Return to Work after Traumatic Brain Injury: Overview of Traumatic Brain Injury in the Workplace

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1 CIHR Research Chair in Gender, Work and Health Chaires de recherche des IRSC sur le genre, le travail et la santé Return to Work after Traumatic Brain Injury: Overview of Traumatic Brain Injury in the Workplace Angela Colantonio, PhD, FACRM University of Toronto; Toronto Rehabilitation Institute, UHN

2 Traumatic Brain Injury (TBI) A traumatic brain injury is a bump, blow, or jolt to the head or a penetrating head injury that disrupts normal function of the brain Centres for Disease Control and Prevention Major cause of death and disability Return to work from moderate to severe injury (~ 40%)

3 Work-related traumatic brain injury: Burden Based on worldwide estimates, approximately 2-24% of all TBI cases are work-related Recent studies show that the rate of work-related traumatic brain injury may be as high as 33.1/100,000 TBI accounts for a large proportion of severe and fatal work-related injuries

4 Workers compensation claims Increasing trend of wrtbi in Ontario The number of claims for work-related concussion increased by 371% in Ontario from However Total number of claims has decreased over this timeframe

5 Work-related mild traumatic brain injury large proportion of work-related TBIs are mild In Ontario, there is an increasing trend in the number of concussions (mild/moderate TBI) vs intracranial injuries (e.g. cerebral hemorrhages) in 2012: approx. 80% of TBI claims filed to the WSIB are for concussion (~50% prior to 2010) in the US, concussions account for approx. 90% of nonfatal wrtbi (US Bureau of Labour Statistics)

6 Brain injury in the workplace in Ontario: Lost-time claims Intracranial injuries excluding concussions Concussions Cranial region, including skull By the Numbers: 2013 WSIB Statistical Report

7 Work-related traumatic brain injury: Causes In Ontario, the leading causes of work-related TBI are being struck by or against an object and falls. Colantonio et al. (2010). Examining occupational traumatic brain injury in Ontario. Can J Publish Health Image:

8 Work-related traumatic brain injury: Sex/Gender The vast majority (>85%) of severe/fatal wrtbi occur among men. This percentage decreases when milder injuries are included; in other words, women are more likely to sustain a mild TBI than a severe/fatal TBI in the workplace. Across all injury severity levels, more than 40% of wrtbis were sustained by females.

9 Work-related traumatic brain injury: Sex/Gender Females are older than males at the time of injury Two-thirds of women who sustained occupational TBI worked in the government and services industry Colantonio A, Mroczek D, Patel J, Lewko J, Fergenbaum J, Brison R. Examining occupational traumatic brain injury in Ontario. Can J Public Health. 2010;101(Suppl 1):S58-S62. Three young women employees of the National Research Council in Ottawa at their drafting board,

10 Perceived Facilitators of RTW support from family/friends - 92% support from treatment providers - 80% job modifications/employer accommodation 76% Colantonio et al., 2012

11 What happens in brain injury and where can I find help? Mark Bayley MD, FRCPC Medical Director, Brain and Spinal Cord Rehab

12 What Happens in Traumatic Brain Injury? How does it affect return to work? 2

13 Brain moves within Skull Courtesy of www. parachutecanada.org

14 Diffuse Axonal Injury May result in symptoms of: slowed thinking Attention and concentration, Balance impairment 4

15 Concussion may be a biochemical injury..

16 Diffuse Axonal Injury in Inertial Head Injury

17 Focal injury Frontal lobe injury Difficulties with working memory, problem solving, behaviour & executive function Temporal lobe injury.. Impaired memory and difficulties with word finding 7

18 The Vicious Cycle of Post-Concussion Syndrome Injury Decreased Attention Physical Symptoms Cognitive Symptoms Anxiety Muscle tension.

19 Where Can I find Help? 9

20 ERABI Methodology ERABI Purpose: To conduct a systematic review of the rehabilitation literature of moderate to severe acquired brain injuries (ABI) from traumatic and non-traumatic causes. Step 1: Systematic Literature Search references reviewed Inclusion Criteria: - Intervention based study - 50% of participants have a moderate to severe ABI - Published in English - Articles from 1980 Present - 3 participants Step 2: Article Analysis 798 Selected for careful data abstraction and quality determination. Studies are tabled: Study design, study population, intervention and outcomes RCTs are appraised using the PEDro Scale Step 3: Conclusion Statements Statement s about the effectiveness of interventions are made and levels of evidence are assigned for each

21 Assign Level Of Evidence Levels of Evidence: Modified Sackett Scale (Straus et al. 2005) Level of Evidence Description Level 1a 2 or more RCTs with PEDro scores > 6. Level 1b 1 RCT with a PEDro score > 6 Level 2 RCT (PEDro score < 6), Prospective Controlled Trials, and Cohort studies Level 3 Case-Control Level 4 Pre-Post or Post-Study test, and Case Series Level 5 Observational Study and Clinical Consensus Conflicting Studies with results that contradict each other

22 ERABI:

23 ConcussionsOntario.ca

24 1. Diagnosis/Assessment of Concussion/ mtbi 2. Management of Concussion/ mtbi 3. Sports-Related Concussion/ mtbi 4. General Recommendations Regarding Diagnosis/ Assessment of Persistent Symptoms 5. General Recommendations Regarding Management of Persistent Symptoms 6. Post-Traumatic Headache

25 7. Persistent Sleep/Wake Disturbances 8. Persistent Mental Health Disorders 9. Persistent Cognitive Difficulties 10.Persistent Vision & Vestibular (Balance/Dizziness) Disorders 11.Persistent Fatigue 12.Return-To-Activity Considerations 1. General Recommendations Regarding Rest & Return-to- Activity 2. Return-to-Work Considerations 3. Return-to-School (Post- Secondary) Considerations

26 CONCUSSION For More Information: Parachute Website CDC Website

27 Promoting employment success through workplace accommodations following traumatic brain injury and electrical injury Co-Principal Investigators: Angela Colantonio, Mary Stergiou-Kita Qualitative Researcher: Elizabeth Mansfield Co-Investigators: Mark Bayley, J. David Cassidy, Manuel Gomez, Marc Jeschke, Bonnie Kirsh, Vicki Kristman, Oshin Vartanian

28 The injured worker perspective: RTW following a work-related MTBI Qualitative studies on return to work (RTW) following brain injury frequently report on the lived experiences of TBI but not the particular challenges of RTW following a work-related MTBI (wrmtbi) Re-engaging in paid employment is a challenging experience necessitating ongoing rehabilitation and workplace support Little is known about the return to work experiences of individuals who have sustained an occupational TBI even though the number of TBI-related workers compensation claims is increasing in some jurisdictions Number of reported wrmtbi incidents filed with the provincial workers compensation board has more than doubled, from 629 claims in 2004 to 1299 claims in 2013 Research question: How do individuals with persistent wrmtbi impairments experience returning to work?

29 Why focus on workplace and workers compensation context for wrmtbi? The experience of returning to work following a work-related brain injury is also influenced by structural elements of the workers compensation system and workplace cultures Workers compensation representatives, interacting with workers, employers and health professionals, play a prominent role in work reintegration processes The worker typically returns to the same workplace where the injury occurred; employers and coworkers are often aware of the workplace incident Occupational injuries can signify workplace health and safety failures and their occurrence can lead to governmental inspections and fines in addition to increased workers compensation premiums for the employer Injured workers may be blamed for injury incidents while employers may try to deny any responsibility for injury claims

30 Method In-depth semi-structured telephone interviews (60-90 minutes) Workers who had experienced work related mild to moderate traumatic brain injury 12 workers traumatic brain injuries Recruitment through Ontario rehabilitation hospital that assesses and treat clients referred by WSIB

31 Method Analysis: Thematic analysis Three coders (+4th check) Codes Categories Themes

32 Sample characteristics N=12 Sex Marital Status 6 males; 6 females 11 married; 1 single Age 20 to 39: 3; 40 to 65: 9 Education Industry Company size RTW employment status Time from injury to RTW 4 high school; 4 community college; 4 university 4 trades; 4 public sector; 4 protective services Small=4; Medium=4; Large=4 3-4 years=10; 5-6 years=2 <I month=6; 2-4 months=3; 5-8 months=3

33 Workplace context: Awareness of employers focused on reducing injury-related costs Participants reported being aware of their employers concerns with the injury claim costs and the perceived reduced productivity of injured workers. They put me on some really heavy jobs, like a lot of digging and wheelbarrows of concrete, like really heavy stuff that I wasn t ready for. And I was getting, like dizziness and I was having a hard time, like staying or standing. And my foreman had come to me and said, Oh you know that the company really watches for time missed for stuff. Because I had doctor s appointments and stuff like that. (Participant 6)

34 Workers compensation context: Workers awareness of concern with reducing cost of claims Participants reported challenging relations with workers compensation representatives. For example, a participant reported that her adjudicator asserted she was not complying with her rehabilitation and assessment plans and thus deliberately delaying her return to employment: She [the adjudicator] would call me and she would say like, Well, we ve got you scheduled doing this. And I m like really? And I call my doctor. No you re not. No, I haven t said that. I call her back. She goes, Well, what s it going to take? And you re like just following exactly the doctor s advice. She called nonstop [and said], Go back to work! Go back to work! (Participant 7)

35 Workplace context: limited knowledge of best practices in responding to a TBI event Participants discussed how the employer s initial response to an injury reflected an incomplete understanding of MTBI and medical care recommendations. I think I should ve been sent to the hospital right away. But it didn t happen I drove home that night-i still don t remember how-, I don t even remember the ride. (Participant 4)

36 Workplace context: Persistent sequelae poorly understood Once visible signs of injury had resolved, three participants reported that both employers and co-workers appeared unaware of ongoing wrmtbirelated challenges. If I d got sucked into a combine in an agricultural accident and lost a leg, you know, there are visual cues there to remind everybody he s a little bit slow moving from A to B and might have some challenges lifting heavy things. With a brain injury, you know, all I ve got [is] a little scar on my forehead [but] I forget things, or I leave things behind when I leave a room, or I submit work that s half completed. (Participant 1)

37 Workers compensation context: Persistent sequelae poorly understood Participants discussed their perceptions that workers compensation representatives did not understand invisible MTBI sequelae. For example, a participant discussed workers compensation representatives as understanding the visible cut to his head but not the invisible impairments: They didn t understand the severity of the injury. I guess they just thought it was a cut to my head I don t want to say they outright accused me of lying, but that was the feeling I got from them -- that they didn t believe me. (Participant 6)

38 Workplace context: The role of supportive environments in RTW processes following wrmtbi Participants reporting supportive return to work environments stressed the importance of employer and co-worker relations. For example, a participant discussed the supportive role her employer and co-workers played through accommodating her cognitive impairments, and focusing on her abilities: So what ended up happening was that she [employer] went and said I want [her to continue working] which was amazing because in some ways I guess I m a little bit of a liability. Like I m not at my full tilt and she knew that I couldn t do the paperwork end, but she knew that I was really still good with [clients]. (Participant 3)

39 Workplace context: Impact of the MTBI incident on workplace health and safety Participants discussed poor workplace safety and identified unnecessary risks and hazards as contributing to their injuries. These participants were disappointed and upset that their workplace injuries did not lead to improved occupational health and safety (OHS) policies and practices. A participant returned to his workplace to find that hazards that contributed to his injury event had not been addressed: And the thing is too, when I went back to work, the day when I went back, like after a week and a half, they had the broken ladder still sitting there right there where it fell. Everything was right there except their power tools that they had to bring in so they didn t get ruined by the weather. Everything else was just exactly the same. (Participant 8)

40 Workers compensation context: Administrative burdens for workers managing claims Participants reported that the requirements for filing receipts and expense claims were challenging for people with brain injuries and their caregivers. For example, a participant reported that his spouse had to manage the extensive paperwork involved with his claim along with supervising his medications: My wife went through hell too because like I was in no condition to keep track of every damn thing and I had to do that for Worker s Comp My head wasn t even working that good at that time. And my wife, she was just having to write down every date and plus parcel out my medications and everything else. (Participant 5)

41 Study limitations Two thirds of those contacted declined to participate in this study. Non-participants may not have had similarly negative RTW experiences as reported by our participants. Sample included only English speaking participants with higher levels of education than the wrmtbi clinic population in general Most participants were middle-aged and could have additional interacting co-morbidities

42 RTW after wrmtbi: Key features When a MTBI is work-related, RTW is characterized by several distinct features: 1. Workers typically return to the pre-injury workplace following a wrmtbi. 2. Tensions in the workplace may escalate if employers face increased costs following an occupational injury.

43 RTW after wrmtbi: Key features 3. The legitimacy of an injury claim might be questioned. 4. Injured workers could return to workplaces where unsafe hazards and practices have not been addressed. 5. When a MTBI takes place in the workplace, the injury is a public event and eliminates the individual s choice whether to disclose a brain injury, a stigmatizing condition that can have negative effects on one s career.

44 Recommendations Increasing knowledge of employers, co-workers and workers compensation representatives related to physical, cognitive and psychosocial impairments resulting from MTBI so injured workers can receive appropriate supports, and discrimination, stigmatization and re-injury can be mitigated. Structural and social elements of workplace and compensation environments should inform strategies to break down barriers to successful return to work following a wrmtbi. Greater OHS focus on preventing reinjury following a wrmtbi

45 Thank you!

46 BETWEEN A ROCK AND A HARD PLACE MANAGING STIGMA AND WORKPLACE DISCRIMINATION FOLLOWING MODERATE TO SEVERE BRAIN INJURY D R. M A R Y S T E R G I O U - K I T A ( P I ) M S. D E B B I E H E B E R T D R. C A R O L Y N L E M S K Y M S. C H R I S T I N E D A V I D D R. G U Y L A I N E L E D O R Z E D R. T H E C L A D A M I A N A K I D R. A L I S A G R I G O R O V I C H NOTE: STUDY IN PRE- PUBLICATION STAGE; SOME SLIDES REMOVED FROM THIS PRESENTATION

47 Why embark on this Study? What is well known. What is less well understood how personal elements can influence successful work or return to work e.g. physical abilities e.g. thinking abilities e.g. functional abilities how workplace elements can influence successful work e.g. perceptions of persons with brain injury in the workplace e.g. workplace social relation e.g. stigma and discrimination

48 Why should we be concerned about workplace stigma and discrimination? Study 1: Workplace Accommodations Following Mild Work-Related Traumatic Brain Injury

49 Why should we be concerned re: workplace stigma and discrimination? Study 2: Family Members Facilitating Community re-integration and Return to Productivity Following Traumatic Brain Injury Motivations, Roles and Challenges (Gagnon, Lin & Stergiou-Kita, 2015)

50 Current study What we did Interviewed 10 persons with a brain injury Moderate to severe brain injuries Working age (18-65) 3 females, 7 males Attempted to return to work (part or full time) OR worked with a work/employment professional to find and secure work/work placement following their brain injury Interviewed 5 employment service providers Community service providers 4 females, 1 male Job development, placement, coaching services Therapy/counseling services

51 What we asked Persons with brain injury Experiences with returning to work Social relations at work & supports Discussions/disclosure of brain injury at work Experiences of harassment or discrimination at work Advice to others who are returning to work following a brain injury Service Providers Roles & experiences in supporting persons with brain injuries to work Concerns about persons abilities to work following brain injury Importance of social relations and perceptions of persons with brain injury Managing issues of disclosure, stigma and discrimination

52 Preliminary Findings Perceptions of persons with brain injury Public perceptions Employer perceptions Provider perceptions Reported incidents of workplace stigma and/or discrimination Social exclusion Employer failure to provide supports/accommodations Harassment Disclosure of the brain injury How managed Pros and cons

53 Between a Rock & A Hard Place Need to disclose to request assistance BUT this increases the risk of stigmatization and exposure to discrimination Additional Questions: Should one disclose and discuss one s brain injury at the workplace? Should one request help and supports and if so how should this be done?

54 Acknowledgements We acknowledge funding received from the Ontario NeuroTrauma Foundation- REPAR for this research project We would like to also thank the 10 individuals with TBI and 5 employment service providers who shared their time and expertise to enhance our understanding of workplace supports, workplace stigma and discrimination

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