The effect of telephone counselling on reducing post-traumatic symptoms after mild traumatic brain injury: a randomised trial.

BACKGROUND: Mild traumatic brain injury (MTBI) is a significant public health problem affecting approximately 1 million people annually in the USA. A total of 10-15% of individuals are estimated to have persistent post-traumatic symptoms. This study aimed to determine whether focused, scheduled telephone counselling during the first 3 months after MTBI decreases symptoms and improves functioning at 6 months. METHODS: This was a two-group, parallel, randomised clinical trial with the outcome assessed by blinded examiner at 6 months after injury. 366 of 389 eligible subjects aged 16 years or older with MTBI were enrolled in the emergency department, with an 85% follow-up completion rate. Five telephone calls were completed, individualised for patient concerns and scripted to address education, reassurance and reactivation. Two composites were analysed, one relating to post-traumatic symptoms that developed or worsened after injury and their impact on functioning, the other related to general health status. RESULTS: The telephone counselling group had a significantly better outcome for symptoms (6.6 difference in adjusted mean symptom score, 95% confidence interval (CI) 1.2 to 12.0), but no difference in general health outcome (1.5 difference in adjusted mean functional score, 95% CI 2.2 to 5.2). A smaller proportion of the treatment group had each individual symptom (except anxiety) at assessment. Similarly, fewer of the treatment group had daily functioning negatively impacted by symptoms with the largest differences in work, leisure activities, memory and concentration and financial independence. CONCLUSIONS: Telephone counselling, focusing on symptom management, was successful in reducing chronic symptoms after MTBI. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov, #NCT00483444.

Workers' risk of unemployment after traumatic brain injury: a normed comparison.

We examined, among those persons working preinjury, the risk of unemployment 1 year after traumatic brain injury (TBI) relative to expected risk of unemployment for the sample under a validated risk-adjusted econometric model of employment in the U.S. population. Results indicate that 42% of TBI cases were unemployed versus 9% expected, relative risk (RR) = 4.5, 95% confidence interval (CI) (4.12, 4.95). The relative risk for unemployment was higher among males, those with higher education, persons with more severe injuries, and more impaired early neuropsychological or functional status. Difference in unemployment rates gave similar results for gender, severity of injury, and early neuropsychological and functional status. However, for education, the excess was smaller among those more highly educated, but the unemployment rate in the more highly educated in the general population was sufficiently small to yield a larger relative risk. In conclusion, after accounting for underlying risk of unemployment in the general population, unemployment is substantially higher after TBI for people who were employed when they were injured. The differential employment status varies depending on demographics, severity of brain injury, early functional outcome, and neurobehavioral indicators. For characteristics such as education, associated with rates of unemployment in the general population, different methods used to compare the rates may yield different results.

Vocational rehabilitation in multiple sclerosis (MS): a profile of clients seeking services.

Although a number of innovative vocational rehabilitation (VR) demonstration projects have been completed with MS populations, there remains a lack of clarity as to a profile of these VR participants. An effort is made in this article to carefully describe the demographic and occupational characteristics of people with MS seeking vocational services at intake, as well as their self-perceived psychosocial functioning across a range of pertinent measures. The issue of "program dropouts" in VR services for people with MS is also addressed. Implications for better understanding participants with MS within the VR process and improved nuances in service delivery are then discussed.

Traumatic brain injury rehabilitation: Issues in vocational outcome.

Since the population with a traumatic brain injury is principally young with many years of potential future earning capacity, understanding the issues affecting the vocational outlook for this group is critical. This article overviews the research to date on vocational outcome, emphasizing newly developed multivariate prediction models and encouraging a focus on actually examining the effects of different vocational interventions. The reasons for the variability in current study findings are reviewed with a framework proposed for more meaningful future research on the vocational rehabilitation process for this disability group. It is only through utilization of more standard intake and outcome variables and manipulation of interventions within this more standardized context that efficient and effective vocational rehabilitation for these survivors will be understood.

Employment following traumatic head injuries.

OBJECTIVE: Determine rates of, and factors predictive of, return to work in patients with civilian traumatic head injuries. DESIGN: Inception cohort study with 1- to 2-year follow-up. SETTING: Hospitalized patients in a level I trauma center. PATIENTS: Three hundred sixty-six hospitalized head-injured subjects who were workers before injury and 95 comparison subjects participated in prospective, longitudinal investigations of employment following head injury. Head-injured and comparison subjects were similar on basic demographics and preinjury employment status. The comparison subjects consisted of patients who sustained traumatic injury to the body but not to the head. MAIN OUTCOME MEASURE: Time taken to return to work following head injury. RESULTS: Survival methodology was used for analysis. Whether patients returned to work and when related to both the characteristics of the injured patients (eg, education, preinjury work history), the severity of head injury and associated neuropsychologic problems, and severity of other system injuries. More precise predictions were possible using the multivariate model. CONCLUSIONS: The present study provides a means of assessing employment potential predictively. This can be useful for clinical and research purposes. The results should be used cautiously and should stimulate discussions of appropriate use of services and resources to meet individual patients' needs.

Resection surgery for epilepsy. Outcome and quality of life.

Psychosocial problems frequently are more difficult to manage than the seizures. Quality of life investigations are important in identifying psychosocial issues that impede the benefits of improved or complete seizure control. Three categories of quality of life assessment are discussed: professional observation and ratings, psychometric assessment, and community-based measures of adaptive ability.

Improving functional rehabilitation outcome following epilepsy surgery.

This article reviews the literature on rehabilitation outcome following epilepsy surgery to provide perspective on the research issues in examining vocational and independent living outcome. The existing literature does not suggest dramatic independent living or employment gains as a result of this surgery. Those most likely to profit in these areas are adult seizure patients with excellent surgical outcome, freedom from pre-existing impairments (psychiatric, neuropsychological, or financial dependence on subsidy), and recent presurgical vocational activity. Recommendations are offered toward improving this outcome.

The difficult-to-employ in epilepsy rehabilitation: predictions of response to an intensive intervention.

In this prospective study, 46 adult seizure outpatients with suspected brain impairment were referred for vocational services at the University of Washington Regional Epilepsy Center and counseled for job placement. Among the demographic, intellectual, neuropsychological, and psychosocial variables considered, the Wechsler Adult Intelligence Scale (WAIS) Digit Symbol subtest and the name-writing procedure from the neuropsychological battery by Dodrill (1978) were the best discriminators of later employability. Using discriminant function analysis, these two tests correctly classified 75.0% of the group which ultimately became employed (n = 22) and 73.9% of the group which did not attain employment (n = 26). Implications of these findings are discussed in relation to rehabilitation planning.

Epilepsy rehabilitation: evaluating specialized versus general agency outcome.

This 1982 study was a retrospective comparison of vocational outcome between eight state rehabilitation agencies and the University of Washington Epilepsy Center's Vocational Unit for the years 1977-1978. Hypotheses included: (a) A significantly higher portion of those with epilepsy will find employment through a specialized (i.e., Epilepsy Center) versus a general rehabilitation program. (b) A specialized program will have a significantly lower proportion of program dropouts. (c) Those finding jobs through a specialized program will earn higher salaries and have better job retention than those employing a general agency program. On several comparisons the specialized program outperformed the general agencies--higher proportion of successful job placements and lower proportions of dropouts and those remaining in process (all chi2 tests significant at the p less than 0.001 level). Placement rates for specialized programs have traditionally approximated 50%, whereas these state agencies placed from 9 to 21%. Salary level and job retention differences were inconclusive. Data implications are discussed.

Program evaluation in epilepsy rehabilitation.

The Vocational Services Program of the University of Washington Regional Epilepsy Center is described, and data relating to the first 106 clients who entered the program are examined. A major emphasis of the study was characteristic differences between those clients later competitively employed and program dropouts. Other study purposes related to examining client satisfaction ratings of different aspects of services and establishing whether a relationship existed between seizure occurrences and job loss. Stepwise discriminant function analysis indicated that "months employed in the last 24" appeared to be the stable discriminator between the employed and dropout groups. The group later employed averaged 12 of the prior 24 months in employment, whereas dropouts approximated 7. Associated psychiatric/addictions treatment was initially a key outcome discriminator, but it did not hold up on cross-validation. Subjects were more satisfied with individualized client services (e.g., counseling sessions) than with group activities (e.g., Job Club). As opposed to seizures, emotional/attitudinal difficulties with this rehabilitation population appeared to be the primary reason for job loss. A work adjustment or job station program can be critical for these individuals and others with neurological impairments. The importance of counselor follow-up after the initial job placement is also underscored. This program, with about half of its clients entering unsubsidized jobs, basically replicated the results of other community-oriented epilepsy rehabilitation programs.

Futher validation of the WPSI vocational scale: comparisons with other correlates of employment in epilepsy.

The present study evaluates the relationships between employment status and five types of variables: years of education, intelligence, emotional adjustment, neuropsychological impairment, and psychosocial adjustment. The latter two areas were evaluated by procedures specifically developed for work with seizure patients and include use of the Neuropsychological Battery for Epilepsy and the Washington Psychosocial Seizure Inventory. Fifty-eight patients were divided into groups based on their employment histories and classified as unemployed, underemployed, and employed. Results indicated that the two types of procedures developed specifically for work with clients having seizures demonstrated the most potent and consistent relationships with employment status. The study suggests that the use of these procedures in the evaluation of employability may be more effective than using only those variables which traditionally have been applied.