Continuing professional development: Return to work after head injury

In the UK, helping people who have suffered brain injuries back to work is a challenge because of a lack of ongoing specialist multidisciplinary neuro-rehabilitation services which can support occupational health practitioners. The Social Services Inspectorate1 describes head injury as “a hidden disability”.


Neurological conditions in particular can cause employees to terminate their careers prematurely, but with the appropriate trained support services, many who suffer from this injury will be able to return to work and contribute at levels similar to pre-morbid levels.


The government fully supports the general case for rehabilitation. “Rehabilitation is not about forcing people back to work. Work, in fact, is often a crucial step in helping people return to health. And businesses have much to gain in terms of reduced sickness absence, and improved staff engagement and retention,” said Lord McKenzie, minister at the Department of Work and Pensions, in July 2007.


According to the Vocational Rehabilitation Association2, rehabilitation is “a process which enables people with functional, psychological, developmental, cognitive and emotional impairments or health conditions to overcome barriers to accessing, maintaining or returning to employment or other useful occupation.”


In their book, Waddell and Burton3 say that staying away from work can be as harmful as going to work.


The importance of the employer was demonstrated by the Job Retention and Rehabilitation Pilot4, an initiative developed by the Department of Work and Pensions to test how people may be helped to get back to work. A report of the research published in 2006 said those employers who were open to new ideas, and willing to work with outside agencies, were the most successful.


What are the problems faced by health services, and in particular, OH services in the rehabilitation and return to work of those employees who have suffered a brain injury? This article will suggest how to improve the return-to-work situation for employees with neurological conditions.


Brain injuries include those injuries that are acquired from trauma as a result of falls, road traffic accidents and assaults, as well as non-accidental injury from infections or following oxygen starvation – for example, stroke – as well as some progressive conditions. According to the Disability Handbook5, brain injury can lead to a variety of impairments, physical, cognitive and psychological.


Brain injury


The prevalence of disability after head injury has been estimated to be between 100 and 150 per 100,000 in the UK, affecting one family in 300. Of those, 84% have a minor head injury, 11% a moderate one, and 5% a severe one.


Different measures are used to diagnose the severity of brain injury, including the Glasgow Coma Scale Score. Strokes, cerebral tumours and infections (viral encephalitis and meningitis) are other conditions that could affect the workforce6.


It is important for employers to remember that any person who has a long-term medical condition which affects their day-to-day activities, and that includes work, is likely to come under the Disability Discrimination Act. Therefore, employers must consider what is the most appropriate way to rehabilitate an employee with disability after a brain injury.


The government has published various documents to guide service providers, including the National Service Framework for Long-term Conditions7 from the Department of Health. This document considers important issues for OH services, including the development of a wide range of partnership working and the provision of services that will allow prompt diagnosis, appropriate referral and treatment by experts in the field of neurological rehabilitation.


OH should have access to specialist services that will be able to provide appropriate vocational assessment, rehabilitation and ongoing support to allow employees to find, return to or remain in work. Access to Work, available through JobCentre Plus, for example, offers advice through the services of the disability employment adviser. Grants are also available from Access to Work to help with adaptations of the workplace and the purchase of specialist equipment.


Most people in this group will have suffered a mild or minor brain injury. Given the statistics mentioned above, annually about 80 to 90 people per 100,000 population will suffer a minor brain injury, through sport, occupational or road traffic accidents. These can have serious repercussions if the condition is not diagnosed and support is not offered. Fortunately many will make a good recovery. However, some never return to work, and many will face unnecessary delays.


Problems with work integration and socialising may not cause difficulties until many months after the injury. Unfortunately, NHS provision focuses on the acute event, and so there is limited support and rehabilitation available long term. Multiple factors will affect people who ‘acquire’ brain damage through assault, falls, road accidents, stroke or other neurological conditions.


Physical and intellectual functions can change, and people also often lose their sense of identity. Rehabilitation goals need to include return to social and leisure activities and the development and maintenance of close relationships8.


Neuropsychological rehabilitation is an important service in supporting OH services to ensure employees get the help necessary to give them the opportunity to stay in, or to return to, work9.


Neuropsychologists can bring specific knowledge of functional brain-behaviour relationships, together with the ability to diagnose and measure the objective impact of brain dysfunction10. But what exactly is a neuropsychologist? What does a neuropsychologist do, and how do neuropsychologists work in partnership with OH professionals?


Brain-behaviour experts


The neuropsychologist can provide a source of information and guidance to the OH professional regarding aspects of cognitive dysfunction and brain-behaviour relationships, and help to put support in place to enable the brain-injured person to continue to participate in the working environment.


Neuropsychologists can provide crucial advice in preparing for a return to work. Interventions should focus on the important partnership working between the neuro­psychologist and OH advisers, and on tapping into the resources of other professionals such as occupational, speech and language and physiotherapists.


The neuropsychologist can help OH services, human resource managers and employers by preparing detailed reports to help in understanding the relevant detail and complexities for an employee after brain injury. This may include prognosis to return to work for various groups (mild traumatic brain injury versus moderate and severe brain injury), and considerations necessary to ensure the employee has the best possible opportunity to return to employment.


Although this article has focused on issues relevant to the employee who has suffered a brain injury, neuropsychologists offer services to all patient groups who have suffered a neurological condition.


Complex problems arise following brain dysfunction and many disciplines need to be involved. For instance, mobility (including walking) is the domain of the physiotherapist, while managing day-to-day activities is the domain of the occupational therapist. The individual affected may also need psychological support11.


Success factors


Factors contributing to either successful or poor outcomes after brain injury are summarised by Hawley et al12 and key points for successful brain injury rehabilitation services are mentioned. For example, the authors warn that early return to work or education, without the help of planning or co-ordination by a rehabilitation team, is one factor contributing to poor outcomes.


It is important that there is liaison between the rehabilitation team and employers, often through the OH service. Other aspects that support successful outcomes include early referral to rehabilitation, good communication with all agencies involved, strong interpersonal support systems, and a ‘safety net’ to enable employees to return to the rehabilitation team after discharge.13


Tolley’s14 recommends a graduated or structured return to work, such as a reduction of hours worked per day, working from home or carrying out partial duties. These should be gradually increased over a period of six to eight weeks. It states that there is little point in returning to work for less than four hours per day, but it may be worth the long-term absent employee returning for an ‘ice-breaker’ session such as coffee, tea or lunch with his/her colleagues.


Any treatments required such as physiotherapy should take place outside of these shorter working hours, and the OH service should review the progress on a regular basis.


Funding


In 1991, the Department of Health provided new funding (£5m) for NHS post-acute rehabilitation service initiatives to increase community outreach services for those who have suffered a brain injury. Davies et al (2000) review and describe professional views of service changes in the NHS between 1992 and 1996.


Key points identified that in the long term, internal and external forces prevented the continuation of some of the new services. Elements necessary to maintain services include good communication within multidisciplinary and multi-agency teams (to include OH services) and long-term planning of services by educating and including all stakeholders.15


The author of this article was the head of a neuropsychology service in the NHS for 10 years, contributing to the development of multidisciplinary neuro-rehabilitation services with the main focus on community support. Various factors influenced service development in the NHS and limited progress has been made locally over a 10-year period, despite service commissioners’ motivation to develop comprehensive support services for those with acquired brain injury.


OH professionals can promote the health and wellbeing of head-injured employees by being alert to the symptoms, and proactive in gaining access to appropriate assessment, treatment and support for employees, allowing the best chance for successful return to work.


What is a neuropsychologist?


A neuropsychologist is an expert in understanding the relationship between brain function and behaviour, and can provide assessment, various interventions and support and advice to the employee/client, employer, multidisciplinary rehabilitation team and OH advisers.


After an employee has suffered a brain injury, neuropsychologists contribute by:




  • Assessment of mood and adjustment


  • Identification of nature and degree of cognitive impairment


  • Offering specific interventions to promote emotional adjustment


  • Offering cognitive rehabilitation


  • Promotion of long-term psychological adjustment


  • Dissemination of psychological skills and understanding of brain injury.

After head injury, a neuropsychologist will carry out a full assessment of neurocognitive status (brain function). They will work with the employee/client and the wider multidisciplinary team (including OH professionals where appropriate) to consider the extent of damage and the effects on cognitive functions, adjustment difficulties and other psychological problems (such as anxiety and depression) arising from their injury and issues relevant to return to work.


Neuropsychologists often lead multidisciplinary rehabilitation teams. They can help encourage a stable mood and mental state in an employee which enables rehabilitation to progress by alleviating the negative impact of anxiety and depression.


Neuropsychologists also provide education to the brain-injured client, family, and carers, and where appropriate, the wider system of employer, colleagues and OH advisers. This education helps to increase awareness of the consequences of brain injury which can include a change in personality functioning, specific cognitive problems (including difficulties with memory) and adjustment to changes.


The neuropsychologist can work with OH professionals to increase awareness of the challenges following brain injury and to guide intervention by providing cognitive rehabilitation (which might include strategies to allow memory to function at an optimum level), contributing to a return-to-work programme, and psychological support and treatment, including cognitive behavioural therapy.


Key points for OH professionals




  • Consider what access to specialist services is available.


  • Ensure early referral for assessment and/or treatment.


  • Get access to treatment with an appropriate neuro/neuropsychological rehabilitation service.


  • Work in a multi-disciplinary partnership including OH services, managers, the brain-injured employee/client, multidisciplinary rehabilitation team and family.


  • Provide education and information for the employee affected, their family, managers, appropriate work colleagues and the OH service. This can often be provided by the specialist neurorehabilitation team and should cover training in recognising symptoms, understanding the effects of brain injury on physical, cognitive and psychosocial aspects of everyday life, coping strategies, compensatory strategies, awareness and understanding.


  • Be aware of the needs and challenges that the head-injured employee may face in their social and home life, and how these can impact on their performance at work.


  • Provide long-term support.


  • Play a part in ensuring ongoing and good communication with all involved.

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LJ Conradie is a consultant clinical psychologist and neuropsychologist, and director of Psicon, and clinical lead at Bridgeford Brain Injury Assessment, Rehabilitation and Treatment Service.


Ashleigh Stewart is an assistant psychologist at Psicon.


References




  1. Social Services Inspectorate (1995). Information Strategies and Systems (with reference to community care): Inspection Overview. Department of Health. London


  2. Vocational Rehabilitation Association (2007) Standards of Practice, London VRA


  3. Waddell G, Burton A K, (2004) Concepts of rehabilitation for the management of common health problems, London: TSO


  4. Farrell C, Nice K, Lewis J, Sainsbury R, (2006) Experiences of the job retention and rehabilitation pilot: Research Report 339, DWP


  5. Department for Work and Pensions (1991) The Disability Handbook www.dwp.gov.uk


  6. British Psychological Society Working Party Report (1989). Services for Young Adult Patients with Acquired Brain Damage.


  7. Access to Work www.jobcentreplus.gov.uk


  8. Herbert, C (2000) Challenges of neurorehabilitation. The Psychologist. Vol. 13, No. 1, 24-26.


  9. Prigatano GP, Fordyce DJ, Zeiner HK, Roueche JR, Pepping M, and Wood B (1984). Neuropsychological rehabilitation after closed head injury in young adults. Journal of Neurology, Neurosurgery and Psychiatry. 47, 505-513.


  10. Nelson LD and Adams KM (1997). Challenges for Neuropsychology in the Treatment and Rehabilitation of Brain-Injured Patients. Psychological Assessment. Vol. 9, No. 4, 368-373.


  11. The Encephalitis Support Group (2002) www.nursesnetwork.co.uk


  12. Davies C, Hawley C, Stilwell J, and Stilwell P (2000). Views of service changes in UK brain injury rehabilitation. British Journal of Therapy and Rehabilitation. December 2000, Vol 7, 12, 521-524.


  13. Social Services Inspectorate (1995). Information Strategies and Systems (with reference to community care): Inspection Overview. Department of Health. London


  14. Hughes et al, (2004) Tolley’s Guide to Employee Rehabilitation, London: Lexis Nexis


  15. Hawley C, Stilwell J, Davies C, and Stilwell P (2000). Post-acute rehabilitation after traumatic brain injury. British Journal of Therapy and Rehabilitation. March 2000, Vol 7, 3, 116-122.


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