Access to vocational counselling, educational or job training has often been mentioned as a key issue in enabling return to work after SCI (Jang et al. 2005; Jongbloed et al. 2007; Lidal et al. 2007). However very few studies have empirically tested strategies to increase job opportunities and most reports we found were either case series or observational studies. Various strategies were described through case studies that had successful return to work and job retention. These individualized strategies addressed activities of daily living and mobility needs, job accommodation including workplace support, and employers’ needs and concerns. In this section we reviewed intervention studies examining strategies which lead to return to work.
This review suggests that there is a profound lack of high-level evidence studies which have a focus on work and employment-related interventions. Three randomized controlled studies were found, with Allen and Blaskovich (1996) examining access to trained service dogs, and suggesting an improvement in psychosocial status including self-esteem, internal locus of control, and overall psychological well-being. Other benefits of having trained service dogs were a decrease in assistance time by either a professional assistant or family and friends, an increase in school attendance and part-time employment, and an increase in social participation and community (Allen and Blascovich 1996).
The second randomized trial by Ottomanelli et al. (2012) found that a supported employment (SE) intervention was more effective at returning veterans to work than treatment as usual (TAU). Those receiving SE were 2.5 times more likely than those receiving TAU at the intervention sites (offering both SE and TAU) and 11.4 times more likely than those receiving TAU at the observation sites (offering only TAU) to achieve employment over the 12 month follow-up period. However, subjects in the SE group earned significantly less per week than those in the TAU intervention site group. This study was followed up by a third randomized trial (Ottomanelli et al. 2013) which reported that the supported employment (SE) intervention participants had a significantly higher rate of employment than the control, worked significantly more hours per week and missed significantly fewer hours of work.
There was one prospective studyby Shem et al. (2010) which found that participants who completed a mentorship program improved their functioning, independence, and participation, which may have contributed to their favorable return to work (or return to school) outcomes. However, it was not clear from the study whether or not participation in the mentorship program was directly related to employment post-SCI; hence existence of evidence is uncertain in this case. Other studies included case series and observational studies. These studies examined employment outcomes of people with SCI who received various vocational rehabilitation services. One study (Inge et al. 1998) suggests that people enrolled in a program using person-centered planning tools to identify needs and to direct the job search might gain employment but the workplace support greatly varied- from minor to intensive support. Another study (King et al. 2004) described a modified case management approach to return people with SCI to work. Comparing their preliminary results with those of the U.S. Model Systems, it appears that the program is successful for increasing return to educational training but not to work. Marini et al. (2008) suggest that people with SCI registered in state vocational rehabilitation agencies and receiving job placement services are likely to have a higher employment rate. Likewise, Jellinek and Harvey (1982) supported the conclusion of higher employment rate in individuals with SCI who had access to on-site professional counsellors for vocational / educational rehabilitation in addition to state vocational rehabilitation agency, compared to the state vocational rehabilitation agency only. They concluded that the vocational or educational placement was as high as 78% among those who had on-site vocational or educational services. In their sample of 169 people (49% engaged in gainful employment), Jang et al. (2005) found that fifty percent of the employed had received vocational training, compared with only 28% of the unemployed. Jongbloed et al. (2007) also found that employment re-training and education were identified as important contributors to success. However, the participants stated that services and information were perceived as difficult to access. Another observational study examined whether a publicly funded set of support services such as help with activities of daily living is associated with labour market participation. The authors found no effect of these services on labour market participation compared to support packages from private insurance sources (Rowell and Connelly 2010). Hence, evidence cannot be ascertained in this case. However, the same study found that an individual’s propensity to internalize positive employment outcomes in relation to his or her capabilities may contribute to returning to work.
Two other studies examine vocational interventions. Wang et al. (2002) compared a group of persons with SCI receiving a multimodal 6-month training course to a group without specific training. They found that individuals with paraplegia had higher employment rate which indicated an association between level of injury and employment. Hansen et al. (2007) interviewed male participants with SCI in a work rehabilitation program which included physical conditioning, vocational training, and work placements. Less than half were employed in a similar or identical job as their previous employment and only about a quarter of those who used a wheelchair returned to work. Overall, the studies included in this review investigated different types of interventions and used different measures to assess the interventions. Although this may limit the generalizability of the outcomes, there is evidence in general supporting the use of interventions to enhance employment post-SCI.
One study evaluated a telerehabilitation intervention and included employment as an outcome (Phillips et al. 2012). The intervention arm included a nine week telephone or video-based telerehabilitation intervention (not focused on employment) compared with care as usual. Return to employment was analyzed in those that were employed pre-injury; with those receiving the intervention not returning to work any faster than those receiving standard care.
There is level 1 evidence (Trenaman et al. 2014) suggesting that supported employment shows the strongest evidence that it can improve employment outcomes amongst individuals with SCI. Service dogs have also been shown to increase employment.
There is level 1 evidence (Kent & Dorstyn et al. 2014) that 3 psychological constructs: affective experiences, quality of life, and life satisfaction could be considered clinically important in their effects on employment.
There is level 1b evidence (Allen and Blascovich 1996) that suggests a service dog improves integration and participation in school and employment and decrease the number of hours of paid assistance after the first year.
There is level 2 evidence from two studies (Ottomanelli et al. 2012; Ottomanelli et al. 2013, Ottomanelli et al. 2015) that suggests that a supported employment intervention improves employment rates compared with treatment as usual over a one-year period, increases the number of hours worked per week and decreases the number of missed hours of work.
There is level 5 (Jellinek and Harvey 1982) and level 4 evidence (Marini et al. 2008) that on-site vocational rehabilitation counselling during inpatient rehabilitation can increase employment rates.
There is level 4 evidence (Marini et al. 2008) that use of job placement services may help individuals with SCI find employment.
There is level 4 evidence (Inge et al. 1998) suggesting that person-centred planning tools facilitate employment.
There is level 4 evidence (King et al. 2004) that case management programs increase return to educational training, but not to work.
There is level 4 evidence (Sinnott et al. 2014) that although the supported employment (SE) program for veterans with SCI was more effective in achieving competitive employment than treatment as usual (TAU), it was not cost effective after 1 year of follow-up.
There is level 4 evidence (Dorstyn et al. 2019) that providing structured information on SCI and employment (Work and SCI) over a 4-week period may help to establish vocational interests among job-seeking persons with SCI.
There is level 5 evidence (Rowell and Connelly 2010) that an individual’s propensity to internalize positive employment outcomes in relation to his or her capabilities may contribute to returning to work.
People with SCI may benefit from vocational rehabilitation in the process of job placement and work reintegration.
There is a dearth of high quality research in vocational (re) training. Consequently, conclusions are mostly based on evidence from observational studies or case studies.
Continuous support to the employee and employer before and after vocational placement may lead to a successful return to work and job retention.