El Grado de Enfermería dentro del Espacio Europeo de Educación Superior.

There is a lack of evidence to support the clinical effectiveness or cost-effectiveness of VR for people with TBI. Two systematic reviews3,69_{of RTW following TBI have concluded that there is a need for well-conducted} experimental and observational studies. Saltychevet al.,3_{in a systematic review of pre- and post-injury} predictors of vocational outcome, identified 80 studies, comprising 12 controlled (eight RCTs, two controlled clinical trials and two observational reports) and 68 uncontrolled observational reports. They found no strong evidence that vocational outcomes after TBI could be predicted or improved. However, most of the studies included in the review were generic studies of neurorehabilitation rather than trials evaluating the effectiveness of a VR intervention.

In a systematic review examining the effectiveness of VR in TBI, Grahamet al.69_{identified three small RCTs:} two of military populations in the USA37,70_{and one of civilians in Hong Kong.}71

Salazaret al.70_{compared an intensive in-hospital cognitive rehabilitation intervention and integrated work} programmes delivered by a neuropsychologist, occupational therapist (OT) and speech pathologist (n=67) with an in-home rehabilitation programme including TBI education and individual counselling from a psychiatric nurse (n=53). Participants were active US military personnel with moderate to severe TBI within 90 days of injury. At 1 year, there were no significant differences between groups in fitness for military duty, RTW rate, cognition, physical or verbal aggression, or QoL. However, among those who were unconscious for>1 hour (n=75), the proportion who returned to work was 7% higher in the cognitive rehabilitation and VR group, although the difference was not significant (95% CI–10% to 24%;p=0.43). Twamleyet al.37_{compared a 1-year supported employment programme with the same programme plus} CogSMART (for the first 3 months). Participants were US military veterans with mild to moderate TBI (n=50). The authors hypothesised that augmenting work rehabilitation with compensatory cognitive training may improve functional outcomes because compensatory interventions can be individually tailored to each person’s job search process and job duties. CogSMART sessions were delivered by an employment specialist and included strategies to improve sleep, fatigue, headaches and tension, and compensatory

cognitive strategies for prospective memory, attention, learning and memory, and executive functioning. At 12 months, there was no difference in employment between the groups. However, those also receiving CogSMART had significant reductions in post-concussive symptoms, improvements in prospective memory functioning, less severe post-traumatic stress disorder and less depression, which suggested that adding CogSMART to supported employment might improve post-concussive symptoms and prospective memory. Manet al.71_{compared 12 sessions of three-dimensional artificial intelligence (AI), virtual reality-based} VR with 12 sessions of psychoeducational VR with a vocational trainer. People with mild to moderate TBI were recruited from rehabilitation facilities in Hong Kong (n=50). The programmes included similar problem-solving tasks, instructions and provided time to practise skills. Of the 40 participants self-reporting employment outcomes at 6 months, 8 out of 20 in the AI-VR group were employed compared with only 4 out of 20 in the psychoeducational VR group [odds ratio (OR) 2.20, 95% CI 0.46 to 10.57].

Grahamet al.69_{concluded that VR for people with TBI may improve employment status but no programme} was more effective than its comparator. No studies compared VR with UC or a non-VR attention control group, or reported secondary employment outcomes such as hours worked, wages earned, absenteeism, presenteeism or self-efficacy.

Since this review,69_{two further VR in TBI trials}72,73_{have been published. O’Connoret al.}72_compared VR enhanced by cognitive rehabilitation and a computer-based homework programme with supportive client-centred therapy in a small pilot trial in US veterans with mild TBI and mental illness (n=18). At 12 months, they identified small to moderate effects in the VR group on employment outcomes (more people competitively employed and more days worked). The 12-session VR programme, led by therapists and psychologists, included strategies to manage cognitive difficulties in the workplace, enhance skills to recognise and control unhelpful behaviours at work, deal with negative emotions, and foster positive relationships among coworkers and employers. There was also a computer-based homework programme, in addition to support, from a VR specialist. This feasibility study was small and hampered by poor adherence with therapeutic strategies in both groups, although programme attendance was similar, and high withdrawal rates. Of the 25 participants randomised, six withdrew or were withdrawn in the first two study sessions owing to mental health destabilisation (n=3), an unexpected move out of the area (n=2) and dissatisfaction with the control group assignment (n=1).

Trexleret al.73_{examined the effectiveness of resource facilitation (RF) (i.e. a partnership that supports people} to make informed choices and achieve rehabilitation goals, involving active engagement with a previous employer) in 44 people with mild to moderate acquired brain injury (ABI) who were working pre injury (n=22, 13 with TBI) and a UC control group (n=22, 10 with TBI). At 15 months, 17 out of 22 participants in the RF group with a goal of returning to work, volunteering or returning to education were successful (11 had returned to paid employment, three became volunteers and three returned to education), compared with 12 out of 22 participants in the UC control group meeting return-to-work/volunteering/education goals (10 remained employed and two returned to education). RF participants with a work-related goal had seven times higher odds of returning to productive activity than the control participants (95% CI 1.25 to 39.15). However, although this case-co-ordinated approach in ABI seems positive, the trial73_{took place in a single} centre, numbers were small and there were only 23 participants with TBI (mostly mild). The intervention was staff resource intensive, requiring three more staff than UC, and lasting for 15 months. Both intervention and UC participants had access to acute and outpatient rehabilitation services, neuropsychological services and specialised day treatment programmes. However, the total amount of RF and outpatient therapies provided to the VR and UC groups was not reported, meaning that it is difficult to identify if both groups received similar levels of outpatient therapy and if differences are attributable to RF VR. Data specific to people with TBI were not reported. Interestingly, more participants in the RF group than in the UC group were employed in professional and executive positions to which they returned, which may also have

Overall, current evidence for effectiveness of VR in TBI is limited and inconclusive. Of the five VR trials37,70–73 published to date, three37,70,72_{have been with US military personnel or veterans. Military studies differ from} those in civilian populations as participants present with different challenges (e.g. post-traumatic stress disorder) but also opportunities (e.g. better motivation, adherence and greater opportunities for redeployment within the military).

The effectiveness of neurological rehabilitation in traumatic brain injury