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Brain injury rehabilitation in adults
8 Vocational rehabilitation
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Vocational rehabilitation (VR), or supported employment, focuses on the return to work, education or duty
of an individual following injury. Return to work following ABI has been identified as the most challenging
task that a patient will face in the course of their recovery and remains the most significant marker of return
to their pre-morbid level of function. 145 It has been estimated in a US study published in 2001 that the annual
loss of productivity and wages together with cost associated with care and management of TBI are estimated
to be $28 billion to the US economy. 146 Vocational rehabilitation is not the core business of the NHS. However,
it is clearly important for TBI rehabilitation and supporting patients towards achieving their goals.
The evidence related to the efficacy of VR remains scattered and inconclusive. One review found it difficult
to ascertain employment outcomes considering the range of outcomes and measures that exist and showed
a range of return to work rates from 20% to 90%. 147 Most of the evidence reviewed was carried out in US,
Canada, Australia and New Zealand which should be taken into account when generalising to a Scottish
population because of differences in funding streams and legislation. Evidence in this section was identified
by searching for interventions which were defined by researchers as vocational rehabilitation. This may
underestimate the total available evidence as other interventions which may be defined using cognitive,
physical or behavioural terms may also impact on the individual’s ability to return to work.
8.1 BENEfITS of RETuRNING To WoRK
Return to work is an important stage in rehabilitation after traumatic brain injury for a number of reasons.
Firstly, being employed has been associated with better quality of life in TBI survivors and secondly the
financial costs associated with unemployment after TBI are substantial given that TBI disproportionately
affects young people of working age. 148
8.2 VoCATIoNAl REHABIlITATIoN INTERVENTIoNS
The evidence on the effectiveness of specific VR interventions is inconclusive.
A quantitative synthesis of 26 studies (n=3,688) which used a wide range of interventions indicated that
patients who received VR returned to work quicker than patients who had no VR (mean percentage successful
adjusted return to work 71% v 47%). 147
A systematic review included three studies that looked at VR. The results suggested that there is limited
evidence that VR results in improved outcomes for patients with TBI, however, the study designs were of
widely varying populations and settings. 145 The authors also included one study of supported employment
and suggested that it improves the level of employment outcomes where there are aspects of competition
involved in securing the post, particularly for ABI survivors who are older, have more education, have no
prior work experience or who have suffered more severe injuries. There were significant problems with the
methodology of the study.
A systematic review published in 1999 identified no direct evidence from RCTs about the efficacy of supported
employment. Participants in the supported employment programme showed significantly better results
but the comparison group were so heterogeneous with multiple factors affecting employment that no
conclusions could be drawn from the results. 149
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