guidelines and a consensus of expert opinion, 15 categories of the vocational rehabilitation process were identified. Time spent on each category was recorded in 10-minute units after each occupational therapy session. The records of 21 participants who received occupational therapy focused on vocational rehabilitation were analysed. The proforma was quick and simple to use. The analysis showed that assessment, work preparation, employer involvement, education and dealing with issues of immediate concern to participants accounted for almost 85% of face-to-face intervention. It also showed that for every 1 hour of face-to-face contact, an additional 2 hours was required for liaison and travel. This study showed that there is potential for using a proforma for quantifying and describing occupational therapy. This is the basis for further work to enable meaningful comparisons with other services and use in future studies.

Development and evaluation of an early specialised traumatic brain injury vocational rehabilitation training package

Background In a feasibility randomised controlled trial, training was developed to equip occupational therapists to deliver early specialised traumatic brain injury vocational rehabilitation in the English National Health Service (NHS). Method The package was developed by experts in vocational rehabilitation and traumatic brain injury, and included a manual, direct instruction by six trainers and opportunity for mentorship by four therapists. Following training, therapists were interviewed regarding the effectiveness and ease of use of the package. Interviews were analysed using the framework approach. Results Five trained therapists were interviewed regarding the package. Results were organised into six categories: (1) motivation to participate in research; (2) impact of the learning environment; (3) changing confidence levels over time; (4) growing appreciation of complexities about the intervention; (5) acceptability of the training package; and (6) lessons for future implementation. Conclusion The therapists reported acquiring the knowledge necessary to implement the intervention. The data indicate that the training packages require detailed descriptions of the interventions being taught for local implementation in the NHS and for future research. The training materials are valued by therapists but require time for familiarisation, and reminders from mentors help put training into practice. The therapists have concerns about implementing the interventions within a research context, which researchers should address.

Return to work after stroke – Feasibility of 6-year follow-up:

Introduction Little is known about long-term work sustainability of stroke survivors. A feasibility trial of early stroke specialist vocational rehabilitation had 32/46 (69.5%) participants available for follow-up at 12 months post stroke. Of these, 19/32 (59.4%) were in work. This study aims to determine the feasibility of longer-term follow-up and explore work status 6 years post stroke. Method Forty-eight participants fitting criteria for the feasibility trial were sent postal questionnaires measuring employment, income, mood, functional ability and quality of life, and were invited for interview to explore working 6 years after stroke. Ethical approval was obtained. Results Of the 48 participants, five (10.4%) had died; 19/43 (44.2%) responded. Fourteen were men; mean age 62 (24–78) years. Fourteen (74%) reported working (paid work n = 10, voluntary work n = 3, full-time education n = 1). Five had retired. Most (11/13) remained with preinjury employers. Half (8/15, 53%) reported decreased income since stroke. Compared to one year, median functional ability was marginally higher (extended activities of daily living 63 (IQR 8, range 32–66) to 60 (IQR 9, range 17–66)), but health-related quality of life was lower (EuroQuol Visual Analogue Scale mean 77.4 [SD 11] to 70.7 [SD14]). Six interviewees felt returning to work was the correct decision but struggled with invisible impairments. Conclusion This study suggests that long-term follow-up is feasible and that those who made a good recovery were more likely to respond. Work remains important to stroke survivors 6 years post stroke.

Informing evaluation of a smartphone application for people with acquired brain injury: a stakeholder engagement study

BackgroundBrain in Hand is a smartphone application (app) that allows users to create structured diaries with problems and solutions, attach reminders, record task completion and has a symptom monitoring system. Brain in Hand was designed to support people with psychological problems, and encourage behaviour monitoring and change. The aim of this paper is to describe the process of exploring the barriers and enablers for the uptake and use of Brain in Hand in clinical practice, identify potential adaptations of the app for use with people with acquired brain injury (ABI), and determine whether the behaviour change wheel can be used as a model for engagement.MethodsWe identified stakeholders: ABI survivors and carers, National Health Service and private healthcare professionals, and engaged with them via focus groups, conference presentations, small group discussions, and through questionnaires. The results were evaluated using the behaviour change wheel and descriptive statistics of questionnaire responses.ResultsWe engaged with 20 ABI survivors, 5 carers, 25 professionals, 41 questionnaires were completed by stakeholders. Comments made during group discussions were supported by questionnaire results. Enablers included smartphone competency (capability), personalisation of app (opportunity), and identifying perceived need (motivation). Barriers included a physical and cognitive inability to use smartphone (capability), potential cost and reliability of technology (opportunity), and no desire to use technology or change from existing strategies (motivation). The stakeholders identified potential uses and changes to the app, which were not easily mapped onto the behaviour change wheel, e.g. monitoring fatigue levels, method of logging task completion, and editing the diary on their smartphone.ConclusionsThe study identified that both ABI survivors and therapists could see a use for Brain in Hand, but wanted users to be able to personalise it themselves to address individual user needs, e.g. monitoring activity levels. The behaviour change wheel is a useful tool when designing and evaluating engagement activities as it addresses most aspects of implementation, however additional categories may be needed to explore the specific features of assistive technology interventions, e.g. technical functions.

Can stroke specific vocational rehabilitation (SSVR) be delivered and measured?: feasibility RCT and economic analysis

Background: The stroke survivor’s voice has been identified as a key priority when evaluating rehabilitation interventions. Employer involvement in vocational rehabilitation (VR) studies has been largely absent yet their influence considered important. This study aimed to explore stroke survivors’ (SS) and employers’ views of the VR intervention received in a feasibility randomised controlled trial. Method: Semi-structured interviews with thirteen mild/moderate SS (8 men aged 45-79 mean 61 SD 11.63), 10 in F/T paid employment, 3 P/T volunteers) and six employers postintervention completion, explored acceptability, usefulness and VR implementation issues. Thematic analysis by three independent researchers followed recording and verbatim transcription. Results/Findings: The most valued aspects of intervention content were emotional support, provision of stroke specific information and feedback and the planning, implementing and reviewing of a phased return to work. Liaison with the workplace was particularly valued by employers. Continuity, accessibility and knowledge of therapist, individualised intervention and liaison with other services were aspects of intervention delivery commended by SS and employers. However, for some, the timing and duration of the intervention were not appropriate to their needs and this appeared to be linked with stroke severity. Discussion: Intervention appeared to influence the timing and success of work return. Opinions were divided on whether the NHS should or could fund this type of intervention and whether employers would be willing to contribute to the costs. Conclusion: Trial participants and employers found stroke specific VR useful, acceptable and influential in terms of return to work outcomes. Funding, targeting and implementation require further debate.Background: A quarter of UK strokes occur in working age people. Fewer than half resume work. Rehabilitation frequently fails to address work needs and evidence for post-stroke vocational rehabilitation is lacking. This pilot trial tested the feasibility of delivering SSVR and measuring its effects and costs compared to usual care (UC). Method: Previously employed stroke survivors (SS) aged ≥16 recruited from a stroke unit were randomised to receive SSVR or UC. Exclusion criteria: refusing consent; not intending to work, medical preclusion. Primary outcomes: occupational and benefit status. Mood, function, participation, quality of life and resource use were measured using standardized and bespoke postal questionnaires at 3, 6 and 12 months. Service use was cross-referenced in 10% of participants and costs calculated. Results: 46/126 patients screened (36 men, mean 56 (SD 12.7, 18-78 years) were recruited in 15 months; 40 declined. Most (29) had NIHSS scores ≤ 15, were in professional roles (65%), self-employed (21.7%) at onset. 32 available at 12-month follow-up, with poorer response (61%) among UC. Intervention successfully deployed in 22/23 cases. 39% returned to work at 12 months - twice as many in SSVR. More depression and productivity loss in UC, especially at 6 mths. Cross-referencing for 5 participants involved 51 phone calls, 23 letters/emails. Self-reported and actual service use data were discrepant. SS underestimated GP& consultant and overestimated therapy input. Discussion: SSVR can be delivered and its effects and costs measured. More reliable methods of capturing service use, income and benefit data and clearer definitions of work are needed. Conclusion: Findings inform the definitive trial.Background: Return to work (RTW) is an outcome in determining the effectiveness of rehabilitation post-stroke. However, stroke survivors (SS) may return to different roles with altered work status. Income, hours, responsibilities and job-satisfaction may be reduced. SS may be dissatisfied if unable to resume apriori work status; alternatively adjusted work status may be viewed positively if perceived as a way of reducing the risk of another stroke. The purpose of this study was to explore what is meant by RTW. Method: Information about the nature of RTW (job type, hours, roles, responsibilities) was extracted from 3, 6 and 12 month follow-up postal questionnaires in 46 SS participants in a feasibility randomised controlled trial investigating effectiveness of a vocational rehabilitation intervention. Results/Findings: Participants took a mean 90 (SD:70, range 7-227) days to RTW. 19/46 reported working at 12 months. In 17 who supplied complete data, 7(41%) reported reduced working hours. Participants incurred a mean wage loss of 44% against pre-stroke earnings. 10/17(59%) participants were in the same job with the same employer and 6(35%) were working in different/modified jobs (1 missing:). 10/17(59%) had work-place adjustments. 18/46 (39%) participants were happy with their work situation. Discussion: Participants experienced marked changes in work status post-stroke, with implications for job-satisfaction, financial security and quality of life. Research into psychological adjustment following altered vocational status in SS is warranted. Conclusion: RTW is a complex outcome and may not translate to a return to pre-stroke vocational status. It is important to consider what constitutes a RTW following stroke.