In this descriptive cohort study, the effect of a VR program was evaluated by chart review and a follow-up questionnaire. The so-called “round table VR program” was already part of usual care in the Rijnlands Rehabilitation Centre, Leiden, the Netherlands. The study falls outside the remit of the Medical Research Involving Human Subjects Act (Medical Ethical Review Board of the LUMC, Leiden, the Netherlands) and was performed in accordance with the ethical standards laid down in the 2013 World Medical Association Declaration of Helsinki amendment .
All patients with ABI who participated in the round table VR program of the Rijnlands Rehabilitation Centre, Leiden, the Netherlands, between January 2007 and May 2010 were identified from the patient registry of the rehabilitation centre. Patients were referred to this VR program when expressing a care need for VR after ABI. Inclusion criteria for the VR program were: having non-progressive ABI, being employed before ABI, motivated to get back to work and having an employer willing to participate in the VR program. Exclusion criteria were: being dependent on other people in activities of daily living, having a mental status that prohibits normal social contacts with colleagues or having a physical status interfering with the possibility to travel to or perform work. Additionally, patients were excluded for this study if they had attended only one of the three planned meetings (see description of the program in ‘intervention’).
After identifying the participants from the patient registry, data of the short-term outcomes (defined as the outcomes directly after the end of the VR program) were collected by investigating medical records, the reports of neuropsychological assessments and the minutes of the three meetings related to the intervention. A data extraction form was used. All data were retrieved by one person, not involved in the program (IZ). Data extraction from a random sample of five sets of records, analysed by a second assessor (PG), revealed no relevant differences.
For long-term follow-up, in June 2013 (3–6 years after the end of the patients’ VR programs) all patients were sent a questionnaire by mail that had been self-designed by the investigators to gather information about work status and hours at work (quantitative data). Questions about task adjustments and, if applicable, reasons for not continuing to work in a paid job were included to collect qualitative data. If the questionnaire was not returned within 3 months, patients were contacted by phone as a reminder. To increase the response rate to accurately answer our main research question, patients who had not returned the questionnaire after the reminder were contacted again by phone. Depending on the patients preference and with explicit permission of the patient, either the full questionnaire was completed by phone or the patient just answered the main research question, i.e. performing paid work or not.
Patients took part in a 4-month multidisciplinary VR program. The professionals involved in the multidisciplinary team included the rehabilitation specialist, occupational therapist, social worker, neuropsychologist and, if needed, a speech therapist (in case of aphasia or dysarthria) or physical therapist (in case of work-interfering motor problems). The team collaborated actively with the other stakeholders of the patient’s RTW process, including the patient and his or her partner/important other, the employer, the occupational physician and a co-worker. The co-worker was usually a colleague close to the patient and his work, able to give feedback to the patient on work performance. Before the start of the program all patients gave written permission for an open exchange of information between the stakeholders. The minutes of all meetings were sent to all stakeholders.
The program consisted of six steps involving all stakeholders including three “round table” meetings:
The rehabilitation specialist considered eligibility of the patients for the VR program based on previous mentioned in- and exclusion criteria. During an initial assessment, involving the neuropsychologist and occupational therapist, the patient’s (dis)abilities and wishes related to RTW were identified. Subsequently, the job characteristics and demands were determined. Abilities and disabilities of the patient were determined in accordance with the International Classification of Functioning, Disability and Health (ICF model) .
During the first round table meeting, which marks the official start of the VR program, all stakeholders were informed on the disease and the abilities and disabilities of the patient by the rehabilitation team members. Thereafter, the demands, expectations and possibilities for RTW were discussed. Consensus and commitment between all stakeholders on the first steps of reintegration with regard to working hours and tasks were obtained.
Task-oriented rehabilitation training was provided on the job with the support of a co-worker. The occupational therapist weekly gave individualized support to the patient, either in the rehabilitation centre or on the job. The occupational therapist contacted the co-worker every 2 weeks by telephone or more often if necessary. During these contacts the progress was evaluated and advice was given about an increase in working hours and tasks. The neuropsychologist was in contact with the patient every 2–4 weeks. The social worker contacted the patient and his or her partner/important other every 2 weeks.
8 weeks after the start of the VR program the second round table meeting took place. In this meeting all stakeholders described their experiences: the problems that were experienced during the training weeks were discussed, as were the things that went well. The increase in working hours, the expansion of tasks and the bottlenecks were discussed. At the end of this meeting a decision was made on the continuation of the VR program and adaptations regarding working hours and tasks.
When VR proceeded, the patient continued the task oriented rehabilitation training on the job by a further increase of working hours and tasks, supported by the co-worker and the occupational therapist. Contact with the social worker and neuropsychologist continued.
16 weeks after the start of the VR program the final round table meeting took place. The main subject of this meeting was to discuss the prognosis for RTW with respect to achievable working hours and tasks. The VR program provided by the professionals of the rehabilitation centre stops after the meeting. Further vocational reintegration and on-going support were referred to the occupational physician, which is usual care in the Netherlands.
Socio-demographic characteristics assessed at the start of the VR program were age, gender, social status (‘married/cohabiting’ or not) and education level (‘university/higher education’, ‘professional training/high school’ or ‘occupational training or less/primary school’). The underlying diagnosis of ABI, the time since injury and total duration of rehabilitation were documented. It was registered whether patients had received inpatient rehabilitation (yes/no) prior to their outpatient rehabilitation. Physical and language functions were assessed using four items selected from the National Institutes of Health Stroke Scale (NIHSS) . These items were: limb ataxia, sensory deficits, dysarthria and aphasia and were categorized as present or not. Arm activities were scored as limited (varying from only limitations in fine motor skills to no activities possible) or not (bimanual activities without limits). Further disease characteristics assessing functioning included the ‘Functional Ambulation Categories’ score [FAC; 0 (non-functional ambulator)—5 (independent ambulator who can walk freely on any surface) points ], ‘Test of Sustained Selective Attention’ (TOSSA; expressed as a score between 0 and 100%, with a score lower than 74.4% interpreted as having a disturbance in attention ) and ‘Tower of London Test’ (TLT, expressed as a score between 0 and 100%, with a score lower than 56.9% interpreted as having a disturbance in planning or executive functioning [25, 26]). The number of hours that patients worked prior to the ABI and at the start of the VR program were documented. The size of the company was recorded and categorized in companies with ≤ 100 or > 100 employees. The physical and mental job demands were recorded as blue collar (involving mainly physical labour) or white collar (including mainly professional, managerial or administrative work).
Outcome measures were RTW, hours at work and task adjustment. For the short-term analysis RTW was defined as ‘performing useful tasks for the employer’. For the long-term analysis RTW was defined as ‘performing paid work yes/no’. Hours at work and task adjustment directly after the program were extracted from the minutes of the meetings in the medical records and therefore determined by the VR team and the employer. At follow-up these outcomes measures were self-reported by the patient. Hours at work did not include hours spent on volunteer work.
All statistic analyses were performed using SPSS 19 software package (SPSS Inc., Chicago, IL). Descriptive statistics (i.e., frequencies and percentages) were used for quantitative data in relation to RTW. The Wilcoxon signed-ranks-test was used to compare the number of hours at work before, immediately after the VR program and at follow-up. Significance was set at p ≤ 0.05. Qualitative data (e.g. reasons for no RTW or not maintaining employment) were grouped and summarised.