3.5 Vocational Rehabilitation

Returning to work following ABI is probably the most challenging task that a patient will face in the course of their recovery. The work environment often produces stresses on their physical body, cognitive challenges, and emotional strain. However, given the financial burden of not being able to work for most individuals, it is a very important aspect of full reintegration into society and return to independent living. The research on assisting patients in their goal of returning to work is explored in the following section.

What is the evidence that vocational rehabilitation is of benefit in acquired brain injured individuals?

There is Level 4 evidence that:

  1. Vocational rehabilitation results in greater total taxpayer benefits than either total program operational costs or government costs.
  2.  After vocational rehabilitation the majority of subjects have fair or good adjusted outcome, while more than half become gainfully employed or full-time students.
  3.  Individuals with the most significant cognitive impairments benefit the most from vocational rehabilitation services.
  4. Individuals with severe head injury do benefit from supported employment services.

There were three studies that dealt with the intervention of vocational rehabilitation.  Amongst these, there was a cost-benefit analysis, a single group intervention and an outcome study. 

In the cost-benefit analysis by Abrams et al. 101an individualized work reentry program was evaluated.  Of the 142 persons with TBI who participated in the program, 65% obtained employment during the first year of entering the program and 75% obtained employment during the entire observation period. This resulted in a 2:1 ratio of total taxpayer benefit to total program operational cost and a 4:1 ratio of total taxpayer benefit to state cost.

Klonoff et al. 102looked at the adjusted outcome of sixty-four subjects who participated in the Adult Day Hospital for Neurological Rehabilitation Work/School Re-entry program.  Adjusted outcome was defined as discharge productivity level modified by staff ratings of functional impairment severity at program admission.  At discharge, 89.5% of the subjects displayed fair or good adjusted outcome and 10.5% of them displayed poor adjusted outcome.  With regards to being gainfully employed or full-time students at discharge, 62.5% were, while 15.6% returned to the same level of work or school as pre-injury.

Johnstone et al. 103examined the relationship between receiving services from the Missouri Division of Vocational Rehabilitation and neuropsychological variables and vocational outcomes. They separated 110 patients into the following three groups: successfully employed, services interrupted, and no services provided. The results from Johnstone et al. 103suggest that even individuals with significant cognitive deficits can benefit from vocational rehabilitation services, and individuals should not therefore be deemed ineligible for such services based solely on neuropsychological test scores. Johnstone et al. 103also point out that individuals with less severe cognitive deficits may have successfully obtained employment on their own and did not require the assistance of vocational rehabilitation services. Thus, the subjects of their sample were for the most part individuals with significant cognitive deficits who needed the vocational rehabilitation services to successfully return to work.

Wehman et al. 104looked at the success of 20 individuals who had been referred for supported employment. Several others were initially referred but due to their age at injury they were not included in the final analysis. Employment specialists provided participants in the program with on the job support. Of the 20 that were included, at total of 24 placements were made of which 50% of participants remained in their first placement. Overall there were no significant differences in the number of jobs held by the group or in the numbers of hours the individuals worked across the 3 phases of employment (pre-injury work, post-injury work, supported employment). Differences were noted in the hourly wages (with significant differences noted between the pre and post injury wages) and employment ratios (number of hours worked per week) with the post-injury employment ratio being significantly different from the pre and supported employment ratios. Overall Wehman et al.104found that supported employment did help improve the vocational capacity of severely head injured individuals.


There is good reason to believe that vocational programs are useful in assisting patients with moderate to severe brain injury with their vocational goals. In doing so, the benefits to the individual financially and in terms of their self-esteem are great. In addition, there is an obvious savings to the taxpayer to have programs designed towards assisting patients with returning to work.