From Recovery to Rediscovery: Exploring Vocational Rehabilitation Models for Acquired Brain Injury

While working with various neurological disorders we come across patients from various cultures, age and occupations. A colleague of mine, an occupational therapist and I were having a casual conversation about how important it would be for us personally to return back to work if we ever had to sustain a life altering injury as it is highly linked to our identity. This led to discussing vocational rehabilitation and its importance in long term rehabilitation.

Vocational Rehabilitation (VR) is the process of guiding a client to reach their maximum potential of functionality following an injury to remain, return, or transition to work.? The vitality of VR is reported in follow-up studies that depict higher Quality of Life (QoL) in brain injury patients (British Society of Rehabilitation Medicine, 2010). A study conducted in Glasgow shows a drop in employment rates to 26% post-injury compared to 86% pre-injury (Tyerman, 2012). VR models assist clinicians and therapists in curating vocational interventions for individuals with disabilities. Vocational rehabilitation approaches for Acquired brain injury (ABI) have been a significant focus for several decades, in the rehabilitation sector.? The importance of VR post ABI especially in younger adults has led to the development of numerous models of VR but also a great variance in such approaches. These variances in approaches occur due to the broad nature and severity of ABI pathology. ABI is a multidimensional issue and possesses certain barriers to return to work (RTW). VR rehabilitation is an interaction between sensory, emotional, neurological, physical, and cognitive concerns and their interaction with personal, family, and social life.??

The key biopsychosocial elements interfering with the functional limitations are worth noting. Impairment in metacognition, impulsivity, inappropriate verbal skills, affective disturbances, motor issues, age, negative attitude, and lack of awareness are some of the issues which the models address (Prigatano, 1989), while environmental factors are noted to have a significant impact on workplace performance (McCue, 1992). Inclusion of multi-agencies, ad dressing complex assessment needs, and routine monitoring of the outcomes obtained through specific approaches are some of the markers of quality practice (British Society of Rehabilitation Medicine, 2010). ?

The program-based approach focuses on the individual’s awareness and acceptance of the impairment (Yasuda et al., 2001). It focuses on an individual’s skill set through personalized interventions, a chance for multiple job trials, and assistance with job placements and?transition. These principles help the clients regain the skill set required for RTW. It assists them with transitioning and exploring alternative options when the opportunity to RTW is minimal due to the severity of their injury. It assists them with job search by providing them with resources and teaching them coping strategies for the transition phase. Community based training programs, Program without walls, work re-entry program, and the New York University (NYU) Head Trauma Program are some of the examples of program-based approaches.??

The New York University (NYU) Head Trauma Program includes neuropsychological remediation which focuses on cognitive deficits, developing compensatory strategies, and promoting job trials. A study (Rattok, 1992) based on the New York University Head Trauma 20-week program involving cognitive remediation, small and large group interpersonal exercises, therapeutic communication activities, and personal counselling to assess its effects on vocational outcome, reported higher rates of RTW through improved functional independence based on results obtained on neuropsychological and functional assessments. Through Improved results on WAIS verbal and performance subsets, the logical memory subtest of the Welscher Memory Scale (WMS) and Sentence Repetition portion of the Neurosensory Center Comprehensive Examination for Aphasia [NCCEA] depicted improvements in characteristics of verbal memory and language issues hindering with ABI patients’ functionality. These assessments combined involve aspects of social cognition, psychological well-being, and interpersonal skills which are essential in a vocational setting.??

The supported employment model (Wehman et al. 1988) focuses on support for the job through itself through placement, job skill coaching using partnership strategy. This approach of VR focuses on job placement by assessing the individual’s retained skill set, behaviour & communication rather than the evaluation of the injury itself. This model emphasizes on long-term supervision and evaluation with the interest of outcome efficiency by a job coach. Unlike other interventions, this is based on higher severity of disability which is reflected in its eligibility criteria and is not constricted to a time frame like the NYU head trauma program. Studies have largely supported the cost benefits of this approach and became one of the reasons for its popularity among the public health sector?(Wehman, 1994). Although the average income of a brain-injured person was greater than the amount spent on an individual’s rehabilitation, this data was obtained from clients who have sustained the same job for more than two years, suggesting long-term retainment might play an important role in pay benefits. This model seems to mimic the principles of a comprehensive integrated and community reintegration approach. It provides compensatory strategies for self-management skills, communication skills, and cognitive issues (Vauth et al., 2005). Beyond personal adjustments, this approach facilitates adjustments to the work premises, modifying work equipment, alternative assignments, hours, and setting of work and monitoring these adaptations.??

Rehabilitation models require a holistic approach to challenge the interdisciplinary issues following ABI. The case coordination model provides the opportunity to highly individualize the program. This approach includes referrals from multiple sectors of post-acute rehabilitation services providing evidence to its holistic approach but does not involve regular monitoring of the progress. A few services of this model include State Vocational Rehabilitation, Missouri Division of Vocational Rehabilitation, Brain Injury Vocational Case Coordination, and Vocational case coordination system. Direct results from a study on vocational case coordination systems (Buffington et al., 1997) indicated a success rate of 50% paid employment and 80% community-based employment.??

A medical/vocational case coordination system (MVCC) is one such example. It is a holistic approach to both medical and vocational rehabilitation, job trials, job coaching, and early case detection that facilitates psychosocial adjustment. A study explored the effectiveness of MVCC through five levels of the vocational Independence scale (VIS) with participants in multiple stages. The results reported an improvement in clients present in all, the independent work, transitional placement, supported work, and sheltered work stages (Malec, 2000). Even though this emphasizes the role of vocational rehabilitation in RTW, the authors suggest that RTW after ABI is highly dependent on disability severity and time since injury in this approach (Rao & Kilgore, 1992 & Wehemen, 1993).??

A community-based approach that adapted the staff facilitative role is the consumer directed model. This approach has a higher focus on ABI literature than other approaches discussed. This model is highly derived with a focus on mental health and psychiatric issues faced by patients of ABI. It focuses on the multifaceted issues that interfere with all the aspects of returning, remaining, transitioning, and alternating in RTW or study. The Club house model is an example of this approach. This program is highly governed by the clients themselves; they are given the opportunity to select the skills and staff they would like the program to guide them with. This program is effective in finding paid positions especially if requisite skills are attained. Approximately 18% of clients enrolled in this program over 3.5 years were reported to be a part of a competitive job role in a study presented (Jacob & De Mello 1996).??

The underlying principles of the Club house model are long-term support (Jacobs et al., 1990) rather than an improvement on the functional issues. The support is catered to each need and more importantly their roles in their environment through compensatory strategies, rather than focusing on the injury. This strategy helps them avoid impaired self-identity with a certain capacity to achieve skills and functionality (Murugami, 2009). The clients are held responsible for their goal attainment. This provides the client with goals that are meaningful and achievable which provides them with motivation and higher self-confidence. It assesses clients on various aspects with which ABI individuals might struggle. Such as skill generalization, executive function, problem-solving, and organization and at the end are provided with feedback, providing an opportunity for reflection (Sabella et al., 2020).??

The members of this approach behave as a society who occasionally act as positive role models than have an authoritative role which provides the clients with assurance (South wick, 2013). It is highly modulable as clients go through multiple transitions in a long-term program. These adaptations take place in relation to general life changes and simultaneous cognitive, physical, social and emotional developments. This facilitates room for learning (Evans et al., 2004) and assimilation which is an important aspect of vocational adjustment following ABI. Most importantly, the clubhouse model teaches its members to learn, adapt and compensate for their current living conditions which emphasizes employment in the community. However, the overwhelming role of the client in their own progress and extreme ABI severity might discourage some patients from accessing rehabilitation through this approach (McKay et al., 2018).??

People with disabilities continue to earn comparatively lower than the general public even after vocational training (Blackorby et al., 1996). This issue can be attributed to gaps in rehabilitation, and improper approaches which reflect a lack of assessment. Regular outcome recording, focusing on introducing creativity to these models, specialist VR training in ABI setting, workplaces promoting job opportunities are all evident ways in which these models can facilitate RTW in ABI individuals. There is a lack of standardized methodology in VR research to draw conclusive opinions or comparisons of various models. In conclusion, vocational rehabilitation is a vital process as it not only supports an individual’s personal needs but also reduces overall expenditure on healthcare support in a nation (Knapp et al., 2013).? There is also a need for increasing standardized methodology in the literature which would?assist in drawing conclusions on these various approaches, as ABI symptoms are highly heterogeneous and there is an absence of a uniform criterion for RTW.?

I find this to be a very interesting and niche sector of rehabilitation and if anyone is interested further in reading about it, BSRM has an educating guide to VR, click on this text to access it.