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Addressing Executive Function Deficits For Return To Work Following A Brain Injury

Addressing Executive Function Deficits For Return To Work Following A Brain Injury
Yvonne Monti, OTD, OTR/L
September 27, 2023

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Editor's note: This text-based course is a transcript of the webinar, Addressing Executive Function Deficits For Return To Work Following A Brain Injury, presented by Yvonne Monti, OTD, OTR/L.

Learning Outcomes

  • After this course, participants will be able to:
    • Identify how executive function deficits interfere with return to work (RTW).
    • Examine occupation-based methods for assessing executive function deficits that would interfere with RTW.
    • Analyze client-centered intervention strategies to assist with RTW.


Today, we'll be talking about executive function deficits for return to work following brain injury. 

Brain Injury

  • 2.8 million cases annually
  • 90% mTBI
  • TBI is the leading cause of disability in young people of working age
  • Cognitive deficits present hours, days, and even years following injury
  • Multiple mTBI associated with deficits in memory and executive function
  • The frontal lobe and many neuronal pathways fundamental for EF performance

Traumatic brain injury (TBI) affects millions of Americans each year and can have lasting cognitive effects. According to recent statistics, approximately 2.8 million people in the United States sustain some form of brain injury annually. The vast majority of these injuries, around 90%, are classified as mild traumatic brain injuries or concussions. While the term "mild" may downplay their significance, concussions are no small matter. Even a single concussion can lead to cognitive deficits that disrupt a person's quality of life and ability to work. 

TBI has become the number one cause of disability among young professionals in the prime of their careers. The cognitive effects often appear in the hours or days following an injury and may persist for years. Deficits in memory and executive functioning are common outcomes, especially for those who have suffered multiple concussions over time. Researchers suggest these effects stem from damage to the frontal lobes of the brain and interruption of key neuronal pathways important for executive function. 

Common Deficits Related to mTBI

  • Symptoms may be:
    • Physical/Somatic: headaches, light sensitivity, vestibular, vision issues, cervical issues, fatigue
    • Cognitive: executive function deficits
    • Behavioral: sleep issues
    • Emotional: anxiety, depression, irritability
  • Symptoms often negatively influence each other, creating a vicious cycle
  • Higher reports of mTBI symptoms negatively influence outcomes, such as return to work

(Lumba-Brown et al., 2019)

Mild traumatic brain injuries like concussions often produce an interconnected web of symptoms that can persist long after the initial injury. Beyond the headache and dizziness many associate with concussion, there is an array of physical, cognitive, emotional, and behavioral effects. Physical symptoms may include light and noise sensitivity, vision changes, neck pain, and chronic fatigue. Cognitively, executive functions like planning, organization, and concentrating can be impaired. Emotional changes like anxiety, irritability, and depression frequently occur. Disrupted sleep patterns also commonly follow concussion. 

These symptoms rarely occur in isolation but rather set off a problematic cycle where they exacerbate one another. For example, fatigue degrades thinking abilities and triggers headaches, which then worsen sleep issues and lead to more fatigue. To properly treat a concussion, providers need to address this web of symptoms holistically versus individually. Those struggling with multiple persistent symptoms tend to have poorer rehabilitation outcomes and take longer to return to work or school. 


  • Name: Dan M.
  • Age: 52
  • Gender: Male
  • Occupation: Business Owner, an awards and engraving business
  • Social: Married, two children,10 and 8
  • Medical Condition: Mild traumatic brain injury (mTBI) with executive function disorder
  • Treatment: Attending occupational therapy

Our patient is Dan, a 52-year-old married father of two children, ages 10 and 8. Dan owns and operates an awards and engraving business that he started from the ground up. Over the course of today's presentation, we will reference Dan's case to illustrate the real-world implications of concussion and the importance of proper management. 

  • Background: Sustained mTBI from MVA six months ago
  • Dan is noted to have some executive function dysfunction that affects his ability to plan, organize, initiate tasks, and transition between tasks.
  • Dan is doing well and has a goal to return to his job full-time. He is currently completing some job duties and spending 3-4 hours at his business a day.

Dan recently experienced a mild traumatic brain injury as a result of a car accident, which has led to the development of executive functioning disorder. Currently, he is actively participating in occupational therapy to address his condition. 

One of the prominent challenges Dan faces is the impairment of his executive functions, impacting his capacity to plan, organize, initiate tasks, and smoothly transition between different activities. Despite these difficulties, Dan's progress in therapy has been positive.

Dan has set a clear objective for his rehabilitation journey: he aspires to regain his full-time employment status. At present, he is engaged in some of his job responsibilities and is dedicating approximately three to four hours each day to his work-related activities.

  • Challenges and goals: Before the accident, Dan was highly organized, exceptional at problem-solving skills, multi-tasking, and paying attention to detail in his work.
  • Dan’s business is multi-faceted, requiring a high level of cognitive demands for managing orders, customer service, billing, payroll, managing employees, and tracking inventory.
  • Since the TBI, he has had significant difficulties in all of these areas. He reports anxiety about forgetting orders and high levels of mental fatigue following short periods of work. His anxiety is influencing how he sleeps.

Prior to the accident, Dan was renowned for his exceptional organizational skills. He excelled in problem-solving, multitasking, and meticulously attending to intricate details in his work. His business, a complex venture, demanded a high degree of cognitive prowess involving tasks such as order management, customer service, billing, payroll, employee supervision, and inventory tracking.

However, since sustaining his brain injury, Dan has faced considerable challenges in all these domains. He has expressed anxiety stemming from concerns about forgetting orders and often experiences profound mental fatigue after even brief periods of work. Additionally, his anxiety has begun to affect his sleep patterns, as he finds it difficult to quiet his mind and worries persistently about his business, making it difficult for him to fall asleep.

Executive Function

Let's move into executive function.

  • It is not a single cognitive ability but a number of cognitive components: Multi-faceted
  • Not easy to delineate, no standard definition
  • EF deficits are a problem with occupational performance, not a specific diagnostic problem
  • Focused on three core functions:
    • Inhibition
    • Working memory
    • Cognitive flexibility

(Brownlow & Gehrman 2020)

Executive function is a multifaceted cognitive construct that encompasses a range of distinct cognitive abilities, centering around three fundamental functions. These functions consist of inhibition, which includes inhibitory control and selective attention; working memory, enabling the manipulation of task-related information; and cognitive flexibility, the capacity to adapt based on actions or thoughts. Assessing executive functioning can be challenging, given that its components are task-specific and are best evaluated within the context of the occupation in which they are relevant. It is beneficial to conceptualize executive functioning deficits as issues related to occupational performance rather than a specific diagnosis.

  • Cognitive skills essential for higher-order cognitive processes:
    • Planning
    • Reasoning
    • Inhibitory control
    • Cognitive flexibility
    • Multitasking
  • Required for successful engagement in activities that are:
    • Complex
    • Non-routine
    • Novel
    • Dynamic
    • Unstructured

The realm of executive functioning governs advanced cognitive processes, as mentioned earlier. These processes encompass tasks such as planning, reasoning, inhibitory control, cognitive flexibility, and multitasking. Proficient involvement in intricate, non-routine, innovative, dynamic, and unstructured activities necessitates the utilization of these higher-level cognitive functions. Therefore, executive functioning skills are particularly vital when dealing with complex, unfamiliar, atypical, dynamic, multi-faceted, or unorganized tasks.

Executive Function and RTW

  • The presence of EF deficits is a predictor of poor functional outcomes (IADLs, social participation, etc.)
  • EF skills are important for success in various occupations
  • Disruption in EF can affect the ability to return to work
  • BI patients report EF deficits hinder work performance

The existence of executive functioning deficits serves as an indicator of unfavorable rehabilitation outcomes. The mere presence of these deficits can predict a suboptimal recovery. Such deficits have the potential to impede performance in activities involving higher cognitive functions, including instrumental activities of daily living, social engagement, health management, and occupational responsibilities.

Disruptions in executive functioning can have a profound impact on an individual's capacity to return to work and their effectiveness at work. Many occupational roles encompass various activities that demand complex cognitive interactions. For instance, social engagement is frequently a requirement within the realm of employment. Hence, individuals must possess the necessary executive functioning skills to effectively navigate social interactions, which involve a distinct set of cognitive abilities compared to other work-related tasks.

Factors Influencing Executive Function in BI

Considering the interplay of various factors that can influence executive functioning after a brain injury is essential. Occupational therapists must approach the assessment and treatment of executive functioning with a comprehensive perspective, taking into account the multitude of factors that can impact cognition and occupational performance. While there are numerous such factors, I'll highlight a few that are particularly prevalent in the context of brain injuries, especially mild traumatic brain injuries. The first factor I'd like to discuss is the relationship between fatigue and executive functioning.

Fatigue and Executive Function

  • 70% of brain injury survivors experience interfering fatigue (Theadom et al., 2016)
  • Fatigue is multidimensional with physical, emotional, behavioral, and cognitive factors
  • Mental fatigue is evident during cognitively demanding tasks requiring effort
  • Mental fatigue requires increased time to recover after prolonged cognitive activity
  • Mental fatigue negatively influences working memory (EF)

(Gavelin et al., 2020)

Fatigue is a prevalent issue among brain injury survivors, affecting approximately 70% of them. It's a significant concern because fatigue can substantially impede an individual's ability to engage in various occupations, including work. Fatigue is a complex phenomenon with multiple dimensions, encompassing physical, emotional, behavioral, and cognitive components. This multifaceted nature of fatigue means that it can have wide-ranging effects on an individual's daily life and functioning.

Mental Fatigue

  • The presence of cognitive deficits increases mental fatigue
  • Mental fatigue is subjective and includes:
    • feelings of tiredness
    • low energy levels 
    • decreased motivation
    • decline in performance
    • avoidance of tasks with low rewards  
  • The presence of fatigue following BI delays RTW

(Gavelin et al., 2020)

Mental fatigue is a common experience for individuals with brain injuries, particularly those with executive functioning deficits. It occurs when cognitive activities require increased effort and become mentally stressful. After engaging in such tasks, individuals experiencing mental fatigue need more time to recover and rest. This fatigue can have a significant impact on cognitive function and, consequently, occupational performance.

As cognitive fatigue sets in, working memory is compromised, leading to decreased performance in various activities. Cognitive deficits, which are often present in individuals with brain injuries, can exacerbate mental fatigue. The experience of mental fatigue is subjective, characterized by feelings of tiredness, low energy levels, decreased motivation, a decline in task performance, and avoidance of tasks with low perceived rewards.

Mental fatigue is a critical factor to consider in the context of returning to work after a brain injury. It creates a cycle where fatigue influences cognition, and activities demanding more cognitive effort can worsen fatigue. Ultimately, the presence of mental fatigue, combined with executive functioning deficits, can significantly delay an individual's return to work.

Sleep and Executive Function

  • 50% of BI survivors report sleep dysfunction
  • Sleep deprivation impairs executive function

(Skurvydas et al., 2020)

  • Deprived sleep decreases confidence levels in the performance of cognitive activity, even though performance levels remained unchanged
  • Decreased confidence levels following sleep loss negatively influence metacognitive monitoring; not related to actual performance

(Aidman et al., 2019)

Sleep disruptions are a common issue following brain injuries, with approximately half of all survivors experiencing sleep dysfunction. Research on the relationship between sleep and cognitive performance in individuals with brain injuries is multifaceted and sometimes contradictory due to variations in data collection methods and outcome measures. Many studies on this topic focus on total sleep deprivation rather than the type of dysfunctional sleep patterns commonly observed in brain injury patients, where sleep is often fragmented and interrupted.

One study highlighted here demonstrates that sleep deprivation can impair executive functioning, a critical aspect of cognitive performance. Another study found that even when cognitive performance remained unchanged due to sleep deprivation, individuals reported decreased confidence in their abilities, which could affect their perception of occupational performance. This perception can be a significant factor when patients are considering returning to work after a brain injury. It raises the question of whether the perceived deficits in performance are genuine or influenced by a lack of confidence.

Furthermore, sleep deficits can hinder the use of metacognition, which involves monitoring one's cognitive processing and adjusting behavior to optimize performance. Addressing sleep disruptions in conjunction with executive functioning problems is crucial to improving the chances of a successful return to work for individuals with brain injuries.

Mood and Executive Function

  • EF impairments may contribute to maintaining mood disorders
  • EF may contribute to the development of mood disorders
  • EF deficits may decrease participation in pleasurable meaningful occupations that promote satisfaction in QoL and positive emotional satisfaction

(Warren & Miller, 2021)

Mood disorders are frequently observed in individuals following a brain injury. Executive functioning deficits can both contribute to the development of mood disorders and exacerbate existing mood disorders in brain injury patients.

Moreover, these deficits in executive functioning may hinder participation in enjoyable and meaningful occupations that play a crucial role in enhancing life satisfaction and promoting positive emotional well-being. Individuals with executive functioning deficits may find it challenging to engage in activities that bring them happiness and provide a sense of purpose, limiting their overall quality of life.

Anxiety, Coping, and Executive Function

  • EF impairment is associated with greater disengagement coping strategies
  • EF impairment is associated with greater emotion-focused coping
  • Disengagement coping strategies may increase anxiety
  • Positive coping strategies after RTW are associated with positive outcomes

(O’Rourke et al., 2020; van Der Kemp et al., 2019)

Executive dysfunction is closely associated with increased anxiety and a greater reliance on disengagement coping strategies. Disengagement coping strategies involve attempts to avoid a stressor and can include both efforts to evade the stressor itself and to avoid thinking about it. These strategies may contribute to heightened anxiety, particularly when returning to work, as there may be unavoidable tasks with deadlines or significant implications for other important aspects of life.

Furthermore, executive functioning deficits are linked to greater use of emotion-focused coping strategies. Emotion-focused coping involves attempts to reduce, eliminate, or tolerate an emotional response to a stressor, such as seeking distractions, withdrawing from the situation, ruminating on the issue, or expressing anger. Unfortunately, these coping strategies are often inefficient and can lead to an increase in stress-related health problems. Developing more effective coping strategies is essential for individuals aiming to return to work successfully after a brain injury.

Occupational therapy can play a vital role in addressing coping strategies and executive functioning deficits, and collaboration with other healthcare professionals can enhance the chances of achieving positive return-to-work outcomes.

Headaches and Executive Function

  • 36% of mTBI patients report headaches six months post-injury
  • Headaches are a disabling, longest-lasting symptom of chronic mTBI associated with poor neuropsychological testing
  • Headaches in mTBI are similar to migraines and tension headaches
  • Migraines and tension headaches are associated with decreased EF performance
  • Headaches are associated with depression, anxiety, and sleep issues

(Begasse de Dhaem & Robbins, 2022)

Headaches are a significant concern following mild traumatic brain injury or post-concussion syndrome, with approximately 36% of individuals still experiencing them six months after the injury. These headaches are often the most disabling and persistent symptom in cases of chronic mild TBI. They typically resemble tension headaches or migraines and can have a detrimental impact on executive functioning.

Research has shown that individuals with mild TBI who experience headaches tend to exhibit reduced executive performance. Moreover, headaches are closely associated with other comorbid conditions, such as depression, anxiety, and sleep disturbances, all of which can further impair executive functioning. This interplay between headaches and these comorbidities underscores the need to address and manage headaches as part of a comprehensive approach to improving executive functioning and facilitating a successful return to work.

Occupational therapy can play a role in developing strategies to manage headaches, mitigate their impact on cognitive performance, and support individuals in returning to their work-related activities.

Case, Cont.

  • OTP has Dan complete the Rivermeade Post Concussion Symptom Questionnaire.
  • Results: Dan reports moderate problems with (3): sleep, fatigue, feeling frustrated, difficulty with concentration, memory, and taking longer to think
  • All other areas were reported as the same as prior to the mTBI.
  • OTP decides to further evaluate: sleep, fatigue, and cognition with a concentration on EF skills.

The occupational therapy practitioner conducted a screening for concussion symptoms using the Rivermeade Post-Concussion Questionnaire and identified that Dan had moderate problems in various areas, including sleep, fatigue, feeling frustrated, difficulty with concentration, memory, and taking longer to think. Notably, he did not report any headaches or other specific symptoms related to his brain injury. Given these findings, the occupational therapist decided to conduct a more comprehensive assessment focused on sleep, fatigue, and cognition, with a specific emphasis on evaluating Dan's executive functioning skills in the context of returning to work.

Return to Work Following Brain Injury

Let's talk about returning to work following a brain injury.

  • Employment is one of the most important predictors of quality of life
  • Less health service usage
  • Better health status
  • Return to work (RTW) is a major goal of recovery following mTBI.
  • RTW should be evaluated by at least 3 months post-injury- better RTW outcomes by 6 months
  • RTW = resuming prior work roles at the same quality, efficiency, and stamina as prior to injury

(Yue et al., 2021; Phillips et al., 2019; van der Kemp et al., 2019)

Employment plays a significant role in an individual's quality of life, and research indicates that employed individuals tend to have better health and require fewer health services compared to those who are unemployed. Return to work is a critical goal for individuals with mild traumatic brain injury, and it's essential to evaluate their ability to return to work within the first three months after injury. There's a higher likelihood of successful work reintegration if a patient can return to work within six months following a brain injury. However, the chances of a successful return to work decrease significantly after this six-month window. It's important to emphasize that a successful return to work means the individual can resume their work roles with the same quality, efficiency, and stamina as before the injury.

Predictors of Return to Work

  • Severity of injury
  • Cognitive function
  • Cognitive ability
  • Executive function deficits
  • Number of cognitive disorders
  • Higher scores on cognitive testing associated with RTW 1 year post-injury

(Yue et al., 2021; Phillips et al., 2019; van der Kemp et al., 2019)

Return to work after a traumatic brain injury is influenced by various factors. One of the key predictors is the severity of the brain injury; individuals with more severe injuries are less likely to return to work. Cognitive functioning plays a crucial role in determining an individual's ability to return to work after TBI. Assessments like the Montreal Cognitive Assessment (MoCA) are often used to measure global cognitive ability. Within cognitive functioning, executive functioning deficits are particularly significant and can hinder the return to work process. The number and severity of cognitive disorders also impact return-to-work outcomes. Generally, higher scores on cognitive testing are associated with a greater likelihood of returning to work successfully one year after the injury.

Factors Influencing Return to Work in BI

  • Self-efficacy
  • Mood
  • Physical functioning
  • Communication
  • Coping style

(Phillips et al., 2019; van Der Kemp et al., 2019)

In the literature, various factors influence the return to work after a brain injury. Some of these factors were discussed earlier in the presentation. These include self-efficacy, which will be explored further in one of the upcoming sections. Additionally, mood, physical functioning, communication, and coping style all play significant roles in determining an individual's ability to return to work. Coping style, in particular, has a substantial impact on the potential for a successful return to employment.

Why Return to Work?

  • Wanting to return to prior roles
  • To aid in recovery from injury
  • Ability to work returned
  • Financial reasons
  • Obligation

(Phillips et al., 2019)

There are various reasons why individuals who have sustained a brain injury may want to return to work. These motivations can include a desire to regain a sense of normalcy and resume their previous roles in life. Some individuals believe that returning to work will aid in their overall recovery from the injury. Others may feel that they have reached a point in their recovery where they are back at their baseline functioning and are ready to work again.

Financial necessity is a significant factor for many individuals, compelling them to return to work sooner. Those who return to work earlier may also have a higher likelihood of success, as they can receive support and work on strategies to address any remaining executive function deficits while on the job.

Additionally, some individuals may feel a sense of obligation to their colleagues and management, not wanting to leave their workplace short-staffed during their absence. These various motivations underscore the importance of addressing executive function deficits to facilitate a smoother return to work for individuals with brain injuries.

Failure to RTW

  • Higher rates of economic dependence
  • Poorer psychosocial outcomes
  • Decreased self-esteem
  • Depression

(Phillips et al., 2019)

For individuals who do not return to work following a brain injury, there can be significant negative consequences. This failure to return to work can lead to economic dependence on others or government assistance programs, which can be emotionally challenging and limit financial independence. Psychosocial outcomes may also suffer, as individuals may experience decreased self-esteem and increased feelings of depression.

Work Environment

  • Workplace and work environments have changed drastically
  • Intensive use of digital devices
  • Globalization
  • Changes in worktime scheduling
  • Working from home
  • Increased work pressure
  • Increased demand for EF skills

(Phillips et al., 2019)

The work environment has undergone notable changes over the past decade or two since I began working. There has been a discernible shift in the demands of executive functioning, primarily due to the increasing digitization of the workplace. These shifts have introduced troubleshooting and complex planning as essential components of the job.

Globalization has also played a significant role in altering the work landscape. Changes in work time and schedule, including the impact of events like the COVID-19 pandemic within the past five years, have disrupted traditional routines. This has led to an upsurge in work pressure and productivity demands, which, in turn, has placed greater strain on executive functioning skills. Those currently employed can readily attest to these heightened demands in their daily professional lives.

Factors Influencing Work Performance Following BI

  • Decreased tolerance for loud noises
  • Organizational difficulties
  • Decreased concentration
  • Memory issues
  • Fatigue
  • Slow thinking
  • Word finding issues
  • Loss of confidence

(Phillips et al., 2019)

Individuals with brain injuries have reported several factors that influenced work performance, extending beyond the process of returning to work. These factors include decreased tolerance to loud noises, difficulty organizing (related to executive functioning), trouble concentrating, memory issues, fatigue, slow thinking, word-finding problems, and low confidence (self-efficacy).

Role of OT in EF and RTW

What's our role as occupational therapy professionals in executive functioning and return to work? What does our practice say about this?

OT and Cognition

  • AOTA advocated for OTP’s role in the evaluation and treatment of functional cognition
  • Blurred professional roles may have led OT to allow other professions to take responsibility for cognition
  • Functional cognition definition encompasses EF deficits
  • Functional cognition should be included in occupational performance evaluation and treatment, including RTW

(Giles et al., 2020)

In recent times, many of you may have come across AOTA's significant advocacy efforts to emphasize the crucial role of occupational therapists in the evaluation and treatment of functional cognition. Some of you might have already been involved in this area for a considerable period. However, it's evident that over the years, the lines between professional roles within the field have become somewhat blurred, leading some OTs to relinquish their active involvement in assessing and addressing cognition-related issues. This trend has been noticeable in my own practice, where some professionals have deferred responsibilities by saying, "You handle cognition; I'll focus on something else," often citing time constraints as their rationale.

AOTA aims to reverse this trend and reassert our profession's vital role in this domain. It's essential to understand that executive functioning is encompassed within the broader definition of functional cognition. Therefore, whenever we discuss or engage with the concept of functional cognition, we are inherently addressing executive functioning as well. According to AOTA's stance, functional cognition should be an integral component of every occupational performance evaluation we conduct. This principle applies across the board, including assessments related to returning to work.

In fact, AOTA's commitment to this cause is clear, and it has been highlighted even more recently with the formation of a new functional cognition group, which I happened to come across on CommunOT. For those interested, you can explore and join this group on CommunOT or through AOTA's platform.

It's important to note that I am not currently affiliated with this group, but I wanted to share this information with you to encourage collaboration and engagement in the field of functional cognition and executive functioning within occupational therapy.

  • Traditionally, OT has used non-standardized cognitive assessment and intervention approaches.
  • OT creates occupational activities that require the cognitive demands that the patient will encounter in their daily life, including RTW scenarios.
  • Non-standardized approaches may not be recognized by third parties.
  • Many performance-based assessments for cognition are not standardized and do not have psychometric data.

(Giles et al., 2020)

Historically, occupational therapy practitioners have predominantly employed non-standardized, situation-based cognitive assessments and intervention methods. I want to emphasize that, by the end of this presentation, I will continue to recommend these approaches. OTPs frequently design occupational activities that mirror the cognitive challenges patients face in their daily lives, including scenarios related to returning to work. While these qualitative methods have proven effective in practice, it's important to acknowledge that third-party entities do not officially recognize them. Consequently, they cannot be readily employed in research, lack validation, and may not meet the criteria for reliability. These methods represent a somewhat concealed aspect of our practice, often referred to as our "hidden" or "invisible" practice.

OTPs resort to these non-standardized qualitative assessments because, truthfully, the field lacks standardized performance-based assessments for cognition with robust psychometric data to support their validity and reliability.

So, if you've ever felt that you lack a suitable assessment tool to measure executive functioning accurately, your sentiment is entirely justified; such tools are scarce. Therefore, I want to emphasize that it's up to one of you, among the many who are currently listening and those who will access this recording in the future, to take up the mantle. We need individuals who can contribute to the creation or validation of existing assessments to ensure that they effectively measure what they are intended to, possess validity and reliability, and can be embraced by occupational therapists. This endeavor aligns closely with AOTA's objectives and represents a significant initiative within our profession.

Work According to OTPF-4

  • Labor or exertion related to the development, production, delivery, or management of objects or services; Benefits may be financial or nonfinancial.”

(AOTA, 2020)

And the benefits can be financial or non-financial. So this includes volunteering, right, so volunteering exploration/participation.

  • The occupation of work includes occupations of:
    • Employment interests and pursuits
    • Employment seeking and acquisition
    • Job performance and maintenance
    • Retirement preparation and adjustment
    • Volunteer exploration
    • Volunteer participation

Additionally, it's crucial to consider the broader spectrum of occupational engagement, which encompasses not only the pursuit of employment but also the cultivation of interest in various occupations. This encompasses seeking and acquiring employment, a pivotal aspect of occupational engagement. Evaluating and supporting job performance and its sustainability are vital components, particularly in the context of returning to work. However, it's important to note that these considerations extend beyond paid employment; they also apply to volunteer work and the often-overlooked phase of retirement preparation and adjustment.

In the case of many survivors of mild traumatic brain injuries, a significant portion is not admitted to the hospital for immediate treatment. Some may not even receive a prompt diagnosis, resulting in delayed referrals to occupational therapy services. This delay in access to care underscores the importance of recognizing and addressing these multifaceted aspects of occupational engagement for this population, ensuring that they receive the support and interventions they require to optimize their recovery and quality of life.

OT and RTW

  • Many mTBI survivors do not receive OT referrals or have a delay in services
  • BI survivors found OT following injury an important component of RTW
  • However, patients found OT only beneficial when they focused on the cognitive demands of the job rather than the number of hours working
  • OT needs to take a bigger role in RTW after BI   

(Phillips et al., 2019)

In a noteworthy study conducted by Phillips et al. in 2019, brain injury survivors expressed a highly favorable view of occupational therapy as a crucial component for their successful return to work.

Interestingly, the patients in the study highlighted that they perceived OT to be most beneficial when the focus was on addressing the cognitive demands of their job. They emphasized the significance of strategies and interventions tailored to enhance their cognitive functioning rather than concentrating on the mere number of work hours or strategies to combat fatigue. This underscores the specific needs and priorities of individuals recovering from brain injuries when it comes to returning to the workforce.

AOTA echoes this sentiment and advocates for an expanded role for occupational therapists in the process of returning to work after brain injury. The emphasis is on reclaiming the responsibility for facilitating this transition and dedicating our efforts to helping individuals successfully reintegrate into employment. Promoting timely referrals and providing specialized interventions that address the cognitive demands of the job are vital steps toward this objective, aligning with AOTA's commitment to enhancing the occupational therapy services offered to this patient population.

OT Assessment of Work

  • Patient-reported questionnaires
  • Assessment of Work Performance
  • Occupational Performance Analysis
  • Observation
  • Patient interview
  • Co-worker interview

Occupational therapy employs various methods to assess an individual's capacity for work and their readiness to return to employment. These assessment approaches encompass patient-reported questionnaires, standardized assessments, and occupational performance analysis of work-related tasks.

Patient-reported questionnaires are valuable tools for gathering insights directly from the individual regarding their work-related challenges, preferences, and goals. These questionnaires provide a subjective perspective on the patient's work-related experiences.

Standardized assessments, though relatively limited in number, offer quantifiable data to evaluate work-related skills and performance. These assessments can help in tracking progress over time.

Occupational performance analysis provides a comprehensive evaluation of an individual's work-related abilities. This approach assesses physical skills, process skills, and social skills that come into play when performing work-related activities. To conduct this analysis, therapists follow these steps:

Gathering detailed information about the patient's job is crucial. This involves understanding the nature of their work, its specific requirements, and all relevant details. Data can be collected through direct observation in the workplace, contextual observation in a clinical setting, patient interviews to explain job tasks and challenges, and input from colleagues or employers if the patient is unable to provide information.

In some instances, therapists may employ activity analysis to break down specific job-related tasks into their component steps. This method helps understand the physical and social aspects of completing these tasks.

Therapists may utilize external resources, such as online videos, to gain insights into unfamiliar job roles. For instance, if a patient's job involves tasks unknown to the therapist, online resources can provide valuable information.

Lastly, therapists also assess transportation options for individuals not driving, recognizing that this aspect can significantly impact their ability to return to work successfully.

Occupational Performance Analysis

  • OTPs are experts in occupational performance analysis:
  • “Analysis that is performed with an understanding of the specific situation of the client and therefore [of] the specific occupations the client wants or needs to do in the actual context in which these occupations are performed.”

(AOTA, 2020)

Occupational therapists are experts in occupational analysis or occupational performance analysis, a skill that becomes second nature as we gain experience. During our student years, we practice extensively, breaking down the components of occupations with an understanding of a specific client's situation and their desired or necessary activities within the context in which these occupations occur.

While this analysis can be challenging because we may not always be physically present in those contexts, our primary goal is to facilitate the individual's return to their specific context where these occupations naturally take place. To overcome this challenge, we've embraced innovative approaches:

Patients can record themselves performing specific tasks or engaging in their occupations, allowing us to analyze their performance later. This approach enables us to understand how they function within their real-life context.

We leverage technology, including platforms like Zoom, telehealth, and FaceTime. In some cases, clients may be with us while someone from their workplace (like a significant other or colleague) assists in showing us the context and tasks involved. This collaborative approach enhances our understanding of how to deconstruct and analyze occupations within their specific work environments.

By using these innovative techniques, we ensure our interventions and strategies are tailored to the unique demands of our clients' everyday work environments, ultimately supporting their successful return to meaningful occupations.

Case, Cont.

  • Dan reports having difficulty restarting a task when interrupted- he often has to juggle making awards and waiting on customers
  • Dan is having trouble prioritizing jobs based on timeline- his customers have hard deadlines
  • Dan is having trouble managing payroll, billing, and monthly taxes
  • Divide work roles, responsibilities, and duties into smaller tasks, activities, and occupations to understand EF demands

In the case of Dan, he has reported specific work-related challenges that suggest potential areas of concern in his executive functioning. To gain a better understanding of the executive functioning demands, we can break down his work roles, responsibilities, and duties into smaller tasks and activities. Here are some areas where Dan may be facing executive functioning challenges:

Dan finds it difficult to resume tasks when they are interrupted. This could indicate challenges with inhibitory control, making it hard for him to filter out sensory distractions and refocus on tasks effectively.

Dan's job requires him to balance making awards, attending to customers, and managing administrative tasks with strict deadlines. His difficulty prioritizing and meeting these timelines may suggest executive functioning difficulties related to planning, prioritizing, and time management.

Dan's struggles with managing payroll, billing, and monthly taxes may involve cognitive challenges, such as calculations and attention to detail. This could relate to working memory, as he may have difficulty retaining and manipulating financial information.

Given his varied responsibilities, Dan must be proficient in multitasking and switching between different tasks efficiently. Difficulties in this area could point to challenges with cognitive flexibility and multitasking.

Dan's issues with sensory distractions, like loud noises and conversations, may indicate difficulties in selective attention. He may have trouble focusing on relevant information while filtering out irrelevant stimuli.

Cognitive flexibility involves adapting to changing situations and tasks. Dan may experience challenges in switching gears and adjusting his approach when transitioning between different responsibilities.

By examining these specific areas of concern in Dan's executive functioning, we can develop targeted interventions and strategies to address his cognitive challenges. These interventions will support his successful return to work and improve his overall job performance.

  • What are possible EF concerns??
  • Next Steps: Cognitive Assessment
    • Complex Task Performance Assessment
    • Occupation simulation

The next step for occupational therapists is to assess Dan's cognition comprehensively. This assessment will help tailor interventions and strategies to support his return to work successfully. Two assessments to consider are the Complex Task Performance Assessment and occupational simulation.

Cognitive Assessments

It can be difficult to assess executive functioning.

OT Assessment of EF

  • OT can assess EF using:
    • Observations: occupational performance analysis
    • Occupation-based assessments (Top-down)
    • Single-component standardized assessments (Bottom-up)

In the realm of assessment, there are two primary types to consider. The first is the bottom-up or single-component standardized assessments, which are used in both occupational therapy and neuropsychological testing. These assessments focus on individual components and are valuable for identifying specific executive functioning performance issues.

The second type is occupational-based assessments, which follow a top-down approach. These assessments examine an individual's performance in real-life occupational settings and situations.

EF Assessments: Bottom-Up

  • Designed to evaluate isolated cognitive components
  • Paper-pencil assessments for EF may not be sensitive enough to detect subtle differences with higher levels of cognition
  • Assessments are completed in a quiet environment with little demands on EF
  • Can have EF performance problems without identified impairment
  • Examples: D-KEFS Trail Making, Wisconsin Card Sorting Test, Stroop Test

The bottom-up assessments are specifically designed to evaluate isolated cognitive components. These assessments often involve paper and pencil tasks and are typically administered in quiet environments with minimal cognitive demands. However, they may not be sensitive enough to detect subtle differences within higher-level cognition, and they may not reflect real-world scenarios where executive functioning skills are crucial.

In some cases, individuals can experience executive performance problems that go undetected by these assessments. While these assessments are valuable for specific purposes, they may not fully capture the complexity of executive functioning in practical, everyday situations. Some examples of bottom-up assessments that are commonly used include the Trail Making Test, the Wisconsin Card Sort Test, and the Stroop Test. These assessments play a role in evaluating the impact of various factors on executive functioning but may not provide a complete picture of an individual's cognitive abilities in real-life occupational settings.

EF Assessments: Top-Down

  • Top-Down: Occupation-based performance assessments
  • “Ecologically Valid”:
    • Simulation of the performance of specific daily life activities that require executive functioning 
    • Observation of contextual demands, task demands, and execution of occupation
    • Occupation-based tasks can detect EF deficits in a certain context; however, many assessments available are not work-specific
    • They may not capture EF deficits related to client-specific work performance

Top-down assessments, which occupational therapists commonly use, are gaining prominence due to their ecological validity. These assessments simulate specific daily life activities that require executive functioning skills. By using top-down approaches, occupational therapists can observe how individuals perform tasks within their real-life contexts, taking into account contextual and task demands.

Occupation-based tasks, inherent in top-down assessments, have the advantage of detecting executive function deficits within specific contexts and performance areas. However, it's important to note that many available assessments may not be work-specific. While there is one work-related activity assessment, it may not precisely capture the challenges clients face in their work performance.

Overall, occupational therapy assessments are valuable, but there's a need for more research to validate and refine them further. As the field continues to evolve, the development of work-specific assessments and the validation of existing ones will enhance our ability to address executive functioning challenges in the context of daily life and work environments.

Performance-Based Assessments

  • Complex Task Performance Assessment
  • Multiple Errands Test
  • Kettle Test
  • The Executive Function Performance Test
  • Dynamic Performance Analysis

Among the assessments available for evaluating executive functioning skills in the context of return to work, the Complex Task Performance Assessment stands out as a valuable tool. However, it's important to consider the specific work environment and demands of the client when selecting an assessment. Here are some assessments that may be helpful for different work-related scenarios:

The Multiple Errands Test is suitable for individuals who need to shift between tasks frequently or have work-related demands that take them outside of their immediate environment. It replicates real-world situations and provides insights into executive functioning within varied contexts.

The Kettle Test is deal for individuals working in the food industry, such as cooks or baristas, the Kettle Test assesses executive functioning skills in the context of meal preparation and food service, making it a relevant choice for those in similar professions.

The Executive Function Performance Test covers a range of activities, including bill payment, simple meal preparation, phone use, and medication management. It is particularly useful for individuals working as nannies or caregivers, as these tasks align with their responsibilities.

The Dynamic Performance Analysis may be chosen when following the Cognitive Orientation to the Daily Occupational Performance framework. It helps guide interventions and can be a valuable tool in understanding an individual's cognitive functioning and performance within daily occupational contexts.

The selection of the most appropriate assessment should consider the individual's work environment, specific job responsibilities, and the cognitive demands they face. By tailoring the assessment to match these factors, occupational therapists can gain a more accurate understanding of an individual's executive functioning skills in their unique work context.

Complex Task Performance Assessment.

  • Work-simulation: Library
  • Primary task: Inventory Control
  • Secondary task: Phone messages, check errors  
  • Delayed intentions: Tell time, Give the examiner a message 
  • Rules

The Complex Task Performance Assessment is designed as a simulated work activity replicating a library environment. During this assessment, the patient begins by rating their confidence in their ability to perform throughout the activity. This self-assessment at the outset provides insights into the patient's perception of their executive functioning challenges.

The primary activity within the assessment involves working with cards related to inventory control, budgeting, and calculations. Importantly, the patient is allowed to complete this activity in their preferred manner. However, while engaging in this primary task, they must also manage other responsibilities, such as answering the phone, taking messages, and checking information for errors on a mailing list, with the need to make corrections if required. Transitioning between these tasks is a critical aspect of the assessment.

The patient is additionally instructed to keep track of time and to promptly notify the examiner if a specific individual named Katie calls during the assessment. These requirements further assess the patient's ability to manage multiple tasks and maintain situational awareness.

It's worth noting that during the assessment, the patient is not permitted to engage with anyone entering or leaving the environment, ask questions, or write on the provided paper. However, they are allowed to take notes during the initial instructions.

The Complex Task Performance Assessment is a comprehensive evaluation that assesses multitasking, task resumption, and other executive functioning skills in a context closely related to work, making it a valuable tool for occupational therapists.

Dynamic Performance Analysis.

  • Designed to use with the CO-OP approach
  • It can be used with work activities
  • Helps OTP determine where the EF breakdown is
    • Is the performance competent?
    • Where in the performance is there a breakdown?
      • Does the client know what to do?
      • Does the client want to do it?
      • Can the client do it? 
      • Does he/she have the capacity? 
      • Are the occupational demands/supports appropriate?
      • Are the environmental demands/supports appropriate?

The Complex Task Performance Assessment is specifically designed to align with the Cognitive Orientation to Daily Occupational Performance (CO-OP) approach that we'll be discussing later. It is a versatile assessment that can be applied to work activities, making it a suitable choice for evaluating executive functioning within a work-related context.

When using this assessment, occupational therapists can break down the task or occupation into its essential components by asking several key questions:

1. Competence- Was the client able to perform the task competently? Did they understand what needed to be done?

2. Client's Motivation- Did the client express a desire or willingness to complete the task? Did they have the intrinsic motivation to engage in the activity?

3. Client's Capacity- Did the client possess the necessary skills and capabilities to carry out the task effectively?

4. Occupational Demands and Supports- Were the occupational demands and supports appropriate for the client's needs and abilities? Were there any additional demands or supports that could enhance their performance?

5. Environmental Demands- Were the environmental demands suitable for the task at hand, or were there aspects of the environment that posed challenges or opportunities for improvement?

This assessment can serve multiple purposes, including screening patients to determine their readiness to return to work and assisting in the development of targeted interventions to address work-related challenges. It provides a structured framework for occupational therapists to evaluate and enhance executive functioning within the context of meaningful daily occupations, ultimately supporting clients in their return to work efforts.

Case Assessment Results

  • DKEFS Trail making: WFL
  • CTPA Results:
    • Did not complete before the time limit was reached
    • Task failures: phone messages, inventory control, time-based memory task 
    • Did not have a strategy to complete the tasks (difficulty planning/poor decision-making)
    • Difficulty with phone messages and had to start over on inventory control (perseveration/poor sequencing)
  • Dynamic Performance Analysis: Bill paying
    • The patient is motivated by activity and requires environmental support to stay organized

In Dan's case, a series of assessments were carried out to evaluate his executive functioning skills. The results of these assessments revealed crucial insights into his cognitive abilities in a work-related context:

First, the Trails Test indicated that Dan performed well within functional limits, suggesting that he possessed adequate cognitive abilities for certain tasks.

However, the Complex Task Performance Assessment (CTPA) told a different story. Dan encountered notable difficulties during this assessment. He was unable to complete it within the allotted time and experienced task failures in various areas, including managing phone messages, inventory control, and handling time-based memory tasks. His initial approach lacked effective strategies, highlighting challenges in planning and decision-making. Furthermore, he struggled with phone messages, had to restart the inventory control task when interrupted (indicating perseveration and poor sequencing), and faced difficulties in managing his time effectively.

To further assess his abilities and motivation, a Dynamic Performance Analysis was conducted, focusing on a bill-paying activity that was personally important to Dan. This assessment revealed that he would likely benefit from environmental supports to assist him in staying organized and optimizing his work performance.

In summary, these assessments offered valuable insights into Dan's executive functioning challenges, especially within the context of his work-related activities. They underscored the need for tailored interventions and environmental supports to help him address these challenges and improve his overall work performance.

OT Interventions for RTW

Now let's talk about occupational therapy interventions for return to work.

  • Goals should be client-centered and meaningful
  • Therapy provided within the client’s own environment is beneficial in the BI population

The primary objective of any intervention should always be client-centered and meaningful, which is consistent with the core principles of occupational therapy. Additionally, it's important to note that therapy provided in the client's own environment has demonstrated significant benefits, especially for individuals with brain injuries. Although this approach can present challenges, it remains a valuable and effective strategy.

While many of you are likely familiar with various intervention approaches, it's worth highlighting some differences in the evidence base. These differences may shed new light on the most effective ways to address the unique needs of individuals with brain injuries during the therapeutic process.

Remedial Approach for RTW

  • OTPs work with individuals to improve specific executive functioning deficits
  • The focus is on improving EF skills that interfere with successful work performance
    • Time management, organization, problem-solving, planning, decision-making, self-regulation, and goal setting

The remedial approach in occupational therapy focuses on addressing specific deficits that hinder an individual's ability to return to work successfully. This approach involves targeting the particular cognitive or functional deficits that interfere with work performance and implementing interventions to improve these areas. Importantly, the activities used for remediation do not necessarily need to be directly related to the individual's job tasks. Instead, therapists may employ various activities that help enhance skills such as time management, organization, and problem-solving, all of which are essential for improving the identified deficits. The ultimate goal is to strengthen the individual's cognitive and functional abilities, thereby supporting their successful return to work.

Environmental Approach

  • OTPs can help modify the work environment to support individuals with EF deficits
    • This may include implementing visual schedules, organizing workspaces, developing routines, and providing external cues and reminders
    • A supportive person in the work environment can improve success with RTW

The environmental approach in occupational therapy involves making adjustments to the work environment to facilitate a successful return to work for individuals with brain injuries. This approach includes various strategies such as modifying the physical workspace, implementing visual schedules, establishing routines, and placing cues or prompts in the environment. These modifications are aimed at creating a more supportive and structured work setting, which can enhance an individual's ability to perform job tasks effectively.

Additionally, research in this field suggests that having a supportive individual within the work environment, who is familiar with the individual's needs and challenges, can significantly contribute to the success of the return-to-work process. This supportive person becomes an integral part of the work environment, providing valuable assistance and guidance to the individual in their work-related endeavors.

Compensatory Approach

  • OTPs teach individuals practical strategies and techniques to compensate for EF deficits hindering work
  • Strategies can help individuals break tasks into manageable steps, set priorities, use memory aids (e.g., checklists, calendars), and self-regulate
  • Evidence supports improvements with remedial and strategy-based approaches; however, strategy-based show greater improvements

The compensatory approach in occupational therapy involves equipping individuals with strategies and techniques to compensate for cognitive or functional deficits that may impede their work performance. This approach encompasses a range of strategies, including taking breaks, breaking down complex tasks into smaller, manageable segments, setting priorities, using memory aids, and teaching self-regulation techniques. Research indicates that both remedial strategies (focused on improving deficits) and strategy-based interventions (environmental and compensatory) can lead to improvements in patient outcomes. However, strategy-based interventions tend to yield more significant improvements, underscoring their importance in the rehabilitation process.

Metacognition Approach

  • Compensatory strategies are taught and practiced; individuals internalize external strategies
  • Difficult to know if EF has improved  vs. compensatory strategies applied effectively
  • Allows clients to rely on their strengths to compensate and manage EF deficits during activities
  • Strategies can be transferred across activities
  • Interventions should be unfamiliar, challenging, and complex

Metacognition plays a crucial role in the process of returning to work for individuals with cognitive deficits. It involves the transition of compensatory strategies learned in therapy from external aids to internalized, self-directed strategies. This transition can be challenging because it's difficult to determine whether improvements in executive functioning have occurred or if the individual has simply become adept at applying compensatory strategies.

Metacognition enables clients to rely on their own strengths and abilities to compensate for and manage executive functioning deficits during various activities. What makes this approach particularly effective is that these strategies become internalized and are more likely to transfer across different activities. In essence, clients are using their own cognitive strengths to devise and apply strategies tailored to their specific needs.

During intervention, it's essential to provide clients with tasks and challenges that are unfamiliar and complex and require the use of these internalized strategies. This approach encourages clients to generalize these skills across a broader range of activities and situations, ultimately promoting greater independence and success in returning to work.

Task-specific Training

  • Occupational therapists can work with individuals to improve EF skills within specific work-related tasks or activities
  • The training can involve breaking complex tasks into smaller components, providing guidance and feedback during practice, and grading the level of difficulty
  • Task-specific training is more successful when tasks are performed in context

Occupational therapists frequently employ task-specific training, especially when working with individuals in the neurological population, and it has proven to be highly effective. This approach involves focusing on a particular task that is relevant to the individual's goals, in this context, related to work.

Task-specific training typically includes the following components. Occupational therapists break down complex work-related tasks into smaller, more manageable components. This deconstruction allows for a detailed examination of each element within the task. Therapists provide continuous guidance and feedback to the individual as they work on each component of the task. This support helps the individual develop their skills and techniques. Therapists gradually adjust the level of difficulty as the individual progresses. This gradual increase in complexity ensures that the individual can successfully complete the full task when all components are reintegrated.

Overall, task-specific training is a targeted and systematic approach that enables individuals to build the skills and confidence needed to perform specific work-related tasks effectively.

Generalization and Transfer of Skills

  • OTPs help clients apply their improved executive functioning skills to various settings and activities
  • A supportive person in the environment can help if OTP can not be treated in the context
  • Generalization of skills learned in therapy to real-life work situations promotes independence and success in daily life and work

The primary objective is to promote the generalization and transfer of enhanced executive functioning skills to diverse settings and activities. Occupational therapy practitioners play a vital role in assisting clients in applying their refined executive functioning abilities.

As clients progress and their skills improve, the therapeutic approach involves modifying tasks and facilitating their generalization. Additionally, the presence of a supportive individual within the client's environment can significantly contribute to the generalization and transfer of these newfound skills. Ultimately, the overarching aim is to support individuals in their journey to successfully reintegrate into real-life work situations.

Case, Cont.

  • What would each of these approaches look like for Dan?
    • Remedial approach: Setting Dan up with different scenarios to practice multi-tasking and problem-solving- does not have to be related to work
    • Environmental approach: Designing environmental adaptations to organize his workspace and visual reminders for deadlines and projects to be completed
    • Compensatory Approach: using apps, calendars, and checklists that are shared among staff
    • Task-specific training: completing tasks just as he would at work, in that context, if possible. Tasks are graded, and feedback is provided

The primary objective is to promote the generalization and transfer of enhanced executive functioning skills to diverse settings and activities. Occupational therapy practitioners play a vital role in assisting clients in applying their refined executive functioning abilities.

As clients progress and their skills improve, the therapeutic approach involves modifying tasks and facilitating their generalization. Additionally, the presence of a supportive individual within the client's environment can significantly contribute to the generalization and transfer of these newfound skills. Ultimately, the overarching aim is to support individuals in their journey to successfully reintegrate into real-life work situations.

Applying the Cognitive Orientation to Occupational Performance Framework

Cognitive Orientation to Occupational Performance (CO-OP)

  • When treating a BI patient with EF deficits and return to work, the CO-OP framework can be applied
  • Framework for performance-based problem-solving
    • “Goal, Plan, Do, Check”
    • Verbal self-instruction techniques
    • Goal management training
    • Problem-solving training

The Cognitive Orientation to Occupational Performance framework, originally designed for pediatrics, has gained recognition and application in the adult population, particularly since 2009. Subsequent to 2011, there has been increasing research on utilizing the CO-OP approach with adult patients, including those with brain injuries. This framework can be adapted to individual patients, engaging them on a metacognitive level to address performance challenges, emphasizing metacognition as a critical component.

The CO-OP approach centers on facilitating success through a structured process that involves setting goals, creating plans, executing tasks, and assessing outcomes—a framework often referred to as "goal, plan, do, check." This approach incorporates verbal self-instruction techniques and integrates elements of goal management and problem-solving training. By employing this method, therapists can empower individuals to effectively manage and enhance their executive functioning skills, promoting successful engagement in various activities and tasks.

CO-OP Approach

  • Utilizes:
    • Reinforcement
    • Modeling
    • Shaping
    • Prompting
    • Fading
    • Chaining
  • Intervention provided to support the acquisition of skills

In the CO-OP approach, therapists employ a range of well-established techniques to support the acquisition of executive functioning skills and enhance the individual's ability to return to work successfully. These techniques include reinforcement strategies, modeling, shaping, prompting, fading, and chaining. These are familiar strategies that occupational therapists often use in their interventions to guide individuals toward skill development and improved executive functioning.

  • Patients select their treatment in order to stay motivated and engaged in:
    • acquisition of skills
    • generalization (using skills for the same tasks outside the treatment sessions)
    • transfer of skills
  • The therapist and patient are therapeutic partners

(Dawson et al., 2009)

Collaborative goal setting is a fundamental principle within the CO-OP approach, affording the patient the opportunity to actively participate in determining the treatment's focus. This approach is instrumental in maintaining the patient's motivation and engagement throughout the intervention process. By aligning treatment goals with the patient's personal interests and priorities, therapists can enhance the acquisition of executive functioning skills.

Moreover, this patient-centered approach contributes to the generalization and transfer of acquired skills to various contexts, ultimately fostering a strong therapist-patient relationship based on mutual cooperation and shared objectives.

  • OTPs guide their patients to come up with strategies to solve their own task-performance problems
  • The patient’s work to come up with the “solution” or strategies is integral to the success of the intervention
  • The patient is encouraged to self-talk throughout
  • The strategic interventions are created using the patient’s own strengths and abilities
  • Improves self-efficacy

(Dawson et al., 2009)

Within the CO-OP approach, occupational therapy practitioners play a pivotal role in guiding their patients to develop strategies for solving their own task performance challenges. This key aspect emphasizes patient-driven problem-solving, where patients actively participate in generating solutions or compensation strategies for their executive functioning difficulties. Encouraging the use of self-talk as part of this process, patients create strategies that leverage their unique strengths and abilities.

Importantly, the CO-OP approach enhances self-efficacy, a crucial factor for success, particularly in the context of returning to work. This improvement in self-efficacy arises from the fact that participants attribute the success of their plans to their own contributions and efforts, reinforcing their belief in their ability to overcome challenges.

  • Significant other involvement to help reinforce the use of the global strategy (Goal-Plan-Do-Check)
  • Significant others included in sessions to help assist with transfer strategy to other occupations

(Dawson et al., 2009)

Another crucial aspect of the CO-OP approach, originally designed for pediatrics but highly relevant for adults as well, is the active involvement of a significant other in the intervention process. Encouraging the participation of a trusted individual, such as a family member or caregiver, is a valuable component of this approach. The involvement of a significant other can aid in implementing the global strategy of goal setting, planning, executing, and evaluating (goal, plan, do, check).

Furthermore, significant others can play a vital role in transferring the strategies learned during therapy to other aspects of the patient's life and various occupations. Their support and collaboration contribute to the overall effectiveness of the intervention and the patient's ability to apply newly acquired executive functioning skills in different contexts.

Case, Cont.

  • How would this look for Dan?
    • Goal: Dan wanted to focus on billing customers- the task was broken down into smaller components
    • Plan: Dan made a plan to use an electronic system and organizational system with checklists to ensure all billing needs were met. The therapist helped to guide this plan.
    • Do: Dan implemented strategies and required a trial of different systems that he was able to edit and create himself. The wife and therapist provided feedback and reinforcement as needed. The activity was built upon until the entire task was simulated.
    • Check: Skills were successfully carried over into the work environment with supervision from his wife

In Dan's case, he actively participated in setting his own goal, which was to improve his ability to handle billing tasks efficiently. He took the initiative to develop his own plan, which involved creating an electronic organization system with checklists to ensure all billing requirements were met. Throughout this process, the therapist provided guidance and support.

Dan implemented these strategies and, with the therapist's assistance, experimented with different systems, making adjustments as needed. His wife also played an essential role in the therapy sessions, offering feedback and reinforcement alongside the therapist. The therapy activities progressively built upon one another, culminating in a complete simulation of the billing task, which Dan successfully performed independently.

These newly acquired skills were effectively transferred to his work environment, where his wife provided supervision and support, ultimately leading to his successful return to work. Dan's active involvement, collaborative goal-setting, and the support of his significant other were instrumental in his achievement.

Cognitive Energy Conservation and Executive Function

Cognitive energy conservation is an important intervention to consider, particularly when addressing fatigue and its impact on executive functioning.

Cognitive Energy Conservation and EF

  • Assess fatigue severity and daytime sleepiness prior to cognitive testing
  • Organize tasks and responsibilities, prioritizing the most important ones
  • Break tasks into smaller, manageable chunks and assign a specific time for each task
  • Prevents getting overwhelmed, reduces decision fatigue, and allows the conservation of cognitive energy

Cognitive energy conservation involves several steps to help patients manage their cognitive fatigue effectively. These steps include assessing fatigue and daytime sleepiness, organizing tasks and responsibilities, prioritizing tasks, breaking tasks into smaller manageable chunks, and assigning specific times for task completion. These strategies help prevent cognitive overload, reduce decision fatigue, and conserve cognitive energy, enabling patients to maintain their mental stamina throughout the day without becoming mentally fatigued.

Cognitive Energy Conservation for EF

  • Efficient time management can increase cognitive energy level
  • Pomodoro Technique: working in focused intervals followed by short breaks; this maintains mental alertness and decreases burnout

Efficient time management is essential for conserving cognitive energy. By using techniques like the Pomodoro technique, which involves focused work intervals followed by short breaks, individuals can maintain mental alertness and prevent burnout. This approach helps them make the most of their cognitive energy while ensuring they don't waste it on unproductive tasks or prolonged periods of work without breaks.

  • Decrease multitasking: one task at a time, improves concentration, decreases errors, and conserves cognitive energy
  • Engage in relaxation to recharge: mindfulness, deep breathing, stretching, exercise, or listening to music
  • This leads to improved cognitive performance and sleep quality

Multitasking can be counterproductive, especially for individuals with executive functioning deficits. Encouraging them to focus on one task at a time can improve concentration, reduce errors, and conserve cognitive energy. Additionally, teaching relaxation techniques such as mindfulness, deep breathing, stretching, exercise, or music can help individuals recharge and reduce fatigue. Relaxation exercises not only improve cognitive performance but also contribute to better sleep quality, further reducing fatigue. Occupational therapists can play a vital role in guiding patients through meaningful relaxation activities.

Successful RTW Following BI

  • May require assessment of other areas that influence EF:
    • Sleep Assessments
    • Pain Scales
    • Fatigue and Sleepiness Assessments
    • Depression and Anxiety Assessments
    • Driving Assessments

In addition to assessing executive functioning, it's crucial to evaluate other factors such as sleep, pain, fatigue, sleepiness, depression, anxiety, and driving when working with individuals following a brain injury. These assessments can help identify and address potential issues and contribute to a more comprehensive approach to rehabilitation and return to work. Collaborating with other healthcare professionals and therapies can also be valuable in managing these aspects of recovery.

Ongoing Self-Care and RTW

  • Adequate sleep
  • Healthy eating
  • Regular exercise
  • Stress management techniques
  • Coping skills
  • Mindfulness
  • Gratitude

Ensuring that the patient is taking care of their overall well-being is essential as they return to work. This includes getting enough sleep, maintaining a healthy diet, engaging in regular exercise, and using stress management techniques like mindfulness and gratitude. A holistic approach to health can significantly contribute to a successful return to work following a brain injury.

Case, Cont.

  • Is Dan back to work?
    • Dan has successfully returned to work. He has internalized strategies and adaptations to be successful
    • Using the CO-OP method was helpful because it allowed him to devise his own strategies and adaptations, which improved metacognition and self-efficacy
    • His wife attended therapy and was able to help implement environmental adaptations and organize the workspace
    • Dan still experiences mental fatigue; however, he takes breaks and needs less time to recover

Dan's successful return to work demonstrates the effectiveness of the CO-OP method and the comprehensive approach taken in addressing his cognitive challenges. By allowing Dan to develop his own strategies and adaptations, his metacognition and self-efficacy improved, enabling him to apply these skills in various situations. Involving his wife in the therapy process also contributed to implementing environmental adaptations. Although he still experiences some mental fatigue, he has learned to manage it effectively with breaks and quicker recovery times. Overall, Dan's return to work is a positive outcome of the therapy process.


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Monti, Y. (2023). Addressing executive function deficits for return to work following a brain injury. OccupationalTherapy.com, Article 5642. Available at www.occupationaltherapy.com

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yvonne monti

Yvonne Monti, OTD, OTR/L

Yvonne Monti holds a Bachelor of Science degree from Keuka College, N.Y., and a Doctoral Degree in Occupational Therapy from Chatham University, PA. She has 24 years of clinical experience in the rehabilitation setting, with extensive experience treating individuals with neurological problems such as spinal cord injury, CVA, and brain injury across the continuum. Currently, Yvonne is an Assistant Professor at Utica University in New York. She is passionate about educating students and clinicians and enjoys lecturing nationally and internationally on evidence-based topics to improve intervention techniques for busy practitioners.

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Addressing Executive Function Deficits For Return To Work Following A Brain Injury
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