A considerable number of patients with mild-to-moderate traumatic brain injury (TBI) experience long-lasting somatic, cognitive, and emotional symptoms that may hamper their capacity to return to work (RTW). Although several studies have described medical, psychological and work-related factors that predict RTW after TBI, well-controlled intervention studies regarding RTW in this group are scarce. The current study is an innovative randomized controlled trial (RCT) which explores the effect of combined manualized cognitive rehabilitation efforts (10-session) and supported employment (six months) in real-life competitive work settings for patients with mild-to-moderate TBI who have not returned to work 8 ? 12 weeks post-injury. This is a collaborative project between Oslo University Hospital, Sunnaas Rehabilitation Hospital, the Labor and Welfare Administration (NAV), Work research institute, Personskadeforbundet, LTN, Department of Health Economics (HELED), and Center for Habilitation and Rehabilitation Models and Services (CHARM), University of Oslo, UiO. The study is registered at ClinicalTrials.gov, NCT03092713 and approved by the Regional committee for medical and health research ethics (REK nr.2016/2038).
A total of 121 participants were included in the quantitative and 59 participants in the qualitative part of the study, between July 2017 and April 2019. The dropout rate of 6% in the quantitative study is considered acceptable. Baseline data on 116 participants were obtained. The 12-month follow-up ended in June 2020, slightly delayed due to the Covid-19 pandemic. The project resulted in two Philosophie Doctors and two Master of Sciences as well as 15 international per-reviewed publications.
We assessed if the intervention that included collaboration between healthcare and employment services may increase the chance of identifying important issues and positively influence employment outcomes after TBI. The results from the feasibility study indicated that the manualized cognitive intervention is feasible in a Norwegian context. Most participants attempted to apply the trained skills to real-life situations. Both intervention groups improved significantly during the study period and no between-group differences on employment outcome was observed 12 months after study inclusion. Most had returned to work by 12 months (CCT-SE: 90%, TAU: 84%, p = .04), and all except three of these were stably employed at that time. However, there was a higher percentage of patients in the CCT-SE that had returned to work by the 3 months follow when comparing to TAU (81% vs 60%, p = .02). Compared to TAU, CCT-SE was associated with higher healthcare costs, but lower costs related to informal care and productivity loss. Costs associated with productivity loss accounted for approximately 85% of total costs, while health- and informal care each accounted for approximately 8%, further supporting the implementation of effective intervention programs targeted at return-to-work for this population. Important indicators of successful RTW after TBI appear in the accommodation process in the work organization. Uncertainty about accommodation for employees with TBI affects the RTW process. The qualitative data indicated that lack of long-term focus on accommodation at the workplace is a main barrier in RTW. Increasing workplace inclusion competence among managers may diminish potential barriers in RTW-processes.
In summary, these findings demonstrate that a complex intervention such as the one applied here might aid patients after mild-to-moderate TBI in a speedier RTW after injury and gives support to the notion that targeted early intervention programs for patients with TBI might be cost-effective in this case due to the cost related to informal care and productivity loss.
Prosjektresultatene viste hvordan en kompleks kognitiv og arbeidsrettet intervensjon kan hjelpe personer med mild og moderat traumatisk hodeskade (TBI) raskere tilbake i arbeid og understreker hvordan tidlig rehabiliteringsinnsats kan være kostnadseffektiv på samfunnsnivå mht lavere kostnader knyttet til uformell omsorg og produktivitetstap.
Tilrettelegging på arbeidsplassen er en viktig indikator for vellykket tilbakeføring til arbeid etter TBI. Fravær av langsiktig fokus og usikkerhet knyttet til tilrettelegging for arbeidstakere påvirker tilbakeføringsprosessen. Økt inkluderingskompetanse blant arbeidsgivere kan motvirke barrierer for tilbakeføring til arbeid.
Tversektorielt forskningssamarbeidet mellom klinikere, velferdssystemet og arbeidsforskere har vært verdifullt mhp å fremme en mer kompleks forståelse av tilbakeføring til arbeid etter TBI.
Samarbeidet med forskere fra USA og Australia har bidratt til en internasjonalisering av prosjektets resultater.
Mild-to-moderate traumatic brain injury (TBI) can result in long-lasting somatic, cognitive, and emotional symptoms which affect return to work (RTW). Maintaining employment over time is a major challenge, due to the cognitive symptoms. The persons own perceptions regarding RTW and the impact of the workplace environment have also been associated with RTW after sickness absence. At a service delivery level, the collaboration between the health related rehabilitation services, the Labor and Welfare Administrations (NAV), and the work-place is weak after TBI. There are barely any well-controlled intervention studies regarding RTW in this group, and vocational rehabilitation interventions are seldom included. Rehabilitation and vocational science perspectives will be applied in the project.
Through a mixed methods approach comprising a randomized controlled intervention trial and a qualitative process evaluation, the project will a) explore the effect of combining a group-based manualized cognitive rehabilitation program and supported employment in real-life competitive work settings for patients who have not returned to work 8 weeks post-injury compared to a control group receiving rehabilitation provided by a multidisciplinary rehabilitation team; b) explore roles, time commitment, interdependencies and methods in the supported employment process. Semi-structured interviews will provide an empirical base for increased knowledge on job content and skills requirements, work environment, employers roles, work organization and needed support. Cost-effectiveness of the intervention will be established.
In this multicenter study, research groups from the medical rehabilitation sector and vocational sciences (The Work Research Institute and the NAV Department of Vocational Rehabilitation) will collaborate. This will enable the project to obtain new knowledge about RTW as a multi-disciplinary and multi-sectorial process that can be applicable to other patient groups.