Employment Issues Following TBI


Why is returning to work following TBI important?

Loss of employment negatively affects self-identity, emotional well-being, and autonomy.

How many individuals with TBI are able to return to work?

Post-injury employment rates for individuals with TBI vary between 10-70%.

One study found that while 59% of individuals that sustained a TBI were competitively employed prior to their injuries, only 23% were employed one year post-hospitalization (TBI Model Systems National Data Center, 2001).

Benefits of returning to work include:

  • Increasing financial independence.
  • Decreasing dependence on government financial support.
  • Increasing opportunities for socialization.
  • Providing a sense of accomplishment, productivity and self-worth.
  • Increasing self-awareness.
  • Reducing physical disability and substance abuse.

Issues Faced in Attempting to Return to Work

Common issues following TBI that impact successful attainment and/or maintenance of employment include:

  • Cognitive difficulties such as forgetfulness, inattention, and/or disorganization
  • Behavioral issues such as irritability, lowered tolerance for frustration, apathy, and/or difficulties with social interaction
  • Emotional difficulties such as depression and anxiety due to neurological and/or situational factors.
  • Physical difficulties such as limited mobility, strength, speed, and coordination.

Vocational Rehabilitation to Assist in Return to Work

Many individuals with TBI are able to return to work on their own by developing their own compensatory strategies and/or working with employers to arrange appropriate accommodations.

Many others require additional services/training to obtain and/or maintain employment. The most common services include:

  • Hospital or community based vocational rehabilitation programs
  • Federal/State vocational rehabilitation programs

Under Title I of the Rehabilitation Act of 1973, all U.S. states, territories and tribal nations receive federal funds to provide comprehensive vocational rehabilitation services to qualified residents with disabilities.

What services are offered through Federal and State VR programs?

Services offered by state VR programs are individualized and vary according to:

  • The individual's needs,
  • The likelihood that the service will produce a successful employment outcome, and
  • The availability of services in specific communities/regions.

VR counselors and the individual seeking services work together to:

  • Establish the person's vocational interests, talents and aptitude,
  • Determine an appropriate and informed return to work goal, and
  • Develop and implement a strategy to achieve that goal.

In general, services include training and other services that are essential to return to work, to enter a new line of work, or to enter the workforce for the first time.

Examples of specific VR services include:

  • Assessment for determining eligibility
    • For example, medical or psychological evaluations to determine presence, nature, and extent of a disabling condition.
  • Assessment for determining vocational rehabilitation needs
    • For example, vocational evaluation to determine how a person's specific disability may impact ability to work, and what accommodations/services may address limitations.
  • Vocational rehabilitation guidance and counseling
    • Including specific recommendations from the VR counselor to help identify the most appropriate vocational opportunities and services based on the individual's goals, strengths, and weaknesses.
  • Referral to other service providers
    • For example, speech therapists, counseling services, orthotics and prosthetics, assistive technologies, etc.
  • Physical and mental restoration
    • For example, cognitive retraining services, physical therapy, etc.)
  • Vocational and other training
    • Including technical, college, and/or other postsecondary educational experiences.
  • Maintenance and transportation
    • Including financial funding to assist individuals in paying of basic needs such as rent, food, child care, and transportation while participating in vocational training and/or seeking employment.
  • Services to family members
    • Including supportive services for family members to facilitate opportunities for successful employment.
  • Interpreter services
    • For example, for individuals with deafness or hearing loss.
  • Reader services
    • For individuals with learning disabilities, visual impairments, etc.
  • Job-related placement and supportive services
    • For example, arrangement of interviews, development of interview skills, provision of job coaches.
  • Personal assistance
    • Including services to assist individuals with significant physical or cognitive impairments in activities such as dressing, hygiene, transportation, and other activities that facilitate successful employment.
  • Occupational licenses, tools, equipment, initial stocks, and supplies.
  • Rehabilitation technology
    • Including assistive technologies such as communication boards, wheelchairs, TTY.
  • Technical assistance to develop small business or self-employment
    • For example, professional consulting.

Who qualifies for services through VR programs?

Individuals with documented disability including physical, learning, developmental or mental health disability are potentially eligible for VR services.

For an individual to qualify for services, VR agency personnel (counselors) must determine that:

  • the individual has a physical or mental impairment, AND
  • the impairment negatively impacts obtaining and/or maintaining employment, AND
  • the individual requires VR services to prepare for, secure, retain or regain employment.

The number of individuals serviced by state VR programs is significant. According to the US Department of Education, in 2004:

  • 609,095 individuals requested state VR services;
  • 491,988 people were deemed eligible for services;
  • and 213,431 were successfully employed,
    • 94.60% were placed in competitive employment positions.

Employment Options following TBI

Many individuals with TBI are able to return to work and other meaningful and productive work-related activities following TBI, although they may be unable to return to their pre-injury job and/or may require additional support/accommodations to maintain successful employment.

Competitive Employment:

  • Full-time or part-time work in the competitive labor market, for which an individual is paid at or above minimum wage, and not less than the customary wage paid for the same or similar work performed by individuals who are not disabled.
  • Even when able to return to competitive employment, individuals with TBI may benefit from various accommodations to promote job success. For example:
    • Gradually transitioning back to work, starting with part-time and slowly increasing to full-time.
    • Environmental accommodations such as quieter work space with reduced distractions, frequent rest breaks to prevent cognitive fatigue, etc.
    • Use of compensatory strategies such as taking notes, using tape recorders, use of checklists, etc.

Supported Employment:

  • Competitive work in integrated work settings for individuals with the most significant disabilities, who, because of the nature and severity of their disability, need ongoing support services to perform work.
  • May include individual placement or group placement in which multiple individuals with disabilities work together
  • Generally incorporates use of a job coach who provides various services, including:
    • On the job supervision, skills training, training in work-related behaviors (e.g., when to take breaks, how to ask for help, etc.).
    • Goal is generally to reduce level of support over time as the individual learns specific job duties and can more effectively rely on management support.

Sheltered Employment:

  • Employment in sheltered workshops which are organizations that provide employment opportunities for individuals with disabilities in a protected, supervised environment.
  • Individuals are paid for their work, but it is generally a subminimum wage.
  • Individuals may be able to transition to supported employment with time.

Alternative Work-Related Options:

  • Volunteer work: while unpaid, volunteer work allows individuals to engage in meaningful, productive activities that can increase feelings of self-worth and improve quality of life
  • Education: some individuals may choose to pursue additional formal education, technical training, etc. in order to increase knowledge and skills and to potentially allow pursuit of an alternative career.

Factors Predicting Successful Return to Work

Specific VR Services

  • Vocational counseling and on-the-job training have been found to predict successful return to work for individuals with TBI.
    • In one study, individuals with TBI who received counseling and guidance services from state VR programs were more than 14 times more likely to successfully return to work than those who did not receive these services.
    • And, those who received on-the-job training were almost 16 times more likely to return to work than those who did not.

Environmental Factors

  • Urban residents with TBI may be more likely to return to work than rural residents
    • Related to this, rural residents also tend to discontinue VR services (after qualifying but before receiving services) more often than urban residents which may impact successful return to work.
    • This may be related to the fact that, in general, rural areas have fewer rehabilitation professionals, rehabilitation services, and employment opportunities.

Co-Occurring Disability

  • Individuals with TBI and co-occurring psychological or learning disorders tend to have more difficulty successfully returning to work than those with TBI only, or TBI and physical conditions (i.e., orthopedic issues, seizure).


  • Increasing age may be associated with worse outcomes in terms of return to work;
  • However, data show that after receiving VR services, older and younger adults with TBI are equally successful in returning to work.


  • Men with TBI may have more successful employment outcomes than women, although other factors may influence this finding (e.g., differences in social roles/expectations).


  • African Americans with TBI tend to access services (i.e., VR services) later post-injury than Caucasians and tend to be unemployed for longer periods of time post-injury than Caucasians.
  • However, research has also indicated that African Americans also have better employment rates than Caucasians, although this may be due in part to geographic location (i.e., more African Americans lived in urban compared to rural areas).

Additional Resources

Listing of Missouri Vocational Rehabilitation offices: http://dese.mo.gov/vr/vroffices.htm

Listing of Contact Information for All State Vocational Rehabilitation Programs http://www.psypress.com/neuropsychological-disorders/resources/state-vocational-rehabilitation-programs.php