Leonard Matheson, PhD, CVE Vicki Kaskutas, MHS, OTR/L Mary Seaton, MHS, OTR/L

New Client-Centered Approaches to Work Rehabilitation of Persons with

Acquired Brain Impairment

Washington University School of Medicine Program in Occupational Therapy

Leonard Matheson, PhD, CVE

Vicki Kaskutas, MHS, OTR/L

Mary Seaton, MHS, OTR/L

Deborah Turley, BS, OTR/L

Matthew Dodson, OTD, OTR

Timothy Wolf, NIH T32 Pre-Doctoral Fellow

Historical OT Work Practice

OT Industrial Models from WWI Work Hardening for Workers’ Compensation Clients

Rancho Los Amigos Hospital 1970’s From AJOT 1985 > Current = 110 ± papers. CARF 1987 > Current = 400 ± programs (high 1500 ±).

Musculoskeletal or neuromuscular injuries. Focus on physical impairments & pain.

Usually Intervene after MMI or P&S. Months or years post-injury.

Why the Historical Tie to MSD?

Area Annual Incidence

Back 21.9%

Hands or Fingers 13.0%

Feet, Ankles & Toes 5.2%

Head 5.9%

Days Lost Work-Related InjuriesU.S. Private Industry

Source: U.S. Bureau of Labor Statistics 2005

Current Work Practice

Workers’ Comp injury funding. Musculoskeletal or neuromuscular injuries.

Focus on physical impairments & pain. Work Conditioning often in place of WH.

Usually Intervene after MMI or P&S. Weeks or months post-injury.

Emerging Occupational Problem in U.S. 1 million ED visits annually for TBI; >90% are MTBI 15% with MTBI impaired 1 year later. Illness-related ABI rapidly increasing.

Societal Changes: Aging Workforce, Warfare, & Terrorism.

Emerging Technologies: Imaging OT Alternatives to Neuropsych testing

OT’s have a great skill set for ABI & Work!

Why expand beyond MSD to ABI?

Driving Beliefs & Values

Work is one of seven OT domains that must be raised with all clients of working age.

OT must address work whenever the client identifies work as a priority, no matter the setting.

Early intervention prevents loss of worker role. Many people with cognitive impairments can work. People need to experience successes and failures to

make a realistic self-appraisal of work capacity.

New Work Practice Possibilities

Mix of funding sources for expanded OT services. Full range injuries and illnesses.

Focus on occupational performance limitation and interface of person – environment – job demands.

Intervene before MMI or P&S. Weeks post-injury. Usually pre-discharge from medical care.

New Model of OT Work Practice

Occupational Performance Center (OPC) Client-centered, job-focused, in-hospital. Assessment & work rehab for in / out patients. Small footprint & efficient space utilization. Re-usable structured simulations for eval & intervention.

Collaboration: Washington University Program in Occupational Therapy HealthSouth Corporation The Rehabilitation Institute of St. Louis

PSYCHOLOGICAL

NEUROBEHAVIORAL

PHYSIOLOGICAL

COGNITIVE

SPIRITUAL

SOCIAL SUPPORT

SOCIAL & ECONOMIC SYSTEMS

CULTURE & VALUES

BUILT ENVIRONMENT & TECHNOLOGY

NATURAL ENVIRONMENT

PERSON(INTRINSIC FACTORS)

ENVIRONMENT (EXTRINSIC FACTORS)

PEOP Christiansen and Baum, 1991,1997, 2003

OCCUPATIONAL

PERFORMANCE

AND

PARTICIPATION

OCCUPATION

PERFORMANCE

WUOT Occupational Performance CenterService Goals

Support healthy future orientation & maintain motivation.

Increase social participation. Enhance quality of life through work. Help people make informed decisions if they can’t

work. Smooth transition from hospital to community.

WUOT Occupational Performance CenterClient-Centered Interventions

OPC Structured Intake Interview Job Performance Measure Selective standardized ability testing O*NET Ability Questionnaire Structured Work Activity Groups (SWAG) Occupational performance alternatives to

neuropsychological testing

OPC OT Work Rehab Process

1. Understand the role of work in the client’s life prior – get an occupational history.

2. Understand client’s work goals; client-centered care.

3. Identify client’s supports and barriers to achieving work goals.

4. Measure and understand client’s work.

5. Measure baseline performance relative to target job.

OPC OT Work Rehab Process6. Compare present performance to level needed on the

job.

7. Develop treatment plan.

8. Use simulated and real work, best to get into the context of the actual workplace for trials.

9. Measure the feasibility of the client to be an employee.

10. Identify accommodations needed and work with employer to get these into place.

Case #1: Doug 33 year-old s/p resection of cancerous brain

tumor (oligodendroglioma in the left parietal lobe).

Seizure disorder post-surgically. Impairments identified by Doug include:

Word finding problems RUE/LE tingling

Occupational History

Understand the client’s work and education history and the role work plays in the client’s life.

Identify the client’s vocationally related successes and failures.

Occupational Profile Determine who the client is, their needs/concerns,

and how these concerns affect engagement in occupational performance.(Practice Framework, 2002)

Doug’s Occupational History

Early in long-planned-for career. Bachelor’s in Psychology Master’s in Industrial / Organization Psychology Job as Lead in Change Management for a large

international corporation for 1 year 4 years experience in Change Management

Vocational Goals

Employment interests & pursuits Employment seeking & acquisition Job performance Retirement preparation & adjustment Volunteer exploration Volunteer participation

(Practice Framework, 2002)

Doug’s Work Goals

Return to previous job as Change Management Lead for a Fortune 500 corporation on a part-time basis

Gradually increase to full-time work Identify accommodations needed to work

Doug’s Supports & Barriers Financial

75% short term disability, wife employed Emotional

Family and employer very supportive No premorbid history, no obvious problems

Physical Skull wound healing, but impairment evident Physically fit prior to incident and now

Vocational Good educational preparation Loyal employee with strong work ethic Large, stable employer Job requires high level of processing, organization, & interaction

Generic Job Analysis Tools Dictionary of Occupational Titles

http://www.occupationalinfo.org Work description Physical demand level (weight lifted)

Sedentary, Light, Medium, Heavy, Very Heavy

O*NET (Occupational Information Network) http://online.onetcenter.org Tasks, Skills, Abilities, Knowledge, Work Activities,

Work Styles, Work Context, Work Values, Interests, Wages & Employment

Client-Specific Job Analysis Worker interview Employer’s interview Employer’s written job description On-site evaluation by OT

Analyze tasks performed, skills, positions, pace and rate of work, equipment, tools/machines, contexts, personal protective equipment, schedule, habit, routines.

Job Performance Measure (JPM) Individualized interview process to identify tasks from

the the client is required to perform on his or her job. The client rates his or her performance & satisfaction on

a 10-point scale. Modeled after Canadian Occupational Performance

Measure (COPM) using O*NET content structure. Used to:

Identify focus of assessment and intervention. Identify metacognitive inconsistencies & safety concerns. Track status and progress.

Doug’s Assessment Results Oral Directions Test – 75% white male machinists Wonderlic Personnel Test –

Norm reference: 62% total pop., 17% college grads Criterion reference: Doug – 23, manager/supervisor – 26

Structure Work Activity Group Needed to listen to messages twice to ensure accuracy

and understand the details. When multitasking his verbal comprehension decreases. Effective organization noted, used memory tools indep.

Doug’s Treatment Plan Long Term Goals

Perform the essential functions of his job at a level competitive for employment.

Return to previous job on modified schedule in 1 mos. Effectively negotiate work accommodations with employer.

Short Term Goals Visit worksite and effectively interact with coworkers and

supervisor. Use tape recorder effectively during work simulation. Teach self how to use a new software program. Prepare/deliver a training intervention to a small group.

Purposeful Simulated Work Advantages Disadvantages

relation to work evident more client centered specific conditioning equipment readily

available can be graded

not intrinsically motivating equipment specific longer set up time can use with few clients therapist’s unfamiliarity larger space required

Occupation-Based Actual Work Advantages

Disadvantages relation to work evident very client centered intrinsically motivating very specific conditioning encourages self

management easily transferable best predictor of job

performance

supplies not easy to get as job specific

equipment expensive harder to grade equipment specific longer set up time can use with 1 client therapist unfamiliarity larger space required

Feasibility Evaluation Checklist

General criteria for competitive employment are observed during administration of test protocol & work simulations Productivity

Attendance, quality/quantity of work, tolerance to work

Safety Safety rules, protective behavior, body mechanics, maintain work

environment

Interpersonal Behavior Self awareness, interaction, response to supervision, attitude

Separate forms for OT and client self-report

Doug’s FEC

Accurate perception of his skills and behaviors Productivity

Rated quantity less with unfamiliar tasks Quality was good with all tasks

Safety Interpersonal Behavior

Good coworker/employee behaviors noted Response to change rated lower, dress code too!

Reasonable Accommodations Job Accommodations Network http://www.jan.wvu.edu/ Worksite accessibility Job restructuring

Reallocating marginal job functions that an employee is unable to perform because of a disability; altering when and/or how a function, essential or marginal, is performed.

Modified work schedules & leaves Adjusting arrival or departure times, providing periodic breaks, altering

when certain functions are performed, allowing an employee to use accrued paid leave, or providing additional unpaid leave.

Modified policies Modifying leave policies, making accommodations for conduct

standards, modified dress code or hygiene requirement, working from home

Equipment & services Equipment to modify the environment, personal need items may get

accommodation, Personal Assistance Services in the form of work-related assistance (such as readers, help with lifting or reaching, page turners), but generally not for personal attendant care

Doug’s Return to Work Plan

Modified work schedule – half days x 6 wk Resume work roles gradually Use of tape recorder, especially in meetings

Doug’s Perspective Response to

intervention & first 6 months on the job.

Life now.

WUOT Occupational Performance CenterClient-Centered Interventions

OPC Structured Intake Interview Job Performance Measure Selective standardized ability testing O*NET Ability Questionnaire Structured Work Activity Groups (SWAG) Occupational performance alternatives to

neuropsychological testing

OPC Structured Intake Interview

Initial Vocational Plan Highlights: Job Duties & Work Environment Earnings & Leave Status Perceived Job-Function Limits Work History Stated Vocational Goals Favorite Activities I Can’t Do Initial Assessment Plan & Work Goals

Work-Oriented Measures

Personnel Test for Industry Oral Directions Test Wonderlic Personnel Test Career Assessment Inventory Watson-Glaser Critical Thinking Appraisal

Most norm-referenced to employee groups. More valid for work than neuropsych tests.

Personnel Test for IndustryOral Directions Test Paper & pencil test of ability to follow oral

directions. Very useful screening tool for persons whose brain

injury affects cognition. Can be administered in a group setting. Sometimes frustrating experience for client. Monologue is read from script or CD-ROM. 39 items, 15 minutes.

Wonderlic Personnel Test Predicts ability to learn, understand, and solve

problems on the job. Most highly researched preplacement screening

test in the U.S. Compare client’s abilities to the abilities of

people in hundreds of occupations. 50 items, timed 12 minutes.

Career Assessment Inventory Compares interests of the client in terms of

Holland Occupational Types system. Two different levels, one for persons with high

school or less education and the other for persons with college education.

Links client’s interests to thousands of occupations.

305 or 370 items, untimed, approx. 45 minutes.

O*NET Ability Questionnaire Structured method to aggregate O*NET

Task Domain information to initiate the client-centered job description process.

Begin with blank form and populate from O*NET Download Task Detail Excel spreadsheet,

including “Importance” scores. OPC offers 25 OAQ for our most typical

clients on the OPC website.

Feasibility Evaluation Checklist

Acceptability of client to employers. Three groups of constructs:

Productivity Safety Interpersonal Behavior

Separate observation and self-report. Comparing Obs to SR is excellent feedback.

23 items, untimed, approx 5 minutes.

Structured Work Activity Group (SWAG) Guiding Principles

Each SWAG is a suite of related work activities centered on a “real world” theme that is housed within a virtual business.

Client is challenged with progressive demands, based on the client’s demonstration of competence.

Employee behavior is frequently evaluated. Inexpensive easy to replicate. Widely disseminated.

SWAGs Available SWAG 1: St. Francis International Library

150 overdue patrons, overbooked conference rooms, a stopped-up toilet in the ladies’ room, and a sick child.

SWAG 2: Gepetto’s Workshop Safety training Woodworking Assembly of doll chair, wheelbarrow, and student’s bunk bed.

SWAG 3: St. Francis Hospital (soon) Medical telephone triage Emergency Department report rounds Patient Treatment Unit Clerk

SWAG #1 Library Activities

1. Calculate Fines & Replacement Costs

2. Bookkeeping - State / Province Analysis

3. Bookkeeping - Current Inventory Control

4. Bookkeeping - Future Inventory Control

5. Mailing - Notices of Overdue Fines

6. Database Maintenance - Mailing List

7. Telephone Message Taking

8. Conference Room Scheduling

Mailing List Maintenance

Library Fines and Replacement Costs

2001: A Space Odyssey MacDonald, Nippy 2006 Breezeland Lane Wrightsville Beach, NC 28412

$6.38 $18.95

SWAG #2 Workshop Activities

1. Safety Training

2. Wood Alphabet Fabrication

3. Wheelbarrow Assembly

4. Doll Chair Assembly

5. Bunk Bed Assembly

OPC Resources

OPC Website Resources for download:

OPC & SWAG forms SWAG instructions Slideshow downloads

Test publishers and purchase prices.

http://notesplace.wustl.edu/ot_opc

Case # 2: Joanne 65-year-old female. Stroke 1 month previously. Impairments

Left Visual acuity & Visual Field Concentration/ Processing speed Mobility & Balance Speech Right hand sensation and fine motor skills UE & LE Bilateral Weakness

Assertive and headstrong.

OPC Intake with Joanne

VP of Commercial Properties, earning $80,000 per year.

Highly motivated to return to previous work. Client’s description of Work Activity

Demands, Context & Performance Patterns Specific routine and non-routine activities & tasks Personnel hierarchy, relationships and supports

OPC Intake with Joanne Goals

Not working was not an option. Wants to return to full time work in 4 weeks. Wants to work 5 more years.

Self-Perceived Occupational Limitations Typing Working on Computer Reading Speech Thinking (!)

Initial OPC Assessment of Joanne

PTI Oral Directions Test Untimed & repeated items = 10th percentile Frustrated with writing and coordination problems. Difficulty with concentration.

Wonderlic Personnel Test Raw Score = 9, Age adjusted Score = 14 Real Estate Manager = 24 minimum Middle Management Job Family = 27 minimum

Initial OPC Assessment of Joanne

Brief SWAG Testing- Bookkeeping

Feasibility Evaluation Checklist results: Client:

Expressed satisfaction with quantity and quality of performance.

Therapist: Errors noted in recalling multi-step instructions. Decreased right upper extremity coordination limiting

speed and quantity of output.

Post-Initial Eval Impressions Joanne:

Acknowledged limitations in formal OT, Speech & Neuropsych eval, but expected to perform adequately in work environment.

Even though she accepted job tasks limitations, she thought she could “bullshit & bluff” her way through.

“When I get back to work, it will all be OK.” Therapist:

Screening scores far below minimums for job. Note intrinsic drive to succeed. Minimized her problems & made excuses. Unrealistic over-estimate of readiness for work.

OPC Goals LTG: Return to previous job with modified duties. STG: Client to:

Express realistic awareness of performance strengths and limitations Demonstrate understanding and appropriate application of compensatory

strategies Demonstrate ability to perform detailed tasks consistent with job for 30

minutes duration.

Client-identified performance issues: Writing and taking notes Remembering Transition to taking back her duties Computer speech recognition functional use Effectively functioning in meetings

OPC Interventions Identification of specific limitations and development of

strategies to address them. SWAG 1 Bookkeeping & Conference Room Message Taking

& Scheduling: Handwriting, typing and adding machine - with FEC layered over.

Computer Speech Recognition Training in context of actual work activities - to enhance productivity.

Preparation for procedural & software changes at work. Adaptive and compensatory cognitive strategies- note taking,

use of assistant, memory aids & Palm PDA.

SWAG 1 Performance Progression

Message-Taking (Mid Level Demand) Rated herself “poor”.

Message-Taking (Lower Level Demand) Rated herself “fair” and “good”.

Message-Taking (Mid Level Demand with Interruption) Improvement in recalling multi-step instructions. Identified realistic limitations for work but focused on

physical, rather than cognitive performance areas.

Transition to Work Client returned to work three half-days per week. Client continued in OPC on the afternoons she worked. OPC therapist worked with her in her office on organizational

strategies and use of computer recognition software. OPC therapist sat in on staff meetings, several weeks apart and

then debriefed with her regarding performance and progress. Client and therapist refined performance-based approaches to use

in therapy and at work to enhance performance via technology, compensatory strategies.

Joanne’s Outcome

Immediate: Client successfully transitioned to full-time work with use of

computer speech recognition software.

Long Term: Client worked with use of voice recognition computer

software for 6-9 months and then transitioned back to keyboard use.

Voluntarily retired three years after her return to work.

Case #3: Tony 38 y.o. male. Married with 3 young children TBI 4 months prior Impairments:

R visual field cut Severe memory deficit decreased insight depression decreased frustration tolerance

Neuropsychology, “He certainly cannot be expected to function in pre-morbid employment as a supply store manager. Start a trial of very simple, routine stock work.”

OPC Intake

Branch Manager for electrical & plumbing supply Employed for 13 yrs: High job satisfaction Frustrated with current therapies. Goals:

To return to full time work ASAP. Resume driving again: doesn’t want to burden others.

Self-Perceived Occupational Limitations Vision (?) “Memory is coming back” No transportation to work

Initial OPC Assessment PTI-Oral Directions Test (Score = 34: 75th %tile) O*NET Ability Questionnaire Simulation of SWAG phone answering, taking and placing

orders Client frustrated saying phone task was “too fast” Required extra time to record necessary information and frequent

repetition of information.

Retrieval of items from stock room to fill orders. Client required increased time, missing items on right unless cued

Boss very supportive: “We will do whatever it takes to get him back”.

Initial OT Analysis: Client angry regarding current situation (ready to “take a

break” from therapy process). Not proficient in use of visual scanning techniques. Currently not using memory tech. unless cued. Limited insight Tends to downplay job responsibilities: “It’s not hard. I have

done it for 13 yrs.” Divided attention? Problem solving?

Goals:

LTG: 1. Client readiness for successful return to work with

accommodations after ed.

STG:1. Client will increase insight by stating 3 strengths and

limitations for successful return to work/ community.

2. Client will use compensations to increase success in work tasks after ed.

3. Client will participate in pre-driving screening to determine readiness for formal on-the-road test

Treatment Activities in the Clinic:

Education and reinforcement of memory strategies during simulated job tasks. Given “on-the-go” notebook to aid working memory.

Teaching visual scanning techniques applied to simulated job tasks.

Role-playing work interactions. Test knowledge of work-related information.

Client’s Response

Difficulty learning building layout. Frustration: “I’m not familiar with this hospital”.

Often unable to recognize familiar faces encountered daily in therapy (i.e. his doctor).

Difficulty committing to rehab tasks without being able to see the end goal.

Work Trial Two half-day work trials. Initially to go back to simple stock room position. Job demands included:

Reading order requisition on paper. Retrieving items from large warehouse. Checking and correcting inventory amounts. Simple math. Answering phones and taking detailed messages. Use of computer system to access catalog inventory.

Client’s Performance Easily fell back into familiar job tasks. Required multiple cues to learn and carry over new

method to access new computer screen. Client cued to write things down. On 2nd day of work trial:

Client demonstrated increased carryover of compensation techniques for vision and memory.

Boss was so pleased with his performance that he gave client more of his previous work responsibilities back.

Outcome: Client returned to work part time initially. Boss agreed to communicate with therapist regarding

follow up performance. Client returned to OPC 3 weeks later with good self-

report and boss report. Returned to work full time one month later. Client passed “on-the-road” driving test. Long-term follow-up.

Problem Statement A need existed for a way to validate an OT

assessment of dysexecutive syndrome focused on work.

A potential way to accomplish this is to overlay neuropsychological theory on OT assessment.

The goal of this study was to develop such a measure, the Complex Task Performance Assessment (CTPA).

Predicting Return to Work of “Tony”

Neuropsychology: “He certainly cannot be expected to function in pre-morbid employment as a supply store manager.” Both parties may have been correct in their assumptions

Neuropsychological Testing Self-recognized limitations to assessing performance

Short in duration, very structured, with clear goals/outcomes. Contradicts some of the defined components of higher-level

cognitive processing. Not sensitive to the deficits of people with mild brain injury.

Predicting Return to Work Neuropsychology

Examines these diagnoses under the umbrella of “dysexecutive syndrome”

Recommend a different form of testing referred to as “ecological valid”

Testing representative of real-world performance. A limited number of validated measures exist. Activities commonly center on shopping and financial planning. Work consistently mentioned as a main area of concern for these

individuals

Predicting Return to Work OPC OT Work Rehab Process

Use simulated and real work, best to get into the context of the actual workplace for trials.

“SWAGS” Simulated work activities used in treatment to determine

readiness for return to work Limitations

Not validated Not seen as the gold-standard for predicting work performance.

Practitioners report promising results

Solution Overlay neuropsychological theory on SWAG

activities to develop and validate a measure to predict return to work.

Assessment Neuropsychological Theory

Control-to-Action Theory Multitasking Assessment Criteria

OPC simulated tasks SWAG activities

Research Project “Initial Development of a Work-Related Assessment of Dysexecutive

Syndrome: The Complex Task Performance Assessment” (Wolf, Morrison, and Matheson, in submission).

Adopted activities used in the Structured Work Activity Group Activity (SWAG) #1: The St. Francis International Library

Bookkeeping-Current Inventory Control Telephone Messaging

Modified the tasks to meet neuropsychology design criteria.

Pilot Data-CTPA 6-test subjects with mild stroke and 4-control

subjects Four of six constructs measured on the CTPA

significantly differed between test subjects and controls.

The other two were approaching significance (p = .05 & .10)

None of the measures in the executive based neuropsychological battery correlated to simulated job performance in the CTPA

Discussion Finding indicates it is possible to overlay

neuropsychological theory onto simulated work activities to potentially validate an assessment to predict work performance.

The CTPA can provide a vital link between traditional neuropsychological assessment and rehabilitation professionals’ observations.

Future Directions

It is necessary to continue to validate the measures and tools used with the OPC Work Rehab Model to demonstrate effectiveness to: Third-party payers Healthcare system Employers Consumers

Problem Statement

We need more OT assessments focused on work.

When is a person with ABI ready to return to work?

Neuropsychological Testing is the traditional “Litmus Test” for determining return to work, but is not sensitive to performance limitations due to mild TBI.

Inconsistencies Between NP Testing and Return to Work

“Isolate and Evaluate” Highly Structured Behavioral issues secondary to injury

are controlled for and eliminated during NP testing.

Failure Experiences in Return to Work

Common for mild Acquired Brain Injury Very devastating Potentially avoidable…

…with Neuro-Performance Measures used by Occupational Therapists.

Theory and Brain Injury Assessment

Occupational Performance

NeuroperformanceMeasurement

NeuropsychologicalMeasurement

St. Francis International Library

Clients are “employed” at a hypothetical library. Work activities include:

Keeping up with library fines Scheduling conference rooms Correcting mailing lists Taking phone messages

Library Fines and Replacement Costs

2001: A Space Odyssey MacDonald, Nippy 2006 Breezeland Lane Wrightsville Beach, NC 28412

$6.38 $18.95

CurrentFine

Replacement Cost

Pilot Study of SWAG Activity 1:1

Cognitive Construct Accessed

by Activity 1.1

Sustained Attention

Selective Attention

Working Memory

Learning/Consolidation

Arithmetic Concepts and Operations

Calculating Fines and

Replacement Costs

Neuropsychological Test Assessing

Cognitive Construct

WAIS-III: Digit Symbol

Ruff 2 & 7

WAIS-III: Digit Span Forwards and Backwards

WMS-R: Logical Memory 1 & 2

WAIS-III: Arithemetic

For further information …

Contact Leonard N. Matheson, PhD

[email protected]