Work-related difficulties in patients with traumatic brain injury: a systematic review on predictors and associated factors

<p><b>Purpose</b>: To address the content of work-related difficulties and explore which variables are associated to or determinants of these difficulties in persons that suffered from Traumatic Brain Injury (TBI). <b>Method</b>: Papers published between 1993 and February 2015 were included. Quality was judged as poor, acceptable, good or excellent. Determinants were extracted from longitudinal data, associated variables from cross-sectional data; variables were grouped by similarity. Evidence was judged as strong if the same results were reported by two or more good studies; limited if reported by one good and some acceptable studies. <b>Results</b>: Forty-two papers were selected (25,756 patients). Work-related difficulties were referred as unemployment, job instability or job cessation. Strong evidence of impact was found for: low educational level, pre-injury unemployment, Glasgow Coma Scale score and TBI severity, length of stay in acute and rehabilitation settings, lower Functional Independence Measure scores and presence of cognitive disturbances. <b>Discussion</b>: Evidence on the effect of rehabilitation interventions on TBI patients’ work-related difficulties exists, but is poorly measured. Future studies should address the sustainability of holistic and tailored interventions targeting employees, employers and workplaces and aimed to reduce the gap between work duties and worker’s abilities, using appropriate assessment instruments measuring difficulties in work activities.Implications for rehabilitation</p><p>Traumatic Brain Injury (TBI) primarily affects young persons of working age causing a broad range of motor, sensory and cognitive impairments. A combination of variables related both to pre-morbid and to injury-related factors predict and are associated to work-related difficulties.</p><p>While demographic and injury characteristics cannot be modified, some TBI outcomes (e.g. cognitive impairments or functional status) may be addressed by specific rehabilitative interventions: the knowledge of the specific work-related difficulties of TBI patients is of importance to tailor rehabilitation programs that maximize vocational outcomes.</p><p>Rehabilitation researchers should give attention to vocational issues and use assessment instruments addressing the difficulties in work-related activities, in order to demonstrate the benefits of rehabilitative interventions on TBI patients’ ability to work.</p><p></p> <p>Traumatic Brain Injury (TBI) primarily affects young persons of working age causing a broad range of motor, sensory and cognitive impairments. A combination of variables related both to pre-morbid and to injury-related factors predict and are associated to work-related difficulties.</p> <p>While demographic and injury characteristics cannot be modified, some TBI outcomes (e.g. cognitive impairments or functional status) may be addressed by specific rehabilitative interventions: the knowledge of the specific work-related difficulties of TBI patients is of importance to tailor rehabilitation programs that maximize vocational outcomes.</p> <p>Rehabilitation researchers should give attention to vocational issues and use assessment instruments addressing the difficulties in work-related activities, in order to demonstrate the benefits of rehabilitative interventions on TBI patients’ ability to work.</p

Psychosocial difficulties (PSD) included in the PARADISE data collection protocol.

<p>^<b>§</b> Columns one to three present all PSDs indicating the code of the ICF classification they address and the question we used to operationalize them. Columns 4 to 12 present for each PSD and each brain disorder, the percentage of persons, who had reported difficulties in the study implementing the PARADISE data collection protocol. Those cells above 25% are marked in bold.</p><p>*WHS: World Health Organization (WHO) World Health Survey; CIDI: WHO Composite International Diagnostic Interview; WHODAS II: WHO Disability Assessment Schedule 2.0; HADS: Hospital Anxiety and Depression Scale; HSQuale: Quality of Life Instrument for Young Hemorrhagic Stroke Patients; SIP: Sickness Impact Profile; SCL-90: Symptom Checklist; SCAN: Schedule for Clinical Assessment in Neuropsychiatry; SA-SIP: Stroke Adapted-Sickness Impact Profile; SIS: Stroke Impact Scale; HSQR: WHO Survey on Health and Health System Responsiveness; WHOQoL: WHO Quality of Life.</p><p>Psychosocial difficulties (PSD) included in the PARADISE data collection protocol.</p

PARADISE approach with literature reviews, content analysis of outcome instruments, clinical input and qualitative study.

<p>PARADISE multi-method approach with systematic literature reviews, content analysis of patient-reported outcomes (PROs) and outcome instruments, clinical input and a qualitative study. Information from all sources was harmonized and compiled and a data collection protocol developed also including feedback from an external expert consultation. The protocol included all potentially relevant PSDs and their determinants across brain disorders. This protocol was implemented in a cross-sectional study.</p

Decision tree used for selecting relevant psychosocial difficulties across brain disorders.

<p>The starting point of the decision tree was the list of psychosocial difficulties (PSD) addressed in the 27 patient reported outcome (PRO) or outcome instruments identified in the literature reviews. If a PSD was addressed in at least one of the PROs or outcome instruments and had also been identified in at least two of the three sources of information (literature reviews, qualitative study and clinical input), this PSD was selected for inclusion into the data collection protocol. If a PSD had only been included in one of the sources of information, then if it had been identified in the literature reviews of at least two brain disorders and in those in > 20% of the studies included in the reviews, then the PSD was also included in the PARADISE protocol. If not, then if it had been included in the patient input studies for more than three brain disorders, or in the clinical input for more than three brain disorders, in both cases it was included in the protocol.</p

Demographic characteristics of the persons participating in the study implementing the PARADISE data collection protocol.

<p>^§ Data collection centers: dementia and schizophrenia, Instytut Psychiatrii i Neurologii in Warsaw, Poland; epilepsy, migraine, multiple sclerosis, Parkinson´s disease and stroke, Instituto Nazionale Neurologico “Carlo Besta” in Milan, Italy; substance dependency, Järvanpää Addiction Hospital, Haarajoki, Finland and depression, Hospital Universitario de La Princesa in Madrid, Spain.</p><p>* HDRS: Hamilton Depression Rating Scale; CRS: Clinical Rating of Severity; MIDAS: Migraine Disability Assessment; EDSS: Expanded Disability Status Scale; Hoehn & Yahr: Hoehn & Yahr Score; NIHSS: National Institutes of Health Stroke Scale; CGI: Clinical Global Impression (CGI); MMSE: Mini Mental State Examination; ADS: Alcohol Dependence Scale.</p><p>** In substance dependency, 44 persons had alcohol dependence as their main diagnosis. The data reported here refer to the 34 of those from whom the ADS data were available. Mean is not reported because of the low N. For all other substance dependency conditions, the intention was to collect data with the ‘Severity of Dependence Scale’. There were, however, a larger number missing data and the results are, therefore, not reported.</p><p>*** SCQ Score: Self-reported Comorbidities Questionnaire. The summary score is derived by adding the up to three points obtained from each reported health conditions: one point for its presence, one if treatment is received, and one if it causes decrements in functioning</p><p>Demographic characteristics of the persons participating in the study implementing the PARADISE data collection protocol.</p

Environmental determinants included in the data collection protocol and the percentage of persons who experienced them as having a positive or negative influence in their psychosocial difficulties.

<p>Environmental determinants included in the data collection protocol and the percentage of persons who experienced them as having a positive or negative influence in their psychosocial difficulties.</p

Prevalence of severe/extreme sleep problems by presence of chronic condition and country among adults aged 50 years or over.

<p>Abbreviation: COURAGE Collaborative Research on Ageing in Europe; SAGE WHO Study on global AGEing and adult health; S. Africa South Africa</p><p>Data are % (SE). % is the percentage of individuals with sleep problems by the presence (Yes) or absence (No) of that chronic condition.</p><p>Difference between individuals with and without that chronic condition is statistically significant (P<0.05) in ^aOverall sample, ^bFinland, ^cPoland, ^dSpain,^eChina, ^fGhana, ^gIndia, ^hMexico, ⁱRussia, and ^jSouth Africa.</p><p>Prevalence of severe/extreme sleep problems by presence of chronic condition and country among adults aged 50 years or over.</p

Association between chronic conditions (independent variable) and severe/extreme sleep problems (dependent variable) among adults aged 50 years or over estimated by logistic regression with multiple variables.

<p>Abbreviation: COURAGE Collaborative Research on Ageing in Europe; SAGE WHO Study on global AGEing and adult health; S. Africa South Africa.</p><p>Data are Odds Ratio (95% Confidence Intervals).</p><p>All models are mutually adjusted for all chronic conditions in the model and age, sex, education, wealth, marital status, alcohol consumption, smoking, and physical activity. The model using the overall sample is also adjusted for county.</p><p>*p<0.05,</p><p>**p<0.01,</p><p>***p<0.001.</p><p>Association between chronic conditions (independent variable) and severe/extreme sleep problems (dependent variable) among adults aged 50 years or over estimated by logistic regression with multiple variables.</p

Baseline characteristics of the study sample.

<p>Abbreviations: COURAGE Collaborative Research on Ageing in Europe; SAGE WHO Study on global AGEing and adult health; S. Africa South Africa.</p><p>Data are % (SE) unless otherwise stated.</p><p>Baseline characteristics of the study sample.</p

Association between number of chronic conditions (independent variable) and severe/extreme sleep problems (dependent variable) estimated by logistic regression with multiple variables.

<p>Abbreviation: COURAGE Collaborative Research on Ageing in Europe; SAGE WHO Study on global AGEing and adult health; S. Africa South Africa.</p><p>Data are Odds Ratio (95% Confidence Intervals).</p><p>Trend test was significant for all regression analyses (p≤0.002).</p><p>All models are mutually adjusted for age, sex, education, wealth, marital status, alcohol consumption, smoking, and physical activity. The model using the overall sample is also adjusted for county.</p><p>*p<0.05,</p><p>**p<0.01,</p><p>***p<0.001.</p><p>Association between number of chronic conditions (independent variable) and severe/extreme sleep problems (dependent variable) estimated by logistic regression with multiple variables.</p