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Employment interventions for return-to-work in working-age adults following traumatic brain injury

Additional Info

  • Authors: Carolyn Graham, Michael West, Jessica Bourdon, Katherine J. Inge
  • Published date: 2016-09-01
  • Coordinating group(s): Education
  • Type of document: Title, Protocol, Review, Plain language summary
  • See the full review:

About this systematic review

This Campbell systematic review examines the effectiveness of vocational rehabilitation interventions to help adults with traumatic brain injury get competitive employment. Three randomized controlled trials are included: two of military populations in the US and two of the civilian population in China (Hong Kong).

What are the main results?

None of the programs were better at improving employment outcomes than the comparator program to which it was compared. The intensive in-hospital program was no better than the at-home alternative, CogSMART added no value to supported employment alone, and virtual reality-based training was no better than psycho-educational training. Comparison of employment before and after the interventions showed the interventions in the United States improved employment status. The intervention in China did not improve employment status.

None of the studies reported secondary employment outcomes: hours worked and wages earned.

It was not possible to conduct analysis of the relative effectiveness of different types of programme because of the small number of included studies.


Individuals with traumatic brain injury (TBI) often struggle to obtain competitive employment after sustaining a TBI, commonly as a result of the post-injury difficulties they exhibit (Andelic, Stevens, Sigurdardottir, Arango-Lasprilla, & Roe, 2009; Mansfield et al., 2015). The currently reported unemployment rate for people with TBI is approximately 60% (Cuthbert et al., 2015). Hence, the unemployment for individuals with TBI is considerably higher than for individuals without disabilities.

Many adults with TBI seek assistance in gaining employment through post-acute rehabilitation. Post-acute rehabilitation services focus on helping individuals adjust to ongoing impairments and re-enter their communities, workplaces, and schools. Post-acute interventions are broadly classified into the following groups (Shames, Treger, Ring, & Giaquinto, 2007): residential community reintegration programs, comprehensive day treatment programs, and community re-entry programs that focus on vocational and social reintegration. This review focused on identifying the most effective type of intervention for returning individuals with TBI to work. Theis review drew from a wide range of databases, searched grey literature, included studies with a range of follow-up times, and focused on competitive employment outcomes among individuals with TBI regardless of injury severity.


This review examined the effectiveness of vocational rehabilitation (VR) interventions for adults with TBI on attaining competitive employment.

Search methods

Studies for this review were identified by searching 16 databases, including Australia Education Index, CIRRIE, Academic Complete Collection, EBSCOhost Research Database, MEDLINE/PubMed, ProQuest, and 11 other databases. Further, unpublished papers and grey literature were also searched. Reference lists of papers included in the analysis and previous systematic reviews were searched.

Selection criteria

The following inclusion criteria were used for each potential study: (1) Studies were required to use interventions focused on assisting helping working-aged adults with TBI return to competitive employment, including self-employment. (2) Competitive employment had to be measured as an outcome. (3) Participants must have been between 18 and 65 years of age, experienced a non-penetrating TBI, been engaged in either full-time or part-time employment at time of injury, and been unemployed or on medical leave at time of receipt of the intervention. Studies that included individuals with other disabilities were included only if the results were provided for TBI participants separately from those with other disabilities. (4) Data had to be presented separately for competitively employed participants. (5) The design must be randomized controlled trials (RCTs) or quasi-experimental designs, with a treatment and a control/comparison group.

Data collection and analysis

Odds ratios and log odds ratios were computed and 95% confidence intervals were computed for each included study. Only data from the primary outcome, competitive employment status, were used due to insufficient secondary outcome data.


The literature search resulted in 6,941 unduplicated documents. From these 6,941 documents, 414 documents were selected for full-text review. From these 414 documents, 67 intervention reports were found, with only three return-to-work RCTs meeting inclusion criteria for this systematic review. The last search was conducted November 7, 2015.

The three studies included in this review were RCTs with parallel interventions (Man et al., 2013; Salazar et al., 2000; Twamley et al., 2014, 2015). The Man et al. (2013) study compared two interventions, an artificial intelligent virtual reality–based training program (n = 17) and a psycho-educational vocational training system (n = 20) using a civilian population from China. Salazar et al. (2000) compared an in-hospital cognitive treatment (n = 67) to an in-home treatment (n = 53) for active U.S. military personnel. Twamley et al. (2014, 2015) compared a CogSMART Plus supported employment program (n = 21) to an enhanced supported employment program (n = 21) for U.S. veterans.

Salazar and colleagues (2000) used U.S. active military samples and Twamley et al. (2014, 2015) used U.S. military veterans. Man and colleagues (2013) used civilians in China.

The sample in Salazar et al. (2000) was predominantly African American and White. There were more Hispanic/Latino and White participants in the Twamley et al. (2014, 2015) study. The Man and colleagues (2013) RCT did not report the ethnicity or race of its sample from China. The Twamley et al. (2014, 2015) and Man et al. (2013) studies reported severity of injury as mild to moderate.

All studies were RCTs; however, blinding, incomplete data, and selective outcome reporting were of concern for all studies. Design, review status, publication type, and presence of control group were sufficient.

Findings from this systematic review were inconclusive in that all odds ratios were not significant. Man et al. (2013) had the largest odds ratio (OR = 2.204, p = 0.264) but had the lowest employment rates (30%). Salazar et al. (2000) and Twamley et al. (2014, 2015) had odds ratios less than one. This indicated that the alternate interventions for Salazar et al. (OR = 0.514, p = 0.353) and Twamley et al. (OR = 0.817, p = 0.749) were more effective than the primary intervention. The employment rates for Salazar et al. and Twamley et al. ranged from 55% to 94%, which were rates higher than observed in Man et al. In sum, there were no significant odds ratios. Although all interventions evidenced positive average gains, no intervention was identified as more effective than another.

Authors’ conclusions

All interventions showed positive average gains; however, we were unable to determine which intervention was most effective due to the small number of studies (n = 3). More experimental RCTs need to be conducted with interventions not included in this study. There are several recommendations for the direction of research concerning return-to-work for adults with TBI. First, studies of return-to-work VR interventions for adults with TBI must improve their quality of research by conducting RCTs. Second, separating competitive employment from school attendance would provide a more accurate estimate of impact on return to work. Third, research is needed with other populations outside the United States and civilian samples. Last, future return-to-work VR studies should report time to employment, hours worked, separate rates of competitive employment, sheltered employment, educational training, and continued follow-ups at 12 months or more.

See the full review

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