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Work and employment are terms that are used interchangeably in the literature and in this chapter and would include remunerative and non-remunerative employment regardless of work status, type of industry, and type of occupation. The International Classification of Functioning, Disability and Health (ICF) of the World Health Organization defines employment as “engaging in all aspects of work, as an occupation, trade, profession or other form of employment, for payment or where payment is not provided, as an employee, full or part time, or self-employed” (World Health Organization, 2001). Employment remains one the most important topics to have been studied since the early 50’s when the importance of returning to work after SCI was recognized (Guttmann 1959). Not only does gainful employment help to achieve economic self-sufficiency but it is considered a source of personal growth (Ville and Ravaud 1998), disability adjustment (Krause 1992) and is associated with social integration, life and financial satisfaction and better health (Vogel et al, 1998; Anderson et al. 2007). Exact employment figures in published studies are difficult to capture due to variations in sample characteristics such as the participant’s age, duration of injury, and work experience prior to injury, as well as differences in the definition of the concept of employment (Ottomanelli and Lind 2009). Although variation is observed in the employment rate (2 – 80%) (Ottomanelli and Lind 2009), it is likely that the most accurate overall figure since the 70’s is between 30-50%. It does vary based on the severity of injury in addition to regional disparities. Recent data from the U.S. Spinal Cord Injury Model Systems database suggests that 35% of people with SCI are employed 20 years post-injury (https://www.nscisc.uab.edu) compared to an average unemployment rate of the US general population of 6.1% for a 20-year period (1993-2013).

There is a tangible need to explain why involvement in employment is significantly lower in a population with disabilities than observed in those without disabilities despite a significant proportion of unemployed people with SCI judging themselves able to work (Tomassen et al. 2000). Today, the development of environmental features (technology, robotics, environmental controls, universal design) and the attenuation of prejudices and the opportunity for job accommodation are making positive change. However, it is astonishing that the employment rate has not evolved much over the past decades to an extent that this could have counteracted the detrimental effect of non-modifiable consequences of SCI.

On the other hand, this reveals the complexity of the process of returning to work. Given that work disability results from the interaction of some personal and environmental characteristics (Fougeyrollas et al. 2002; Chan and Man 2005), it remains inappropriate to state that people with SCI experience low employment rate only because of intrinsic or personal characteristics (Fougeyrollas et al. 2002). To ensure a higher likelihood of success in return to work, interventions must target several factors including work retraining and other types of environmental interventions.A major domain to explore is vocational (re)training, which includes vocational rehabilitation. A condensed definition has recently been published, referring to vocational rehabilitation as “a multi-professional evidence-based approach through various settings and interventions and is provided to working age individuals with health-related impairments, limitations, or restrictions with work functioning, and whose primary aim is to optimize work participation” (Escorpizo et al. 2011). Another goal of vocational rehabilitation is early and sustained participation in employment in any form- either remunerative (paid) or non-remunerative (nonpaid).

The objective of this chapter is to identify modifiable and non-modifiable factors related to contextual factors, namely the personal/activity and participation and the environmental factors based on the ICF framework that influence employment and to evaluate the evidence of interventions designed to promote return to work post-SCI. Similar to the other SCIRE chapters that have a focus on an area relevant to community reintegration, the methods used for the development of this review expanded upon the traditional SCIRE methods (see SCIRE Methods). Specifically, two new databases with a focus on the social sciences were searched (Social Sciences Abstracts and Social Work Abstracts), and the inclusion criteria were broadened to include any relevant qualitative studies.