Review of Critical Factors Related to Employment After Spinal Cord Injury: Implications for Research and Vocational Services

Abstract

Background/Objective:

Employment rates after spinal cord injury (SCI) vary widely because of discrepancies in studies' definition of employment and time of measurement. The objective of this study was to provide a comprehensive summary of the literature on employment rates, predictors of employment, and the benefits and barriers involved.

Methods:

A search using the terms spinal cord injury and employment in the databases PubMed, PsycINFO, and MEDLINE. The search included a review of published manuscripts from1978 through 2008.

Results:

A total of 579 articles were found and reviewed to determine the presence of reported employment rates. Of these, 60 articles were found to include a report of employment rates for individuals with SCI. Results indicated that, in studies that examined paid employment, the average rate of any employment after SCI was approximately 35%.

Conclusions:

Characteristics associated with employment after SCI include demographic variables, injury-related factors, employment history, psychosocial issues, and disability benefit status. It is recommended that researchers studying employment after SCI use common outcome measures such as competitive employment rates, duration of employment, and job tenure. Empirical evidence is lacking in regard to the most effective methods of vocational rehabilitation among this population. Evidence-based supported employment practices seem to be the most applicable model for assisting persons with SCI in restoring meaningful employment. Controlled studies are needed to test this assumption.

INTRODUCTION

According to the National Spinal Cord Injury Statistical Center (NSCISC), it is estimated that there are 12,000 new cases of spinal cord injury (SCI) every year in the United States. Approximately 60% of cases occurred in people 16 to 30 years of age, corresponding to the developmental periods associated with career development and establishment (1). Average age at injury was 39.5 years, and more than one half (57.4%) were employed at the time of their injury. Ten years after injury, 32.4% of persons with paraplegia were employed, whereas only 24.2% of those with tetraplegia were employed at that time. Compared with the general population, unemployment rates in the SCI population have been reported in excess of 10-fold. It has been estimated that only 12% of individuals with SCI return to their preinjury jobs (2). According to polls of unemployed persons with disabilities, 79% report that they want to work, and recent data suggest many persons with SCI who are currently unemployed judge themselves to be capable of working (3) and express a desire to work (4).

Unemployment remains a prevalent and serious problem for persons with SCI, which is especially disturbing in light of evidence that vocational outcomes affect both quality of life and longevity (5–7). Low employment rates after rehabilitation are cause for concern since return to gainful employment may be the most recognized primary marker of successful rehabilitation outcome after disability (8). Thus, the aim of this review is to examine the literature regarding the effect of SCI on employment characteristics such as rates of employment, characteristics associated with obtaining and sustaining employment, and benefits and barriers associated with work after SCI. The literature search was conducted using the terms spinal cord injury (SCI) and employment in the databases PubMed, PsycINFO, and MEDLINE. This search included a review of published manuscripts dating back 30 years (1978–2008). Available vocational services for SCI are reviewed and implications for future research and practice are discussed. Information related to veterans, who comprise almost one fifth of current SCI cases in the United States, are also reviewed.

SCI AND VOCATIONAL OUTCOMES

Rates of Employment After SCI

Of the studies reviewed that included employment rates in individuals with SCI, rates varied from 3% to 80%. Such a wide range in rates may be attributable to factors such as sample characteristics, method of obtaining data, definition of employment used, and time since injury (Table 1). Of the studies reviewed that reported participant age at the time of study, the mean age of participants ranged from 25.3 to 53.8 years. Although not consistently indicated, age at time of injury ranged from childhood to 30 years. However, in many cases the mean age of the respondents reported was not specified to indicate whether it was the age of the respondent at time of injury or time of participation in the related study. Also, the amount of time that passed since SCI has not always been reported by researchers. In the studies reviewed that reported this variable, time since injury varied from 2 to 25 years. Rates of employment between studies can only be meaningfully compared if the samples involved in the particular studies are equivalent in regards to key participant characteristics. However, as seen in Table 1, study participants greatly varied in such key characteristics as age, time since injury, and level of injury.

Table 1.

Rates of Employment in SCI studies

Employment rates show significant variation depending on the definition of employment used. The definition of employment, when described, seems to substantially vary among studies. For example, employment was described in some studies as “working for pay” (8), “working for a living: (9), “employed or actively looking for work” (10), and “performance of significant, productive physical or mental work for pay or profit” (11). Furthermore, some researchers divided their samples into groups that included homemakers and students (5,12). Instead of focusing solely on a dichotomous indicator of vocational status (eg, employed vs unemployed), some researchers (5,12,13) used multiple status variables for classifying employment status, such as “employed,” “ gainfully employed,” “unpaid productive” (including volunteers, students, and homemakers), and “unemployed.” Using such a classification system to describe vocational outcomes of persons with SCI warrants consideration for use in future studies to generalize classification groups among research studies. Currently, the significant variations in definitions used by researchers make it difficult to interpret the meaning of employment rates across studies that use differential definitions. Even more concerning is the fact that no definition of employment was given in nearly one half of the studies reviewed.

Related to definition of employment is the time frame used for capturing employment status. For example, some researchers have defined being employed as working at the time of the study (14–17), whereas others used other time frames such as being employed within 6 months of the study (18) or any time after SCI injury (2,19–21). If vocational status is solely based on current status at time of the interview, it only allows for a snapshot of the person's employment history. For example, Castle (22) reported that in addition to the 31% who were employed at the time of the survey, 4% had been employed since injury but unemployed at the time of the study. In addition, cumulative employment over time can result in a distorted picture of vocational status because it may include individuals who have limited vocational success as having positive outcomes (eg, someone who has worked for only a few months during the past 2 years would be counted in the employed group). In other words, measuring employment cumulatively over time may artificially increase the likelihood of reporting successful vocational outcomes. For example, in a study that had an average time since injury of 18.6 years (20,21), the participants had a significant amount of time to return to work, likely influencing the higher employment rate (48%) found in comparison to that reported in previous studies that found lower employment rates among persons with tetraplegia within a few years of being injured. Using current employment status allows for comparison with conventional indices of employment status such as the employment rate for the general population. Examining current employment rates and employment history in conjunction with each other may be more beneficial than looking at either alone.

An additional factor to consider is that researchers often do not indicate the percentage of subjects who were employed at the time of their SCI. Research indicates that employment rates dramatically decrease when comparing preinjury to postinjury vocational status (23). If a person was not employed at the time of their SCI, comparing their employment rate after SCI with someone who was employed at the time of their SCI is not optimal. In other words, expecting someone who is unemployed before injury to become employed after a tragic injury is different than expecting an employed person to continue being employed after an injury. Also, it has been shown that those individuals with SCI who return to former jobs do so much earlier than those who are seeking new employment (22,24). Thus, assessing employment history before injury, at time of injury, and after injury may be important to provide the best descriptive employment picture to maximize one's ability to generalize study findings. Krause (24) has used classification systems where unemployed participants have been categorized into groups based on whether they had worked at any time since injury (24). He classified participants into 4 groups based on a cross-tabulation of employment status at the 2 times of measurement after injury: (a) employed on both occasions, unemployment (stable employment), (b) employed at time 1 but unemployed at time 2 (negative transition), (c) unemployed at time 1 but employed at time 2 (positive transition), and (d) unemployed on both occasions (chronic unemployment) (25). Extrapolating this classification system to include employment status at time of injury and then at different data points after injury may be most beneficial in capturing the potential effects of employment history on current employment status and associated outcomes.

Employment rates can be adversely affected by external incentives, such as compensation and availability of government support for postinjury employment. For example, an unemployment rate of 80% was found among veterans rehabilitated in a Boston VA facility (26). However, it should be noted that 63% of the sample reportedly received nonservice-connected VA benefits, which suggests that they could lose benefits if they became employed. In a study by Siosteen et al (27) of SCI in Sweden, a 70% employment rate was found, which may be attributable to the extent to which government legislation in Sweden facilitates providing assistance to even those with severe SCIs to earn an income. Alternatively, compensation for injuries related to SCI may adversely affect employment outcomes. For example, in a study of patients with SCI in Australia, 52% of the sample received entitlements to third-party compensation as the result of their injury, which likely influenced the 26% employment rate reported (10). Overall, it is difficult to quantify the nature and impact of financial disincentives to employment because of the variability of federal and state benefit systems within the United States, as well as in other countries.

With a few exceptions (14,22,28,29), most studies do not indicate what type of employment positions are obtained after SCI, although some researchers have indicated that a small percent of individuals return to their preinjury jobs (14,30). It has been reported that, among those who return to work, more individuals enter into new occupations than return to preinjury jobs (22). Although a few studies have indicated that common occupations obtained by individuals with SCI include office, finance, clerical, administrative, technical, and professional jobs (22,31,32), it is rare for researchers to report what type of positions are obtained after injury and whether there is a significant difference from that of preinjury occupation.

Since 2005, motor vehicle crashes have accounted for 42% of reported SCI cases (33). Given that motor vehicle accidents account for almost one half of the traumatic brain injuries (TBIs) in the United States (34), it would be expected that a great number of individuals with SCI may have suffered head injuries and subsequent cognitive impairment. In fact, there is a high rate of comorbidity between TBI and SCI, and it has been suggested that TBI accompanies SCI more often than once thought (35–37). However, it is the rare exception (27) that researchers address whether subjects suffered head injuries and/or accompanying cognitive impairments. Cognitive impairment is related to worse employment outcomes and more intensive vocational services for persons receiving supported employment (38,39). For example, for those persons diagnosed with mental illness and cognitive impairments, those with cognitive impairments receive more supported employment services per hour of competitive work (38). Given that supported employment specialists can assist their clients with specific strategies for coping with cognitive impairment (40), it would seem important to identify those persons with SCI who also have cognitive impairment as the result of their injury.

In studies involving individuals with SCI seeking employment, it is very rare for the mental health of research participants to be addressed, which is unfortunate given that mental health conditions such as depression and anxiety can negatively affect motivation and energy levels. Siosteen et al (27), for example, showed that return to work after SCI was not only impacted by physical status but also emotional status and quality of life. Some researchers have concluded that psychologic variables, such as locus of control, personality variables, and work attitude, significantly impact returning to work after spinal cord injury (15,16). Subjective variables, such as satisfaction level, have been identified as being related to working after SCI. For example, Decker and Schulz (41) found that being satisfied with life was significantly positively correlated with being employed, whereas income only showed a slight positive correlation. In other words, regardless of the level of financial remuneration, employment may have a positive influence on life satisfaction. Optimism, self-esteem, achievement orientation, and work ethic have also found to be associated with obtaining employment after SCI (28,42). Having positive expectations has also been shown to be related to successful vocation reintegration and higher employment rates (17,29). In a matched sample of employed and unemployed individuals with SCI, the employed individuals tended to view work as enhancing self-esteem, described more positive role model experiences, were more optimistic, reported positive coping, and reported increased motivation (42).

Characteristics Associated With Returning to Work

A review of the literature indicates that 11 key factors are associated with employability among persons with SCI (43). These include education, type of employment, disability severity, age, time since injury, sex, marital status and social support, vocational counseling, medical problems related to SCI, employer role, environment, and professional interests. Educational attainment is perhaps the strongest predictor of return to work for persons with SCI (1,2,44–46). Persons with college level educational backgrounds are most likely to return to work (3,21), whereas those with less than 12 years of education are at a disadvantage (20). One study showed re-employment rates of 95% for persons with SCI who had 16 or greater years of education (24). Obtaining further education or retraining after SCI has also been associated with a greater likelihood of employment (3,47) and availability of a wider range of occupations for which individuals were qualified (1). It has been suggested that higher levels of education may be related to increased employability because of higher level of education being associated with higher social economic status and increased employment options (1). Those with higher levels of education are less likely to obtain manual labor jobs, which favors their potential to return to work in cases where SCI is involved. Other reasons cited for higher education being associated with better rates of returning to work after SCI include those with high education (a) require less change in their occupation, (b) may have more autonomy and motivation, and (c) have more positive personal expectations (43).

Many researchers have found that age of onset of SCI significantly relates to return to work after SCI (12,19,48,49). Being younger at the time of injury is associated with the best employment outcomes, with poorer employment outcomes found as age of onset increases (20,24). Having a greater number of years living with a SCI is also associated with more positive employment outcomes (1,2,8,20,24). It is reported that the probability of employment after SCI improves with increasing time since injury (20,21). Persons who incur their SCI at an older age are much less likely than younger persons to return to work (44). Furthermore, persons injured during adulthood have lower reported employment rates and physical functioning vs those injured in childhood (50). A 25-year cross-sectional study of employment and aging in persons with SCI showed that rates of employment increased over time, and as rates increased, levels of satisfaction with employment did as well (51). A curvilinear relationship has been found regarding age and amount of time spent working, with number of hours per week peaking from age 36 to 45 years (52). However, there is evidence to suggest that, as persons approach retirement age, employment may terminate prematurely among persons with SCI, with people retiring in the 51- to 60-year age range rather than the traditional over-60 range (53).

Race has also been associated with obtaining employment after SCI. Whites have been found more likely to be employed than minorities. Several studies (1,2,8,12,45,54,55) suggested that individuals with SCI from minority backgrounds are disadvantaged in terms of return to gainful employment, with this racial disparity mirroring patterns found among the general population. This difference persists even when controlling for educational level (8).

The influence of sex on obtaining employment has shown mixed results. In many cases, men have been found more likely to return to work (3,56–60), whereas in some cases, women have been found more likely to be employed after SCI (2,44,49) When type of work is considered, it has been found that men are more likely to return to competitive (paid) employment, whereas women are more likely to be engaged in nonpaid, productive roles (eg, homemaker) (61). However, in a large sample of individuals with SCI in 2 regions of the United States, sex was not predictive of employment status based on logistic regression analyses (8). Interestingly, employment was defined in this study as “working for pay,” which excluded homemakers and students.

Although many studies have found an association between severity of injury and employment (12,45,47,57,61–63), others have not (5,8,20,64,65). One study found that considering the functional interaction between level of injury and degree of completeness enhances the ability to predict return to work (1), with those individuals who had greater physical abilities being more likely to be employed.

About 40% of persons with paraplegia and 30% of persons with tetraplegia eventually return to work (33). The odds of participants with paraplegia being currently employed were 2.0 to 2.2 times higher and the odds of having been employed at some time since injury were 3.5 to 5.3 times higher than for participants with tetraplegia (8). Veterans with paraplegia are reported to be more likely to return to work compared with those with tetraplegia, but persons with tetraplegia are equally as likely to sustain employment once achieved (19,47). In a study examining only persons with tetraplegia and comparing vocational status in those who were ventilator dependent on discharge from inpatient rehabilitation and those who had required mechanical respiration some time during rehabilitation but were free of such at discharge, less than 5% of each group were employed in the competitive labor market 1 year after injury (66). The somewhat greater autonomy of the ventilator-independent group did not translate into different vocational outcomes, because both groups had similar unemployment rates. In a study by Krause (20), those with paraplegia were more likely to return to their preinjury jobs and worked more total years since injury than those with tetraplegia. It was suggested that it may take longer for those with tetraplegia to return to work. Therefore, examination of employment rates over a length of time since injury may be important to capture a comparable outcome for individuals with tetraplegia. The reader is referred to Table 2 for summary of studies citing characteristics related to returning to work after SCI.

Table 2.

Characteristics Associated With Returning to Work After SCI

Benefits of Returning to Work

Benefits of employment after SCI are multiple and well documented in the literature, with productivity and employment being consistently associated with life satisfaction, quality of life, and adjustment. Among persons with chronic SCI living in the community, money matters and employment are among the life domains with the lowest satisfaction ratings (67). Although life satisfaction has been reported to be lower in persons with SCI overall, it is relatively greater in those individuals involved in productive activities such as work (68). In fact, among employed individuals, there is not a significant difference in quality-of-life ratings between persons with SCI and persons without SCI. Employment is more related to satisfaction with life than level of impairment or disability itself (21) Among persons with SCI, those who are employed evidence significantly better psychologic adjustment than those who are unemployed (5,24). Furthermore, evidence strongly suggests that there is a directional influence between employment and adjustment. As persons with SCI transition from unemployment to employment, adjustment increases, and if they transition from employment to unemployment, adjustment decreases (5). Related benefits of employment among persons with SCI include higher activity levels and less medical treatments (5). Reports from qualitative data cite several perceived advantages of returning to work after SCI, including mental stimulation, social contact, a sense of purpose, and personal growth (42). Given these data (2,25), it is crucial to address vocational goals in rehabilitation, because employment seems to have a “spread effect” where it enhances many areas of life adjustment. Although this body of research does not establish causality, a likely path is that characteristics that are established as known predictors, such as education, increases the probability of employment, which in turn is associated with many life rewards such as improved quality of life and well being.

Although not specific to those with SCI, quality of life has been shown to be greater for individuals who are employed vs those who remain unemployed, but the persistence of overall quality-of-life spilling over into an individual's satisfaction with work and accomplishment of long-range vocational goals is correlated with the intensity of supported vocational rehabilitation the individual receives (69). Most quantitative studies evaluating vocational rehabilitation programs fail to consistently distinguish any significant differences in nonemployment factors, such as sustaining care needs or level of handicap, among individuals participating in different vocational rehabilitation programs or individuals who receive no vocational rehabilitation (70). Although participation in vocational rehabilitation does not seem to have any effect on social changes, sustaining care needs, or overall lifestyles of participants, evidence does abound in the literature substantiating the positive benefits correlated with return to work for persons with disabilities. Although type and length of disability may be conversely related to employment ratios in populations of persons with severe disabilities, the individual's type or severity of disability does not seem to affect employment successes after vocational rehabilitation (69).

Barriers to Returning to Work

The perception of barriers associated with employment differs between employed and unemployed persons with SCI. It has been found that, although employed persons with SCI tend to not perceive significant barriers to employment (11), 25% of individuals perceived lack of transportation and lack of Social Security benefits as the main barriers. For persons with SCI who were unemployed, 64% indicated lack of transportation, whereas 48% indicated having no time off for health-related concerns as being main perceived barriers to employment (11). Having reliable transportation, especially being able to drive oneself, has been identified in numerous studies as one factor related to returning to work (18,19,71,72). Difficulty accessing healthcare has also been related to higher unemployment or part-time employment (55). An additional barrier facing persons with disabilities for return to work is the perceived biases held by employers and others in the workforce about the capabilities of persons with disabilities (73–77). Poor physical health, physical limitations, and frequent hospitalizations have been reported by some as being associated with unemployment (19,26,30,48,78–80). A reluctance to return to work for fear of losing financial and/or medical benefits has also been reported (26,72,81,82). Level of injury (12,45,47,57–59,61–63) and having greater functional ability (1,3,12,49,56,61) have also been associated with returning to work among individuals with SCI. Additional factors such as low level of income, high cost of medical equipment and supplies, chronic pain, and perceived poor attitude of rehabilitation professionals have also been noted as barriers reported by those with SCI (78). Veterans with SCI listed various reasons for lack of employment including inability to sit for long hours, inability to find a suitable job, frequent grounding at home, retirement because of disability, frequent hospital admissions, fear of losing disability benefits, and fear of not being hired because of handicap (19).

Survey data indicate that many persons with SCI received little to no information during their rehabilitation about employment support and resources that are available to them (83). When asked what would improve services in this area, survey respondents listed (a) more provider training about SCI-specific issues, (b) increased communication between provider and patient/family, and (c) increased flexibility and availability of services to ensure access to necessary care (83). Clearly, maintaining adequate healthcare, a mechanism to understand and evaluate the impact of work on disability benefits, and accessing and understanding vocational services are all necessary and essential services that need to be included in rehabilitation after SCI to address vocational barriers.

Chronological age and associated factors have been found to be related to barriers to employment. In a study that examined age cohorts of their sample, those in the older cohorts had a less optimistic view of returning to work and those in the oldest cohort (55–64 years) reported that they were retired despite being younger than the retirement rate for their non–SCI-injured peers (84). In fact, the hope of returning to work declines with each decade lived after SCI. The overall likelihood of maintaining hope to return to work declines in those individuals who remain unemployed after the first decade of onset of SCI injury (45). In addition, 4 times as many individuals in the oldest cohort reported they were not physically capable of working compared to the younger cohorts. Older age of onset of injury has also been found to be associated with additional barriers to employment, such as requiring additional support and decreased energy (84). Interestingly, chronological age and age at injury onset have shown to also be influenced by sex, whereas nonparticipation in work was increased for men who were older than 55 and also in men who sustained an injury past the age of 40.

Vocational Rehabilitation Services

Most vocational rehabilitation programs reported in the literature are tailored to the needs of persons with mental illness, drug or alcohol abuse, brain injury, mental retardation, or workers' compensation injuries. The design of reported vocational rehabilitation programs for these populations of individuals disabled from work because of cognitive or mental impairments may not readily generalize in terms of the issues faced in overcoming vocational liabilities by persons with severe physical disability such as persons with SCI. Nevertheless, there are some lessons to be learned from extant vocational rehabilitation approaches in terms of program operations, potential outcomes, and systems for program evaluation.

Vocational rehabilitation usually adheres to 1 of 2 frameworks, conventional vocational rehabilitation and supported employment, each with very diverse operational standards and approaches. Conventional vocational rehabilitation approaches usually involve some form of either sheltered workshops or transitional employment experiences. Sheltered workshops represent the earliest form of vocational rehabilitation, where persons with severe disabilities are given tasks to perform in a workshop managed by vocational specialists. Transitional employment programs most often provide core services emphasizing preparing individuals with severe disabilities to obtain and hold competitive jobs, with salaries essentially the same as other jobs in the community. The methods used in transitional employment programs include training in job skills, job readiness counseling and education, placement in potentially permanent jobs, and postplacement support/follow-up by vocational counselors to assist the client to become reoriented to being gainfully employed and fitting in with the work force (85).

The supported employment (SE) approach emphasizes competitive employment as the goal, rapid job search, individualized job finding, and continuous follow-along supports after employment (86–89). It began in the field of developmental disabilities (90) and was subsequently modified and adapted for persons with mental illness (91). It has been identified as an evidence-based strategy for people with severe mental illness according a well-specified model (92). The SE approach has been successfully used to promote return to work for persons with psychiatric illnesses and brain injuries and has strong empirical support (93). Several different supported employment models exist, including the Individual Placement and Support (IPS) model (94), Program of Assertiveness Community Treatment (95), Family-Aided Assertiveness Community Treatment (96), Employer Consortium (97), and Employment Assistance through Reciprocity in Natural Supports (EARNS) (98). Bond et al (99) recently published a comprehensive and rigorous review of randomized controlled trials of high fidelity IPS supported employment and concluded that evidence-based SE is 1 of the most robust interventions available for persons with serious mental illness. It has been reported that from 40% to 60% of people enrolled in SE obtain competitive employment, whereas less than 20% of similar consumers do so when not enrolled in supportive employment (93). Recent data also suggest that the cumulative costs generated by supported employees are much lower than the cumulative costs generated by sheltered employees (100). Despite SE being recognized as an efficacious model and cost-effective model, it has been reported elsewhere that less than 10% of supported employment participants have a physical impairment, such as SCI (101). Although there are no controlled outcome studies to date on vocational rehabilitation after SCI, there are several documented case examples where a supportive employment approach has been used successfully to reduce barriers and return individuals with SCI to work (102–104). Lessons learned from these examples of success emphasize the need for individualized supports to help persons with SCI find employment and the importance of ongoing follow-along services to maintain employment. Targett and Wehman (102) outlined critical characteristics of successful work supports for persons with SCI. These features include real community-based employment, full integration of the person with SCI into the workplace, eligibility of all level of disability for services, job search assistance and on-the-job support, individualized customer-driven services, and personal choice. See Table 3 for a summary of conventional vocational rehabilitation vs supported employment approaches.

Table 3.

Key Components of Conventional VR Compared With SE

VETERANS WITH SCI

Of the more than 250,000 Americans with serious SCIs and disorders, about 42,000 are veterans (105). The Veterans Health Administration (VHA) has the largest and most comprehensive network of SCI care in the nation. It provided a full range of care to nearly 26,000 veterans with SCIs and disorders in 2006 and SCI specialty care to about 13,000 of these veterans (105).

Three studies dated from the 1970s to early 1980s were found that specifically examined employment among veterans. These studies reported employment rates for veterans with SCI ranging from 20% to 28% (19,26,81). These rates are within the typical range of employment rates reported for the general population of persons with SCI (Table 1). A more recent study that focused primarily on assistive technology in the workplace reported significantly different employment rates among veterans with heterogeneous educational backgrounds compared with nonveteran sample of college graduates. Among the veterans in their sample, 18% of veterans and 73% of the nonveterans were currently working, and 70% of the veterans and 8.6% of the nonveterans had not been employed in the last 5 years (106). As in other studies, educational attainment increased the probability of employment. Hence, education more likely than military service history contributed to the varying employment rates. Not only did the groups differ significantly in terms of educational level, but the veterans also reported significantly more medical comorbidities than the nonveterans included in the study. Current studies are needed to determine the current level of unemployment among veterans with SCI compared with the general population of persons with SCI with similar educational backgrounds.

The Department of Veterans Affairs (VA) traditionally has offered veterans an opportunity to return to work through their compensated work therapy (CWT) program, giving veterans the opportunity to work in sheltered workshops or in transitional employment programs either with community employers or on VA grounds (107,108). In contrast to IPS, CWT has traditionally offered a limited choice of jobs, and until recently, SE was not offered because it did not constitute the statutory definition of medical care as proposed by the VA (109). In 2004, the VHA implemented a large-scale initiative to provide SE to veterans with serious mental illness (SMI) under the auspices of the CWT Programs (110).

Researchers recently published findings regarding the use of the IPS model of supported employment at 9 VA programs and compared client outcomes for homeless veterans with psychiatric or addiction disorders before and after the program was implemented (109). IPS emphasizes rapid job placement, a focus on obtaining competitive jobs chosen by the client, ongoing support without a time limit, and integration of vocational support and clinical care (92). Results of the study suggested that competitive employment days per month over a 2-year follow-up period were 15% higher for veterans in IPS program. This is a smaller effect compared to other studies using IPS (93), and it may be somewhat attributable to methodologic limitations in the study, such as the veterans recruited for IPS had a better long-term work history, had greater employment potential, lower levels of psychiatric symptoms, and a less negative attitude toward work. Another limitation of the study was that 20% of sites did not achieve acceptable model fidelity, suggesting that more intensive onsite training and monitoring may be necessary to optimize dissemination of IPS in veteran samples, where there is a strong tradition of CWT programs.

IMPLICATIONS FOR FUTURE RESEARCH

As a starting point, it is recommended that researchers begin to use common target guidelines when reporting descriptive characteristics of their samples, definition of employment, and accompanying variables of importance. For studies of employment and vocational rehabilitation to be meaningfully interpreted, employment-specific outcome data need to be reported in terms of competitive employment rates, duration of employment, and job tenure (99). See Table 4 for recommended descriptors to be used in SCI research to enable generalizability across studies.

Table 4.

Recommended Descriptors for Future Research on Employment and SCI

Considering the different methods of vocational rehabilitation studied, evidence-based SE practices seem to most applicable and hold the most promise for assisting persons with SCI restore meaningful employment. SE began in the field of developmental disabilities and was modified for those with mental illness. It is now believed to be one of the most robust interventions available for persons with serious mental illness (99) and has been adapted for populations such as those with an intellectual disability (111), aging adults with schizophrenia (112), bipolar disorders (113), depressive disorders (114), and people with dual disorders (115), and is currently being adapted for populations such as posttraumatic stress disorder, TBIs, and substance abuse problems. Until recently, evidence-based SE had not been widely used or clinically tested among persons with physical disabilities, such as SCI. However, a multisite randomized clinical trial of SE among veterans with SCI is currently underway at 6 VA Medical Centers (116). Research conducted in these various populations will likely lead to population-specific modifications of SE, as has been shown before with individuals with dual mental disorders (115). Efforts directed at adapting evidence-based practices in vocational rehabilitation to effectively meet the needs of persons with SCI and other physical disabilities are critically important to maximize rehabilitation outcomes.

SUMMARY

Employment rates after SCI vary widely depending on several factors, particularly the definition of employment and time of measurement. When only studies that use a strict definition of paid employment are considered, the average rate of any employment after SCI is approximately 35%. This rate is much lower than the employment rate of 79% reported for persons without disabilities in the United States (117). Characteristics associated with employment after SCI include demographic variables (education, sex, race, marital status), injury-related factors (age at injury, level of injury/impairment/functional status, time since injury), employment history (employment at or before injury), psychosocial issues (transportation, physical health, life satisfaction, locus of control, motivational level/expectation to work, social support), and disability benefit status. Those individuals with SCI who are employed experience significantly better quality of life and life satisfaction among other benefits. However, the barriers to returning to meaningful work can be formidable and numerous, such as inadequate transportation, concerns about benefits or finances, employer biases, and access to healthcare. Vocational rehabilitation programs that address these barriers are essential. To date, the supported employment model of vocational rehabilitation has not yet been widely used or clinically tested among persons with physical disabilities, such as SCI. Although some modifications may be necessary, this approach would seem to hold great promise as an effective method for treating the vocational rehabilitation needs of persons with physical disabilities as well. This area of study needs to be a focus of research efforts to explore, understand, and implement effective programs to improve vocational rehabilitation outcomes among this population of individuals with disabilities.