Work and Employment

Personal Factors

Several personal characteristics have been identified as factors which may interfere with the ability to return to the labor market (Anderson et al. 2007; Lidal et al. 2007, Ottomanelli & Lind 2009). Some of these characteristics cannot be modified (e.g. level of injury) while others such as level of education, health status, and work skills can be modified with appropriate and targeted interventions. Tables 2 and 3 identify the non-modifiable personal factors and the modifiable personal and activity/participation factors, respectively, which influence employment after SCI. All of these studies are Level 5 evidence.

Table 2. Non-modifiable Personal Factors Influencing Employment After SCI

Personal factors	Impact on employment	Study (N)	Study reference
Sex	Being male tends to favour return to work. Exceptions: Anderson and Vogel 2002 (195), Arango-Lasprilla et al. 2009* (11424), Arango-Lasprilla et al. 2010(11090), Gunduz et al. 2010 (152), Krause and Reed 2011 (781), Ottomanelli et al. 2011 (238)	195 3756 259 615 1397 165 559 5925 82 234 181 2986 183 247	Anderson and Vogel 2002 Krause et al. 1999 Krause 2003 Krause and Terza, 2006 Krause 2010c* Lidal 2009 Marti et al. 2012 Meade et al. 2004 Pell et al 1997 Tomassen et al. 2000 Rowell and Connelly 2010 Tsai et al. 2014 Ullah et al. 2015 Clark et al. 2017
Ethnicity	Being Caucasian tends to favour return to work Exception: Ottomanelli et al. 2011 (238)	195 11424 11090 3514 1177 1032 3756 615 1362 1134 1397 14454 781 5925 111 118 247	Anderson and Vogel 2002 Arango-Lasprilla 2009* Arango-Lasprilla 2010* Arango-Lasprilla 2011 Hess et al. 2000 Krause et al. 1998 Krause et al. 1999* Krause and Terza 2006 Krause and Reed 2009* Krause et al 2010b* Krause 2010c* Krause et al 2010d* Krause and Reed 2011* Meade et al, 2004 Phillips et al. 2012 Paul et al. 2013 Clark et al. 2017
Age	Employment tends to increase with age up to 30 and remain the same up to middle 40’s Employment is lower in individuals aged 55-64 compared to those aged 45-54	195 167 20143 234 181 353 620 149 1323 1159	Anderson and Vogel 2002 Conroy and McKenna 1999 Pflaum et al. 2006 Tomassen et al. 2000 Rowell and Connelly 2010 (labor market participation may ↓ w/ age) Huang et al. 2017 Hirsh et al. 2009 Blauwet et al. 2013 Jetha et al. 2014 Marti et al. 2018
Age at time of injury	Younger age at injury tends to increase employment	167 1177 1032 3756 84 2986	Conroy et McKenna 1999 Hess et al. 2000 Krause et al. 1998 Krause et al., 1999* Ramakrishnan et al. 2011 Tsai et al. 2014
Duration of injury	The rate of employment increases with duration of injury (20-30	167 20143 2986 353	Conroy and McKenna 1999 Pflaum et al. 2006 Tsai et al. 2014 Huang et al. 2017
Severity of injury (cervical or tetraplegia)	Higher and more severe injury (i.e., tetraplegia and complete injury) has a negative influence on employment People experiencing fewer functional limitations have a higher likelihood of obtaining employment Exception: Botticello 2012 (1013), Gunduz 2010 (152), Marti et al. 2012 (559), Phillips et al. 2012 (111), Ottomanelli et al. 2011 (238)	195 11424 11090 114 167 403 1177 1032 259 1362 1398 1134 781 165 219 91 2986 353 120	Anderson and Vogel 2002 Arango-Lasprilla 2009* Arango-Lasprilla 2010* Castle 1994 Conroy and McKenna 1999 Franceschini 2012 Hess et al. 2000 Krause et al. 1998 Krause 2003 Krause and Reed 2009* Krause et al. 2010* Krause et al. 2010b* Krause and Reed 2011* Lidal 2009 Murphy et al. 1997 Wang et al. 2002 Tsai et al. 2014 Huang et al. 2017 Kader et al. 2018
Education pre-injury	Higher education pre-injury is a key factor in employment. People with tertiary education prior to injury were up to 8 times more likely to be in employment post-SCI. Exception: Ottomanelli et al. 2011 (238)	11424 3514 1013 114 169 403 152 60 259 615 1362 1398 1134 1397 781 1329 219 559 219 234	Arango-Lasprilla 2009* Arango-Lasprilla 2011 Botticello 2012 Castle 1994 Conroy and McKenna 1999 Franceschini 2012 Gunduz 2010 Hilton et al. 2017 Krause 2003 Krause and Terza 2006 Krause and Reed 2009* Krause et al. 2010* Krause et al. 2010b* Krause 2010c* Krause and Reed 2011* Krause et al. 2012* Lin et al. 2009 Marti et al. 2012 Murphy et al. 1997 Tomassen et al. 2000
Pre-injury work	Positive influence on employment: – Being employed at injury – Returning to pre-injury job – Lower physical demands of job pre-injury	11424 167 3756 259 1398 1134 192 72 20143 61 234 192 60 114 183	Arango-Lasprilla 2009* Conroy and McKenna 1999 Krause et al. 1999* Krause 2003 Krause et al. 2010* Krause et al. 2010b* Kurtaran et al. 2009 Murphy et al. 2009 Pflaum et al. 2006 Ramakrishnan et al. 2011b Tomassen et al. 2000 Young et al. 2004 Young et al. 2011 Ferdiana et al. 2014 Ullah et al. 2015
Pre-injury chronic conditions	Negatively impacts post-injury employment	219	Lin et al. 2009
Felony convictions	Negatively impacts ability to find employment regardless of vocation rehabilitation program	157	LePage et al. 2014
* These studies are based on data from the National Spinal Cord Injury Statistical Center (NSCISC) in the United States. In general, two different types of analyses are undertaken (1) retrospective analysis of data in the database (2) a cross-sectional survey that is sent out to individuals identified from the database. Given that the same eligibility criteria are often used for studies relating to work and employment, it is likely that the data from the same individuals are being used for multiple studies.

Personal factors

Impact on employment

Study (N)

Study reference

Sex

Being male tends to favour return to work.

Exceptions:

Anderson and Vogel 2002 (195), Arango-Lasprilla et al. 2009* (11424), Arango-Lasprilla et al. 2010*(11090), Gunduz et al. 2010 (152),

Krause and Reed 2011* (781), Ottomanelli et al. 2011 (238)

195

3756

259

615

1397

165

559

5925

234

181

2986

183

247

Anderson and Vogel 2002

Krause et al. 1999

Krause 2003

Krause and Terza, 2006

Krause 2010c*

Lidal 2009

Marti et al. 2012

Meade et al. 2004

Pell et al 1997

Tomassen et al. 2000

Rowell and Connelly 2010

Tsai et al. 2014

Ullah et al. 2015

Clark et al. 2017

Ethnicity

Being Caucasian tends to favour return to work

Exception:

Ottomanelli et al. 2011 (238)

195

11424

11090

3514

1177

1032

3756

615

1362

1134

1397

14454

781

5925

111

118

247

Anderson and Vogel 2002

Arango-Lasprilla 2009*

Arango-Lasprilla 2010*

Arango-Lasprilla 2011

Hess et al. 2000

Krause et al. 1998

Krause et al. 1999*

Krause and Terza 2006

Krause and Reed 2009*

Krause et al 2010b*

Krause 2010c*

Krause et al 2010d*

Krause and Reed 2011*

Meade et al, 2004

Phillips et al. 2012

Paul et al. 2013

Clark et al. 2017

Age

Employment tends to increase with age up to 30 and remain the same up to middle 40’s

Employment is lower in individuals aged 55-64 compared to those aged 45-54

195

167

20143

234

181

353

620

149

1323

1159

Anderson and Vogel 2002

Conroy and McKenna 1999

Pflaum et al. 2006

Tomassen et al. 2000

Rowell and Connelly 2010 (labor market participation may ↓

w/ age)

Huang et al. 2017

Hirsh et al. 2009

Blauwet et al. 2013

Jetha et al. 2014

Marti et al. 2018

Age at time of injury

Younger age at injury tends to increase employment

167

1177

1032

3756

2986

Conroy et McKenna 1999

Hess et al. 2000

Krause et al. 1998

Krause et al., 1999*

Ramakrishnan et al. 2011

Tsai et al. 2014

Duration of injury

The rate of employment increases with duration of injury (20-30

167

20143

2986

353

Conroy and McKenna 1999

Pflaum et al. 2006

Tsai et al. 2014

Huang et al. 2017

Severity of injury

(cervical or tetraplegia)

Higher and more severe injury (i.e., tetraplegia and complete injury) has a negative influence on employment

People experiencing fewer functional limitations have a higher likelihood of obtaining employment

Exception:

Botticello 2012 (1013),

Gunduz 2010 (152),

Marti et al. 2012 (559),

Phillips et al. 2012 (111),

Ottomanelli et al. 2011 (238)

195

11424

11090

114

167

403

1177

1032

259

1362

1398

1134

781

165

219

2986

353

120

Anderson and Vogel 2002

Arango-Lasprilla 2009*

Arango-Lasprilla 2010*

Castle 1994

Conroy and McKenna 1999

Franceschini 2012

Hess et al. 2000

Krause et al. 1998

Krause 2003

Krause and Reed 2009*

Krause et al. 2010*

Krause et al. 2010b*

Krause and Reed 2011*

Lidal 2009

Murphy et al. 1997

Wang et al. 2002

Tsai et al. 2014

Huang et al. 2017

Kader et al. 2018

Education pre-injury

Higher education pre-injury is a key factor in employment. People with tertiary education prior to injury were up to 8 times more likely to be in employment post-SCI.

Exception:

Ottomanelli et al. 2011 (238)

11424

3514

1013

114

169

403

152

259

615

1362

1398

1134

1397

781

1329

219

559

219

234

Arango-Lasprilla 2009*

Arango-Lasprilla 2011

Botticello 2012

Castle 1994

Conroy and McKenna 1999

Franceschini 2012

Gunduz 2010

Hilton et al. 2017

Krause 2003

Krause and Terza 2006

Krause and Reed 2009*

Krause et al. 2010*

Krause et al. 2010b*

Krause 2010c*

Krause and Reed 2011*

Krause et al. 2012*

Lin et al. 2009

Marti et al. 2012

Murphy et al. 1997

Tomassen et al. 2000

Pre-injury work

Positive influence on employment:

– Being employed at injury

– Returning to pre-injury job

– Lower physical demands of job pre-injury

11424

167

3756

259

1398

1134

192

20143

234

192

114

183

Arango-Lasprilla 2009*

Conroy and McKenna 1999

Krause et al. 1999*

Krause 2003

Krause et al. 2010*

Krause et al. 2010b*

Kurtaran et al. 2009

Murphy et al. 2009

Pflaum et al. 2006

Ramakrishnan et al. 2011b

Tomassen et al. 2000

Young et al. 2004

Young et al. 2011

Ferdiana et al. 2014

Ullah et al. 2015

Pre-injury chronic conditions

Negatively impacts post-injury employment

219

Lin et al. 2009

Felony convictions

Negatively impacts ability to find employment regardless of vocation rehabilitation program

157

LePage et al. 2014

* These studies are based on data from the National Spinal Cord Injury Statistical Center (NSCISC) in the United States. In general, two different types of analyses are undertaken (1) retrospective analysis of data in the database (2) a cross-sectional survey that is sent out to individuals identified from the database. Given that the same eligibility criteria are often used for studies relating to work and employment, it is likely that the data from the same individuals are being used for multiple studies.

Discussion

Several personal characteristics cannot be modified but must be taken into consideration in the assessment of potential (re-)employment after SCI as summarized in table 2. These factors can be divided into 4 categories: 1) demographics, 2) time-related, 3) injury-related, and 4) work/education factors. The evidence of the influence of these factors (level 5) is based on observational studies. Being Caucasian is a demographic factor that favors employment. Male gender has been a strong demographic predictor of employment, but a number of recent studies have shown no significant difference between males and females. However, 3 of the 6 studies showing no significant difference come from the same data source. The interaction between age, age at injury and the duration of injury is very complex making it difficult to determine their individual influence on employment. While the proportion of employed people tends to increase with age (increases up to about 30 years of age and is maintained up to 40 years), younger age at injury and longer duration of injury (up to 20 years post-injury) are better predictors of being employed than age alone. Due to a non-linear effect of age on labor market participation, it is likely that work participation may decrease with increasing age at some point after 40. Hirsch et al. (2009) reports that individuals aged 45-54 were significantly more likely to be employed than those aged 55-64. A more severe injury tends to decrease the probability of employment. A higher level of education seems to be a factor in increasing the probability of employment. Factors related to pre-injury work such as being employed at injury, returning to pre-injury job or holding a job requiring a lower physical intensity tend to positively influence employment.

Conclusion

There is level 5 evidence (see Table 2) that being male, Caucasian, and younger at time of injury; having a longer duration of injury, higher education pre-injury, and a low-intensity pre-injury job are non-modifiable personal factors that positively influence employment opportunities after SCI.

There is level 5 evidence (Hirsch et al. 2009) that the severity of injury is a non-modifiable personal factor that negatively influences employment opportunities after SCI.

Non-modifiable personal characteristics such as being male and Caucasian, younger at injury, with a longer duration of injury (20-30 years), with higher pre-injury education, being less severely injured, and being employed at injury in a low-intensity job increase the likelihood of employment post-SCI.

Table 3. Modifiable Personal/Activity and Participation Factors Influencing Employment After SCI

Personal	Impact on employment	Study (N)	Study reference
Education / training post-injury	Positive influence on employment: – higher level of education (high school or above) – vocational retraining – attaining post-secondary education	114 167 152 169 259 1362 1398 1329 192 559 5925 459 20143 234 118 181 60 1323 176 353	Castle 1994 Conroy and McKenna 1999 Gunduz 2010 Jang et al. 2005 Krause 2003 Krause and Reed 2009* Krause et al. 2010* Krause et al 2012* Kurtaran et al. 2009 Marti et al. 2012 Meade et al. 2004 Murphy et al. 2003 Pflaum et al. 2006 Tomassen et al. 2000 van Velzen et al. 2009 Rowell and Connelly 2010 Hilton et al. 2017 Jetha et al. 2014 Ferdiana et al. 2014 Huang et al. 2017
Household income	Higher household income group had higher vocational satisfaction. The lower income group had greater improvements in vocational satisfaction over the course of the 10-year study.	434	Cao et al. 2014
Secondary health conditions	In 10 papers, secondary health conditions are a barrier to employment (e.g., medical complications, bowel incontinence, urinary tract infection, chronic pain, depression, pressure ulcer) Exception: Hirsch et al. 2009 (N=620; pain, fatigue, sleep) Krause et al. 2011 (N=781; health status) Meade et al. 2011 (N=5925; secondary health conditions) Matthew et al. 2013 (N=108; pressure ulcers) Ramakrishnan et al. 2011 (N=84; medical co-morbidities.)	195 1013 781 403 559 103 234 83 219 2986	Anderson and Vogel 2002 Botticello et al. 2012 Hirsch et al. 2009 (psych functioning) Franceschini 2012 Marti et al. 2012 (pain) Mann et al. 2013 (pain) Wehman et al. 2000 Burns et al. 2010 (depression) Lin et al. 2009 (depression) Tsai et al. 2014 (catheter indwelling in bladder, pain)
Functional independence	Functional independence increases the likelihood of being employed Independence in bladder emptying is positively associated with return to work Physical function was the most important in relation to return to work in patients with SCI	195 1013 14620 169 72 109 234 2986 192 2986 167	Anderson and Vogel 2002 Botticello et al. 2012 Cohen et al. 2012 Jang et al. 2005 Murphy et al. 2009* Ramakrishnan et al. 2011 (personal care) Tomssen et al. 2000 Tsai et al. 2014 Kurtaran et al. 2009 Tsai et al. 2014 Jeong et al. 2015
Psychological component (locus of control, values placed on work, expectations)	Positive influence on employment: – endorsement of gender norms – internal locus of control – valuing work – positive expectations toward work – positive attributional style (the individual’s propensity to “internalize” positive employment outcomes to his/her own attributes, capabilities or functioning – personal sense of motivation – family and rehabilitation professionals serving as extrinsic motivators – social participation is correlated with wellbeing, decreased anxiety and depression – subjective wellbeing – hope and sense of direction – gaining self confidence – self-efficacy and secure attachment	83 459 57 109 181 60 30 60 13 44 190 4 84	Burns et al. 2010 Murphy et al. 2003 Schonherr et al. 2004 Wehman et al. 2000 Rowell and Connelly 2010 Murphy et al. 2011 Boyle et al. 2014 Hilton et al. 2017 Ramakrishnan et al. 2016 Reed et al. 2016 Umucu et al. 2016 Willbanks et al. 2015 Blake et al. 2017
Relationship status	Positive influence on employment – participants in a relationship at the time of injury were 3.5 times more likely to be employed at 2 years post discharge – married participants	60 461 1323	Hilton et al. 2017 Hwang et al. 2015 Jetha et al. 2014
Social Roles	Participating in more social roles had a positive influence on employment for young/middle aged, and older adults	1323	Jetha et al. 2014
Wheelchair skills	People with better wheelchair skills are more likely to return to work. Manual wheelchair users have higher employment rates than power wheelchair users	118 30 2986	van Velzen et al. 2009 Hastings et al. 2011 Tsai et al. 2014
Activity / participation factor	Impact on employment	Study (N)	Study reference
Sport participation	Participation in organized sports was associated with increased likelihood of employment.	149	Blauwet et al. 2013**
Social Participation	Decreased social participation reduces the odds of being employed	3162	Tsai et al. 2017
* These studies are based on data from the National Spinal Cord Injury Statistical Center (NSCISC) in the United States. Generally speaking, two different types of analyses are undertaken (1) retrospective analysis of data in the database (2) a cross-sectional survey that is sent out to individuals identified from the database. Given that the same eligibility criteria are often used for studies relating to work and employment, it is likely that the data from the same individuals are being used for multiple studies. **The definition of employment varies among different studies. These studies consider full-time students to be unemployed while others include students within the definition of employment.

Discussion

Several factors can be modified in the post-injury period to prevent deleterious effects or to increase the likelihood of employment after SCI. These factors are categorized as: 1) education / training, 2) health status, 3) functional independence, 4) psychological issues, 5) wheelchair skills and 6) participation. Secondary health conditions such as pain, depression, spasticity, pressure ulcers, severe urinary tract infections and respiratory problems are likely to limit employment opportunities but this finding should be considered in conjunction with the severity of injury. For example having tetraplegia leads to a higher occurrence of secondary health complications due to larger extent of affectation than paraplegia. The level of education or pursuit of training after SCI remains a key factor that can offset other factors such as the severity of injury. Specifically, a professional degree and work that is not physically demanding increases the likelihood of employment. Some psychological attributes such as an internal locus of control, positive values and expectations regarding work including internalization of positive work outcomes are likely to favor employment. Participation in organized sports may facilitate employment through the building of mentorship/relationships, socialization and self-confidence (Blauwet et al. 2013). Reducing environmental barriers may enhance social participation and facilitate employment status.

Conclusion

There is level 5 evidence (see Table 3) that being married, having education post-injury, having fewer secondary health conditions and higher functional independence, having better work related values and a higher internal locus of control, and better wheelchair skills are modifiable personal factors that positively influence employment opportunities after SCI.

Modifiable personal characteristics such as being highly educated post-SCI, limiting the occurrence of health complications, having a higher level of independence (including wheelchair skills), and having the trait of valuing work can increase the likelihood of employment post-SCI.