Characterising Early and Late Return To Work Following Tbi

Journal
of Neurotrauma
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© Mary Ann Liebert, Inc.

DOI: 10.1089/neu.2018.5850
1
Title: Characterising early and late return to work following
traumatic brain injury
This paper has been peer‐reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof.
Running Head: Early and late RTW following TBI
Journal: Journal of Neurotrauma
Authors:
Gershon Spitz, BA(Hons), PhD
Characterising early and late return to work following traumatic brain injury (DOI: 10.1089/neu.2018.5850)
Downloaded by IDAHO STATE UNIV LIBR from www.liebertpub.com at 03/30/19. For personal use only.
Monash Institute of Cognitive and Clinical Neurosciences, School of Psychological Sciences,
Monash University, Clayton, 3800 VIC, Australia.
Monash‐Epworth Rehabilitation Research Centre, Epworth HealthCare, Melbourne,
Australia, 3121.
Gershon.spitz@monash.edu
Journal of Neurotrauma

Behrooz Hassani Mahmooei, PhD
behrooz.hassani.mahmooei@monash.edu
Pamela Ross, BAppSci OT(Hons), PhD
Epworth HealthCare, Melbourne, 3121, Australia
Pamela.Ross@epworth.org.au
Dean McKenzie, BA(Hons), PhD
Monash‐Epworth Research Centre, Epworth HealthCare, Melbourne, Australia
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and School of Public Health and Preventive Medicine, Monash University, Melbourne,
Australia Dean.McKenzie@epworth.org.au
Jennie L Ponsford, BA(Hons), PhD
Monash Institute of Cognitive and Clinical Neurosciences, School of Psychological Sciences,
Monash‐Epworth Rehabilitation Research Centre, Epworth HealthCare, Melbourne,
Australia, 3121.
Jennie.ponford@monash.edu

Correspondence author:
Gershon Spitz, BA(Hons), PhD, Monash Institute of Cognitive and Clinical Neurosciences,
E‐mail: Gershon.Spitz@monash.edu
Number of words in text (Abstract Until References): 3230
Number of Figures: 2
Number of Tables: 3
Number of references: 36
COMPETING INTERESTS STATEMENT
This study was funded by the Transport Accident Commission (TAC), through the Institute
for Safety, Compensation and Recovery Research (ISCRR). The cost data used in the
current study was supplied by the TAC. All of the authors were independent from the TAC
and ISCRR in terms of input into study design, analysis, interpretation of data, and decision
to submit the article for publication.
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Abstract
Facilitating successful return to work (RTW) is a key rehabilitation objective following
traumatic brain injury (TBI). This study modelled early (within 6 months) and late (7‐34
months) RTW by leveraging a large and comprehensive compensation database. The
sample comprised 666 participants with TBI, the majority of whom sustained a moderate
or severe injury caused by motor‐vehicle accident. Early RTW was more likely for
individuals who were premorbidly employed in a managerial or professional occupation
(Odds Ratio (OR) = 2.1, CI = 1.29‐3.37) and those who experienced shorter post‐traumatic
amnesia (PTA; OR = 0.96, CI = .94‐.98). RTW was less likely in the late phase for individuals
who were older (HR = 0.99, CI = .98‐1.00), experienced longer PTA (HR = 0.98, CI = .97‐.99),
had an abdominal injury (HR = 0.90, CI = .67‐1.21) and used more specialist practitioner
(HR = 0.99, SE = .98‐1.00), and analgesic services (HR = 0.91, CI = .82‐1.00). Conversely,
RTW in the late phase was more likely for individuals using a greater number of specialist
return‐to‐work supports (HR = 1.03, CI = 1.01‐1.05). Patterns of early service utilization,
may thus contribute to prediction of RTW outcome. It is encouraging that RTW was more
likely for individuals using vocational supports.
Keywords: traumatic brain injury, return to work, employment

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INTRODUCTION
Traumatic brain injury (TBI) remains a significant international health burden,

despite efforts to reduce injury‐related mortality and morbidity. The annual cost of TBI is
estimated at €33 billion in Europe and US$76.5 billion in the USA.1,2 Loss of productivity,
including return to work (RTW), accounts for a significant proportion of TBI‐related costs.3
The capacity for RTW can be limited for many years due to residual physical, cognitive, and
psychosocial difficulties resulting from the brain injury. The majority of individuals with
moderate and severe TBI do not RTW, or work fewer hours than desired, placing additional
burden on family members and social support services.3–5 Facilitating RTW in a timely
fashion following TBI thus represents one of the most important goals of rehabilitation.
Many of the factors shown to be associated with delayed RTW following TBI are
unmodifiable. These include the severity of injury, premorbid employment status, age,
education, cause of injury and presence of other injuries.4,6–23 Other factors, including
injury‐related physical and cognitive impairments, as well as behavioural and emotional
difficulties, may be more amenable to modification through rehabilitation. The likelihood
of returning to work may be increased using rehabilitative interventions, such as the
assistance of specialist vocational coordinators and the implementation of work‐related
compensatory strategies.8,9,24–32 The aim of the study was to examine the contribution of
pre‐injury, injury‐related, and post‐injury service utilisation factors to RTW following TBI.
Two RTW end‐points were defined in the current study, an early period between the time
of injury and six‐months post‐injury, and a later phase between seven months and three
years. It was hypothesised that individuals would be more likely to RTW if they sustained
less severe injuries, were younger at injury, more highly educated, were employed in
professional or managerial positions prior to injury, and accessed a greater amount of
rehabilitation supports.
METHOD
Study population and Design
The study was approved by the Human Ethics Committees of Epworth Healthcare and
Monash University. In the state of Victoria, Australia, individuals are provided with
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medical, hospital, allied‐health, and long‐term care assistance following their accident,
regardless of accident fault. Importantly, individuals who were employed prior to their
injury are provided income support until they point of RTW, or for a maximum of three
years following their injury. Those with very severe injuries are eligible to receive income
support until retirement. This compensation system, therefore, provides a large and
unique database that may be used to longitudinally track individuals’ RTW as well as the
type of services used by individuals following their injury. Patients in the present study
were recruited into a longitudinal head injury outcome database from consecutive
admissions to a TBI rehabilitation centre, which treats approximately half of all patients
with TBI who are injured in motor vehicle accidents and require rehabilitation in the state
of Victoria. Once patients have become medically stable they are transferred from their
acute trauma centre to this rehabilitation centre. This patient cohort acquired
predominantly moderate‐to‐severe TBI patients and were considered to require
rehabilitation for TBI. Patients were injured in a motor vehicle accident or as a pedestrian
or public transportation accident, but from a broad socio‐economic spectrum as
rehabilitation was available to all regardless of fault or socio‐economic status. This centre
is funded by the Transport Accident Commission (TAC) no‐fault accident compensation
system. From this database, 666 individuals were identified who were employed prior to
injury and being compensated for loss of earnings between 1995 and 2015.
Demographic and injury‐related variables
Medical and demographic information was collected from medical records upon
hospital admission. The Australian and New Zealand Standard Classification of Occupations
(ANZSCO) classification system was used to categorise premorbid occupations. The
ANZSCO is a classification system that categorises individuals based on the skill levels and
specialisation necessary to perform the tasks of the specific occupation. For the purposes
of analysis, occupations were combined into three higher‐level classification based on skill
level. These aggregated measures were: a) labourers, machinery workers, and technicians;
b) community, clerical, and sales; c) managers and professionals. Post‐traumatic amnesia
was measured daily using the Westmead Post‐traumatic Amnesia Scale. Socio‐economic
status (SES) was measures using the Index of Relative Socio‐economic Advantage and
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Disadvantage (IRSAD). The IRSAD summarises information about the economic and social
conditions of individuals. A low score indicates relatively greater disadvantage and a lack
of advantage, whilst a higher score indicates a lack of disadvantage and greater
advaantage. Medical files indicated whether individuals acquired, no, minor, moderate,
and major physical injuries. These categories were collapse into no/minor vs
moderate/major categories.
Timing of Return to Work
The timing of RTW was tracked using the recorded loss of income payments
received by study participants. Daily payments for loss of earnings were extracted for each
individual up to three years post‐injury. In the current study, RTW was defined as the first
whole month where the individual did not receive any daily payments for loss of earnings.
Data were subsequently aggregated into monthly intervals. At 36 months following injury
individuals must pass a stringent threshold of incapacity (severe impairment) to continue
receiving loss of earning payments. Therefore, discontinued payments made around this
time may reflect cessation of payments for reasons other than RTW. To avoid falsely
claiming individuals had returned to work around this time‐point, participant end‐points
were right censored under two conditions: at 34 months for individuals who had not yet
returned to work and at the latest follow‐up time‐point for individuals who had not yet
reached 34 months post‐injury.
Service utilisation variables
The type and number of services utilised by individuals was obtained from the
Compensation Research Database (CRD) held at the Institute for Safety, Compensation and
Recovery Research (ISCRR). The CRD records the services paid by the TAC for the life of
each individual’s claim. For the current study, each individual’s services were aggregated
over the first six months post‐injury. This included medical services, including surgeries,
medical consultations, pathology, radiology, and psychiatry, as well as allied health
services, including psychology, social work, physiotherapy, occupational therapy, and
vocational rehabilitation. Use of medication, such as analgesics, anti‐depressants, and anti‐
psychotics was quantified.
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Statistical analysis
All statistical analyses were conducted using State version 15.33 Participants were
categorized into two groups: individuals who experienced early (0‐6 months) RTW, and
individuals who experienced late (7‐34 months) RTW or remained unemployed for the
duration of the study. In the first stage of analysis, we examined the factors that were
significantly different between individuals who experienced early compared to late, or no,
RTW. Initially, a series of independent univariate logistic regressions were conducted
modelling each background and injury‐related factor as the independent variable and RTW
group (early vs late) as the outcome variable. These regressions were conducted to
constrain the number of factors considered for the subsequent multivariable model.
Variables with a p‐value of .2 or lower were retained for subsequent multivariable
modelling.34 A sequential multivariable modelling procedure was conducted to ensure that
newly‐entered variables at each step resulted in an improved model. This was
accomplished by using a log‐likelihood ratio test, comparing the model with and without
the new variable entered.35 Background variables were entered first, followed by injury‐
related factors. Results of logistic regression are presented as odds ratios (OR). For
example, an odds ratio of 2 for the ‘managers/professional’ factor indicates that the odds
of early RTW were twice as large for individuals premorbidly employed as manager or
professionals.
In the second stage of analysis we examined factors influencing the course of RTW
in the late phase. For this analysis we quantified services used within the first 6 months for
each individual. This analysis only included those individuals in the late RTW group. RTW
was modelled using Cox regression survival analysis.36 The survival models were modelled
using robust variance estimation due to concerns over meeting assumptions, such as
normality and observations with large residuals. Similar to the first stage, univariate
survival analyses were conducted to screen for potentially important factors, with a p‐
value cut‐off of .2. A series of sequential survival models was conducted. Each model was
assessed using the log‐likelihood, Akaike Information Criterion (AIC), and Bayesian
Information Criterion (BIC). These model‐fit statistics are useful indicators of how well a
model fits the data, taking the number of variables into account. A log‐likelihood test was
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used to determine whether variables were kept in the model at each step. Moreover, a
likelihood ratio test was used to drop factors for the final model. That is, factors that, if
dropped, did not significantly alter the log‐likelihood of the model. Hazard ratios (HR) and
their standard errors are reported. For example, a hazard ratio above 1 indicates greater
likelihood of individuals returning to work.
RESULTS
Patient Characteristics
Early and late RTW subsamples were largely comparable with regards to
background and injury related factors (Table 1). An exception to this was the mean
duration of PTA, which was lower for the early (M = 12.1 days, SD = 12.3), compared to the
late (M = 26.2 days, SD = 29.0), RTW group. A difference was also evident between groups
in pre‐injury occupation, with 40% of the ‘early’ group being in a managerial or
professional occupation prior to injury, compared to 24% of the ‘late’ group. Sixteen
percent (n = 106) of the overall sample returned to work within the first six months
following their injury. The majority of individuals, however, experienced late RTW or did
not RTW within the first three years following their accident. At three years, 50% of
individuals in competitive work prior to injury had not yet returned to work.
__________________________________________________________________________
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INSERT TABLE 1
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Early Return to Work
Univariate logistic regressions showed that compared to participants in the RTW to
work group, individuals returning to employment within the first six‐months post‐injury
were more highly educated (OR = 1.11, CI = 1.02‐1.21), had a higher relative socio‐
economic status (OR = 1.00, CI = 1.00‐1.01), were in managerial or professional
occupations prior to their injury (OR = 2.13, CI = 1.37‐3.31), and had shorter duration of
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PTA (OR = .96, CI = .94‐.98). Labourers, machinery workers, and technicians (OR = .54, CI =
.35‐.82) and individuals sustaining a moderate or major limb injury (OR = .63, CI = .41‐.95)
were less likely to RTW within the first six months.
The final multivariable model (Table 2; M9) comprised two factors: being employed
in a managerial or professional occupation prior to injury (OR = 2.09, CI = 1.29‐3.37) and
duration of PTA (OR = .96, CI = .94‐.98). Individuals in managerial or professional
occupations prior to injury and those with shorter duration of PTA had a higher probability
of RTW within the first six months following TBI, compared to those participants in the late
RTW group (Figure 1).
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INSERT TABLE 2
__________________________________________________________________________
____
__________________________________________________________________________
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INSERT FIGURE 1
__________________________________________________________________________
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Late Return to Work
Univariate survival analyses of background and injury‐related variables identified

that RTW, between 7 and 34 months following injury, was associated with age at accident
(HR = .98, CI = .97‐.99), years of education (HR = 1.06, CI = .1.02‐1.12), SES level (HR = 1.00,
CI = 1.00‐1.003), premorbid labourer, machinery worker or technician occupation (HR =
.74, CI = .58‐.94), premorbid community, clerical, or sales occupation (HR = 1.34, CI = 1.01‐
1.76), duration of PTA (HR = .98, CI = .97‐.98), moderate or major spine/back injury (HR =
.73, CI = .55‐.96), and moderate or major abdominal injury (HR = .79, CI = .59‐1.06).
Specific types of service utilisation were also associated with the likelihood of returning to
work. Use of driving assessment and rehabilitation (HR = 1.08, CI = .99‐1.16), specialist
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RTW services (HR = 1.04, CI = 1.03‐1.06), use of specialist practitioner (HR = .98, CI = .97‐
.98), surgery (HR = .98, CI = .97‐.99), pathology (HR = .99, CI = .99‐1.00), radiology (HR =
.98, CI = .97‐.99), analgesics (HR = .93, CI = .85‐1.02), and anti‐psychotics (HR = .65, CI = .37‐
1.12). Refer to supplemental material for the descriptive statistics of univariate factors and
results of survival analyses.
Six factors were identified that related to late RTW in the multivariable model
(Table 3; Figure 2). The final model (M17) suggests that individuals were less likely to RTW
in the long‐term if they were older age at accident (HR = .99, CI = 98‐1.00), experienced a
longer duration of PTA (HR = .98, CI = .97‐.99), sustained a moderate or major abdominal
injury (HR = .90, CI = .67‐1.21), and used a greater number of specialist practitioner (HR =
.99, CI = .98‐1.00) and analgesic medication (HR = .91, CI = .82‐1.00) services. Conversely,
greater use of specialist RTW services was associated with a greater likelihood of RTW in
the long‐term (HR = 1.03, CI = 1.01‐1.05).
__________________________________________________________________________
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INSERT FIGURE 2
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____
DISCUSSION
This study examined RTW within the first three years following TBI using a unique
and comprehensive compensation database. Using this database, we were able to
precisely track RTW at each month whilst incorporating a range of background, injury‐
related, and service utilisation factors. The results of the current study align with the
literature, indicating that individuals encounter a high degree of difficulty returning to
work following TBI.12,24 Only sixteen percent of the sample returned to work within the
first six months following their injury. The majority of individuals experienced protracted
unemployment or did not RTW within the first three years. At three years, 50% of
individuals who were competitively working prior to injury had not returned to work.
These patterns of RTW are similar to those reported in another recent longitudinal study.17
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Several factors, when considered individually, were associated with early RTW—
within the first 6 months following injury. Individuals who were more highly educated, had
a relative socio‐economic advantage, were in managerial or professional occupation prior
to their injury, and had milder injuries—assessed by shorter duration of PTA—were more
likely to experience early RTW. Labourers, machinery workers, or technicians as well as
individuals sustaining a moderate or major back or limb injury were less likely to
experience early RTW.
Our final multivariable model suggested that the likelihood of returning to work in
the early phase was best determined by just two factors: whether individuals were in
managerial or professional occupations prior to injury and duration of PTA. These two
factors have been consistently associated with RTW in previous studies.7,12,15 For example,
Walker et al.15 reported that individuals employed in a managerial or professional
occupation were most likely to RTW within the first year, whilst Forslund et al.7 identified
poorer RTW rates for ‘blue‐collar’ workers. Early RTW for managers and professionals
might be related to motivational factors, to greater loyalty or flexibility on the part of
employers, or perhaps suggests that return to these occupation is less affected by the
early consequences of the injury.19 For example, managerial and professional occupations
often do not require physical exertion. The finding that severity of injury is related to early
RTW is, perhaps, unsurprising, and is consistent with most other studies that have
examined RTW.7,10,12–14 Given that the current sample largely comprised individuals with
moderate to severe injuries, many of the participants would likely have still been
recovering during the initial six months following injury.
Late RTW, between 7 and 34 months, was associated with a more complex set of
factors. Univariate modelling identified a number of variables, including age, education,
SES, premorbid occupation category, duration of PTA, physical injuries, and greater service
utilisation. The final multivariable model of late RTW, however, comprised age at injury,
duration of PTA, a major or moderate abdominal injury, use of specialist practitioner, RTW,
and analgesic medication services. Consistent with previous studies, severity of injury as
well as moderate physical injuries were associated with delayed RTW.8,20,21 It is interesting
that age at injury was only a significant factor for late, but not early, RTW, especially given
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that age is a robust predictor of RTW in the literature.4,5,7,10,13,16,18,22,23 Most previous
studies have examined RTW at longer periods after injury, most commonly 12 months,
which is consistent with this longer time‐frame. Our finding that older age was associated
with a lower likelihood of RTW aligns with that of another large, and recent study.18 Other
studies, suggest that older age might be associated with poorer RTW stability. 22,23
Unlike early RTW, type of premorbid occupation did not influence the likelihood of
RTW in the late phase. These results are in opposition to other studies,7,12,15 but are in
agreement with a recent Dutch study that found no significant differences in return to
employment three years post‐injury according to job status.17 Our findings may diverge
from the results of others due to differences in compensation systems available to
individuals. The participants in the current study had an extensive array of supports
available, which may have rendered other premorbid factors less influential. In addition,
unlike other studies that measured stability of employment, the current study did not
assess whether individuals were able to remain at work, or whether they subsequently left
competitive employment.12
One of the most unique aspects of this study was the incorporation of service
utilisation into our models of RTW. It was encouraging to find that greater use of specialist
RTW services was associated with a greater likelihood of returning to work. This is
encouraging since the purpose of these services is to plan a RTW program with the patient
and employer in accordance with the requirements of the occupation. These services also
provide ongoing support and adjustment as required. On the other hand, using more
specialist practitioner and analgesic medication was associated with longer time to RTW.
This highlights the roles of complex physical injuries and pain in delaying or preventing
RTW following TBI.
Using a compensation database may have also introduced some methodological

limitations. There are plausible cases where the use of cessation of income loss as a proxy
may not match the actual RTW status of the individual. The general rates of RTW,
however, are similar to those of a previous study from the same cohort that established
RTW status directly from the individual using a questionnaire.12 This gives us some
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assurance that our proxy reflects the true patterns of RTW. More generally, there is
potential for the compensation system provided by the TAC in Victoria, Australia, to result
in patterns or models that do not generalise to rehabilitation systems around the world.
For example, individuals in high‐earning occupations may have been more financially
motivated to RTW, since the loss of earnings income under the TAC are capped to a certain
maximum rate. Conversely, guaranteed income benefits may have reduced the motivation
or need for certain individuals to RTW, consequently reducing their likelihood of RTW.
These data also cannot tell us whether, and when, individuals with TBI had returned to
their previous duties. This requires further investigation.
The strength of this study was the use of a large and detailed compensation
database, which enabled us to model RTW using factors that have not been extensively
examined. Our results provide further evidence of key factors that modulate RTW. This
study uniquely contributes to the field by demonstrating the utility of specialist RTW
rehabilitation services. Conversely, use of specialist medical practitioner and high use of
analgesics may reflect persistent physical and pain issues that may delay or prevent RTW.
It would seem important that RTW rehabilitation support services are made available to
those at risk of delayed RTW. Future directions of the research will examine further why
various employee groups differ in time taken to RTW and the extent to which employees
who RTW are able to resume their pre‐injury duties.
COMPETING INTERESTS STATEMENT
This study was funded by the Transport Accident Commission (TAC), through the Institute
for Safety, Compensation and Recovery Research (ISCRR). The cost data used in the
current study was supplied by the TAC. All of the authors were independent from the TAC
and ISCRR in terms of input into study design, analysis, interpretation of data, or decision
to submit the article for publication.

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Haboubi, N., and Jones, T. (2013). Return to work after traumatic brain injury: cohort
comparison and economic evaluation. Brain Inj. 27, 507–520.
26. Erez, A.B.‐H., Rothschild, E., Katz, N., Tuchner, M., and Hartman‐Maeir, A. (2009).
Executive functioning, awareness, and participation in daily life after mild traumatic
brain injury: a preliminary study. Am. J. Occup. Ther. 63, 634–640.
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27. Girard, D., Brown, J., Burnett‐Stolnack, M., Hashimoto, N., Hier‐Wellmer, S.,
Perlman, O.Z., and Seigerman, C. (1996). The relationship of neuropsychological status
and productive outcomes following traumatic brain injury. Brain Inj. 10, 663–676.
28. Green, R.E., Colella, B., Hebert, D.A., Bayley, M., Kang, H.S., Till, C., and Monette,
G. (2008). Prediction of return to productivity after severe traumatic brain injury:
investigations of optimal neuropsychological tests and timing of assessment. Arch. Phys.
Med. Rehabil. 89, S51–60.
29. Kreutzer, J.S., Wehman, P., Morton, M.V., and Stonnington, H.H. (1991).
Supported employment and compensatory strategies for enhancing vocational outcome
following traumatic brain injury. Int. Disabil. Stud. 13, 162–171.
30. O’connell, M.J. (2000). Prediction of return to work following traumatic brain
injury: Intellectual, memory, and demographic variables. Rehabil. Psychol. .
31. Sander, A.M., Kreutzer, J.S., and Fernandez, C.C. (1997). Neurobehavioral
Functioning, Substance Abuse, and Employment after Brain Injury: Implications for
Vocational Rehabilitation. J. Head Trauma Rehabil. 12, 28.
32. Sherer, M., Sander, A.M., Nick, T.G., High, W.M., Jr, Malec, J.F., and Rosenthal, M.
(2002). Early cognitive status and productivity outcome after traumatic brain injury:
findings from the TBI model systems. Arch. Phys. Med. Rehabil. 83, 183–192.
33. 2017., S. ([date unknown]). Stata Statistical Software: Release 15. College Station,
TX: StataCorp LLC.
34. Lemeshow, S., Sturdivant, R.X., and Hosmer, D.W. (2013). Applied Logistic
Regression (Wiley Series in Probability and Statistics). Wiley, Hoboken, New Jersey.
35. Singer, J.D., and Willett, J.B. (2003). Applied Longitudinal Data Analysis: Modeling
Change and Event Occurrence. Oxford University Press, New York..
36. Collett, D. (2015). Modelling Survival Data in Medical Research, Third Edition. CRC
Press, Boca Raton, Florida.
Page 18 of 36

18
Table 1. Sample Demographic and Injury Characteristics
Total Early RTW (within Late RTW (7 months

6 months) ‐ 34 months)
n=666 n= 106 n=560
M (SD); M (SD); % M (SD); %

%
Gender (male) 77% 74% 78%
Age at assessment 33.3 33.3 (12.5) 33.3 (13.2)

(13.1)
Years of education 11.6 (2.3) 12.1 (2.4) 11.5 (2.3)

Socioeconomic status 997.3 1012.7 (68.6) 999.4 (65.8)

(66.6)
Living in major city 65% 71% 64%
Married/defacto prior to injury 39% 38% 40%
PTA duration (days) 24.0 12.1 (12.3) 26.2 (29.0)

(27.5)
Accident type
Driver 46% 51% 45%
Passenger 17% 13% 17%
Motorcyclist 16% 19% 16%
Pedestrian 17% 13% 18%
Cyclist 4% 4% 4%

Page 19 of 36

19
Employment type prior to injury
Labourers/Machinists/Technici 53% 40% 55%

ans
Community/Clerical/Sales 21% 20% 21%
Managers/Professionals 26% 40% 24%

Moderate/major physical injuries
Spine/back 35% 28% 36%
Chest 33% 28% 34%
Abdomen 25% 25% 25%
Limb 59% 49% 61%

Facial 33% 28% 34%
Note. The Late return to work group comprises those individuals who returned to work
between 7 and 34 months following their injury and those individuals who did not return
to work within the first three years. The Socioeconomic status was measured using the
Index of Relative Socio‐Economic Advantage‐Disadvantage.

Page 20 of 36

20
Table 2. Logistic regression model building for early RTW
eviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof.
M0 M1 M2 M3 M4 M5 M6 M7 M8 M9 Final

Univariate
Odds ratio (95% Confidence Intervals); n = 597
Years of education 1.11 1.11 1.09 1.09 1.05 1.03 1.01 1.02 1.01
(1.02‐1.21)a (1.02‐ (.99‐1.19) (.99‐ (.96‐ (.94‐1.13) (.92‐1.12) (.92‐ (.92‐

1.22)a 1.19) 1.15) 1.12) 1.11)
Socioeconomic status 1.00 1.004 1.003 1.003 1.003 1.003 1.002 1.002
(1.00‐1.01)a (1.00‐ (1.00‐ (1.00‐ (1.00‐ (1.00‐ (1.00‐ (1.00‐

1.01) 1.01) 1.01) 1.01) 1.01) 1.01) 1.01)
Living in major cities 1.39 1.14
(.88‐2.20) (.67‐
1.95)

Page 21 of 36
Limb injury
PTA duration
Manager/prof
Spine/back injury
Labour/mach/tech
0.96
0.63
0.70
0.54
2.13
(.35‐.82)b
(.94‐.98)c
(.45‐1.11)
(1.37‐3.31)b
.67
(.42‐
1.07)

1.94
(1.21‐
3.13)a
.96
1.92
(1.17‐
3.17)a
(.95‐.98)c
.96
.94
1.91
(.56‐
1.57)
(1.15‐
3.18)a
.96
.68
1.94
(1.18‐
3.21)b
.96
(.95‐.98)c (.94‐.98)c (.94‐

2.09
.98)c
(1.29‐
3.37)b
21
Page 22 of 36

22
(.41‐.95)a (.43‐
1.08)
Log likelihood ‐258.95 ‐256.81a ‐256.68 ‐255.54 ‐253.67a ‐238.29c ‐238.27 ‐236.96 ‐239.45
AIC 521.90 519.63 521.37 519.07 515.34 486.58 488.53 485.93 485.90
BIC 530.68 532.80 538.93 536.64 532.91 508.54 514.88 512.28 498.08
Note. Models can only be compared to one another using a log‐likelihood ratio if they are created using the same sample of participants.
Therefore, only individuals with full data were used for sequential modelling, equating to a sample of n = 597. The baseline model (M0
Univariate) presents the odds ratio, 95% confidence intervals, and statistical significance categories obtained from the univariate logistic
regressions. The factors in M0 demonstrated a p‐value of 0.20 or lower and were used in the sequential multivariate modelling approach—
models M1 to M9. Each new model, where a new factor was entered, was compared to the previous statistically significant model using a log‐
likelihood ratio test. Model M9 presents the final, defined as the most parsimonious model that educed the log likelihood, AIC (Akaike
Information Criterion), and BIC (Bayesian Information Criterion). Socioeconomic status was measured using the Index of Relative Socio‐
Economic Advantage‐Disadvantage. PTA duration = Postraumatic Amnesia measured in days; Labour/mach/tech = Premorbidly employed in a
labourer/machinery operator/or technician occupation; Manager/prof = Premorbidly employed in a managerial or professional occupation;
Spine/back = Moderate or major spine/back injury; Limb injury = Moderate or major limb injury.
a= < .05; b= <..01; c= <.001
Page 23 of 36

23
Table 3. Multivariate Cox regression survival models for late RTW
M0 M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 M1 M14 M15 M16 M17
Univa 3 Final
riate
Hazard ratio (95% Confidence Intervals); n = 528
Age at .98 .98(. .98 .98 .98 .98 .98 .98 .98 .99 .99 .99 .99 .99 .99 .99 .99 .99
injury (.97‐ 97‐ (.97‐ (.97‐ (.97‐ (.97‐ (.97‐ (.97‐ (.97‐ (.98‐ (.98‐ (.98‐ (.98‐ (.98‐ (.98‐ (.98‐ (.98‐ (.98‐
.99)b 99)b .99)b .99)b .99)b 1.00 1.00) 1.00 1.00) 1.00) 1.00 1.00 1.00 1.00) 1.00)a 1.00) 1.00 1.00
)b b
)b b a
)a )a )a a a
)a )a
Educatio 1.06 1.07 1.06 1.05 1.07 1.06 1.06 1.05 1.05 1.05 1.05 1.05 1.05 1.05 1.05 1.05
n (1.02‐ (1.02 (1.0 (.99‐ (1.0 (1.00 (1.0 (1.00 (1.00 (1.0 (1.0 (1.0 (1.00 (1.00‐ (.99‐ (1.0
1.12)b ‐ 1‐ 1.11 1‐ ‐ 0‐ ‐ ‐ 0‐ 0‐ 0‐ ‐ 1.11) 1.10) 0‐
1.13) 1.12 ) 1.12 1.11) 1.11 1.11) 1.11) 1.11 1.11 1.11 1.11) 1.10
a a a a a a a a a a a
) ) ) ) ) ) )
Page 24 of 36

24
SES 1.00 1.00
(1.00‐ (1.0
1.003) 0‐
1.00
4)

Lab/mac .74 .76
h/tech (.58‐ (.58‐

.94)a 1.00
)a
Com/cler 1.34 1.20

ic/sale (1.01‐ (.90‐
1.76)a 1.59
)

PTA .98 .98 .98 .98 .98 .98 .98 .98 .98 .98 .98 .98 .98
duration (.97‐ (.97‐ (.97‐ (.97‐ (.98‐ (.97‐ (.98‐ (.98‐ (.98‐ (.98‐ (.98‐ (.98‐ (.97‐
.98)c .99)c .99) c .98)c .99)c .99)c .99)c .99)c .99)c .99)c .99)c .99)c .99)c
Page 25 of 36

25
Spine/ba .73 .85
ck (.55‐ (.64‐
.96)a 1.12
)
Abdome .79 .80 .86 .87 .86 .89 .86 .89 .90 .89 .90
n (.59‐ (.60‐ (.64‐ (.64‐ (.64‐ (.65‐ (.64‐ (.66‐ (.67‐ (.66‐ (.67‐
1.06) 1.06) 1.16) 1.17 1.17 1.21 1.16) 1.20) 1.21) 1.20 1.21
) ) ) ) )

Spec prac .98 .99 .99 .99 .99 .99 .99 .99 .99 .99
(.97‐ (.98‐ (.98‐ (.98‐ (.98‐ (.98‐ (.98‐ (.98‐ (.98‐ (.98‐
.98)c 1.00) 1.00 1.00 1.00 1.00) 1.00)a 1.00) 1.00 1.00
b
) ) ) b a
)a )a
Surgery .98 .99

(.97‐ (.98‐
.99)b 1.01
)

y
y
b
RTW
Drive
rehab
Ax/Reha
Radiolog
Patholog
.98
.99
(.99‐
(.97‐
(.99‐
.99)c
1.04
1.08
1.16)
(.1.03‐
1.06)c
1.00)c

0‐
3)
(1.0
1.00
1.00
)
1.01
(.99‐
1.00
(.93‐
1.02
1.13)
1.03
(1.01‐
1.05)b
‐
(1.01
1.05)
1.03
1)b
(1.0
1‐
(1.0
1.05
1.03 1.03
26
Page 26 of 36
Page 27 of 36

27
b
)b

Analgesic .93 .91 .91 .91

s (.85‐ (.83‐ (.83‐ (.82‐
1.02) 1.01) 1.01 1.00
) )
Anti‐ .65 .73

psych (.37‐ (.44‐
1.12) 1.20
)
Log ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐
likelihoo 1424 1421 1420 1419 1421 1394 1393 1386 1382 1382 1382 1382 1382. 1377. 1375 1374 1376
d .69 .80a .72 .93 .11 .66c .95 .39c .66b .43 .62 .40 54 25b .32a .87 .65
AIC 2851 2847 2847 2845 2848 2795 2795 2780 2775 2776 2777 2776 2777. 2766. 2764 2765 2765
.39 .60 .43 .86 .23 .33 .91 .78 .32 .87 .15 .79 08 50 .64 .74 .30
Page 28 of 36

28
BIC 2855 2855 2859 2858 2860 2807 2812 2797 2796 2801 2802 2801 2802. 2791. 2793 2798 2790
.55 .92 .91 .34 .71 .81 .55 .40 .10 .80 .18 .72 01 43 .72 .98 .23
Note. To compare models using a log‐likelihood ratio test, only individuals with full data, and those in the ‘late’ group of RTW were used for
sequential modelling, equating to a sample of n = 528.The baseline model (M0 Univariate) presents the Hazard Ratio, 95% confidence intervals,
and statistical significance categories obtained from univariate survival regressions. The factors in M0 demonstrated a p‐value of 0.20 or lower
and were used in the sequential multivariate modelling approach—models M1 to M17. Each model was compared to the previous statistically
significant model using a log‐likelihood ratio test. Model M17 presents the final, defined as the most parsimonious model that educed the log
likelihood, AIC (Akaike Information Criterion), and BIC (Bayesian Information Criterion). Socioeconomic Status (SES) was measured using the
Index of Relative Socio‐Economic Advantage‐Disadvantage. Labour/mach/tech = Premorbidly employed in a labourer/machinist/or technician
occupation; Comm/cleric/sale = Premorbidly employed in a community, clerical, or sales occupation; Spine/back = Moderate or major
spine/back injury; Abdomen = Moderate or major abdomen injury; Spec prac = Specialist practitioner services; Drive Ax/Rehab = Drive
assessment and rehabilitation services; RTW rehab = Return to Work rehabilitation services; Anti‐psych = Anti‐psychotic medication services.
a= < .05; b= <..01; c= <.001

Page 29 of 36

29

Figure 1. Model‐based estimates for the final early multivariate logistic model (M9). Each
plot presents the probability of returning to work within the first 6 months following injury
for different factor values. 95% confidence intervals of the estimates are used for the error
bars. A) Manager or professional vs other premorbid occupations; B) Duration of post‐
traumatic amnesia measured in days.

Page 30 of 36

30

Figure 2. Model‐based margins for the final late multivariate cox regression survival model
(M17). Each plot presents the Hazard Ratio of returning to work between 7 and 34 months
following injury for different factor values. Lower HR values indicate a lower likelihood of
RTW. 95% confidence intervals of the estimates are used for the error bars. A) Age at
accident; B) Duration of post‐traumatic amnesia; C) Major or moderate abdominal injury
vs No or Minor abdominal injury; D) Number of specialist practitioner services within first 6
months; E) Number of RTW specialist services within first 6 months; F) Number of
analgesic services within first 6 months.

Page 31 of 36

31
Supplemental Table 1. Univariate logistic regressions for early
return to work
Background and injury‐related variables 95% confidence interval
Odds Ratio P value LL UL

Gender (male) .84 (.21) .48 .52 1.36

Age at injury 1.00 (.05) .98 .98 1.02
Years of education 1.11 (.05) .02 1.02 1.21
Socioeconomic status 1.00 (.002) .01 1.00 1.01

Accident type
Driver (reference)
Passenger .68 (.22) .24 .36 1.29
Motorcyclist 1.08 (.31) .80 .61 1.90
Pedestrian .67 (.22) .21 .36 1.26
Cyclist .81 (.46) .72 .27 2.45
Living in major cities 1.39 (.33) .16 .88 2.20
Married/defacto prior to injury .92 (.20) .70 .60 1.41

Page 32 of 36

32
Labourers/Machinists/Technicians .54 (.12) .004 .35 .82
Community/Clerical/Sales .96 (.25) .87 .57 1.61
Managers/Professionals 2.13 (.48) .001 1.37 3.31
PTA duration .96 (.01) <.001 .94 .98

Worst GCS 1.07 (0.03) 0.01 1.01 1.12
Spine/back .70 (.16) .13 .45 1.11
Chest .75 (.18) .22 .48 1.19

Abdomen .96 (.24) .87 .59 1.56
Limb .63 (.13) .03 .41 .95
Facial .75 (.18) .23 .48 1.19
LL = Lower Limit; UL = Upper Limit

Page 33 of 36

33
Supplemental table 2. Univariate cox regression survival models for background and injury‐
related variables
Background and injury‐related variables 95% confidence
interval
Coefficient P value LL UL
Gender (female) 1.16 (.16) .46 .84 1.49

Age at injury .98 (.01) .003 .97 ..99
Years of education 1.06 (.03) .008 1.02 1.12
Socioeconomic status 1.00 (.001) .10 1.00 1.003
Accident type
Driver (reference)
Passenger .94 (.16) .74 .67 1.33
Motorcyclist 1.10 (.20) .58 .78 1.56
Pedestrian 1.01 (.19) .96 .70 1.45
Cyclist .82 (.25) .52 .45 1.50
Living in major cities 1.03 (.14) .78 .80 1.34
Married/defacto prior to injury .93 (.12) .60 .73 1.20
Labourers/Machinists/Technicians .74 (.09) .02 .58 .94
Community/Clerical/Sales 1.34 (.19) .04 1.01 1.76
Managers/Professionals 1.16 (.17) .34 .86 1.55
PTA duration .98 (.003) <.001 .97 .98


Limb
Chest
Facial
Abdomen
Spine/back

.73 (.10)
.79 (.12)
.87 (.11)
1.02 (.13)
1.02 (.13)
.02
.11
.90
.30
.90
.55
.68
.59
.79
.79
.96
1.12
1.06
1.32
1.32
34
Page 34 of 36
Page 35 of 36

35
Supplemental table 3. Univariate cox regression survival models for services utilisation
95%
confidence
interval
Service utilisation Mean Median Range Coefficient P LL UL

value
Specialist practitioner 27.90 38 0‐125 .98 (.004) <.001 .97 .98
Psychiatry .59 0 0‐54 .98 (.04) .61 .90 1.06
Surgery 8.21 4 0‐72 .98 (.01) .003 .97 .99

Pathology 69.43 54 0‐501 .99 (.002) <.001 .99 1.00
Radiology 33.23 29.50 0‐135 .98 (.003) <.001 .97 .99
Psychology 7.24 1 0‐77 .99 (.01) .26 .98 1.00
Social work 4.89 0 0‐85 1.00 (.01) .98 .99 1.01
Physical rehabilitation 11.56 0 0‐183 1.00 (.002) .58 .99 1.00
Musculoskeletal therapy 34.21 19 0‐287 1.00 (.001) .23 1.00 1.003
Occupational therapy 20.12 10 0‐234 1.00 (.002) .62 1.00 1.002
Driving .40 0 0‐12 1.08 (.04) .08 .99 1.16

assessment/rehabilitation

Sedatives
Analgesics
RTW services
Antipsychotics
Antidepressants
Neuropathic pain
Schedule 8 medications
.49
.10
.16
.03
.55
.09
2.27
0
0
0
0
0
0
0
0‐9
0‐6
0‐4
0‐7
0‐23
0‐24
0‐47
90 (.09)
.99 (.03)
.81 (.14)
.65 (.18)
.93 (.04)
1.06 (.09)
1.04 (.01)
.75
.23
.12
.50
.32
.13
<.001
.93
.37
.58
.90
.74
.85
1.03
1.05
1.12
1.25
1.14
1.02
1.10
1.06
36
Page 36 of 36

Characterising Early and Late Return To Work Following Tbi

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Traumatic brain injury (TBI) remains a significant international health burden,

Univariate survival analyses of background and injury‐related variables identified

Using a compensation database may have also introduced some methodological

Total Early RTW (within Late RTW (7 months

n=666 n= 106 n=560

M (SD); M (SD); % M (SD); %

Gender (male) 77% 74% 78%

Age at assessment 33.3 33.3 (12.5) 33.3 (13.2)

Years of education 11.6 (2.3) 12.1 (2.4) 11.5 (2.3)

Socioeconomic status 997.3 1012.7 (68.6) 999.4 (65.8)

Living in major city 65% 71% 64%

Married/defacto prior to injury 39% 38% 40%

PTA duration (days) 24.0 12.1 (12.3) 26.2 (29.0)

Driver 46% 51% 45%

Passenger 17% 13% 17%

Motorcyclist 16% 19% 16%

Pedestrian 17% 13% 18%

Cyclist 4% 4% 4%

Labourers/Machinists/Technici 53% 40% 55%

Community/Clerical/Sales 21% 20% 21%

Managers/Professionals 26% 40% 24%

Spine/back 35% 28% 36%

Chest 33% 28% 34%

Abdomen 25% 25% 25%

Limb 59% 49% 61%

Facial 33% 28% 34%

M0 M1 M2 M3 M4 M5 M6 M7 M8 M9 Final

(1.02‐1.21)a (1.02‐ (.99‐1.19) (.99‐ (.96‐ (.94‐1.13) (.92‐1.12) (.92‐ (.92‐

Socioeconomic status 1.00 1.004 1.003 1.003 1.003 1.003 1.002 1.002

(1.00‐1.01)a (1.00‐ (1.00‐ (1.00‐ (1.00‐ (1.00‐ (1.00‐ (1.00‐

1.01) 1.01) 1.01) 1.01) 1.01) 1.01) 1.01)

Living in major cities 1.39 1.14

(.95‐.98)c (.94‐.98)c (.94‐

h/tech (.58‐ (.58‐

Com/cler 1.34 1.20

Surgery .98 .99

Analgesic .93 .91 .91 .91

Anti‐ .65 .73

Odds Ratio P value LL UL

Gender (male) .84 (.21) .48 .52 1.36

Age at injury 1.00 (.05) .98 .98 1.02

Years of education 1.11 (.05) .02 1.02 1.21

Socioeconomic status 1.00 (.002) .01 1.00 1.01

Passenger .68 (.22) .24 .36 1.29

Motorcyclist 1.08 (.31) .80 .61 1.90

Pedestrian .67 (.22) .21 .36 1.26

Cyclist .81 (.46) .72 .27 2.45

Living in major cities 1.39 (.33) .16 .88 2.20

Married/defacto prior to injury .92 (.20) .70 .60 1.41

Community/Clerical/Sales .96 (.25) .87 .57 1.61

Managers/Professionals 2.13 (.48) .001 1.37 3.31

PTA duration .96 (.01) <.001 .94 .98

Worst GCS 1.07 (0.03) 0.01 1.01 1.12

Spine/back .70 (.16) .13 .45 1.11

Chest .75 (.18) .22 .48 1.19

Abdomen .96 (.24) .87 .59 1.56

Limb .63 (.13) .03 .41 .95

Facial .75 (.18) .23 .48 1.19

Coefficient P value LL UL

Gender (female) 1.16 (.16) .46 .84 1.49

Age at injury .98 (.01) .003 .97 ..99

Years of education 1.06 (.03) .008 1.02 1.12