Occupational Reintegration in Patients with Traumatic Brain Injury

Copyright: © 2015 Catano A, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


Introduction
Traumatic brain injury [TBI] remains a leading cause of death and disabilities among young adults [1,2]. Incidence of TBI varies greatly between studies. As compared to 98/100,000 in USA or to 160/100,000 in India, it has been reported that the annual incidence of TBI was 235/100,000 in Europe with large disparities among countries: 91/100,000 in Italy, 435/100,000 in England or 546/100,000 in Sweden [3][4][5].
In Western countries, one person is victim of a TBI every three minutes, which represents 200,000 victims/year from which 50,000 will be hospitalized, 2,800 will die and 5,000 will keep permanent disabilities [6][7][8]. Th ese fi gures do not include the 15,000 accidents of sport per year which are responsible for various behavioral disorders [9,10].
In neuro-rehabilitation practice, diff use cerebral lesions, either of hemorrhagic or of traumatic origin, are generally associated with a coma whose initial severity and duration will determine (a) the chances of survival and (b) the degree of the subsequent recovery [11][12][13]. In survivors, the impacts on the cerebral functioning are numerous and complex, aff ecting motor control, sensory modalities, psychointellectual function, language and writing, recognition of the familiar faces, perception of the environment, … Unfortunately, patients will remain in a state of complete functional dependence for the Activities of Daily Life (ADL) in many cases. special section is mainly dedicated to coma (whatever the origin), in particular during the phase of awakening. Th e multidisciplinary team is composed of medical specialists in physiatry, neurological, cardiac and pulmonary rehabilitation who are assisted by physiotherapists, psychologists, speech therapists, nurses, and social workers. Th ey all work in conjunction to provide the best available care, taking into account the most recent scientifi c knowledge in this fi eld.
Th e rate of unemployment is usually about 13% in professionally active people of our urban area which is of multi-ethnic and multicultural type [15]. As there is little information in the literature on the effi ciency of the professional reintegration models for patients suff ering from TBI, we strived for identifying which factors are needed to establish an accurate individual professional reintegration program.

Materials and Methods
We indexed the problems encountered in various fi elds (clinical, psychological, social, professional, administrative,...) during the process of professional integration among patients suff ering from a TBI from January 2010 until December 2011. 56 consecutives patients were included in this retrospective study. Th ey were all suff ering from a TBI following motor vehicle accidents (n = 31), falls or domestic accidents (n = 8), work-related accidents (n = 6), violence with physical abuse (n = 6) and sport or recreational activities accidents (n = 5), resulting in a closed head injury with initial altered state of consciousness. Th e patients were hospitalized in our Department with the aims of a rehabilitation of the TBI. Th ey were in the general market of labour at the time of the TBI. All the patients (or their relatives) gave their agreement for the present study, knowing that the results would not infl uence their medical and ancillary treatments.We excluded from the study the patients with a former disease interfering with the usual capacities of sustained work (neurological malformation, psychotic state, ...), those who were not in the market of labour at the time of the TBI, and those with standards of living interfering with the essential prerequisites of the market of labour (clan destinity, illegality, fi nancial bankruptcy, social disintegration, ... ).

Patients
All the patients were addressed to our Department by the emergency department aft er stabilization of their vital functions or by the intensive care unit when their clinical state was compatible with rehabilitation. Th e primary neurological diagnosis on admission was cerebral concussion (6 men and 6 women), intra-ventricular haemorrhage (6 men and 4 women), subdural haematoma (10 men and 7 women) and diff use axonal injury (10 men and 7 women). In line with the published recommendations, our 56 patients were divided into 3 groups according to the initial severity of the TBI as evaluated by (a) the Glasgow Coma Scale (GCS) (16) which grades a person's Level of Consciousness (LOC) on a numerical scale of 3 to 15 based on verbal, motor, and eye-opening reactions to stimuli, (b) the duration of Post-Traumatic Amnesia (PTA), and (c) the duration of the loss of initial conscience (LOC) [13,[17][18][19]. Patients with "mild" TBI had an initial GCS score between 13 and 15, a duration of PTA lower than 24 hours and duration of initial LOC of less than 30 minutes. Patients with "moderate" TBI had initial values of GCS from 9 to 12, duration of PTA of less than 7 days and a LOC having lasted more than 30 minutes but less than 24 hours. Th e group with "severe" TBI had initial GCS values from 3 to 8, duration of PTA of more than 7 days and LOC lasting more than 24 hours. Once in our Department, all the patients received a multidisciplinary rehabilitation consisting of daily physiotherapy, occupational therapy, speech and psychology therapies, according to the individual needs. Th e basic principles of rehabilitation and the procedures of hygiene, nutrition and medical supervision were adapted to each case according to the individual clinical state. Th e nursing care emphasized preventive interventions against pressure sores and eventual complications of prolonged immobilization. When present, the disorders of swallowing were treated accordingly by usual therapeutical measures or by parenteral nutrition.
Th e demographic, social, clinical and functional data were collected for all the patients of the 3 severity groups ("Mild", "Moderate" and "Severe") at days0 (D0, day of admission in our Department), 180 (D180) and 365 (D365).

Patients' families
Th e patients' families and relatives were regularly informed on the functional evolution and progress of the patient. Th ey were asked to adopt a positive attitude. Counselling or psychological aid was provided when necessary.
During this study, the families and close relations were informed that they could visit the patient by their own way (providing the respect of the usual constraints of the medical therapeutics) and that they could accompany them in the eventual administrative procedures without any restriction.

Socio-professional status evaluation
Th e socio-professional status was recorded on admission in our department (D0), then at D180 and at D365 according to structured and directed questioning about the educational, fi nancial, marital, familial and professional aspects.
Th e educational background was estimated by considering the educational level with the highest diploma obtained by the person in primary education, secondary and higher education degrees. As a majority of surveyed people do not declare reliably their annual income, and their fi nancial status was evaluated by investigating the standards of living of the households. Th e familial and marital status was investigated in order to determine whether a person was socially isolated.
Th e professional status was estimated following the French nomenclature of the professions and socio-professional categories which contains 6 professional groups [20]. Within these 6 professional groups, the unemployed persons who had already occupied an employment were classifi ed among the categories of professionally active ones according to their last profession.
Patients ensuring a professional training or working on a parttime or full time basis were considered as having a paid job. In patients who had no paid job at D180 and D365, the causes of unemployment were collected and classifi ed into medical reasons, lack of motivation, inability to cope with prior job, unavailability of job arrangement and inability to cope with administrative procedures.

Clinical status evaluation
Th e clinical status was recorded at day 0 (D0, date of admission in our department), D180 and D365 by using a structured interrogation procedure followed by a clinical examination including the somatic, neurological, functional and neuropsychological evaluations.
Th e functional evaluations were performed using the Barthel Index (BI; 21) which measures the functional consequences of the patient's incapacities and their temporal evolution [22,23].
Th e neuropsychological testing consisted of the evaluation of the cognitive and linguistic functions, the capacities of attention and orientation (including the memory and attention areas) as well as tests assessing executive functioning; these tests were possibly supplemented by the evaluation of apraxia, agnosia, calculation, writing, and reasoning. All the neuropsychological tests were calibrated according to age, gender and socio-cultural level.

Statistical analysis
Statistical analysis was carried out by using the "Statistical Social Package for the Sciences" (SPSS, version 16). We fi rst assessed the normality of data before performing nonparametric statistical tests; all the tests were bilateral. Th e results are listed with mean values ± Standard Deviations (SD). When indicated, we used contingency tables with Chi-square or Fisher's Exact Test with two-sided P values.

Results
Th e main demographic and socio-professional data of all the patients included in this study (n = 56) are summarized in Table 1.

Demographic data
Th e 56 patients with TBI were 32 men and 24 women with respective mean ages of 39 ± 11 and 33 ± 13 years. Th ere was no statistical diff erence between the 2 groups in comparison with the 36 ± 12 years of the initial cohort (Student t test; P = 0.28). According to the initial severity of the TBI, the 56 patients were divided into 3 severity groups ("Mild", "Moderate" and "Severe" TBI). Within each of the 3

Mortality
Th e overall mortality rate at D365 was 34% (19 patients, 12 men and 7 women). 27% of patients (n = 15, 10 men and 5 women) died before D180. Statistical analysis revealed that there was no signifi cant diff erence in mortality according to gender or between each severity group at D180 and at D365 (Fisher's Exact Test ; P = 0.6) ( Table 1).

Socio-professional status
Th e educational background was evaluated on admission. Th e social status evaluation on admission is listed in Table 1. Analysis indicated that for eachseverity group, the mean number of patients in each education category did not signifi cantly diff er according to the gender (Chi-squared Test; P = 0.75). Within each severity groups, there was no signifi cant diff erence in the education status according to the gender (Chi-squared Test; P=0.95). Statistical analysis indicated no signifi cant diff erence between categories within each severity group accordingly at D180 and D365 (Kruskal-Wallis; P=0.31).
Th ere was no signifi cant diff erence in the patients' fi nancial status as evaluated with the standards of living of the households within each severity groups, according to gender or between them respectively (Chisquared Test; P=0.64).Th e evaluation of the social status (determining if a patient was socially isolated) indicated no statistical diff erence for gender at D0 (Fisher's Exact Test; P = 0.69) in severity groups. Statistical analysis indicated no signifi cant diff erence between categories in each group accordingly at D180 (Fisher's Exact Test; P = 1.0) and D365 (Fisher's Exact Test; P = 1.0) ( Table 1).
Th e professional status (determining if a patient had a paid job at the time of the TBI) indicated no statistical diff erence for gender (Fisher's Exact Test; P = 0.85) at D0. Analysis indicated no signifi cant diff erence between survivors in each group accordingly at D180 (Fisher's Exact Test; P = 0.29) and D365 (Fisher's Exact Test; P = 0.57).
Statistical analysis (Fisher's Exact Test) indicated that within the "Mild" severity group there was no signifi cant diff erence between categories at D0, D180 and D365 (P = 1.0) ( Table 1). Within the "Moderate" group, there was a signifi cant association between the initial severity of the TBI and the level of employment at D180 (P = 0.0124, Fisher's Exact Test). For the "Severe" group, there was a signifi cant association between the initial severity of the TBI and the level of employment at D180 (P < 0.0001) and D365 (P = 0.0002; Fisher's Exact Test).
Aft er pooling the data of employment outcomes in the 56 patients at D0, in the 41 survivors at D180 and in the 37 survivors at D365, statistical analysis (Fisher's Exact Test) revealed a signifi cant diff erence in the professional status at D180 (P < 0.0001) and at D365 (P = 0.0002) while there was no statistical diff erence between D180 and D365.
On admission, the mean age (years) of the patients who had a job at the time of the brain injury (n = 46) was 36 ± 12 years. Th e mean age was 36 ± 12 years in patients who were unemployed (n = 10). At D180, the mean age was 28 ±9 years in patients who had recovered a job and 35 ± 10 years in the unemployed patients. At D365, the mean age was 27 ± 7 years in patients who had recovered a job and 39 ± 11 years in the patients who did not. By comparison with the mean age of patients who were unemployed on admission (Mann-Whitney U-Statistic), the mean age of patients who regained a job was signifi cantly smaller at D180 (P= 0.0101) and at D365 (P = 0.0008).
Among the 5 patients who had no diploma or specialized qualifi cation at D0 (one patient with "Moderate" TBI and 4 patients with "Severe" TBI), none of them was found to have recovered a job or to follow a professional training at D180 or D365. From the 6 patients (4 men and 2 women) who were socially isolated on admission, one (female) patient from the "Moderate" group wasworking on a part-time basis at D180 and at D365 while one (male) patient from the same severity group was following a professional training at D365.Among the 4 patients who were both socially isolated and jobless at D0 (2 men and 2 women, equally distributed into both "Moderate" and "Severe" groups), none of them had regained a job or followed a professional training at D180 or D365. Th e causes of unemployment were collected in the patients who had not recovered their job at D180 (n = 26, 14 men and 12 women) and D365 (n = 17, 9 men and 8 women). Th e causes of unemployment at D180 and D365 are listed in Table 2. Statistical analysis showed no signifi cant diff erence between the 2 severity groups for each category of cause of unemployment according to the gender at D180 and D365 (Fisher's Exact Test; P = 1.0 respectively) ( Table 2).

Clinical evaluation
Besides the classical clinical and functional examinations, the specialized and clinical evaluations at D0, D180 and D365 indicated persistent neurological complications such as post-traumatic hydrocephaly (n = 5), epilepsy (n = 10), frontal lobe syndrome (n = 6), chronic vegetative state (n = 3) and minimally conscious state (n = 5). Seven patients had post-traumatic epilepsy. All the patients eligible for neuropsychological evaluation at D180 (n = 33) and D365 (n= 29) had evidence of disorders of attention, memory and executive functions.

Clinical status evolution
Furthermore, many patients presented mood disorders along with character and personality changes. Th e frequencies of the neuropsychiatric anomalies at D180 and D365 are presented in Table 3.
Th e main complaints referred spontaneously by the patients at D180 and D365 were anxious disorders, asthenia and headache. At D180, 21 patients suff ered from a depressive state and at D365, they were still 18 patients to be treated for depression. Some anxious manifestations such as sleep disorder, dizziness, disorder of vision, psychomotor agitation, and tinnitus tended to lessen over time while character disorder did not.

Functional status evolution
Th e functional status (evaluating the functional consequences of the patient's incapacities) was measured at D0, D180 and D365 in all patients by using the BI.   Reduced libido 18 16 Disorders of vision 12 0 Psychomotor agitation 12 0 Character disorder 9 9 Tinnitus (whistling/ buzzing) 6 2  3 severity groups by gender over time. On admission, at D180 and at D365, there were signifi cant diff erences for the mean BI in the "Severe" TBI group as compared to the "Moderate" or "Mild" groups (Mann-Whitney U-Statistic, Dunn's Multiple Comparisons Test).
When comparing the mean BI of all patients by gender over time, statistical analysis indicated a signifi cant diff erence between the mean BARTHEL Index at D180 with P = 0.0137 in men and P = 0.0449 in women (Mann-Whitney U-Statistic) while there was no statistical diff erence at D365 in comparison with D180 (Mann-Whitney Test ; P = 0.49).
Analysis of the data of all the patients showed a statistical diff erence between the mean BARTHEL Index at D180 (P = 0.0011; Mann-Whitney U-Statistic) and at D365 (P <0.0001; Mann-Whitney U-Statistic) while there was no statistical diff erence between D180 and D365 (Kruskaul-Wallis Statistic; P =0.94).

Discussion
In our study, the 56 patients were in the general market of labour at the time of their TBI. We grouped them according to the initial severity of the brain injury. Th eir demographic data and their socio-professional status on admission showed no statistical diff erence. Although the sample of our study is very small, our results indicate globally that mean functional recovery was signifi cantly improved from D180 on, as was the mean job recovery rate that was statistically diff erent either when gathering the data from the whole cohort or when pooling them according to the gender or to the initial degree of severity of the TBI (Table1). Th is suggests that in our series the job recovery rate could eventually be associated mainly with the degree of functional recovery at D180 although improvement of neurological function can occur for two or more years aft er the initial trauma [13].
Administrative procedures are a complex matter that commonly requires intact executive functions and cognitive skills in healthy people. 48% had presented a severe initial coma and there were 14 cases out of 56 (25%) with known poor outcome as 6 patients had a "frontal lobe syndrome", 3 patients had a"chronic vegetative state" and 5 patients suff ered from a minimally conscious state [17,[24][25][26][27][28]. All the patients evidenced neuropsychological disorders of attention, memory and executive functions with possible negative impact upon work performances at D180 and D365 [2,29,30]. Furthermore, at D180, 21patients (51%) suff ered from a depressive state and 9 from a character disorder (22%) which did not improve signifi cantly overtime. Th e frequencies of the neuropsychiatric disorders collected at D180 and D365 (Table2) suggest actual diffi culties in coping with occupational activities and/or with main administrative procedures in order to keep, regain or fi nd a job. Similar results have already been reported [31]; in a series of 846 patients with severe TBI less than one-third of cases had a good recovery (defi ned as mild or no disability) and able to return to work or school [32]. When considering the rates of unemployment overtime in our series, we noticed that, on admission, 10 out 56 patients were already unemployed (18%). Th is rate of unemployment is slightly above the expectation in our area (13%). Th is could result from our procedures of recruitment since we had a predominance of 48% of patients in the group with "Severe" TBI on admission. At D180, 16 patients out of 41(39%) were unemployed. At D365, they were 17 out of 37(46%). However, statistical analysis showed no signifi cant diff erence between these fi gures.
Compared to the unemployed patients, the mean age of patients who recovered a job was signifi cantly lower at D180 (P=0.0101) and at D365 (P=0.0008) (Mann-WhitneyU-Statistic). An eventual eff ect of mortality upon the employment out comes can be discarded as there was no statistical diff erence in mortality from D180 until D365 (Table1). Generally, younger adult patients with TBI have better recovery than older ones. Th is is in agreement with the literature; this parameter is a powerful independent prognostic variable of positive outcome aft er a TBI [13], the odds for a poor outcome being increased by 40 to 50% per 10 years of age [33]. Younger patients with better recovery could develop earlier compensatory strategies and work with employers to arrange appropriate accommodations.
Similar consideration can be made for the fi nancial status aspects as analysis showed no statistical diff erence between the 3 severity groups. Actually, our recruitment procedures had discarded patients with standards of living interfering with the prerequisites of the market of labour. Low fi nancial income tends to worsen clinical outcomes in patients with TBI [34,35]. Nevertheless, all our patients had equal access to medical care facilities and could benefi t from national insurance resources. Among the 5 patients who had no diploma or specialized qualifi cation at D0 (one patient with "Moderate" TBI and 4 patients with "Severe" TBI), none of them was found to have gained a job or to follow a professional training at D180 or D365. Severity of the initial injury to the brain and poor level of education have shown lower functional outcome [6,13,[36][37][38] which could result in lesser employment rates. From our 6 patients (4 men and 2 women) who were socially isolated on admission, only 2 were working or following a professional training at D365 and among the 4 patients who were both socially isolated and jobless at D0, none of them had found a job or was engaged in a professional training at D365. Social isolation has proved to be a negative factor on employment outcomes aft er a TBI [39][40][41]. Using the Craig Handicap Assessment and Reporting Technique(CHART), O'Neill etal. (1998) identifi ed a signifi cant positive correlation between employment and social integration for individuals with TBI that had returned to full or part-time work. Indeed, even in otherwise healthy individuals social isolation may result in psychological and physical disintegration [42]. Among the causes mentioned to justify unemployment aft er the TBI, only one (male) patient mentioned lack of motivation at D180 but not at D365. Th is suggests that the majority of our patients actually considered work as a value of one individual's life. Improvement in outcomes could result from the use of models taking into account or favouring the view points and preferences of patients with TBI [43]. Th e other justifi cations of unemployment at D180 were the persistence of medical symptoms (n=13), the inability to cope with prior job (n=5), the inability to cope with administrative procedures (n=5) and the unavailability of job arrangements (n=2). Medical causes of unemployment were more common in the "Severe" (n=11) than in the "Moderate" group (n=2). Most of the patients from the "Severe" group were suff ering from chronic vegetative state or minimally conscious state without effi cient improvement aft er their "Severe" initial TBI. Inability to cope with administrative procedures was more frequent in the "Moderate" (n= 4) than in the "Severe" group (n= 1).
At D365, the reasons justifying unemployment were medical disorders (n=10), unavailability of job arrangements (n=5), inability to cope with prior job (n=1), and inability to cope with administrative procedures (n=1). Medical causes of unemployment were more frequent in the "Severe" (n= 9) than in the "Moderate" group (n=1), but unavailability of job arrangements was rather equally distributed in the "Severe" (n= 3) and in the "Moderate" group (n= 2). Although prevalence of subjective and behavioural complaints is high whatever the initial head trauma severity [44], the medical complaints in our series were still numerous in the "Severe group" from D180. Besides the medical disorders resulting from the brain injury, inability to cope with administrative procedures and unavailability of job arrangements were leading causes of poor employment outcomes from the 6 th month aft er the brain injury in our series. Indeed, better medical support could improve the patients' clinical states according to their own welfare standards. Th e medical management of TBIs could provide effi cient multidisciplinary approach to optimize outcome inorder to foster vocational rehabilitation as supportive employment matching job demands to the worker's abilities [13,45]. Better understanding of the diff erent parts of the work outcome profi le of patients with TBI may also benefi t the management of these cases [46]. Administrative procedures area complex matter that commonly requires intact executive functions and cognitive skills in healthy people. In our series, most of the patients presented disorders of attention, memory and executive functions at D180 and D365. Major depressive state, psychomotor agitation, character disorder and personality change are usually incompatible with complex processes which necessitate initiation, planning, organization, problem solving, verbal reasoning, mental fl exibility, task switching and adequate monitoring of actions. Th us, our fi ndings tend to reinforce the notion that the operating models and organizational structures commonly adopted by well-being individuals when solving complex issues are not consistent for most patients with TBI [47][48][49][50]. Recovery from cognitive defi cits is greatest within the fi rst 6 months aft er the TBI but further recovery can occur later on a more gradual mode [51]. Improvement may result from a multidisciplinary approach involving neuropsychologists to early evaluate and manage cognitive defi cits along with mental health professionals such as psychiatrists and clinical psychologists. Cognitive and behavioural disturbances may also have a substantial impact on the functioning of the family systems as a result of many causes. Frustration to have lost a suitable pre-injury status, inability to cope with problems, diffi culty in setting reachable goals, poor quality of communication and/or of reciprocal understanding have been mentioned [52][53][54]. In our study, communication problems were taken into account and appropriately treated (55); both the patients and their families had access to sustained psychological support. Psychoeducation and counseling models have been demonstrated to be eff ective in minimizing family disruption [52,56]. Nevertheless, the low success of professional reintegration programs suggests that further eff ort is required to further improve employment outcomes.

Conclusion
TBI encompasses its impact on society and rehabilitative management. Occupational reintegration takes time and requires a total apprehension of the problems which must be treated in all their clinical, psychological and social dimensions.
Although the sample of our study is very small, our results indicate that in all the patients who returned to work aft er their insult, professional reintegration was achieved along with both familial and social integration processes. Among positive features, young age at the time of the onset and facilities of arrangement of the work conditions tended to be useful. Early effi cient multidisciplinary approach could early improve the patients' neuropsychological performances with positive impact upon the employment outcomes. Socioeconomic status appears to aff ect the possibilities of work recovery as patients with lower levels of education and employment showed poor outcome in returning to work. Severity of the initial injury to the brain, poor level of education and social isolation have shown lower functional outcome with lesser employment rates. Job arrangements are crucial at D365 for the patients who were severely injured and who were jobless or socially isolated on admission. Due to frequent cognitive and executive disorders, the common professional reintegration models are not consistent for most of the patients suff ering from TBI. Larger improvement can be expected with oriented neurorehabilitation programs that nurture vocational rehabilitation as supportive employment matching job demands to the worker's abilities. Aft er a TBI, both the patients and their families need psychological support, psychoeducation or counseling models in order to minimize distress and disruption. Complex problems management is frequent aft er a TBI and may require an external professional counseling or aid. Our results have to be confi rmed at larger scale. However, due to the low success of the professional reintegration process, we conclude that further research is needed to improve the employment outcomes in patients aft er a TBI.