Employment Interventions for Return to Work in Working Aged Adults Following Traumatic Brain Injury (TBI): A Systematic Review
Authors: Graham Carolyn W. , West Michael D. , Bourdon Jessica L. , Inge Katherine J. , Seward Hannah E. 
Published: January 2017

This Campbell systematic review examines the effectiveness of vocational rehabilitation interventions to help adults with traumatic brain injury (TBI) get competitive employment. Three randomized controlled trials are included: two of military populations in the United States and two of the civilian population in China (Hong Kong).Studies are included which assess interventions focused on assisting helping workingaged adults with TBI return to competitive employment, including self‐employment. Participants must have been between 18 and 65 years of age, experienced a nonpenetrating 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. The studies must have competitive employment as an outcome.Three randomized controlled trials (RCT) are included in the analysis, two studying US military personnel and one of civilians in China (Hong Kong). All three studies compared alternative programmes. One compared an intensive in‐hospital program versus an at‐home program. The second study compared the CogSMART program plus supported employment with supported employment alone. And in the third study the control group received psycho‐educational training with the treatment group receiving the same content via a virtual reality‐based training platform.Synopsis/Plain Language SummaryThe Campbell review in briefPrograms for adults who have suffered traumatic brain injury may improve employment status. However, no programme was found to be more effective than its comparator programme.What is this review about?The unemployment rate in the United States for people who have suffered traumatic brain injury (TBI) was around 60 percent for 2001‐10, compared to a national average of around 7 percent. Post‐acute rehabilitation services ‐ such as residential community reintegration programs, comprehensive day treatment programs, and community re‐entry programs ‐ focus on helping individuals adjust to ongoing impairments and to re‐enter their communities, workplaces, and education. This review assesses the most effective type of intervention for returning individuals with TBI to work.What is the aim of this review?This Campbell systematic review examines the effectiveness of vocational rehabilitation interventions to help adults with traumatic brain injury get competitive employment. Three randomized controlled trials are included: two of military populations in the United States and two of the civilian population in China (Hong Kong).What studies are included in this review?Studies are included which assess interventions focused on assisting helping working‐aged adults with TBI return to competitive employment, including self‐employment. Participants must have been between 18 and 65 years of age, experienced a nonpenetrating 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. The studies must have competitive employment as an outcome.Three randomized controlled trials (RCT) are included in the analysis, two studying US military personnel and one of civilians in China (Hong Kong). All three studies compared alternative programmes. One compared an intensive in‐hospital program versus an at‐home program. The second study compared the CogSMART program plus supported employment with supported employment alone. And in the third study the control group received psycho‐educational training with the treatment group receiving the same content via a virtual reality‐based training platform.How effective were the programs?None of the programs were better at improving employment outcomes than the comparator program to which it was compared. That is the intensive in‐hospital program was no better than the at‐home alternative, CogSMART added to no value to supported employment alone, and virtual reality‐based training was no better than psycho‐educational training. Comparison of employment before and after the interventions suggests that the interventions in the United States improved employment status, but not that in ChinaNone of the studies reported secondary employment outcomes: hours worked and wages earned.It was not possible to conduct analysis of the relative effectiveness of different types of programme because of the small number of included studies.What are the implications of this review for policy makers and decision makers?These three studies have limited implications for practice and policy. No intervention was found to be more effective than any other. In two of the studies the populations were limited to military subjects, who present with significantly different challenges such as posttraumatic stress disorder.The comparator interventions of at‐home training and supported employment appear promising.What are the research implications of this review?There is a need for more RCTs on RTW interventions with adults with TBI, preferably separating competitive employment from school attendance. Military interventions should be conducted with civilian samples in order to determine their effectiveness in the civilian population, including on populations outside the United States. A broader range of employment outcomes should be studied, with regular follow up at standard intervals (e.g., six months, 12 months, 18 months, etc.).How up‐to‐date is this review?The search was completed in 2015. This Campbell Systematic Review was published in July 2016.What is the Campbell Collaboration?The Campbell Collaboration is an international, voluntary, non‐profit research network that publishes systematic reviews. We summarise and evaluate the quality of evidence about programmes in the social and behavioural sciences. Our aim is to help people make better choices and better policy decisions.About this summaryThis summary was written by Howard White (Campbell Collaboration). This PLS is based on Campbell Systematic Review 2016:6 ‘Employment Interventions for Return to Work in Working Aged Adults Following Traumatic Brain Injury (TBI): A Systematic Review’ by Carolyn W. Graham, Michael D. West, Jessica L. Bourdon, Katherine J. Inge and Hannah E. Seward (DOI:10.4073/csr.2016.6). Anne Mellbye (RBUP, Norway) designed the summary, which was edited and produced by Tanya Kristiansen (Campbell Collaboration).Executive Summary/AbstractBACKGROUNDIndividuals 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.OBJECTIVESThis review examined the effectiveness of vocational rehabilitation (VR) interventions to help adults with TBI attain competitive employment.SEARCH METHODSStudies 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.SELECTION CRITERIAThe 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.DATA COLLECTION AND ANALYSISOdds 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.RESULTSThe 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.AUTHORS' CONCLUSIONSAll interventions showed positive average gains. However, we 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.