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1 Shafi R, Colantonio A. BMJ Open 2021; 11 :e041581. doi:10.1136/bmjopen-2020-041581 Open access Assessing the effectiveness of workplace accommodations in facilitating return to work after traumatic brain injury: a systematic review protocol Reema Shafi , Angela Colantonio To cite: Shafi R, Colantonio A. Assessing the effectiveness of workplace accommodations in facilitating return to work after traumatic brain injury: a systematic review protocol. BMJ Open 2021; 11 :e041581. doi:10.1136/ bmjopen-2020-041581 Prepublication history and additional online supplemental material for this paper are available online. To view these files, please visit the journal online (http://dx.doi.org/10. 1136/bmjopen-2020-041581). Received 18 June 2020 Accepted 28 April 2021 Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada Correspondence to Dr Reema Shafi; [email protected] Protocol © Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ. ABSTRACT Introduction Returning to work and sustaining employment can be a significant challenge for traumatic brain injury (TBI) survivors. Within the literature, there is recurring support for the role of workplace accommodations in effective and early return-to-work (RTW). To date, however, there has been a lack of systematic reviews exploring the specific role of workplace accommodations within the context of RTW after TBI. The primary objective of this protocol is to outline the methodological approach that will be undertaken to systematically review the literature and to assess the effectiveness of workplace accommodations in facilitating RTW. Methods and analysis A total of nine databases will be searched systematically using the concepts 'Brain injury,' 'RTW' and 'Job Accommodations.' Study selection will be performed independently by three reviewers, based on predetermined eligibility criteria through two rounds of screening using, first, the title and abstract, followed by a full-text search. Extracted information will include the study's purpose, design, and setting; the data source and type; the severity of TBI and the diagnostic criterion used; a comprehensive description of the intervention provided; the RTW outcome variables and the statistical methods used, etc. The data will be tabulated and narratively synthesised. Systematic review registration: This protocol has been registered with International Prospective Register of Systematic Reviews. Ethics and dissemination As this review intends to use pre-existing published studies hence research ethics board approvals will not be required. Nevertheless, this review will follow the ethical and governance standards in the data management and presentation of results. The findings from this review will potentially be published in a peer- reviewed scientific journal (electronically and in print). The results of this review will be presented at both national/ international conferences and shared with stakeholders influencing RTW practices. PROSPERO registration number CRD42016043517. BACKGROUND Return-to-work (RTW) postinjury is a primary rehabilitation goal and perhaps the most reliable marker of functional recovery within a real-world context. 1 Returning to work and sustaining employment is a signif- icant challenge for traumatic brain injury (TBI) survivors. 2 It is estimated that 60% of working age individuals with moderate to severe acquired brain injury are unable to RTW postinjury 3 and a substantial propor- tion cannot sustain RTW. There is evidence that early and targeted vocational rehabili- tation is cost-effective and leads to improved Strengths and limitations of this study This focused review addresses critical knowledge gaps in understanding how workplace accommoda- tions can influence return-to-work (RTW) outcomes and which categories of workplace accommoda- tions have a greater impact on the sustainability of RTW in the traumatic brain injury (TBI) population. Impact on health practitioners (physicians, rehabil- itation professionals, vocational counsellors, etc.), researchers, policy-makers and survivors alike, that is, acquisition of implementable knowledge regard- ing the nature of the accommodations and their im- pact; directing resources towards evidence-based and cost-effective solutions; engaging TBI survivors to trial such accommodations early in their rehabili- tation journey, etc. Exploration using a sex and gender lens offers a distinct advantage to understand the sex-based and gender-based influences on vocational outcomes. Heterogeneity of the TBI population, uniqueness of the employer/occupational variables as well as the individualised preferences and specific needs of the worker, as they relate to workplace accom- modations, may pose a challenge for more precise interpretations. Environmental variables such as country of origin and, more specifically, variations in disability provi- sions, will need to be considered when interpreting the findings. on May 26, 2023 by guest. Protected by copyright. http://bmjopen.bmj.com/ BMJ Open: first published as 10.1136/bmjopen-2020-041581 on 19 May 2021. Downloaded from
2 Shafi R, Colantonio A. BMJ Open 2021; 11 :e041581. doi:10.1136/bmjopen-2020-041581 Open access work-related outcomes. 2 Since TBI more frequently occurs during prime working years, when people aim for vocational goals and are acquiring the skills needed for success, 4 poor employment outcomes constitute a global health issue producing significant financial and societal burdens. The indirect economic cost of a TBI for working age Canadians is expected to increase to US$8.2 billion by the year 2031, far exceeding costs of other common neurological conditions such as spinal cord injury, Parkin- son's disease and multiple sclerosis. 5 TBI is caused by 'a bump, blow, or jolt to the head or a penetrating head injury that disrupts the normal function of the brain'. 6 TBI is rated as mild, moderate and severe based on the initial trauma that caused the injury. Concus- sion and mild TBI (mTBI) are the most common of all TBIs, 7 yet there is lack of understanding regarding their management in the workplace. mTBIs and concussions can have long-term functional effects on activities of daily living and return to productivity. 8 This is evidenced by the fact that the number of time loss claims for work-related concussions has increased by over 400% in Ontario, Canada, from 2005 to 2013. 9 The sequelea resulting from TBI are often diverse (eg, headaches, memory difficul- ties, seizures, fatigue, visual and auditory deficits, etc.) and accommodating for these impairments is necessary to ensure successful functioning in any reintegrative setting, including academic environments. 10 11 While memory loss and attention/concentration concerns are the most common functional limitations reported by TBI survivors, the persistent difficulties with emotional dereg- ulation and the presence of medical symptoms have been identified as strong indicators limiting job retention. 12 Workplace accommodations (WAs) refer to the individually-tailored supports resulting from adaptations, alterations and/or modifications to job demands or work- place operations, which enable employee's equal access to essential aspects of their work. 13 14 Within the context of personal injury, WAs attempt to facilitate re-integra- tion to pre-injury work status. 15 WAs can be implemented in various forms across all stages of recovery to facilitate RTW. They may include provisions for flex days, opportu- nities for untimed breaks, the option to work from home, the arrangement of a job coach for specific work-oriented tasks etc. 16 17 Within the literature, there is recurring support for the role of WAs in effective and early RTW (e.g., shorter work absence duration, 18 reduced disability costs, 19 postpone- ment or prevention of job loss, fewer job disruptions 20 and reduced productivity loss 21 ). It is estimated that a signif- icant proportion (83.5%) of workers with mental health conditions need accommodations, yet only 30.5% receive them. 22 After a musculoskeletal injury, workers who accept WAs are not only able to RTW but are also able to sustain work, compared to employees who rejected or did not receive an offer to accommodate. 23 In general, the use of compensatory strategies and supported employment practices enhance the likelihood of employment success after TBI. 24 Colantonio et al 25 have reported that 76% of TBI survivors identified 'job modifications' and 'accom- modations for treatment needs by employers' as factors that facilitated RTW. Stergiou-Kita et al have indicated that there is a lack of adequate understanding regarding the scope of WAs among both stakeholders, employers and employees. 26 27 A systematic review 28 did not find strong evidence to support that the patients' preinjury or post- injury characteristics, or rehabilitation interventions had any effect on productivity status and vocational outcomes after TBI. Yet, the review did not consider organisational or vocational modifications such as accommodations and natural supports. Kristman et al , 29 however, later reported that organisational factors are more important than demographic and occupational factors when considering RTW among employees with injuries other than TBI. Non-traditional determinants, such as family support, have been shown to play an equally important role in facilitating community and work reintegration following TBI. 30 There is evidence to suggest that sex and gender exerts significant influences on RTW processes, yet the influence of sex and gender on workplace injuries and outcomes is understudied. 31 32 Further, these terms are often used interchangeably in the literature but they refer to different constructs. Recent evidence reveals low and inconsistent support for the argument that sex and gender significantly informs RTW after TBI 33-35 partly given the small number of females included in these samples; nevertheless positive outcome related to females in resuming work status after severe TBI is present. 36 After adjusting for demographic and health characteristics, adverse life events independently predicted increased rates of sickness-related absences among women 37 in a sex-balanced sample. Franche et al have reported that, following an occupational musculoskeletal injury, pink- collar employees (referred to as female-dominated occu- pations such as clerical, sales and service) are significantly more likely to receive an offer for accommodation, they are also more likely to refuse accommodations compared with their blue-collared counterparts (referred to as male- dominated occupations such as manufacturing, mate- rials handling, construction, transport, mining). 23 The reasons for these discrepancies remain to be explored. A systematic review 38 on prognostic indicators of mTBI outcomes found that only 7% of >200 studies reviewed provided data stratified by sex. We are not aware of any other recent systematic reviews on RTW after TBI wherein the evidence was stratified by sex and gender. To date, there has been a knowledge gap created by the lack of systematic reviews exploring the specific role of WAs within the context of RTW after TBI. While there are studies and reviews that have investigated the role of work- related interventions on RTW, these reviews have focused on care and therapeutic programmes or multidisciplinary intervention(s) that impact RTW including vocational rehabilitation. 39-41 Donker-Cools et al conducted a system- atic review 42 and found strong evidence that interven- tions with a combination of work-directed components on May 26, 2023 by guest. Protected by copyright. http://bmjopen.bmj.com/ BMJ Open: first published as 10.1136/bmjopen-2020-041581 on 19 May 2021. Downloaded from
3 Shafi R, Colantonio A. BMJ Open 2021; 11 :e041581. doi:10.1136/bmjopen-2020-041581 Open access are facilitating RTW in TBI survivors. Nevertheless, the extracted data in this particular review paired rehabil- itation interventions with work-related supports/aids to explain combined effects, vs stratifying for specific outcomes. Another scoping review concluded that WAs appear to be important for supporting employees with mental illness, but identified the implementation and evaluation of WAs as an area for further research. 43 A more recent systematic review focused on workplace factors, conducted by Alves et al , 44 identifies that onsite workplace adaptions are potential avenues for increased RTW yet there remains lack of a robust evidence base concerning the association between modifiable workplace factors and work retention after experiencing ABI; the scope of their work, however, was broad and included both traumatic and non-TBIs. Hence, while it is important to understand WAs from policy, legislative and social perspectives, it is perhaps more paramount to investigate the direct impact of WAs on employment re-entry and retention. Also, it is important to investigate the influence of sex and gender on the offer, acceptance and implementation of WAs. The primary purpose of this protocol is to outline the methodology for a project that will systematically review the literature to identify and characterise the categories of WAs that best facilitate re-entry to work and investigate the translational effect of successful WAs on the effective- ness of vocational outcomes, specifically RTW and, more importantly, long-term sustainability after RTW. The secondary aim is to consolidate and synthesise the quanti- tative and qualitative evidence in the literature, although separately. This review's final goal is to determine whether sex and gender variables are correlated with the effective- ness of accommodations in promoting re-entry into the workplace. METHODS/DESIGN International Prospective Register of Systematic Reviews This protocol has been registered with International Prospective Register of Systematic Reviews (PROSPERO 2016:CRD42016043517), an international prospective register of systematic reviews database in health and social care, welfare, public health, education, crime, justice and international development, where there is a health related outcome. PATIENT and public involvement No patients involved. Search strategy The search strategy was developed with an information specialist at the Toronto Rehabilitation Institute-University Health Network. A modified Population, Intervention, Comparison, Outcome (PICO) framework was used to facilitate and refine the search strategy in accordance with an evidence-based approach. The PICO framework was modified given that a comparison patient popula- tion and/or intervention was not considered. The search strategy was developed using a combination of compre- hensive and specific subject headings and keywords, to balance sensitivity with specificity, and render articles across a wide spectrum of specific literature. The patient population was defined using broad terms such as "brain injuries", "craniocerebral trauma", "head injuries, closed" and "TBI" and the use of specific keywords which included but were not limited to "head", "intracran*", "concuss*" and "brain" combined with "trauma", "edema" and "lesion" using adjacent and wildcard operators. Broader terms such as 'return to work', "employment", "occupa- tions" and "workplace" were used to search for articles, while specific narrow-focussed keywords such as "absen- teeism", and "work" were searched with "status", "activit*", "abilit*" and "capacity" while additional keywords such as "return" were searched with "work" and "dut*" using the adjacent and wildcard operators to render relevant non- traditional publications. In the latter combination, the intend was to include a broad range of literature where the title, abstract and/or author provided keywords included traditional keywords like 'return to work' but also other variants such as 'returning back to work' or 'return to part time work' or 'returning to modified duties' or 'returned to preinjury duties' etc. Similarly, generic heading such as "equipment and supplies" and "Work Capacity Eval- uation" were searched alongside "ergonomic", "jobsite" with "interven*", "duties" "counsel*, "training" and "approach*", again using the adjacent and wildcard oper- ators. These alternative terms helped capture publica- tions that may have been excluded with reliance on more commonly deployed workplace adaptation keywords. Search terms were also adapted from previously published systematic reviews on the topic. 45 46 The search terms and search strategy were independently peer- reviewed by another information specialist. Changes and suggestions were incorporated before the search terms were translated across nine databases, that is, (1) Ovid MEDLINE(R) In-Process & Other Non-Indexed Cita- tions, (2) EBM Reviews Cochrane Central Register of Controlled Trials, (3) EBM Reviews Cochrane Database of Systematic Reviews, (4) Embase, (5) PsycINFO, (6) CINAHL, (7) PubMed, (8) OT SEEKER and (9) Health and Safety Science Abstracts. Additional online supple- mental file 1 provides the search strategy for each data- base. Furthermore, conference materials such as abstracts, editorials and/or commentaries will be excluded as they do not provide sufficient information required for the purposes of this review. All database results will be limited to English language. A limit to human only studies will be applied. Study selection The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for systematic reviews will be used to report the findings of this review. 47 Study selection will be completed by three reviewers, pre-determined eligibility criteria will guide all three reviewers and screening will be undertaken in two steps. on May 26, 2023 by guest. Protected by copyright. http://bmjopen.bmj.com/ BMJ Open: first published as 10.1136/bmjopen-2020-041581 on 19 May 2021. Downloaded from
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