Discussion

This 3-year review of vocational outcome in military patients with significant brain/neurological impairment following neurorehabilitation showed 31.7% of patients successfully returned to military duties and 39.7% (27–52) successfully gained civilian work (cumulative average of 2015 follow-up, see Table 1). Overall, 71.4% (64–81) of all patients were in paid employment rising to 80.7% (76–85) when training/actively seeking work was included. These findings demonstrate return to productive employment/training is the likely outcome for the majority of those undergoing inpatient neurorehabilitation.

Follow-up over this 3-year period identified challenges/limitations. Over reliance on historical records and contact details documented many years ago resulted in only 46% (43–49) of potential subjects being successfully contacted. Additional contact details are now taken from all patients such as a personal established email address that is unlikely to change.

To evaluate the detrimental effect of not including over half the potential study population, characteristics of those ‘uncontactable’ were compared with ‘contacted’. No significant difference was seen in type of injury, severity of injury or demographics (age/sex/duration of military service). It would therefore appear those contacted are representative of those uncontactable. Regarding inclusion/exclusion criteria, every patient was included and none were excluded. Further analysis of the interview data may show associations between injury pattern and superior/inferior rates of long-term employment. Although not explored on this occasion due to small numbers, this is planned in the future as the population sample grows.

Examining factors that may influence employment outcomes, all were in full-time military employment preinjury. Indeed, this positive relationship has been well established in civilian populations.15 16 Early transfer to rehabilitation is a strong predictor for successful vocational outcome.17 Additionally, the younger age of this military population may have contributed—age has been demonstrated as influential in civilians18 and in improving return to duty in military populations.19

Nearly a third of all contacted patients in 2015 (31.7%) returned to military duties (notably back to their former role) reflecting recovery level high functioning enough to warrant responsibility with weapons that could potentially cause harm to self/others. The training/monetary/time investment in creating skilled military personnel is substantial and their key roles can prove critical during times of war. Returning a third to military duties is more effective than recruiting/retraining/replacing with new individuals and demonstrates the value of providing neurorehabilitation for all neuroimpairment in the military.

It could be claimed that severity of injury is a greater determinant than therapeutic intervention (vocational rehabilitation). Impairment was graded as ‘mild, moderate or severe (Tables 2 and 3), and no link was seen between severity of injury and return to work (Figure 1). Severity of injury is often incorrectly taken as a surrogate marker of inability to fully recover,20 and these results negate this assumption. Indeed, function is a better indicator of brain/neurological injury and eventual outcome—functional assessments (eg, Mayo Portland Adaptability Inventory 4) are therefore recommended to gauge severity and improvement. Clinicians treating severe brain/neurological injury should actively expect their patients to return to work and treatment decisions should reflect this expectation.

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Figure 1

Relationship between severity of injury and per cent of patients returning to work. TBI, traumatic brain injury; CVA, cerebrovascular accident.

Return to work relies on many factors—personal motivation, aspirations, interview techniques, qualifications, location and job availability all influence gaining employment.21 Vocational rehabilitation addresses all these areas as well as conducting functional capacity tests to detect ‘hidden’ deficit. A multidisciplinary team assess preinjury military role and create work simulation tasks. Civilian options are explored if return to duty is not likely. Discharge does not mean the end of care—ongoing monitoring continues with a 4-month review during which time patients have often returned to the workplace. In this population, varying in age/gender/social class/educational background/employment role/neurological impairment/functional impairment/illness, vocational rehabilitation is the only intervention that targets all of these factors/barriers resulting in this high rate of return to work.22

Two components were identified as particularly beneficial—‘trial placement in the workplace’ and a ‘graduated return to work (GROW) programme’.23 Both interventions build on established opinion that interventional therapy is most effective if connected and allied to the workplace.24–27 Both interventions bring confidence to returning employee (patient) and employer. The ‘trial placement in the workplace’ is an extension of rehabilitation with protected time to return to full performance while implementing strategies learnt through rehabilitation.28 The employer reviews performance, evaluating potential and witnessing real improvements. Regular contact between vocational therapist, patient and line manager is essential to ensure appropriate tasks are set and feedback is communicated to encourage patient development. While this model seems to primarily benefit the patient, it also enables the employer to accommodate deficits over a risk-free period. On paper, only the drawbacks are prominent, yet with this method ‘in-role’ suitability is demonstrated and employers see advantages not previously apparent. Work trials further enable therapists to assess in a real-work environment rather than artificial simulated ‘comfort zones’ in hospital. The educational benefit is perhaps greatest for the patient—this protected work placement is a multifaceted awareness-raising tool providing physical, social and environmental cues/challenges. Patients are often resistant to the reality of not achieving the employer’s requirements. Allowing this judgement based on personal experience is beneficial for therapist, patient, family and employer. This positive relationship between accurate self-awareness and long-term employment outcome is well recognised.29 30

The GROW programme is a tailored package recommended by the rehabilitation team and managed by occupational health.31 This collaboration confers additional benefits—more efficient use of resources facilitating workplace adjustments through the eyes of both experts. Although seen as time consuming by patients, slower graded programmes are more successful in achieving longer term employment.32 While currently used predominantly by the military and in some NHS centres, these strategies could be adopted by the wider NHS, given the significant relationship between work/health.33 Indeed, one of the most influential interventions with greatest impact and minimal inconvenience would involve ensuring future employment is always considered during the first week of admission to any hospital.

The ‘Continuation of responsibility’ that prevails in the military rehabilitation pathway34 is another identifiable factor positively influencing successful vocational outcome. An assigned individual, the ‘Rehab Guardian’, monitors progress at each step ensuring continual overview of progress even when immediate health provider changes multiple times.35 Crucially, this ‘Rehab Guardian’ can be clinical (ie, current medical officer) or welfare depending on the stage at which the patient currently resides, for example, hospital/GROW/civilian transition. At any point, the ‘Rehab Guardian’ can ask for assistance and guidance from vocational occupational therapists. Where patients are destined for civilian work, the vocational occupational therapist then informs of medical needs that could be neglected were decisions purely career focused. Therapists are able to engage with a network of providers, such as career counsellors via the ‘Career Transition Partnership’, thus amalgamating medical needs and real-world necessities protecting ‘health as well as wealth’. This is encouraged in the National Service Framework for Long Term Conditions where ‘People with long term neurological conditions are to have access to appropriate vocational assessment, rehabilitation and ongoing support’. 36 Resources in healthcare are scarce and ‘ongoing support’ could prove very expensive—appointing a ‘Rehab Guardian’ achieves this ambition for ‘ongoing support’ in a way that reaches out into the patient’s life beyond hospital and ends only when help is no longer required.

Overall, 39.7% (27–52) of patients returned to civilian work in various degrees. Military work is specialised with physically demanding roles in austere conditions and moving to a civilian occupation is often regarded as an easy option for injured personnel. This is not true— returning to the military is return to a familiar role in an environment that’s inclusive and established. Civilian life and employment requires different skills in unfamiliar environments with completely different hierarchies necessitating different interpersonal skills.37 While many civilians undergo this process when changing jobs, this is not comparable. The military is a lifestyle and the transition is from military life to civilian employment as well as a different civilian lifestyle—for neurological patients this can mean even more difficulties. The results from this 3-year follow-up of military patients demonstrate that over a third were able to leave the military, change lifestyle, change roles, pass civilian interviews, compete with other candidates (who had universally been ‘civilian’ longer) and successfully gain and hold full-time/part-time employment. This is a substantial achievement given that discharge was forced for all but one of these patients now successfully in civilian work.

For those presently in civilian employment, 82.3% (77.7%–90.9%) were dismissed as a result of their neurological impairment. The functional effects of impairment were therefore significant enough to prevent employment in a military role. Despite this, the majority were able to work in civilian roles. Return to alternative work is therefore possible despite neurological impairment preventing them ‘returning to work’ (noted in military veterans elsewhere).38 Thus employment for all should be considered the norm and alternative employment should always be explored.

The 2012 data represent the longest follow-up (3 years) showing 29% in military employment and 52% in civilian work, rising to 67% if voluntary work/courses/actively seeking work are included. Notably, the number out of work was the lowest over this 3-year study period at 4% (one person). The highest rate of return to work was also seen at the 3-year point. These improved results could be due to a number of reasons. Given the longer time since initial injury, there may be further recovery of initial deficit; equally as patients settle, a combination of acceptance, adjustment and/or adaptation can improve functional ability advancing employment prospects. This is supported by numbers progressing from unemployment to training/employment and training to employment as time progressed. This somewhat contradicts previous evidence suggesting that there is reduction in employment as the years’ progress.39

The number of patients remaining in the military for 3 years is also encouraging. These injured personnel were not only able to return to soldiering but pass military-wide rigorous physical annual tests that do not allow for individual deficit. Neurorehabilitation (with vocational rehabilitation) can enable military personnel to provide sustained duty (at least 3 years), and this should support continued investment in this therapy.40–43

It could be argued that patients returning to military duties may reflect nominal return to uniform but not necessarily return to full duty, but 88.2% (67%–100%) of returnees were in their full role without restriction across all four cohorts. Indeed, 2012/2014 data showed 100% of contactable patients in their full-time active role. The remainder were either on graduated return to work or reduced hours with restrictions. Neurorehabilitation will return a functioning soldier to their unit compared with many therapies that simply treat one illness. This valuable direct ambition is unique to vocational rehabilitation and important for the military to note when measuring whether rehabilitation is effective.

Patients in ‘civilian work’ could potentially require full-time support, and this may falsely represent their true work status. Comparing all annual cohorts, 83.5% (66–100) in civilian roles were working full time unsupported, with the remainder working part time (less than 15 hours) and only one patient over the 3-year follow-up period required permanent support.

Various non-pathological factors (eg, depression, anxiety, family, age, previous work, etc) correlate well with predicting future return to work, although uncertainty exists on the effect years later).44 Looking at employment expectations on discharge compared with actual outcome showed 62% of patients’ discharge expectations matched the reality of their employment at 2 and 3 years following discharge (2012 cohort); 79% matched at 2 years (2013 cohort); 74% matched at 1 year (2014 cohort)—this consistent high correlation may be due to employment ‘goal-setting’. The team appreciated brain-injured patients initially exhibited reduced insight and emphasis was placed on finding strategies to enable return to work. This dominant focus encouraged progress and although the ambition was to return to military service, the skills and improvements gained were equally applicable in any employment.

While return to work is a considerable achievement, sustaining this employment over successive years is the best possible outcome and more indicative of permanence in recovery. Evaluating this requires interviewing exactly the same patients over consecutive years—quite a demand on patients who are understandably reluctant to participate in a 45 min interview. We were able to successfully contact the same 52% and 44% of the total patients for the 2012 and 2013 cohorts, respectively, 63.6% and 78.6% still had the same vocational status 2 and 3 years later, respectively and 36.3% and 21.4% demonstrated improved vocational outcomes—early intervention can therefore result in sustained employment. The positive effect of employment on every aspect of health/life (self and dependants) has already been highlighted as significant.45 Early vocational rehabilitation as a treatment therapy46 47 should be regarded akin to life-prolonging interventions in chronic disease; indeed, the strategies learnt during neurorehabilitation are designed to encourage continual improvement even when no longer under the supervision of rehabilitation staff.

The effects of vocational rehabilitation are therefore substantial and reach far beyond the immediate work place. The value of this therapeutic intervention should be recognised for the extensive effect it has on personal health, family and society for many years beyond their therapy.48