Employment Interventions for Return to Work in Working Aged Adults Following Traumatic Brain Injury (TBI): A Systematic Review. Campbell Systematic Reviews 2016:6

Individuals with traumatic brain injury (TBI) often struggle to obtain competitive employment after sustaining a TBI, commonly as a result of the post-injury difficulties they exhibit (Andelic, Stevens, Sigurdardottir, Arango-Lasprilla, & Roe, 2009; Mansfield et al., 2015). The currently reported unemployment rate for people with TBI is approximately 60% (Cuthbert et al., 2015). Hence, the unemployment for individuals with TBI is considerably higher than for individuals without disabilities. Many adults with TBI seek assistance in gaining employment through post-acute rehabilitation. Post-acute rehabilitation services focus on helping individuals adjust to ongoing impairments and to re-enter their communities, workplaces, and education. Post-acute interventions are broadly classified into the following groups (Shames, Treger, Ring, & Giaquinto, 2007): residential community reintegration programs, comprehensive day treatment programs, and community re-entry programs that focus on vocational and social reintegration. This review focused on identifying the most effective type of intervention for returning individuals with TBI to work. The authors of this review drew on a wide range of databases, searched grey literature, included studies with a range of follow-up times, and focused on competitive employment outcomes among individuals with TBI regardless of the injury severity of the individuals. This review examined the effectiveness of vocational rehabilitation (VR) interventions to help adults with TBI attain competitive employment. Studies for this review were identified by searching 16 databases, including the Australian Education Index, CIRRIE--the Center for International Rehabilitation Research Information and Exchange Databases, the Academic Complete collection, EBSCOhost Research Databases, MEDLINE/PubMed, ProQuest, and 11 other databases. Unpublished papers and grey literature were also searched. Reference lists of papers included in the analysis and previous systematic reviews were searched. The following inclusion criteria were used for each potential study: (1) Studies are of interventions focused on assisting helping working-aged adults with TBI return to competitive employment, including self-employment. (2) Competitive employment had to be measured as an outcome. (3) Participants must have been between 18 and 65 years of age, experienced a non-penetrating TBI, been engaged in either full-time or part-time employment at time of injury, and been unemployed or on medical leave at time of receipt of the intervention. Studies that included individuals with other disabilities were included only if the results were provided for TBI participants separately from those with other disabilities. (4) Data had to be presented separately for competitively employed participants. (5) The design must be a randomized controlled trial (RCTs) or quasi-experimental design, with a treatment and a control/comparison group. Odds ratios and log odds ratios were computed and 95% confidence intervals were computed for each included study. Only datab for the primary outcome, competitive employment status, were used due to insufficient secondary outcome data. The literature search resulted in 6,941 unduplicated documents. From these 6,941 documents, 414 documents were selected for full-text review. From these 414 documents, 67 intervention reports were found, with only three return-to-work RCTs meeting inclusion criteria for this systematic review. The last search was conducted November 7, 2015. The three studies included in this review were RCTs with parallel interventions (Man et al., 2013; Salazar et al., 2000; Twamley et al., 2014, 2015). Man et al. (2013) compared two interventions, an artificial intelligent virtual reality-based training program (n = 17) and a psycho-educational vocational training system (n = 20) using a civilian population from China. Salazar et al. (2000) compared an in-hospital cognitive treatment (n = 67) to an in-home treatment (n = 53) for active U.S. military personnel. Twamley et al. (2014, 2015) compared a CogSMART Plus supported employment program (n = 21) to an enhanced supported employment program (n = 21) for U.S military veterans. Salazar and colleagues (2000) used active military samples and Twamley et al. (2014, 2015) used U.S. military veterans. Man and colleagues (2013) used civilians in China.The sample in Salazar et al. (2000) was predominantly African American and White. There were more Hispanic/Latino and White participants in the Twamley et al. (2014, 2015) study. Man and colleagues (2013) RCT did not report the ethnicity or race of its sample from China. The Twamley et al. (2014, 2015) and Man et al. (2013) studies reported severity of injury as mild to moderate. All studies were RCTs; however, blinding, incomplete data, and selective outcome reporting were of concern for all studies. Design, review status, publication type, and presence of control group were sufficient.Findings from this systematic review were inconclusive in that all odds ratios were not significant. Man et al. (2013) had the largest odds ratio (OR = 2.204, p = 0.264) but had the lowest employment rates (30%). Salazar et al. (2000) and Twamley et al. (2014, 2015) had odds ratios less than one. This indicated that the alternate interventions for Salazar et al. (OR = 0.514, p = 0.353) and Twamley et al. (OR = 0.817, p = 0.749) were more effective than the primary intervention. The employment rates for Salazar et al. and Twamley et al. ranged from 55% to 94%, which were rates higher than observed in Man et al. In sum, there were no significant odds ratios. Although all interventions evidenced positive average gains, no intervention was identified as more effective than another. All interventions showed positive average gains. However,the authors were unable to determine which intervention was most effective due to the small number of studies (n = 3). More experimental RCTs need to be conducted with interventions not included in this study. There are several recommendations for the direction of research concerning return-to-work for adults with TBI. First, studies of return-to-work VR interventions for adults with TBI must improve their quality of research by conducting RCTs. Second, separating competitive employment from education would provide a more accurate estimate of impact on return to work. Third, research is needed with other populations outside the United States and civilian samples. Last, future return-to-work VR studies should report time to employment, hours worked, separate rates of competitive employment, sheltered employment, educational training, and continued follow-ups at 12 months or more.