Research ObjectivesWe investigated whether fear avoidance was associated with return to work-related activity (RTW) after mild traumatic brain injury (mTBI). Fear avoidance has been associated with persisting symptoms but the potential links with return to work remain unexplored.DesignSecondary analyses of two prospective observational cohorts, with follow up assessments conducted six-nine months after mTBI.SettingOutpatient concussion services.ParticipantsAdult participants (n=175), were included if they were aged 16 or over, were within three months of injury and engaged in work-related activity at time of injury.InterventionsN/A.Main Outcome MeasuresThe primary outcome was return to usual levels of work-related activity six-nine months after mTBI. Participants completed the Fear Avoidance Behavior after Traumatic Brain Injury (FAB-TBI) questionnaire at enrolment and six months later.ResultsOverall, 53% of participants had returned to usual work levels by six-nine months after mTBI. While early fear avoidance was weakly associated with RTW outcome, persistent high fear avoidance between study assessments or increasing avoidance over time were associated with greater odds of still being off work six-nine months after injury.ConclusionsPervasive and increasing avoidance of symptom triggers after mTBI were associated with lower rates of RTW six-nine months after mTBI. Work place accommodations and pacing interventions can be useful early after mTBI, but potentially unhelpful for those who are highly fear avoidant. For this group, interventions encouraging pacing and symptom avoidance may reinforce dangerousness beliefs. High or increasing levels of fear avoidance behavior should flag to clinicians that alternative treatment approaches are indicated. Further research is needed to better understand transition points along the recovery trajectory where fear avoidance behaviors fade or increase.Author(s) DisclosuresThis research was supported by grants from the Health Research Council of NZ (Study 1: ref 18/046 (Dr Snell); Study 2: ref 20/041 (Dr Faulkner)). Professor Alice Theadom is supported by a Rutherford Discovery Fellowship, administered by The Royal Society–Te Aparangi. Professor Surgenor receives book royalties from Thomson Reuters. The authors report no other declarations of interest.

ObjectivesFear avoidance is associated with symptom persistence after mild traumatic brain injury (mTBI). In this study, we investigated whether fear avoidance was associated with other outcomes such as return to work-related activity (RTW).Materials and MethodsWe analyzed associations between fear avoidance and RTW 6-9 months after mTBI, in two merged prospective mTBI cohorts. Adult participants aged 16 or over (n=175), presenting to outpatient services in New Zealand within 3 months of their injury, who were engaged in work-related activity at the time of injury, were included. Participants completed the Fear Avoidance Behavior after Traumatic Brain Injury (FAB-TBI) questionnaire at enrollment and 6 months later. Associations between FAB-TBI scores and RTW outcome were analyzed using multivariate approaches.ResultsOverall, 53% of participants had RTW by 6-9 months after mTBI. While early fear avoidance was weakly associated with RTW, persistent high fear avoidance between study assessments or increasing avoidance with time were associated with greater odds of still being off work 6-9 months after injury.ConclusionsPervasive and increasing avoidance of symptom triggers after mTBI were associated with lower rates of RTW 6-9 months after mTBI. Further research is needed to better understand transition points along the recovery trajectory where fear avoidance behaviors fade or increase after mTBI.

Background: Rates of return-to-work after stroke are low, yet work is known to positively impact people’s wellbeing and overall health outcomes.Objective: To understand return-to-work trajectories, barriers encountered, and resources that may be used to better support participants during early recovery and rehabilitation.Participants: The experiences of 31 participants (aged 25–76 years) who had or had not returned to work after stroke were explored.Methods: Interview data were analysed using reflexive thematic analysis methods within a broader realist research approach.Results: Participants identified an early need to explore a changed and changing occupational identity within a range of affirming environments, thereby ascertaining their return-to-work options early after stroke. The results articulate resources participants identified as most important for their occupational explorations. Theme 1 provides an overview of opportunities participants found helpful when exploring work options, while theme 2 explores fundamental principles for ensuring the provided opportunities were perceived as beneficial. Finally, theme 3 provides an overview of prioritized return-to-work service characteristics.Conclusion: The range and severity of impairmentsexperienced by people following stroke are broad, and therefore their return-to-work needs are diverse. However, all participants, irrespective of impairment, highlighted the need for early opportunities to explore their changed and changing occupational identity. LAY ABSTRACTThe aim of this study was to understand how best to support people returning to work after a stroke. A total of 31 people who had or had not been able to return to paid work after stroke were interviewed. We listened to their experiences and considered what worked best for different people with a range of needs and aspirations. People talked about wanting opportunities soon after their stroke to explore changing thoughts about themselves and their ability to return to work. Conversations with participants and their families, often starting very early after stroke, were important. People also wanted opportunities to practise skills they typically used at work, such as social skills or planning and organizational tasks. Through these ongoing conversations and opportunities to practise, people talked about gradually regaining their confidence in the skills they had retained after their stroke, rather than focusing only on the difficulties they were experiencing.

BACKGROUND: Early intervention vocational rehabilitation (EIVR) is used to optimize return to work (RTW) outcomes for people following spinal cord injury (SCI). However, theoretical clarity is required about how EIVR works, for whom and under what circumstances. OBJECTIVE: To develop a theoretical understanding of how people respond to EIVR following SCI and the contexts in which mechanisms of intervention effect are likely to be activated. METHODS: Realist research methods were used to analyze interviews with 30 participants who had received EIVR following SCI. RESULTS: We conceptualized the reporting of our analyses using a travel metaphor, encapsulating the types and degree of wayfinding support participants required to think about, plan and action their vocational aspirations. Developing, maintaining and enacting hope, supporting self-identity and vocational identity, and focusing on environmental context adaptations required to enact vocational aspirations, appear to be critical mechanisms of intervention effect within EIVR. CONCLUSIONS: Various contexts and mechanisms of EIVR contribute to successful negotiation, achievement and sustainability of RTW outcomes for people following SCI. These theoretical understandings can refine EIVR service provision within SCI rehabilitation and inform how EIVR can improve RTW outcomes for people with acquired neurological conditions in other rehabilitation contexts.

Purpose Little is currently known about how early intervention vocational rehabilitation (EIVR) works for people with newly acquired neurological conditions such as traumatic brain injury, acquired brain injury and spinal cord injury. This study aims, from a realist framework, to identify relevant literature and develop an initial programme theory to understand how EIVR might work for people experiencing acquired neurological disability. Realist reviews are ideally placed to address the identified knowledge gap as they assist in gaining a deeper understanding of how the intervention works, for whom it works best, and the contexts that promote the activation of desired outcomes. Methods We used a seven-step iterative process to synthesise literature using a realist approach. The steps included: development of initial programme theory, literature search, article selection, extracting and data organising, synthesis of evidence and programme theory refinement. We performed a literature search using the following databases: Cinahl, Embase, EMcare, Medline, PsychInfo and Scopus. Articles were selected if they contributed to the knowledge describing what is EIVR and how it works in newly acquired neurological conditions. Data were extracted and synthesised to develop a programme theory for EIVR. Results Following screening of 448 references, 37 documents were eligible for data extraction. We developed a refined programme theory of EIVR consisting of three contexts (prioritisation of exploring work options, return to work discussed as an option, and workplace support), nine mechanisms (ensuring rehabilitation teams’ culture, fostering hope, exploring options, optimising self-efficacy, maintaining worker identity, staying connected, setting goals, engaging employer, and flexing roles) and three outcomes (confidence in ability to work, psychological adjustment, and engagement in solution focussed options). Conclusions This appears to be the first paper to explore how EIVR works, for whom and in what situations. We have produced a programme theory that may provide an initial understanding of EIVR following acquired neurological conditions.

BACKGROUND: Early vocational rehabilitation following spinal cord injury (SCI) improves return to work (RTW) outcomes, but there is limited information about who benefits from such interventions, why and in what contexts. OBJECTIVE: We aimed to describe demographic and clinical characteristics and RTW outcomes of adults with SCI who received early vocational rehabilitation. We sought to identify key mechanisms of early vocational rehabilitation. METHODS: This is a cross-sectional survey of people with SCI recruited from the New Zealand Spinal Trust Vocational Rehabilitation Service, who had sustained an SCI within the previous five years. RESULTS: Of the 37 people who responded to the survey, 54% returned to paid work (90% of whom retained their pre-injury employment). Those in autonomous roles returned to work faster with greater odds of returning to their pre-injury employer and role. Participants highlighted the importance of feeling hopeful about RTW while still in the spinal unit as a key mechanism of effect within the early vocational intervention. CONCLUSIONS: Findings suggested key mechanisms of early vocational intervention could be framed by models of hope. However, for gains to be optimised, continuity of support beyond the acute stage was suggested as an area for future research.

Introduction Return to work after spinal cord injury (SCI) is linked to well-being and better physical and mental health outcomes. In New Zealand, work rates after SCI are lower than the general population. Vocational rehabilitation is one method of supporting return to work. Although the best model has not been determined, there is evidence supporting early intervention. However, most vocational rehabilitation research focuses on return to work outcomes without considering why vocational rehabilitation works, for whom and under what circumstances. Given this knowledge gap, we detail a realist synthesis protocol aiming to explain how contextual factors trigger relevant mechanisms to facilitate return to work after SCI.Methods and analysis This study will use a realist synthesis approach, following Realist And MEta-narrative Evidence Synthesis: Evolving Standards (RAMESES) guidelines. First, we will undertake a realist review of existing published and grey literature. Second, to assist with theoretical conceptualisation, we will interview people with SCI who have received vocational rehabilitation. Finally, we will survey people with SCI who received early vocational rehabilitation for theoretical testing and refinement.Ethics and dissemination University of Otago Ethics Committee (Reference H19/170) has been obtained. A knowledge translation event will address issues relevant to wider implementation of the intervention and study findings. Findings will be also be disseminated through peer reviewed journals, conference presentations and formal reports.