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Rehabilitation Practices

Vocational Rehabilitation

Rates of employment after an SCI is low, with one systematic review reporting a global rate of 11.5% (Young & Murphy 2009), with rates in the United States (Cao & Krause 2020; Ottomanelli et al. 2009; Ottomanelli et al. 2020) and Australia (Dorsett & McLennan 2019; Young & Murphy 2009) at 35% and 30%, respectively. Of those that returned to work, most tend to be younger, obtained higher education, or were previously employed in a middle-class occupation (Calliga & Porto 2019; Leiulfsrud et al. 2020; Ottomanelli et al. 2020). In a small observational study, Ottomanelli et al. (2009) assessed veterans with SCI employment history, employment rate, awareness of vocational services, and utilization of vocational services. The majority of veterans were unaware of vocational services and awareness was significantly lower for persons with tetraplegia (95%) compared to paraplegia (80%) (p<0.05). Of the veterans aware of vocational services (20%), only 10% used them. Among those who did not return to work, 65.2% stated this was due to medical issues, followed by unsuccessful attempts at finding employment (13%), social barriers (8.7%), and not needing the income (8.7%). The findings of this study emphasize the need to educate veterans, especially those with more severe injuries, about vocational rehabilitation services as a possible means of improving employment outcomes in this special population.

Most vocational rehabilitation is conducted in the community, well after an individual endures a lengthy in-patient rehabilitation stay. Vocational programs have been shown to be effective. For example, in a review of employment outcomes among veterans with SCI, Ottomanelli et al. (2017) reported that a 24-month program of individual placement and supported employment resulted in an overall employment rate of 43.2%; further, participants averaged 38.2 weeks of employment. Although shown to be effective, in one study it was found that the majority of rehabilitation programs do not include vocational rehabilitation (Dorsett & McLennan 2019).

Studies have found that early intervention is one factor related to positive vocational outcomes, particularly when medical and vocational rehabilitation overlap (Langman 2011; Lukasczik et al. 2011). A qualitative study by Johnston et al. (Johnston et al. 2016) explored the perceptions of health professionals with respect to InVoc, an early vocational rehabilitation intervention provided to inpatients with SCI. To understand the program’s most critical elements and whether it was successful, 25 allied staff participated in focus groups. Four main themes emerged: timeliness of the intervention, support and advocacy, value of early intervention, and conflicting messages to patients. Three critical program elements were identified: flexibility, coordinators working on the ward, and good communication between all staff. Overall, the early vocational rehabilitation program was perceived as appropriate and successfully implemented.

These findings were echoed in another qualitative study by Ramakrishnan et al. (2016) who performed semi-structured interviews with participants who completed an early-intervention vocational program. The program was viewed positively with emerging themes from participants suggesting it gave them a sense of direction and distraction, a feeling of advocacy and support, and “hope.” This is supported by an observational study which found that participants who completed vocational rehabilitation experienced the greater quality of life, albeit, no changes in depression (Calliga & Porto 2019). Criticisms of the program were that it was offered too early in the intensive care unit when there were competing interests and information overload in the early recovery phase (Ramakrishnan et al. 2016).

Overall, vocational rehabilitation represents a small proportion of the scientific literature on SCI rehabilitation. A recent scoping review by Cotner et al. (2019) collated the resources, tools, and educational materials available on vocational rehabilitation in SCI care. The authors reported that there are few resources to guide the implementation of Individual Placement and Support (IPS); however, 16 essential resources were identified that, when combined, formed a toolkit. The toolkit, Tools for a Working Life: Individual Placement and Support in SCI Toolkit, could be used by all rehabilitation providers to educate individuals on effective ways of assisting people with SCI to find employment and transition into their placement. The toolkit is currently being field-tested with clinical providers with an overall goal to adopt it into regular rehabilitation programs (Cotner et al. 2019).

Finally, Rapidi et al. (2018) published a professional practice guide for physicians trained in the care of persons with SCI in the acute, subacute, and chronic phases of illness. A single recommendation was made with respect to vocational rehabilitation such that it should be “systematically and adequately offered to improve employ­ment rates and decrease the high rates of unemployment of persons with SCI during their working life (pg. 803).”

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