Nicole Beauchesne, OT Reg. (MB) Owner/Manager Block Building Therapies & Concussion Care...

Strategies for Successful Integration

into Work following ABI

Nicole Beauchesne, OT Reg. (MB)

Owner/Manager

Block Building Therapies &

Concussion Care Community Clinic

Prevalence

• TBI’s result in 200-300 hospital admissions per 100,000

• The majority of TBI’s are mild-moderate (GCS > 8)

• Workplace injuries and MVA are primary cause

• Many more TBI patients surviving than before with more severe impairments

( Reference : Traumatic Brain Injury & Return to Work; Scollon. J, 1998)

Research on RTW after ABI

• Rates of RTW following TBI range from 10%-70%

• Highest rates of RTW following TBI have been found to occur in the first 6 months post-injury

• RTW is an important end point in terms of measuring effectiveness of rehabilitation among TBI patients

• RTW is determined by demographics, severity of injury, access to rehab and work assistance, modes of verifying work status.

( Reference : Traumatic Brain Injury & Return to Work;

Scollon. J, 1998)

Best Practice Recommendations

• Most predictors/indicators are only weakly correlated with RTW therefore caution is required.

• Assessment/Evaluation of employment outcome should be a minimum of 2 years, if not more.

• Emotional/Functional impairments are greater barriers to success (than cognitive), therefore thorough assessment is required.

• Stabilize neurological/psychiatric/affective conditions first.

• Chronic Pain and TBI symptoms overlap so co-treatment is required.

• Always consider pre-injury status in relation to IQ.

• Interventions should be multidisciplinary to address all areas of function.

• Severe TBI functional status was stable at 1 year, but shown to improve at 3 year follow up. ( Reference : Traumatic Brain Injury & Return to Work; Scollon. J, 1998)

Symptoms• Somatic – headaches, fatigue, nausea, light or

noise sensitivity

• Physical – strength, ROM, activity tolerance, impaired balance, vertigo

• Cognitive- memory, speed of processing, distractibility, attention/concentration, executive dysfunction

• Affective – anxiety, depression, agitation, labile

• Visual – acuity, diplopia, visual field cuts, ocular pursuits

Risk Factors (Red Flags)

Risk factors associated with poor outcome:

• Prior brain injury/concussion

• Increased age

• Pre-existing psychiatric illness (anxiety/depression)

• Existence of chronic pain (pre or post)

• Psychosocial factors

Case Study

SH Case Study

Barriers to Return to Work in mTBI

Avoiders

• Associated fear and anxiety about increased symptoms

• Medical clearance is a huge challenge!

• Slow to recover!

Over-Achievers

• Type A students, workers, parents

• High risk of persistent symptoms

• Slow to recover!

Your client has a brain injury….Now what??

Early intervention

• Make connections and build rapport with client, family and even the employer

• Educate the client and employer about brain injury, recovery and rehabilitation

• Reassurance is of the essence to both the client and the employer!

EVIDENCE SUPPORTS THAT REASSURANCE AND EDUCATION ABOUT

SYMPTOMS IS MOST EFFECTIVE FOR LOWERING RISK OF PERSISTENT

SYMPTOMS.

(SOURCE: MACCIOCCHI, A.W., 1993). 

The key to successful case management of

the brain injured client is hiring the right clinical team!

Return to Work Team• Client and family

• Case Manager

• PT, OT, SLP, SW

• Neuropsychologist, Psychologist, Psychiatry

• Vocational Consultant

• Employer – Supervisor, Union, Occupational Health Nurse

Assessments

•Cognitive/Behavioral Assessment

•Physical Assessment

•Worksite Assessments

•Vocational Assessments

Understanding Symptoms• Critical areas to review include:

• Sleep• Levels of Fatigue• Headaches• Vertigo• Sensitivity to light/noise• Changes in auditory processing,

concentration, attention• Tolerance for physical activity

Barriers to Returning to Work

• Person has greater desire than actual readiness

• Lack of supports in work environment

• Lack of Opportunities to demonstrate capabilities

• Poor emotional control

• Fatigue

• Lack of self confidence

• Poor initiation (interpreted as poor motivation)

Determining Readiness for

GRTW

Work Readiness is….

• Managing headaches and fatigue

• Adequate self care (grooming, good sleep, diet)

• Able to tolerate adequate physical task (1-2 hours)

• Managing social/emotional status

• Independence with appointments, daily activities(finance/medication), rehabilitation program/exercise

• Ability to use strategies for memory, social skills, etc.

• Adequate decision making, planning and judgement

• Being motivated and positive about the plan!

Return to Work Options

• Return to previous place of employment

• Start new job (casual, part time of full time)

• Adult Ed or Vocational Training

• Start own business

• Volunteer (especially when unemployable)

Best to consult with Vocational Rehabilitation Consultant with brain injury experience!

Work place Exposure

• Simulate work related tasks at home

• Increase activity levels in the home first then in community

• Consider volunteer work first

• Early integration in the work environment (as an extra, just a presence..)

• Make goal rehabilitative versus vocational

Key to success…..is to decrease anxiety and fear of failure!

GRTW program

• Working supernumary….always as an extra.

• Consider other appointments and rest required (cognitive and physical)

• Sample GRTW:• Week 1-2 = M/W/F : 8 -10 am• Week 3-4 = M/W/F : 8 – 12 pm• Week 5-6 = M/W/F: 8-2 pm• Week 7-8 = Monday-Friday 8 - 12 pm• Week 9-10 = Monday-Friday 8 – 2 pm• Week 11-12= Resume FTE with ongoing monitoring

Goal is rehabilitation not vocational!

Intervention Strategies

Options for Managing

Impairments•Remediation

•Substitution

•Accommodation

•Assimilation

Physical Accommodations

• Physical – environmental modifications, adaptive computer equipment and accessibility

• Visual – Font, large print, lighting

• Tolerance – flexible scheduling and frequent breaks, GRTW program increase every 2 weeks

Assistive Technology for Physical Deficits

1. Alternative Input Devices

2. Pointing Devices

3. Sip and Puff System

4. Keyboard Filters

5. On-screen Keyboards

6. Voice Recognition Programs

Addressing Cognitive Deficits

• Many clients may have difficulties with focus, concentration, memory, organization and word-finding.• Large monitor• Task Oriented Software• Word prediction software• Calender programs, alarms and timers• Task lists, checklists• Background music and earplugs

Cognitive Accommodations

• Executive Functioning– give frequent direct feedback, use watch and timer

• Memory - verbal and written instructions, mentors/work partner

• Social/Emotional – frequent meetings, open to feedback, organize time to decrease anxiety, take breaks as needed, relaxation/meditation, counselling

Assistive Devices For Cognitive Deficits

• Memory: contact lists, alarms, timers, reminder systems, screen saver

• Organization: calendar programs with auditory reminders, Outlook/iCalender, To-Do lists; color coded priorities

• Visual: larger screen, magnifiers, oversized keyboards, screen reader, glare guard, text to speech

• Emotional: instant messaging, connections with webcam, email, support groups

Facilitate Computer Access

• Accessories • Workstations, sit/stand station, headsets

• Compensatory Strategies• Favorites, address book, auto complete/Correct,

templates

• Accessibility Options• Icon Size, magnifier, on screen keyboard, high contrast,

trackpad sensitivity, sticky keys, toggle keys, voice over

• Iphone/Ipad• Apps, calendar, social media, memo, alarms

JB Case Study• 52 year old woman slipped on ice at work. Co-workers

drove her home, sat in ER, went home and describes the following symptoms:• Sleeping 14 hours a day for almost 3 weeks• Headaches, confusion, labile, irritability• Hiding in a dark room (noise, lights)• Inability to read, write, work on computer, etc

• Saw doctor, advised to stay off work as a manager

• Attempts to go back to work 3 times

• Attends physiotherapy for WAD and referred to CCCC

Plan, Pace & Prioritize!

Pacing Points System

The Toolkit

• Biweekly meetings with ongoing review

• Tools/strategies included:• Ongoing education and reassurance• Increasing activity tolerance (physical and cognitive)• Gradual Return to work Program• Tedtalks/Websites on mindfulness• Meeting other clients with concussion• Regular reports to case manager

Summary• Early intervention : Rapport, Education and

Reassurance

• Employer Education

• Consider volunteering first or as option when unemployable

• Modifications:• Hours • Tasks• Physical Workplace• Cognitive Strategies• Social/Emotional Accommodations

• Make goal rehabilitative, not vocational in early stages

• Active Management

Resources

• www.brainstreams.ca

• www.apple.com/accessibility

• www.microsoft.com/accessibility

• www.synapse.org.au

• G.F. Strong Rehabilitation Centre, BC

• Parkwood Institute: St. Josephs Health Care

• Ontario NeuroTrauma Foundation, 2013

• Scollon, J, Traumatic Brain Injury and Return to Work (WCB), 1998

Forcem.co.uk

Questions

Nicole BeauchesneOT Reg. (MB), BSc O.T.Owner/ManagerBlock Building Therapies &Concussion Care Community Clinicnicole@blockbuilding.ca204-231-0785

Mynamesnotmommy.com