Return to work for patients with low back pain: two case studies.

Dismal return to work rates and mounting disability costs in the chronic low back pain (LBP) population imply the need for innovative re-employment strategies. The supported employment approach utilizes a vocational specialist under close physician supervision. It is more proactive, less biased, and more specialized than the more traditional case management approach used by many insurance companies. Supported employment has been used extensively at our institution in the brain injured population and we have recently begun exploring its use in LBP patients. Herein, we describe the successful use of supported employment in two individuals with chronic disabling LBP.

Return to work for persons following severe traumatic brain injury. Supported employment outcomes after five years.

Supported employment is a recently developed rehabilitation alternative that is being used to assist individuals with traumatic brain injury to return to work. The present study reports the results of a supported employment program that has placed 80 individuals into competitive employment during a 5-year time period. All individuals had sustained a severe traumatic brain injury; 72% of the injuries involved a motor vehicle. A mean of 6.1 years had passed since injury for all participants, who had been unconscious an average of 48 days. Neuropsychologic evaluation revealed defective cognitive functioning, which contributed to diminished employment potential. A key outcome indicator used to assess return to work capacity is the monthly employment ratio, which is computed by dividing the number of months employed during an employment phase (i.e., pre/post injury) by the total possible months an individual would have the opportunity to be employed. The monthly employment ratio increased from 13% after injury with no supported employment to 67% with supported employment services. The majority of individuals were employed in warehouse, clerical and service-related occupations. A mean of 250 staff intervention hours were required to train and provide follow-up services to program participants.

Critical factors associated with the successful supported employment placement of patients with severe traumatic brain injury.

A number of investigations have recently demonstrated the effectiveness of supported employment programmes in improving the vocational status of clients with traumatic brain injuries. The present study investigated a sample of 39 individuals participating in a return to work programme emphasizing a supported employment approach to identify key functional characteristics which differentiated successful and unsuccessful clients. Clinical ratings of employment specialists were used to identify two groups of individuals rated least and most difficult to place and maintain. Results indicated that the two groups differed markedly on key employment outcomes. Individuals rated most difficult tended to be younger, possess functional limitations such as visual and fine motor impairments, and display significant deficits in numerous work-related skills. Recommendations are made for applying these findings to assessment, placement, and training activities within vocational rehabilitation programmes for persons with traumatic brain injuries.

Costs of operating a supported work program for traumatically brain-injured individuals.

This paper presents a preliminary analysis of costs associated with a return-to-work program emphasizing a supported employment approach for persons who had sustained severe traumatic brain injuries. This analysis spans almost three years. Results indicated that a mean of 237.8 hours of staff intervention time was required to achieve job stabilization, at a cost of +6896. Ongoing follow-along and support services averaged 1.64 hours per week at a cost of +47.56. Over 68% of total staff time and costs were expended in job-site training and advocacy efforts. Application of these findings to state-level and agency-level policies should be weighed against individual characteristics and needs of clients, program design, and outcomes which clients achieve as a result of services.

Return to work for persons with traumatic brain injury: a supported employment approach.

Supported employment was used to place 41 persons into competitive employment during 30 months. All individuals had experienced severe head injuries; almost 70% of injuries were due to motor vehicle accidents. A mean of seven years had passed since injury for all referred clients, who had been unconscious a mean of 53 days. Only 36% of referred clients had achieved any competitive postinjury employment, compared with 91% of the same group who were competitively employed before injury. A job retention rate of 71% was reported, with most jobs in warehouse, clerical, and service-related occupations. A mean of 291 hours of job coaching was required to place and maintain all clients in supported employment.

Employment outcomes of persons following traumatic brain injury: pre-injury, post-injury, and supported employment.

This paper provides a prospective analysis of the pre-injury, post-injury and supported employment work histories of 20 persons who survived a severe head injury. All persons had a very limited or inconsistent work history post-injury, due to the severity of the injury. Data are presented on the placement outcomes and include factors such as wages, hours worked, months of employment and type of occupation. The supported employment model is described and the job coach approach is presented in some detail. The most significant finding of this preliminary report is that, as an aggregate group, supported employment was able to facilitate restoration of vocational capacity from pre-injury levels based on total months worked.

Effect of supported employment on the vocational outcomes of persons with traumatic brain injury.

This paper reports the job placement of 5 males with severe traumatic brain injury. An individual placement model of supported employment was used. All individuals were placed in competitive employment and received staggered intervention over time by trained employment specialists. A multiple baseline design across persons was used to evaluate results. All individuals had been unable to work consistently or at all in competitive work environments. The range of wages was $4.25 to $5.00 per hour with an average of 339 hours of employment specialist intervention time required per case. The major problems experienced by employment specialists were insubordinate and disruptive behaviors as well as other inappropriate social behaviors displayed at the job site.

Site of conduction delay and electrophysiologic significance of first-degree atrioventricular block in children with heart disease.

Associated electrophysiologic abnormalities and site of delay were studied in 20 patients, aged 1.5 to 16.5 years, with congenital heart disease and first-degree atrioventricular (AV) block (PR interval above the 98th percentile for age and heart rate). Eight of the 20 patients with first-degree AV block were studied after 1 or more cardiovascular operations. Refractory periods of the atrium, AV node, His-Purkinje system and ventricle were determined. As a further test for AV nodal integrity, rapid atrial pacing was performed and the cycle at which Wenckebach periodicity occurred was noted. Four groups were identified. Group I included 4 patients (20%) with intraatrial conduction delay (long PA interval). Three patients had depressed sinus nodal function and 1 had depressed AV nodal function. Group II included 7 patients (35%) with AV nodal delay (long AH interval). One patient had sinus nodal depression and 2 had AV nodal depression (prolonged AV nodal refractory period or Wenckebach at a long paced cycle length). Group III included 3 patients (15%) with His-Purkinje delay (long HV interval). Measured functions were normal in all patients. Group IV included 6 patients (30%) with normal or high normal intracardiac intervals with long PR. One patient had sinus nodal dysfunction, 2 patients had long atrial refractory periods, 1 had AV nodal depression; 2 had long refractory period of the His-Purkinje system, and 1 had long ventricular refractory period. Atrial flutter was induced in 1 patient.(ABSTRACT TRUNCATED AT 250 WORDS)