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General Introduction

Rehabilitation following spinal cord injury (SCI) recognises the importance of returning to work and the essential role employment plays in participation within a community.

Remunerative (paid) employment is a vital aspect of human functioning, a concept that reflects the dynamic interaction between the body functions, body structures, and activities and participation of an individual within a social and environmental context.1234 In the International Classification of Functioning, Disability and Health (ICF), work and employment make up an important element of the major life areas that include apprenticeships, acquiring, keeping and terminating a job, and both remunerative employment and non-paid/volunteer work.5

For persons living with the consequences of SCI, physical challenges are just one of many obstacles that they are confronted with as they work to rebuild their lives. Finding and securing employment presents a further challenge. In many countries, there is societal pressure to work; the expectation to work also applies to those with SCI. Among adults, one of the most important indicators for reintegration into the community is participation in productive work. Considering this, it would be important to identify the factors that facilitate work participation.2367

Studies have shown that employment rates among persons with SCI varies, partly due to varying study methodologies. In general the employment rate among persons with SCI is relatively low, approximately 30-50%.267

""...the employment rate among persons with SCI is relatively low, approximately 30-50%.""

Facilitators and Barriers to Work Participation

A number of facilitators and barriers to work participation among persons with SCI have been elaborated in several studies.238910111213 The facilitating factors that are associated with a higher rate of employment after SCI include:

  • a higher level of education
  • younger age at SCI onset
  • being male and Caucasian
  • longer time since SCI onset
  • being employed at the time of SCI onset
  • returning to pre-injury job
  • less physically demanding job (both pre- and post-injury job)
  • greater functional independence and mobility in the community e.g. independent driving
  • access to assistive devices and possibility of job accommodation e.g. shorter working hours

Barriers to work participation that have been most frequently reported include severe injury level and health complications, problems with transportation, architectural barriers, perceived discrimination at the workplace, financial disincentives such as fear of losing benefits, lack of work experience, and insufficient education or training.2811

In addition to identifying facilitators and barriers to work participation, one study found that persons with SCI need sufficient time to explore their employment potential and to undertake steps for acquiring sustainable work.11 In this study, persons with SCI required on average 4.8 years to return to work and 6.3 years before engaging in full-time employment. This time interval from SCI onset to employment depends on the factors previously mentioned, especially on the possibility of returning to the pre-injury job.

""...persons with SCI need sufficient time to explore their employment potential and to undertake steps for acquiring sustainable work.""

While returning to the pre-injury job has been found to be a key factor in successful work participation following an SCI, one study found that only 17% actually return to their pre-injury job.11 This finding, however, does not have to be disheartening. Another study, despite a small sample size, found that those who had no option to return to the pre-injury job received more vocational training, took more time for vocational exploration and seemed more satisfied at work than those who quickly returned to the pre-injury job. The study team offered the explanation that the job with a new employer tended to be less physically demanding and more suitable in light of the person's functioning status.614

An understanding of the association between facilitators and barriers and a specific person's work participation can be a valuable tool for rehabilitation and vocational professionals in preparing this person for community integration, specifically in optimising the person's vocational potential.3891115 Ideally, vocational rehabilitation (VR), that includes a comprehensive assessment of functioning, should be available early in the rehabilitation of a person with SCI. The VR program offered should be person-oriented, allowing the person to steer the direction and focus of the VR activities.

""Ideally, vocational rehabilitation, that includes a comprehensive assessment of functioning, should be available early in the rehabilitation of a person with SCI.""

Supported Employment – One Approach of Vocational Rehabilitation

One approach of VR is supported employment. Supported employment is one model that can help “enable those with disabilities to achieve sustainable, long-term employment and businesses to employ valuable workers.”16 Supported employment involves evaluating and profiling a person's skills, work experience and interests, vocational counselling, job-matching, on-the-job vocational interventions e.g. support through a job coach, possible workplace adaptations and accommodations, and long-term support even after the person has been on the job of a period of time. Supported employment advocates the utilization of the person's existing skills and further developing them on the job rather than undergoing extensive training before starting a job. Supported employment also emphasises the importance of engaging the employer in the VR activities.161718

The work of Ottomanelli and colleagues1819 has shown that supported employment is effective in improving employment outcomes (i.e. finding and keeping a paid job) of persons with SCI, even 2 years after entering the supported employment program. The results of their research also confirms the value of individualised, person-centred and evidence-based VR services that is conducted within a multi-disciplinary team (including vocational specialists) and in close partnership with employers in the community. Along with supported employment, there are other VR interventions that can be employed to enhance a person's vocational potential and possibly help increase satisfaction at the workplace.217181920

Box 1 | Targets of Vocational Rehabilitation Interventions

VR interventions provided to persons with SCI aim to optimise work participation, support them to secure employment and promote life satisfaction through work participation. Strategies for meeting these aims are multi-faceted, and address an interrelated range of targets.2781720 This includes:

Identification of facilitators and barriers, and personal goals that may impact a person’s work participation – This can be achieved through individual VR counselling that also involves setting a plan for the exploration of vocational possibilities, including education and training, and assessing realistic and feasible job options based on the person’s skills, past experiences, health situation, facilitators and barriers, and personal goals.

Addressing personal care issues – Assistance can be provided by family, a personal assistant or job coach for example to help the person get ready for work and on time, or to manage toileting issues at the workplace.

Improvement of mobility – This includes ensuring adequate transportation to and from the workplace as well as independent personal mobility within the workplace e.g. wheelchair accessibility.

Modification of employer perceptions – Open and regular communication with employers can minimise possible discrimination, promote realistic expectations, facilitate the employer’s receptiveness to possible workplace accommodations, and help ensure a “win-win situation” for both the employee with SCI and employer.

Exploration of necessary accommodations – Possible accommodations include physical accessibility at the workplace e.g. providing ramps, availability of elevators, office desk is wheelchair accessible, flexible work hours, availability and/or possibility to modify work tools and equipment, and providing on-the-job personal assistance.

Contact with peers – The possibility of exchanging ideas and experiences with peers who are in the workforce can facilitate the job search and maintenance of work participation.

Reduction of financial disincentives to working – Disincentives to working can be present when financial assistance is greater than the remuneration for employment. A disincentive could also simply be the perception that benefits, e.g. disability benefits or funding for assistive devices and equipment or services would be taken away.

Identifying the factors that could influence a person’s work participation, as indicated in box 1, is the first step in the VR process. This case study of Martin, a 26-year old man with SCI engaged in the VR process at an inpatient rehabilitation centre, will show the importance of integrating VR counselling and training early in the rehabilitative process.