RESEARCH PAPER

Employment of persons with spinal cord lesions injured more than 20years ago

INGEBORG BEATE LIDAL1, NILS HJELTNES2, JO RØISLIEN3,

JOHAN KVALVIK STANGHELLE1 & FIN BIERING-SØRENSEN4

1Sunnaas Rehabilitation Hospital and Faculty of Medicine, University of Oslo, 1450 Nesoddtangen, Norway, 2Sunnaas

Rehabilitation Hospital, 1450 Nesoddtangen, Norway, 3Department of Biostatistics, Faculty of Medicine, University of Oslo,

Sognsvannvn, 9, 0027 Oslo, Norway, and 4Clinic for Spinal Cord Injuries, Neuroscience Centre, Rigshospitalet, University of

Copenhagen, Copenhagen, Denmark

Accepted April 2009

AbstractPurpose. The primary objective was to study factors influencing post-injury employment and withdrawal from work inpersons who sustained traumatic spinal cord injury (SCI) more than 20 years ago. A secondary objective was to study lifesatisfaction in the same patients.Method. A cross-sectional study with retrospective data of 165 SCI-patients admitted to Sunnaas Rehabilitation Hospital1961–1982. Multiple logistic regression was used to identify predictors for obtaining work post-injury. A Cox proportionalhazards regression model was used to study factors influencing early withdrawal from work, i.e. time from injury untildiscontinuing employment.Results. Sixty-five percent of the participants were employed at some point after the injury. Thirty-five percent still had workat the time of the survey. The odds of obtaining work after injury were higher in persons of younger age at injury, higher inmales versus females, higher for persons with paraplegia versus tetraplegia, and for persons classified as Frankel D-Ecompared to a more severe SCI. Factors associated with shorter time from injury until discontinuing employment werehigher age at injury, incidence of injury after 1975 versus before, and a history of pre-injury medical condition(s). Lifesatisfaction was better for currently employed participants.Conclusion. The study indicates a low employment-rate in persons with SCI, even several years after injury. From theresults, we suggest more support, especially to persons of older age at injury and/or with a history of pre-injury medicalcondition(s), to help them to obtain work and sustain employed for more years after injury.

Keywords: Spinal cord injury, employment, life satisfaction

Introduction

A spinal cord trauma implies an enormous change

in a person’s life. The physical and psychosocial

adjustments to traumatic spinal cord injury (SCI) are

complex and extraordinarily challenging. During the

past decades, research has increasingly focused on

social and psychological adjustment to the SCI, long-

term consequences, and aging. The employment-

situation in persons with SCI has been given much

attention because of the psychological, social, finan-

cial, and political implications [1]. Being employed is

associated with better self-esteem, higher life satis-

faction, and sense of well-being in persons with

SCI [2].

To work plays an important role in most adult

lives. In Norway, persons of age 16–67 are expected

to study or work. Historically, the national rate of

unemployment was less than 2% during the period

1970–1984, but increased to about 6% in the 1990s,

before it decreased to 3.4% in 2006 [3]. In Norway,

the incidence of medically based disability pension

(DP) started to grow in 1982–1983, after a stable

period in the 1970s [4]. The number of DPs

Correspondence: Ingeborg Beate Lidal, MD, Sunnaas Rehabilitation Hospital, Faculty of Medicine, University of Oslo, 1450 Nesoddtangen, Norway.

Tel: þ 47-66-96-90-00. Fax: þ 47-66-91-25-76. E-mail: Ingeborg.lidal@sunnaas.no

Disability and Rehabilitation, 2009; 31(26): 2174–2184

ISSN 0963-8288 print/ISSN 1464-5165 online ª 2009 Informa UK Ltd.

DOI: 10.3109/09638280902946952

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increased with 30% during the period 1993–2003,

and constituted 10% of the Norwegian population

aged 18–67 in 2003/2004 [3]. The eligibility criteria

for granting a DP in Norway was established by law

in 1967 [4]. The applicant must meet five criteria:

(1) Disease, injury or disability must be the reason

why income is reduced with more than 50%, (2) The

person must undergo appropriate medical treatment

and rehabilitation, (3) The earning ability must be

impaired long-term, (4) The applicant is between 16

and 67 years, (5) The person must be a member of

the National Insurance Scheme for at least 3 years

(all persons who are resident in Norway are auto-

matically members).

Most persons who sustain SCI are working or

studying at the time of injury. After SCI, the level of

employment is low [5–11]. However, varying em-

ployment rates have been reported, and some of this

variability may be due to differences in the opera-

tional definitions of employment used, and differ-

ences in study settings [12,13]. The majority of

persons with SCI do not immediately obtain employ-

ment after their primary rehabilitation. The longer an

individual has been injured the more likely it is that

he or she will enter into employment [14–16], and

Meade et al. [1] showed that the overall percentage

of persons categorized as ‘working’ increased with

years after injury. Krause [17] investigated employ-

ment rates in highly educated persons with SCI, and

found that more than 85% of persons injured at least

20 years ago had been gainfully employed at some

time after injury. However, it has been indicated that

less than 30% of all individuals with SCI are working

at any given point in time [18].

The influence of specific individual and injury

related factors on employment in persons with SCI

have been studied by several authors [5,6,11,14,16,

19–22]. Among factors that have been found to

matter are: Age at injury, race, gender, level of formal

education, employment status at injury, impairment

type, length of time since injury, and vocational

training [1,17].

In addition to challenges confronting persons with

SCI in obtaining employment, further problems may

be experienced in sustaining employment [12,14,

15,19]. Athanasou et al. [10] found that 61% of

Australians with SCI were engaged in employment at

some point after injury, but there was a decrease in

the employment rate to 31% at the time of the study.

Recently, a study showed that employment rates

decline faster and more extensively in individuals

with disabilities, including SCI, compared to people

without disabilities [23].

Gainful employment after SCI has been linked to

psychosocial and medical adjustment. Studies of SCI

populations have shown better life satisfaction and

higher quality-of-life in persons participating in work

[24–26], and it has also been demonstrated that

employment is associated with higher level of activity

and fewer medical complications [27].

The main purpose of this study is to present

employment outcomes from a larger Norwegian

investigation on persons who sustained traumatic

SCI in 1961–1982. The intention with the study

was to investigate the employment-situation of

persons with SCI of long duration, living in a

Scandinavian country, and to identify factors that

might have influenced the participants in obtaining

and sustaining employment after injury. In addition,

we studied the life satisfaction in the same persons

with SCI currently employed versus persons not

employed.

Methods

Material

A total of 237 persons with SCI of more than 20

years duration were contacted by mail requesting

their participation in the study. For those who agreed

to participate, data collection was obtained in a

three-stage process during 2002–2004: (1) Informa-

tion was gathered retrospectively from each patient’s

medical record, comprising demographic data, pre-

injury employment status and occupational classifi-

cation, date of admission and discharge from the

rehabilitation hospital, injury related data including

associated injuries, neurological level of injury,

severity of the SCI judged by the Frankel classifica-

tion [28], pre-injury medical condition(s), and

secondary medical complications during initial re-

habilitation. (2) A set of questionnaires was mailed

out, along with a stamped return envelope and a call-

up notice for a personal interview. (3) A personal

interview was conducted to obtain information on

medical history.

The existing Norwegian rules, intended to protect

the privacy of the individual, demands an acceptance

from each individual, respondents as well as non-

respondents, if any data from their medical record

were to be used. Therefore, such a request was

mailed out to all non-respondents, along with a brief

questionnaire on current health- and employment

status.

Employment data of the Norwegian general

population were obtained from Statistics Norway.

Instruments

For information on the vocational situation of the

participants, a checklist conducted at Sunnaas Reha-

bilitation Hospital was used. It contains questions on

Employment of persons with SCI 2175

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pre-injury and present employment status and

occupation, changes in occupation after the SCI, work

intensity, possibly degree of disabled pension (DP)

(50–100%), and the time (date) of withdrawal from

work. Although information on ‘ever having

worked since injury’ was not originally included in

the checklist, all subjects were asked whether he/she

obtained work at some time after injury. To assess the

reproducibility of the questionnaire, it was answered

two times by *9% (n¼ 14) of the respondents.

The reproducibility of the questionnaire was good:

83% of the answers were in accordance with the

answers given in the first place. More information on

this is available on request. Additionally, the partici-

pants answered an open question on currently

perceived health-problems, which has been presented

in our study on Health-related quality-of-life

(HRQOL) [26].

Employment status was categorized into ‘em-

ployed’ (defined as paid work), ‘student’, and

‘unemployed’, including homemaker. For analytic

purposes, these variables were dichotomized into

‘employed’ (paid work) and ‘not employed’ (stu-

dents and unemployed/homemaker). Persons516

years at injury were registered as ‘under-aged’

concerning employment status and occupational

classification at injury. Occupational classification

was determined by a modified version of the Erikson

Goldthorpe Portocarero (EGP) social class scheme

[29]. Pre-injury medical condition(s) included all

chronic conditions or severe traumas noted in each

patient’s medical record.

The material was dichotomized into two incidence

groups according to the time of injury, i.e. from 1961

to 1975 versus 1976 to 1982. This was done because

the SCI-rehabilitation gradually became organized as

a specialized unit with multidisciplinary teams from

the early to mid 1970s.

Life satisfaction was assessed by the LiSat-11

checklist containing 11 items; one question on

satisfaction of life as a whole and 10 questions on

satisfaction within different life domains [24,25].

The level of life satisfaction was described through a

6-grade scale ranked from 1 (very dissatisfying) to 6

(very satisfying). The LiSat-11 scale was dichoto-

mized into satisfied (grades 5–6) and not satisfied

(grades 1–4) as recommended by Fugl-Meyer et al.

[30]. Persons who did not have a steady partner

relationship (42%) were not included in analysis of

partner relationships. We performed comparisons of

the life satisfaction results between employed and

unemployed participants, part-time versus full-time

employed persons, as well as between persons with

tetraplegia versus paraplegia, and between persons

with Frankel grade A–C versus D–E.

The study was approved by The Regional Ethics

Committee, Oslo, Norway.

Statistical analysis

Data are summarized using mean and standard

deviation (SD), or as proportions. The Chi-

squared-test of independence (w2), or Fisher’s exact

test when necessary, was applied to compare

categorical data. For comparisons on continuous

variables between the two groups, t-tests and Mann–

Whitney U- tests were performed where appropriate.

Univariate logistic regression analyses were per-

formed to look at the association between the

dependent variable ‘employment after injury’ and

each of several possible explanatory variables. Based

on these univariate results a multiple logistic regres-

sion model was fitted using a forward stepwise

procedure, including all variables with p5 0.25 in

the univariate analyses.

We then moved on to explore factors influencing

the time (number of years) elapsed from injury until

discontinuing employment. Only persons who were

working at some time post-injury were included in

these Cox regression analyses. First, a Kaplan–

Meyer plot was used to illustrate the time passed

from injury to discontinued employment for different

age groups (age at injury). Then, several Cox

proportional hazard regression analyses were per-

formed. Persons who were still employed at the time

of the study or withdrew from work because of

retirement (465 years) were censcored. For those

with age at injury516 years, the time from injury

until withdrawal from work was adjusted to number

of years from age 16 until discontinuing work

participation, so-called ‘delayed entry’. First, we

examined the univariate relation between each

possible explanatory variable and the time elapsed

from injury until when opted out of work or when

censored. Next, several multiple Cox regression

models were evaluated, as well as considerations of

Akaike’s Information Criterion (AIC) values, to

select the final model. AIC is, in short, a weighting

between model parsimony and goodness of fit to the

sample data [31].

The software SPSS 13.0 was used for most

statistical analyses, except the Cox regression ana-

lyses, for which we used the R statistic software

(http://www.r-project.org). p-values less than 0.05

were considered statistically significant.

Results

Of the 237 persons invited to participate in this study,

179 individuals (76%) accepted to do so. However,

five persons could not find time for participation, five

persons were no longer accessible/could not be

reached, and another three persons deceased before

the data collection took place. One further person was

2176 I. B. Lidal et al.

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excluded due to incomplete data. For these 14

individuals general characteristics, injury related data

(aetiology, level and extent of SCI, time-period of

injury), and pre-injury medical conditions did not

diverge from those who finally participated.

Non-respondents

Fifty-eight (24%) persons did not accept to participate

in the study. Out of these, 23 persons (40% of the non-

respondents) did not allow us to use any information

from their medical record. The remaining 35 non-

respondents with available data were significantly

older at injury and at the time of the study

(p5 0.001), and contained a smaller proportion of

persons with functionally complete injury, i.e. Frankel

grade A–C, (p5 0.001), than the study participants.

Differences in other demographic factors or injury

characteristics were not found. Twenty-two out of

these 35 non-respondents answered a simple ques-

tionnaire, which showed that *20% were currently

working full-time, 11% were employed part-time, 9%

were retired, and 60% were disabled pensioners.

Participants and their employment-situation

The total number of participants was 165, of which

82% were men. At the time of injury, 58% were

employed, 22% were students, 13% were youth and

children (516 years), 4% were unemployed, and 4%

reserve officers. A total of 107 (65%) of the

individuals obtained work at some time after injury.

A significantly higher proportion of persons injured

1961–1975 was employed after injury compared to

those injured 1976–1982 (56% vs. 44%, p¼ 0.02).

At the time of the study, 58 persons (35%) were still

working; 31 (53%) full-time, 25 (43%) part-time,

while two persons did not indicate whether they

worked full-time or part-time. Table I presents the

biographic and injury characteristics of the study

participants, including differences between persons

currently employed and persons not employed.

The characteristics did not differ between genders

or between persons working full-time versus those

working part-time.

Figure 1 shows the percentage of the study

population employed in (2002–2004), compared

with the fraction employed in the general Norwegian

population in 2004, and divided into age groups.

There were statistically significant fewer who were

working in the SCI group compared to the normal

group (p5 0.05 for all age groups, after Bonferroni

correction for multiple testing).

Nine variables were entered into the logistic

regression models for prediction of ‘employment

after injury’: Gender, age at injury, place of residence

at injury, pre-injury occupational classification,

employment status at injury, level of injury, Frankel

classification (A–C, D–E), incidence period, and the

presence of pre-injury medical condition(s). The

final multiple logistic regression model showed that

the odds ratio (OR) and 95% confidence intervals

(CI) of not entering into employment after injury was

1.11 (1.06–1.16), p5 0.001, for each year of

advancing age at injury. Further, the results showed

higher odds of not entering into employment in

females versus males; OR 3.1 (1.2–8.5), p¼ 0.025, in

tetraplegic versus paraplegic subjects; OR: 3.8 (1.7–

8.5), p¼ 0.001, and for persons with functionally

complete SCI (i.e. Frankel grade A–C) versus

persons with less functional impairment (i.e. Frankel

grade D–E); OR 15.7 (3.4–73.8), p5 0.001.

Withdrawal from work

Out of the 107 persons who obtained work after injury,

49 persons withdrew from work after a certain period

post-injury, including three persons who stopped

working because they reached retirement age. The

mean (SD) age at withdrawal from work was 43 (13.0)

years. A Kaplan–Meyer plot (Figure 2) was used to

illustrate the time passed from injury to discontinued

employment for different age groups at injury.

The univariate association of the following variables

with time from injury to discontinued employment

were analysed using Cox proportional hazards regres-

sion: Gender, age at injury, place of residence,

employment status at injury, presence of pre-injury

medical condition(s), incidence period (1961–1975

versus 1976–1982), aetiology of injury, associated

injuries, duration of primary rehabilitation, level of

injury, and Frankel classification (A–C, D–E). The

results are presented in the left columns of Table II.

All but two of the variables, namely place of

residence and aetiology of injury, were then entered

in a multiple Cox regression model. From this large

model the significant factors were extracted, based on

AIC values for model optimization. This final multiple

Cox regression model, right columns of Table II,

indicates that for each year of advancing age at injury,

the likelihood of early withdrawal from employment

after SCI increased. Furthermore, the hazard ratio for

early withdrawal from work was higher in persons

injured after 1975 as well as for persons who

experienced medical condition(s) prior to the SCI.

Life satisfaction

A total of 104 (63%) of the participants rated their

level of global life satisfaction as satisfying, i.e. LiSat

Employment of persons with SCI 2177

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scale grade 5 or 6. Regarding the 10 domain-specific

items, the highest proportions of persons satisfied

were reported with the questions on ‘partnership’,

‘family life’, and ‘mental health’. Few persons were

satisfied with ‘sexual life’ (24%) and ‘physical health’

(54%). Figure 3 shows the percentages of persons

satisfied, both for participants still working at the time

of the study and for those who were not employed.

Statistically significant differences between the two

groups were found with ‘life as a whole’, on

‘vocational situation’ and ‘financial situation’.

Discussion

The principal result of the study is that a total of

65% of the participants obtained work post-injury.

The odds of non-participation in work after injury

are higher in persons of older age at injury, higher in

females than in males, and higher for persons with

tetraplegia versus paraplegia, as well as for persons

classified as Frankel A–C compared to a less severe

SCI. The percentage of the study population

employed at the time of the study was 35%. A

higher risk of early withdrawal from work was seen in

persons with higher age at injury, incidence of injury

after 1975, and in persons with a history of perceived

chronic medical condition(s) or severe trauma(s)

prior to injury.

This investigation, on persons with SCI, supplies

the existing literature with some important aspects

concerning employment several years after injury.

Our study gave no exact data of the prevalence of

work at different times after injury, but 65% were

Table I. Characteristics of the participants (n¼165), including differences between those currently employed versus those not employed.

Category

Total

n¼165

Employed

n¼ 58

Not employed

n¼ 107 p-value

Men/women (n) 135/30 49/9 86/21 0.468

Mean (SD) age at injury in years 23 (9.7) 19 (6.7) 26 (10.2) 50.001*

Mean (SD) age at the time of the study in years 50 (10.1) 46 (6.7) 53 (10.8) 50.001*

Mean (SD) time since injury in years 27 (4.3) 27 (4.4) 27 (4.2) 0.241

Cause of injury

Sports 16% 16% 16% 0.808

Assaults 5% 7% 3% 0.198{

Transport 53% 59% 51% 0.786

Fall 19% 16% 22% 0.354

Others or unknown 7% 3% 8% 0.352{

Impairment group 50.001*

Tetraplegia, Frankel A–C 28% 19% 34%

Tetraplegia, Frankel D–E 8% 10% 7%

Paraplegia, Frankel A–C 55% 55% 54%

Paraplegia, Frankel D–E 9% 16% 6%

Complications during initial rehabilitation 56% 47% 62% 50.001*

Associated injuries 53% 60% 50% 0.229

Presence of disorder(s) or trauma prior to SCIa 9% 2% 13% 50.001*

History of pre-injury alcohol or substance abuse 2% – 2% 0.270{

Time period of onset of injury: 1961–1975/1976–1982 49%/51% 57%/45% 43%/55% 0.086

Occupational classification at injury (n¼ 143)b

Higher grade professionals (e.g. dentist. lawyer) 2% 2% 2% 0.695{

Lower grade professionals (e.g. nurse, teacher) 10% 15% 7% 0.140

Subordinate staff/Non-professional 5% 4% 6% 0.488{

Self-employed workers (e.g. artisan, farmers) 5% 2% 7% 0.203{

Lower grade technicians and skilled manual work 33% 29% 35% 0. 304

Unskilled manual work and housewife 22% 17% 25% 0.254

Unemployed (including disabled pensioners, homemakers) 4% 2% 5% 0.365{

Students 16% 25% 12% 0.045*

Unknown 2% 4% 1% 0.246{

Presence of currently perceived health problem(s) (n¼160) 79% 74% 81% 0.282

Painc 21% 12% 27% 0.032*

Urogenital problemsc 20% 26% 17% 0.162

‘My disability’c 10% 3% 14% 0.037*

*Significant difference between employed/not employed.

SD, standard deviation; SCI, spinal cord injury.aAll chronic conditions or severe traumas noted in each patient’s medical record are included (n¼ 4 rheumatologic diseases, n¼ 3 brain

injuries, n¼2 cancer, n¼2 urogenital diseases, n¼1: asthma, gastric ulcer, psychiatry, severe musculoskeletal problems.bPersons younger than 16 years (n¼ 22) were not included. Groups tested separately.cSelf-reported main health problem at the time of the study categorized.{Fisher’s Exact Test used because of small groups.

2178 I. B. Lidal et al.

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employed at some time during the period between

injury and 2002–2004. Krause and Broderic showed

in a longitudinal study that the number of persons

returning to work progressed over the years after

injury [32]. The number of persons in work at some

time post-injury probably increased over time in our

sample too, but early withdrawals from work during

the same period resulted in a low employment rate at

the time of the study. Most cross-sectional studies

have investigated aspects concerning employability

the first years after SCI, and some authors have

investigated employment in persons with SCI with a

wide range in time since injury. Since employment

outcomes change with time post-injury, and since the

employment rate is dependent upon how employ-

ment is defined, we searched to compare our data

with studies with similar premises, i.e. paid employ-

ment several years post-injury. Meade et al. [1]

reported an employment rate of *32% in white

Americans 20 years post-injury. More recently,

Krause et al. [33] found 33% employment in persons

average 15.1 years post-injury. Other researchers

have reported somewhat higher figures of employ-

ment in persons with longstanding SCI [34,35].

Krause [17] wrote in another article that persons

with less than 10 years since injury had the lowest

percentage of participants who had ever worked since

injury (57%).

Both medical and non-medical factors determine

employment outcomes after SCI. The findings from

the present study differ from previous research,

which consistently has shown that pre-injury employ-

ment status and educational level are factors

associated with work after injury [33]. Employment

Figure 1. The figure shows fractions of the study participants with

spinal cord injury (SCI) employed in 2002–2004, and fractions of

the general population employed in 2004, by current age.

Figure 2. Time interval from spinal cord injury to discontinued employment in persons employed for a certain period post-injury (n¼107)

divided by age at injury. (Persons sustaining employment at the time of the study were censored. Persons who stopped working because they

reached retiring age (n¼ 3), were censored. Persons516 years at injury were incorporated as delayed entry, i.e. from 16 years.)

Employment of persons with SCI 2179

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status and/or pre-injury occupation did surprisingly

not predict employment after injury in our study

population. However, in accordance with other

studies [1,5,18], we showed that age, gender and

injury-severity were predictive factors of post-injury

employment.

This study shows that withdrawal from work at an

early point in life is common among persons with SCI

in Norway. Early withdrawal from work was seen more

often in persons who were injured during the later

period (41975). One explanation could be that those

injured 1961–1975 was a more selected group, and it

can also be explained by the fact that the age at injury

was lower in persons injured during the first period.

However, no participants injured after 1975 withdrew

from work because of retirement.

Our findings augment the existing literature by

reporting risk indicators to early withdrawal from

work in persons who obtain post-injury employment,

which seem to be a limited investigated topic. An

important finding is that a history of pre-injury

medical condition(s) is associated with early with-

drawal from work, indicating that more attention to

other conditions might influence the employment-

situation in persons with SCI in a positive way. It is a

possibility that a recent SCI is overwhelming and

results in less attention to other conditions. On the

other hand chronic conditions not related to SCI

obviously bring a complicated situation on top of

SCI related problems. When looking into the data

from the point of the study, the presence of any

perceived health-problems showed no statistically

difference when comparing employed/unemployed

people. However, when comparing employed/unem-

ployed and their most frequent reported health-

concerns, significantly more unemployed persons

reported severe pain-problems compared to persons

in work. Other researchers investigated barriers to

employment, showing that energy, health, health

considerations, physical limitations, lack of work

Table II. Cox regression models.

Univariate Cox regressions

Multiple Cox regression model

based on AIC

Covariate Hazard ratio (95% CI) p-value Hazard ratio (95% CI) p-value

Age at injury 1.05 (1.02–1.08) 50.001 1.05 (1.02–1.09) 0.003

Gender

Male (Ref.)

Female 1.14 0.74

Time period of injury

1961–1975 (Ref.)

1976–1982 1.94 (1.04–3.61) 0.04 2.09 (1.09–4.00) 0.03

Residence area

Central area (Ref.)

Else 0.73 0.28

Employment status at injury

Employed (Ref.)

Not Employed 0.57 0.09

Under aged 0.61 0.25

Duration of primary rehabilitation 1.00 0.39

Neurological level of SCI

Paraplegia (Ref.)

Tetraplegia 0.97 0.94

Frankel class

A–C (Ref.)

D–E 0.66 0.26

Aetiology

Transport (Ref.)

Sport 1.58 0.24

Other 1.33 0.47

Fall 1.03 0.95

Pre-injury medical condition

Absent (Ref.)

Present 3.02 (1.08–8.50) 0.04 4.38 (1.51–12.71) 0.007

Associated injuries

Absent (Ref.)

Present 0.67 (0.38–1.18) 0.17 0.58 (0.32–1.06) 0.07

The underlying time axis was the time from injury to withdrawal from work. Only persons obtaining work after injury were included in this

analysis, n¼107.

CI, confidence interval; Ref., reference for the analysis; AIC, Akaike’s Information Criterion.

2180 I. B. Lidal et al.

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experience, and lack of sufficient education or

training are among reported reasons for unemploy-

ment [36,37].

Both problems to return-to-work as well as to

maintain work after SCI have, to some degree,

probably been influenced by the social possibilities in

Norway, including the level of unemployment and

disability compensation policies. As an example, the

pattern of more withdraws from work in participants

injured in the later period, corresponds to the

incidence rates of DPs in national rates [4]. In

Norway, there was an increase in number of DPs

during the period 1982–1999 [38,39]. Krokstad et al.

[4] wrote that the variation in incidence of DPs

reflects the strong influence of non-medical determi-

nants of disability, which may be associated with

conditions in the labour market. The unemployment

rates reached a top in 1984, and increased again

during the period 1987–1993. Krokstad et al. also

claimed that the social gradient in risk of receiving a

DP was higher for people below 50 years compared

to older people. This reflects great problems for

young people with less education in the

labour market, and a strong and maybe increasing

health-related selection out of work in these cohorts

affecting people with low socioeconomic status.

El Ghatit [15] indicate an inverse relationship

between annual disability income and return to

employment, and Pflaum et al. [16] show that high

disability benefits reduce the likelihood that the

unemployed will secure work. Changes in social

possibilities in Norway, like improvement in the

social welfare system and higher official financial

compensations, might have influenced the employ-

ment rate after SCI. Additionally, private insurance

is relatively common in most classes of our commu-

nity, and contributes to higher benefits after injury.

Since 1981, also a supplementary disability-benefit

has been guaranteed for young disabled persons. It is

a possibility that persons who suffered from SCI

more recently did not have the same economical

reasons to be employed compared with the need of

those who sustained SCI in the 60s and 70s. A

Danish study [40] concludes that financial compen-

sation is associated with increased risk of negative

vocational rehabilitation outcome. Thus, we suppose

that differences in social possibilities between nations

to a high degree influence the differences in

the employment rates between nations. In the

Scandinavian countries, disability benefits, social

rights, societal resources, and the labour markets

are comparable [41]. Further, the incidence and the

Figure 3. Life satisfaction. Percent of the participants with spinal cord injury rating different life domains as satisfying (grades 5–6), divided

by persons employed versus those not employed at the time of the study.

Employment of persons with SCI 2181

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prevalence of SCI in these countries are at approxi-

mately the same level, and the social welfare systems,

covering all people in the society, make it possible to

do such studies. However, it seems complicated to

compare return-to-work rates and employment in

SCI between nations with different social policy and

labour market. In the USA, the potential loss of

access to public health insurance was identified as a

barrier to work, resulting in the Ticket to Work and

Work Incentive Improvement Act in 1999.

Jongbloed et al. [42] concluded in a Canadian study

that the cause of a person’s SCI directly affects the

amount and type of assistance he/she receives

related to returning to work or finding new work.

Those with some form of insurance received more

help than those not covered by programs such as

the Canada Pension Plan and Social Assistance.

Priebe et al. [43] wrote that economic issues,

higher unemployment rates, and difficulties in

transportation are among factors that influence

employment.

Assertions given by some of the participants in the

current study add some aspects that might have

influenced our results as well. These are the changes

in the rehabilitation programmes over time, includ-

ing increased focus on coping with a disability, as

well as expectations and attitudes to persons with

SCI. More focus on time consumption (energy-

saving/energy economization) probably influences

more people to apply for DP in recent years.

Regarding work intensity, our results indicate that

almost half of the participants who obtained work

after injury were working part-time. Meade et al.

show in a study from the USA 10.8 years post-injury

that only a low proportion (8%) of persons with SCI

worked part-time [44], and Krause found in another

study that 74% were full-time employed [45]. We

assume that work intensity in SCI populations vary

because of different national legislation. There are

few economical disadvantages with working part-

time compared with working full-time for persons

with disabilities in Norway. The social rights for

persons working part-time are the same as for

persons employed full-time, including the rights to

receive paid vacation and sick leave. Further,

medication is subsidized and the cost of the Health

Service is free of charge, paid by the general

Norwegian social welfare.

Previous research has shown that occupational

status is associated with perceived level of life

satisfaction in persons with SCI [2,46,47]. Our

results indicate that participants still employed at

follow-up were more satisfied than persons who

withdrew from work. However, we did not collect

data on why persons gave up working. In our earlier

investigation on HRQOL in the same group of

participants, being employed seemed to be related to

better HRQOL [26], especially concerning the

domains Physical Functioning (PF), Role Physical

(RP), Bodily Pain (BP), and Social Functioning

(SF). It is likely that those who withdrew from work

experienced more medical complications, such as

pain, and/or other barriers to employment, which

also affect their level of life satisfaction.

Sixty-eight percent of persons with cervical level of

SCI were satisfied with their vocational situation

versus 51% of the subjects with paraplegia. Maybe

this tendency is related to expectations of higher

capacity in persons with paraplegia? In comparison,

only 54% of a general Swedish population were

satisfied with their vocational situation [30].

For future research, longitudinal studies evaluat-

ing employment outcomes at different times after

SCI would provide valuable information. Addition-

ally, to improve employment outcomes in individuals

with SCI, more knowledge is required concerning

their perceived barriers to work, their motivations for

work, as well as their reasons for withdrawal from

work. The influence of employment and disability

compensation policies should be further investigated.

More information on health-status, including med-

ical co morbidities, and employment in SCI is

needed.

In conclusion, data from this study provide

information concerning risk indicators of not obtain-

ing work after SCI as well as indicators of early

withdrawal from work. A total of 65% of persons

with SCI returned to work post-injury. However, the

percentage of persons in work decreased to 35% with

time, and time from injury until withdrawal from

work was shorter in persons with a history of pre-

injury medical condition(s). There are indications

that participants still employed at the time of the

study were more satisfied with their situation than

participants who withdrew from work. More effort

must be made to improve the employment-situation

in persons with SCI, and the premises for maintain-

ing work for several years after SCI must be

elucidated.

Limitations

There were some limitations in this study worth

mentioning. First, we believe that the group of

persons admitted to Sunnaas Rehabilitation Hospital

prior to 1973, were more selected cases than patients

admitted later. There is a lack of information on

strategies concerning patient-selection to Sunnaas

Rehabilitation Hospital during this period, and there

is no available data on patients who were not

admitted for rehabilitation to the hospital. Therefore,

the representativeness of our study population

may be low for the incidence period 1961–1969.

2182 I. B. Lidal et al.

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A second weakness of the current investigation is

that we do not know the real return-to-work rate in

the total sample of persons who suffered SCI during

the actual incidence period. This is caused by; (1) the

selection of the sample as described above and (2)

missing information concerning deceased persons

and non-respondents. Since we were not allowed by

the Norwegian Directorate for Health and Social

Affairs to provide any details on persons without the

patients signed consent, including variables such as

gender, age and injury-aetiology, we cannot conclude

whether or not the participants comprise a represen-

tative group of Norwegian persons with spinal cord

lesions injured during the same period. There is a

possibility that those with a more severe impairment

and/or living with a long distance to the hospital, did

not consider study participation feasible.

Third, the design of the investigation is cross-

sectional with some retrospective data, which implies

a limitation to some valuable information. As an

example, we do not know how the employment rates

appeared at different points in time post-injury, for

example 5, 10, or 15 years post-injury. The number

of persons employed after injury, withdraws from

work, and the proportion currently employed,

changes with time.

Important to mention is also the fact that we do

not know the work-intensity during the post-injury

time until data collection, earnings and income after

SCI, for how long persons were employed before

they withdrew from work, nor the reasons for stop

working. As described in our study on HRQOL [26],

we registered health-problems in a non-standard

way.

Acknowledgements

This project was mainly financed from the Norwe-

gian Foundation for Health and Rehabilitation

(EXTRA). The Eastern Norway Health Authority

(‘Helse Øst’) also contributed with financial support.

The authors thank The Norwegian Association of the

Disabled, The Norwegian Association for Spinal

Injuries, and the participants.

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