1. 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

2. Historical OT Work Practice OT Industrial Models from WWI Work Hardening for Workers Compensation Clients Rancho Los Amigos Hospital 1970s 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.

3. Why the Historical Tie to MSD? Days Lost Work-Related Injuries U.S. Private Industry Source: U.S. Bureau of Labor Statistics 2005

4. 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.

5. 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 OTs have a great skill set for ABI & Work! Why expand beyond MSD to ABI?

6. 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.

7. 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.

8. 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

9. 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

10. WUOT Occupational Performance Center Service Goals Support healthy future orientation & maintain motivation. Increase social participation. Enhance quality of life through work. Help people make informed decisions if they cant work. Smooth transition from hospital to community.

11. WUOT Occupational Performance Center Client-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

12. OPC OT Work Rehab Process 1. Understand the role of work in the clients life prior – get an occupational history. 2. Understand clients work goals; client-centered care. 3. Identify clients supports and barriers to achieving work goals. 4. Measure and understand clients work. 5. Measure baseline performance relative to target job.

13. OPC OT Work Rehab Process 6. 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.

14. 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

15. Occupational History Understand the clients work and education history and the role work plays in the clients life. Identify the clients 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)

16. Dougs Occupational History Early in long-planned-for career. Bachelors in Psychology Masters in Industrial / Organization Psychology Job as Lead in Change Management for a large international corporation for 1 year 4 years experience in Change Management

17. Vocational Goals Employment interests & pursuits Employment seeking & acquisition Job performance Retirement preparation & adjustment Volunteer exploration Volunteer participation (Practice Framework, 2002)

18. Dougs 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

19. Dougs 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

20. 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

21. Client-Specific Job Analysis Worker interview Employers interview Employers 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.

22. 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.

23. Dougs 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.

24. Dougs 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.

25. Purposeful Simulated Work AdvantagesDisadvantages 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 therapists unfamiliarity larger space required

26. Occupation-Based Actual Work AdvantagesDisadvantages 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

27. 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

28. Dougs 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!

29. Reasonable Accommodations Job Accommodations Network http://www.jan.wvu.edu/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

30. Dougs Return to Work Plan Modified work schedule – half days x 6 wk Resume work roles gradually Use of tape recorder, especially in meetings

31. Dougs Perspective Response to intervention & first 6 months on the job. Life now.

32. WUOT Occupational Performance Center Client-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

33. 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 Cant Do Initial Assessment Plan & Work Goals

34. 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.

35. Personnel Test for Industry Oral 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.

36. 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 clients abilities to the abilities of people in hundreds of occupations. 50 items, timed 12 minutes.

37. 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 clients interests to thousands of occupations. 305 or 370 items, untimed, approx. 45 minutes.

38. 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.

39. 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.

40. 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 clients demonstration of competence. Employee behavior is frequently evaluated. Inexpensive easy to replicate. Widely disseminated.

41. 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: Gepettos Workshop Safety training Woodworking Assembly of doll chair, wheelbarrow, and students bunk bed. SWAG 3: St. Francis Hospital (soon) Medical telephone triage Emergency Department report rounds Patient Treatment Unit Clerk

42. 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

43. Mailing List Maintenance

44. Library Fines and Replacement Costs 2001: A Space Odyssey MacDonald, Nippy 2006 Breezeland Lane Wrightsville Beach, NC 28412 $6.38 $18.95

45. SWAG #2 Workshop Activities 1. Safety Training 2. Wood Alphabet Fabrication 3. Wheelbarrow Assembly 4. Doll Chair Assembly 5. Bunk Bed Assembly

46. 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

47. 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.

48. OPC Intake with Joanne VP of Commercial Properties, earning $80,000 per year. Highly motivated to return to previous work. Clients description of Work Activity Demands, Context & Performance Patterns Specific routine and non-routine activities & tasks Personnel hierarchy, relationships and supports

49. 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 (!)

50. 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

51. 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.

52. 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.

53. 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

54. 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.

55. 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.

56. 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.

57. Joannes 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.

58. 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.

59. 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: doesnt want to burden others. Self-Perceived Occupational Limitations Vision (?) Memory is coming back No transportation to work

60. Initial OPC Assessment PTI-Oral Directions Test (Score = 34: 75 th %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.

61. 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: Its not hard. I have done it for 13 yrs. Divided attention? Problem solving?

62. 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

63. 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.

64. Clients Response Difficulty learning building layout. Frustration: Im 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.

65. 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.

66. Clients 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 2 nd 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.

67. 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.

68. 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).

69. 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.

70. 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

71. 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

72. 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

73. 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.

74. 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

75. 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.

76. 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

77. 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.

78. 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.

79. Failure Experiences in Return to Work Common for mild Acquired Brain Injury Very devastating Potentially avoidable… …with Neuro-Performance Measures used by Occupational Therapists.

80. Theory and Brain Injury Assessment Occupational Performance Neuroperformance Measurement Neuropsychological Measurement

81. 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

82. Library Fines and Replacement Costs 2001: A Space Odyssey MacDonald, Nippy 2006 Breezeland Lane Wrightsville Beach, NC 28412 $6.38 $18.95 Current Fine Replacement Cost

83. 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

84. For further information … Contact Leonard N. Matheson, PhD len@Epicrehab.com