| | Barriers to Return to Work After Burn InjuriesPresented in part to the American Burn Association, April 7, 2006, Las Vegas, NV. Abstract Esselman PC, Wiechman Askay S, Carrougher GJ, Lezotte DC, Holavanahalli RK, Magyar-Russell G, Fauerbach JA, Engrav LH. Barriers to return to work after burn injuries. ObjectiveTo identify barriers to return to work after burn injury as identified by the patient. DesignA cohort study with telephone interview up to 1 year. SettingHospital-based burn centers at 3 national sites. ParticipantsHospitalized patients (N=154) meeting the American Burn Association criteria for major burn injury, employed at least 20 hours a week at the time of injury, and with access to a telephone after discharge. InterventionPatients were contacted via telephone every 2 weeks up to 4 months, then monthly up to 1 year after discharge. Main Outcome MeasuresA return to work survey was used to identify barriers that prevented patients from returning to work. A graphic rating scale determined the impact of each barrier. ResultsBy 1 year, 79.7% of patients returned to work. Physical and wound issues were barriers early after discharge. Although physical abilities continued to be a significant barrier up to 1 year, working conditions (temperature, humidity, safety) and psychosocial factors (nightmares, flashbacks, appearance concerns) became important issues in those with long-term disability. ConclusionsThe majority of patients return to work after a burn injury. Although physical and work conditions are important barriers, psychosocial issues need to be evaluated and treated to optimize return to work. SEVERE BURN INJURIES often result in significant barriers to return to work that include contractures, amputations, weakness, and psychologic issues such as body image concerns, depression, and posttraumatic stress.1 The ultimate goal of a rehabilitation program for people who were employed before their burn injuries is to return them to work at their previous jobs. This is often a challenging task, and it may require a gradual reintegration into the workplace with modified work duties and close coordination with the employer. The vocational plan has to address the barriers to returning to work for people with burn injuries, but these barriers have not been systematically studied or identified from the patient’s perspective. In a previous analysis of the multicenter data on patients with major burn injury as defined by the American Burn Association (ABA),2 70% of adult patients were working outside of the home before their burn injuries.3 Unlike other severe traumatic injuries such as brain or spinal cord injuries, a large percentage of burn injuries occur at the workplace. Up to 30% of all major burn injuries among adults occurred at the workplace, and in the group that was employed before the burn injury 42% were injured at the workplace. Furthermore, people who were injured at work were more likely to have hand burns and to require hand surgery, factors that can have an impact on the ability to return to work.3 Multiple variables influence a person’s ability to return to work after a burn injury. In a study using the Community Integration Questionnaire, the productivity score—reflecting work, school, and volunteer activities—was best predicted by a subject’s age, severity of burn injury, and level of preinjury job satisfaction.4 Brych et al5 reported that 66% of subjects with burn injuries had returned to work at 1 year and 90% at 2 years after injury. The average time off work was 17 weeks, and predictors of not returning to work included burn size, having an extremity burn, and psychiatric history. Similar findings were reported by Helm and Walker,6 who found that the mean time off work was 17 weeks in a sample of 65 patients. The severity of the burn injury was the most significant predictor of time to return to work. In a cross-sectional study from Sweden, Dyster-Aas et al7 found at an average follow-up time of 9 years postinjury that 83% of subjects with burn injuries were employed. Those not working reported worse outcomes on the Burn Specific Health Scale and reported significantly more problems with pain. Of those employed, 62% had the same job as before the injury, but 11% of them reported job difficulties. Although most were in a similar or better job than before the injury, 8% reported being in a worse or less skilled job because of burn-related factors. Tanttula et al8 also found that the severity of the burn injury and age correlated with return to work, but the presence of hand burns did not. Two studies8, 9 have reported that an important predictor of working after a burn injury is the employment status at the time of injury. Fauerbach et al10 found that preburn substance abuse was associated with unemployment 4 months after the burn injury. In addition, trends for higher unemployment rates 12 months after discharge were noted among those with a preburn history of complex psychiatric comorbidity and alcohol use, anxiety, or mood disorder. Electrical injuries often have complications such as amputations and neurologic injury, but return to work after an electrical injury has not been studied in detail. In a case series of patients with electrical burns, 91% of the injuries were reported to be work related, and of those who returned to work, the average time off work was 17.4 weeks. Only 23% of patients with electrical burns returned to the same work duties, 46% had to change work responsibilities, and 32% did not return to work at the average follow-up time of 5 years.11 Although studies have identified predictors of returning to work such as age and the severity of the burn injury, there is limited information regarding the barriers to returning to work after a significant burn injury. The aim of this study was to identify the specific barriers to returning to work resulting from the burn injury, as identified by the person with the burn injury and the changes in the perceived barriers over time. Methods  Participants This study is a prospective study of 154 patients from 3 burn centers that participated in a federally funded, multisite data collection project (University of Washington, University of Texas Southwestern Medical Center, Johns Hopkins University). Patients were included if they met ABA criteria for major burn injury2 and if they were employed at least 20 hours a week at the time of the injury. Patients were excluded if they were not working at the time of the injury, did not have access to a telephone, or did not speak English (the University of Texas site was an exception, because Spanish-speaking patients were included at that site). All 3 institutions’ institutional review boards approved this study. The mean total body surface area (TBSA) burn sustained by the patients ± standard deviation was 17.4%±13.7%, and the majority (57.5%) of our sample sustained burn injuries of less than 15% of TBSA. The mean length of hospitalization was 18.6±19.4 days, 80.4% of the patients were men, and 72% were white. The mean age was 37±12.3 years, and 34% of the patients were burned at work. Measures and Procedures Before hospital discharge, all patients who met study criteria were approached by a member of the research team to determine their interest in participating in the study. Patients who expressed interest gave consent for the study and completed the first part of a return-to-work (RTW) survey, which was developed specifically for this project. This survey is based on the Work Experience Survey (WES) developed by Roessler et al.12, 13 The WES survey is a structured interview that identifies essential job functions in 6 categories: physical abilities, cognitive abilities, task-related abilities, social abilities, working conditions, and company policies; and it has been used to study vocational issues in people with disabilities.14, 15, 16, 17, 18 Each person completing the WES is asked to identify the essential job functions that are barriers to work, and these can be used to develop appropriate workplace accommodations. The RTW survey used in this study incorporated elements of the WES but was modified to include items pertinent to people with burn injuries such as wound issues. In addition, the WES list of essential job functions was modified to shorten the survey. For example, the WES includes 5 items regarding lifting of specific weight ranges, and this was consolidated in the RTW survey to 1 item asking about lifting as a barrier. The RTW survey is a structured interview that has 3 sections. Section 1 is completed before hospital discharge and provides information concerning patients’ assessments of any preburn injury impairments, work environment, and satisfaction with the work or employer. It also asks if the employer or coworkers have contacted them while hospitalized. After discharge, patients were contacted by telephone to complete section 2 of the RTW survey every 2 weeks until 4 months postdischarge and then monthly up to 1 year postdischarge or until they returned to work, whichever came first. The survey was completed within a 7-day window of time before or after the scheduled 2-week follow-up or a 2-week window of time before and after the scheduled monthly follow-up. Section 2 asks patients to identify what they perceive as barriers to their returning to work by selecting from the 9 general categories (appendix 1). Patients were also asked to identify what they perceived as any specific barriers under each broad category (see appendix 1). To quantify the data, patients were asked to rate each general category on a 10-point graphic rating scale (GRS) in terms of how much of an impact each category had in preventing them from returning to work, ranging from 0 (no impact) to 10 (a lot of impact). Once the patient had returned to work, he or she no longer was asked to complete section 2 but completed the exit survey, section 3, of the RTW evaluation via telephone interview. Section 3 of the survey was obtained within a month after returning to work. This section gathered information concerning job accommodations and difficulty in returning to work as well as satisfaction in returning to work. A manual outlining the use of this survey was developed for use by the 3 study sites. All institutions conducted the survey on 2 mock patients to ensure 80% interrater reliability. Data Analysis One-way analysis of variance methods were used to compare means of the GRS impact scores for each of the 9 major domains (see appendix 1). Means of the GRS scores were calculated using the latest valid assessment that each patient provided just before returning to work. Means for a single comparison group (the censored group), with which all others are compared, were derived from the assessments of patients who had not returned to work. The censored group includes subjects who had not returned to work at the time of their last follow-up and it is not known if they ever returned to work and those who completed the 1-year follow-up and had not returned to work. The use of the censored group implies that the analysis did not make assumptions regarding subjects in the censored group, who could have returned to work the day after their last follow-up or after the 1-year follow-up. This strategy provides 2 advantages. First, the samples at each time point for which means were computed are independent from each other and also independent of the censored group. Second, these comparisons allow evaluation of changes in barriers among groups of people with burn injuries based on elapsed time from discharge and provides insight into the durability of identified barriers over time. The goal was to determine if the barriers remained the same the longer people did not return to work. The Dunnett multiple-comparisons procedure was used to determine the statistical significance between each of the time periods and the single comparison (censored) group. P values less than .05 for simple pairwise comparisons were not deemed statistically significant unless the overall test of mean differences across all the assessment periods evaluated was significant at the .05 level of significance. This approach controls the overall experimental error rate for each comparison with the nominal .05 level of significance. It was hypothesized that the severity of the burn injury as measured by TBSA burned and length of hospitalization would delay return to work and that employer contact during hospitalization would facilitate return to work. To evaluate this, logistic regressions were performed to evaluate the independent effects of these risk factors on the likelihood that subjects returned to work within 1 year postdischarge. In addition, Kaplan-Meier product-limit estimates and testing procedures were used to compare time-to-event (TTE) curves for these 3 factors. Both the log-rank tests, which assess median time to event, and Wilcoxon tests, which compare overall TTE curves, were calculated to assess statistical significance across the various risk strata for each risk factor. Chi-square tests of significance were executed to compare the individual elements that influenced a particular composite score, each determined by the binary response yes or no. Similar to the previous strategy used for computing the means of the composite scores, we calculated percentages of times a characteristic was mentioned as a barrier to returning to work at each of the time periods and in the censored group. As before, depending on the number of assessment periods considered (t), each comparison was represented as a 2×t contingency table with t-independent samples, and thus the simple chi-square test was applicable. Because of the large number of composite scores (n=9), the diversity of items within each composite score (range, 2–11 items; average, about 5 per composite score), and the total number of assessment periods (n=16) included in this study, not all of the results of all the possible statistical tests are presented in this study. Only significant and interesting ones are described. All data processing, calculations, and statistical tests were performed using SAS.a Tests were deemed statistically significant if the computed significance levels were less than .05. Results A total of 154 patients were entered into the study, for whom baseline data were collected. One patient with baseline data was excluded because this person did not provide any follow-up data and it was not known if this person ever returned to work. Although the maximum number of section 2 assessments for people could range from 0 to 16, the actual number depended on when the person returned to work, and rarely did anyone complete all their possible evaluations. The number of assessments per person ranged from 0 (for 24 subjects) to 16 assessments (for 1 person), with a mean of 3.0 evaluations per patient (median, 1.5). A patient who returned to work before the first 2-week evaluation would not have answered any of the section 2 survey questions. If patients were not contacted at a specific time point, their data for that period were coded as missing. In this study, only 31 (20.3%) subjects did not return to work before the end of the 1-year follow-up period; alternatively, 79.7% returned to the workforce within 1 year postdischarge. Most in the sample were working 40 to 50 hours a week, had been at their jobs an average of 8.3 years, and reported a job satisfaction rating of an 8.3 out of a 10-point scale (range, 1 [extremely unsatisfied] to 10 [very satisfied]). A total of 71% of patients reported that their employer contacted them to offer support during their hospitalization, and 81% reported that coworkers had called to offer support. Only 13% reported that they had any health concerns before the burn injury. Barriers to Work (Section 2 of RTW Survey) At each section 2 follow-up, patients used a GRS (range, 0 [no impact] to 10 [a lot of impact]) to rate the impact that each identified barrier had on their inability to return to work at that time (table 2). Shortly after discharge, “physical abilities” was identified as the most important barrier to returning to work until 10 months postdischarge, when “work conditions” became the most significant barrier. “Wound issues” was the second greatest barrier in the early follow-up time points but became less important at the mid to late time points. The pattern of the “social abilities” barrier over time also showed that it was not a significant barrier at the early follow-ups but became another important barrier around 10 months after discharge. | | |  | Time After Discharge | Physical | Cognitive | Social Abilities | Task-Related Issues | Working Conditions | Wound Issues | Legal, Family, or Employer Reasons | |
|---|
| 2wk | 7.1 | 0.9 | 2.1 | 4.7 | 4.4 | 6.2 | 1.6 | | | 4wk | 6.6 | 0.7 | 2.5 | 4.8 | 4.5 | 5.8 | 2.6 | | | 6wk | 7.3 | 0.8 | 2.3 | 4.9 | 4.8 | 5.6 | 1.9 | | | 8wk | 7.2 | 1.8 | 3.2 | 5.1 | 5.0 | 5.5 | 3.4 | | | 10wk | 6.9 | 1.3 | 3.5 | 5.8 | 5.6 | 3.6 | 2.8 | | | 12wk | 7.2 | 1.8 | 2.7 | 5.9 | 6.1 | 5.9 | 3.9 | | | 14wk | 6.9 | 2.7 | 4.3 | 5.8 | 6.4 | 5.4 | 4.4 | | | 16wk | 7.2 | 2.7 | 4.5 | 6.1 | 6.3 | 4.8 | 3.9 | | | 5mo | 7.2 | 2.6 | 4.3 | 6.0 | 6.5 | 4.7 | 2.9 | | | 6mo | 7.1 | 3.2 | 4.4 | 4.5 | 6.0 | 5.1 | 3.6 | | | 7mo | 6.7 | 2.5 | 4.1 | 5.6 | 5.9 | 5.9 | 2.1 | | | 8mo | 6.5 | 3.2 | 4.0 | 5.8 | 5.6 | 4.9 | 2.5 | | | 9mo | 6.6 | 4.0 | 4.8 | 5.4 | 6.6 | 4.2 | 4.1 | | | 10mo | 6.4 | 2.4 | 6.3 | 5.4 | 6.8 | 5.9 | 4.0 | | | 11mo | 6.4 | 3.2 | 5.6 | 4.2 | 6.8 | 6.4 | 2.6 | | | 12mo | 7.7 | 2.7 | 6.2 | 4.7 | 8.1 | 6.0 | 3.2 | | | | |
Statistical tests were performed among all 9 GRS composite mean scores, at the selected assessment times of 2 weeks, 6 weeks, and 10 weeks, to compare these means with the censored group means. These tests showed that only the cognitive abilities, social abilities, and working conditions categories were statistically significant (P<.05) when compared with the means of the censored group who responded to the 1-year survey. “Physical abilities” had the highest impact for both of the groups who had returned to work shortly after discharge and those not returning by 1 year. Cognitive abilities, social abilities, and working conditions did not have an impact early after discharge; however, these factors became highly significant barriers a year after discharge, as can be seen by the fact that their respective means at 1 year were significantly increased over the 2nd, 6th, and 10th week means. Although chi-square tests of each of the 9 major categories and all individual items within a category were performed, our analyses focused on the social abilities category, because of previous reports of the incidence of depression and posttraumatic stress symptoms after burn injuries.19, 20, 21 The social abilities category included evaluations of symptoms of both depression and posttraumatic stress disorder. The percentages of positive responses for all the specific reasons within this major category are provided in table 3. The reasons of “working alone” and “depressed mood” were the most common barriers identified in this category. All symptoms, with the exception of “supervising others” and being “afraid of workplace” rose steadily over time. Chi-square tests of all individual items within the social abilities category were performed, and comparisons of the 2nd, 6th, and 10th weeks with the censored group found statistically significant differences for all the specific elements that make up the social abilities category. | | | | Time After Discharge (n) | Working With Others | Afraid to Leave Home | Afraid of Workplace | Nightmare/Flashbacks | Concern Over Appearance | Depressed Mood | |
|---|
| 2wk (82) | 11 | 5 | 10 | 10 | 20 | 23 | | | 4wk(73) | 15 | 3 | 12 | 14 | 20 | 32 | | | 6wk(58) | 14 | 7 | 7 | 15 | 12 | 24 | | | 8wk(47) | 23 | 6 | 12 | 19 | 27 | 42 | | | 10wk(35) | 19 | 11 | 8 | 17 | 22 | 42 | | | 12wk(23) | 26 | 17 | 9 | 17 | 18 | 35 | | | 14wk(22) | 18 | 23 | 23 | 23 | 36 | 59 | | | 16wk(22) | 36 | 32 | 27 | 27 | 32 | 55 | | | 5mo(16) | 31 | 31 | 25 | 31 | 25 | 63 | | | 6mo(17) | 29 | 18 | 24 | 24 | 18 | 53 | | | 7mo(11) | 27 | 36 | 27 | 27 | 27 | 60 | | | 8mo(10) | 30 | 40 | 10 | 20 | 20 | 60 | | | 9mo(13) | 38 | 31 | 23 | 31 | 38 | 62 | | | 10mo(11) | 45 | 45 | 27 | 45 | 45 | 73 | | | 11mo(9) | 55 | 44 | 44 | 67 | 67 | 78 | | | 12mo(9) | 67 | 56 | 22 | 67 | 89 | 88 | | | | |
Post–Return to Work (Section 3 of RTW Survey) Once patients had returned to work, they completed section 3 of the RTW survey, which included 2 questions on a scale of 0 to 10. The first rated how difficult it was to return to work, ranging from 0 (not difficult at all) to 10 (very difficult). The mean rating was 4.2±3.0. The second question asked how satisfied they were to be back at work, with 1 being “not satisfied” and 10 being “very satisfied.” The mean rating was 8.0±2.8. Of those returning to work, 94% returned to the same employer and 67% reported that they received special accommodations, including limited work hours (38%), limited days per week (14%), and light duty (38%). Return-to-Work Risk Factors Logistic regression models were evaluated to assess other contributors to returning or not returning to work within 1 year. The risk factors of employee concern, hospital length of stay, and TBSA were evaluated for their independent contributions to delayed return to work. None of these factors played a significant role in delaying return to work after discharge, as shown by significance tests results of .48, .32, and .25, respectively. To assess whether these factors influenced the speed at which subjects returned to work, several TTE analyses were performed. Evaluations of Kaplan-Meier curves among the various strata of these risk factors showed no effect of employer concern (log-rank, .49; Wilcoxon, .55) or TBSA (log-rank, .35, Wilcoxon, .20); however, length of stay (log-rank, .052; Wilcoxon, .051) tended toward having a significant impact in delaying return to work. Discussion For people who were employed at the time of a severe burn injury, return to work is often the most important and challenging treatment goal. As seen in a previous study,5 most of the patients in this study were successful in returning to work by 1 year after discharge, but over 20% of the patients did not return to work because of burn-related disability. The patients in this study had stable work situations, with an average preinjury time at their jobs of 8.3 years and good job satisfaction. Subjects also reported that 71% of them were contacted by their employers during their hospitalization, and 81% were contacted by coworkers. Franche et al22 report that there is evidence that early contact by the employer reduces the duration of disability, but contact by the employer during hospitalization was not found to be a significant predictor of time off work in this study. This may be due to the large number of subjects (71%) who had some contact by their employers and the fact that we did not characterize the nature or amount of contact between injured workers and their employers. It is possible that in-depth or multiple employer contacts during the acute hospitalization would correlate to a work situation more likely to make accommodations and facilitate a return to work. Return to work after an injury involves multiple stakeholders, including the employee and his/her family, the employer, the health care system, and the insurance and workman’s compensation systems.23 As such, multiple complex and possibly competing factors can influence the potential for return to work after an injury. Previous studies have generally not focused on the perspective of the injured worker in the analysis of return-to-work outcomes.23 This study focused on the perception of patients with burn injuries and their perceived barriers to returning to work. To interpret the impact of different categories on return to work (see Table 2, Table 3), the changes in the subject sample over time must be recognized. When a subject returned to work, he/she no longer participated in the ongoing section 2 follow-up phone calls. Therefore, the study started with 154 subjects, and almost 70% had a relatively short-term disability and had returned to work by 4 months. The last several follow-up calls were completed on less than 40 subjects who had not returned to work by that time, a sample with long-term disability due to their burn injuries. It was expected that the physical and wound-related barriers would be important factors early after discharge from the hospital, and the treatment of physical and wound-related problems is the initial primary focus of a burn care and rehabilitation team after a significant burn injury. Many people are unable to return to work with wound care issues requiring dressing changes and risk of wound contamination at the work place. Physical barriers such as decreased range of motion or decreased hand function may also prevent a person from returning to work and are a priority of the rehabilitation treatment plan. Physical barriers continued to be a significant problem throughout the study, but as expected, wound issues decreased over time. An injured worker has little control over work task−related issues and working conditions, but patients identified these as important factors in the inability to return to work. In fact, working conditions was the most important barrier in those who had not returned to work at 12 months. These barriers can be minimized through accommodations by the employer, and 67% of the subjects in this study who had returned to work received workplace accommodations. There is evidence that the availability of workplace accommodations does decrease the duration of disability.22 An employee can negotiate the necessary workplace accommodations in discussions with the health care provider and the employer, and there is evidence that the duration of disability is reduced when a health care provider contacts the workplace.22 This contact can be made by any member of the health care team, but it is ideally made by a vocational rehabilitation counselor who has the training and expertise to evaluate each patient’s impairment and the demands of the workplace and who can negotiate suitable accommodations. This intervention will facilitate a successful return to work. There are also multiple psychosocial factors that prevent a successful return to work.24 There is increased recognition of these factors as health care moves away from a traditional biomedical model of disability toward a biopsychosocial model. This model is proposed by the World Health Organization in the International Classification of Functioning, Disability and Health (ICF) and recognizes the complex relationship between a person’s body function and structure, environmental factors, personal factors, and the impact on the ability to complete activities and participate in daily roles such as vocational pursuits.25, 26 The ICF model has been used to examine the consequences of burn injuries.27, 28, 29 The psychosocial risk factors for prolonged disability can exist within a person (depression, anxiety/fear, lack of confidence) but can also exist within the workplace (job stress, coworker support).30 In this study these psychosocial barriers to work were measured under the general category of social abilities. In the early follow-up periods, the social abilities category had a low impact rating of approximately 2.0, and this increased to approximately 6.0 at the last follow-up. The percentages of patients endorsing items in the social abilities category significantly increased over time. This indicates that in those people with prolonged disability, psychosocial factors were a very important factor preventing them from returning to work. Further review of the data shows very high rates of psychologic issues such as nightmares or flashbacks, concern over appearance, and depressed mood preventing return to work. Other studies have shown the role of depression in predicting return to work.31 Long-term psychologic issues need to be evaluated and treated after burn injuries, but in this study we did not collect information regarding the accessibility of psychologic services or if subjects received counseling or medications. Study Limitations The study has several limitations. The sample, on average, consisted of subjects with relatively small burn injuries (vs people with >50% of TBSA burn injuries), which may not present long-term physical barriers to work. The sample included only those who were employed at the time of the injury and did not address the population of those who were unemployed and have a very difficult time finding employment at a new job after a burn injury. In addition, we did not collect information on work retention or the ability to keep a job over time. People may receive workplace accommodations only for a limited period of time and have difficulty progressing back to full duty and keeping their jobs over the long term. The data collected in the study are limited to each patient’s perception of the barriers to returning to work. Although this was the intent of the study, there is no objective measure to verify the significance of the perceived barrier. The final limitation is the limited number of subjects included at the later follow-up periods, due to a majority of subjects having returned to work before 4 to 6 months after discharge. Conclusions This study shows the barriers to return to work over time as perceived by people with burn injuries. Although there is a group of people who return to work within a few months of hospital discharge and report problems primarily with physical and wound issues, over 30% of subjects with burn injuries have longer-term disabilities. In these subjects, vocational rehabilitation counseling is recommended to assist with the assessment of the workplace, identification of appropriate workplace accommodations, and facilitation of a successful return to work. People with long-term disability also report increasing problems with psychosocial issues in addition to physical and work issues. These people can benefit from psychologic intervention as part of the overall treatment plan that includes a return-to-work goal. If these people are identified early in the recovery period and a psychologic and vocational treatment program is started, they may be able to return to work sooner. 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a Department of Rehabilitation Medicine, University of Washington, Seattle, WA b Department of Surgery, Division of Plastic Surgery, University of Washington, Seattle, WA c Department of Preventive Medicine and Biometrics, University of Colorado Health Science Center, Denver, CO d Department of Physical Medicine and Rehabilitation, University of Texas Southwestern Medical Center, Dallas, TX e Department of Psychiatry and Behavioral Science, Johns Hopkins University School of Medicine, Baltimore, MD.  Correspondence to Peter C. Esselman, MD, Dept of Rehabilitation Medicine, 325 9th Ave, Box 359740, Seattle, WA 98104
Supported by the National Institute on Disability and Rehabilitation Research, Office of Special Education and Rehabilitative Services, U.S. Department of Education (grant no. H133A020402). No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated. Reprints are not available from the author. PII: S0003-9993(07)01560-2 doi:10.1016/j.apmr.2007.09.009 © 2007 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved. | |
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