Return to work following spinal cord injury: a review

INGEBORG BEATE LIDAL1, TUAN KHAI HUYNH2 & FIN BIERING-SØRENSEN2

1Department of Research, Sunnaas Rehabilitation Hospital, 1450 Nesoddtangen, Norway, and 2Clinic for Spinal Cord

Injuries, Neuroscience Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark

AbstractPurpose. To review literature on return to work (RTW) and employment in persons with spinal cord injury (SCI), andpresent employment rates, factors influencing employment, and interventions aimed at helping people with SCI to obtainand sustain productive work.Methods. A systematic review for 2000 – 2006 was carried out in PubMed/Medline, AMED, (ISI) Web of Science,EMBASE, CINAHL, PsycInfo and Sociological abstracts database. The keywords ‘spinal cord injuries’, ‘spinal corddisorder’, ‘spinal cord lesion’ or ‘spinal cord disease’ were cross-indexed with ‘employment’, ‘return to work’, ‘occupation’or ‘vocational’.Results. Out of approximately 270 hits, 110 references were used, plus 13 more found elsewhere. Among individuals withSCI working at the time of injury 21 – 67% returned to work after injury. RTW was higher in persons injured at a youngerage, had less severe injuries and higher functional independence. Employment rate improved with time after SCI. Personswith SCI employed ranged from 11.5% to 74%. Individuals who sustained SCI during childhood or adolescence had higheradult employment rates. Most common reported barriers to employment were problems with transportation, health andphysical limitations, lack of work experience, education or training, physical or architectural barriers, discrimination byemployers, and loss of benefits. Individuals with SCI discontinue working at younger age.Conclusions. This review confirmed low employment rates after SCI. Future research should explore interventions aimed athelping people with SCI to obtain and sustain productive work.

Keywords: Spinal cord injuries, spinal cord lesion, spinal cord disorder, employment, return to work, occupation, vocational

Introduction

Donald Munroe described in 1954 that the general

outlook for persons with spinal cord injury (SCI) was

becoming more optimistic compared with the situa-

tion for these patients prior to the Second World War

[1]. Munroe studied 445 patients with SCI, and he

was particularly preoccupied with the possibilities of

making persons with SCI ambulatory and capable of

working. He stressed the importance of an active

social life and stated that persons ‘with full self-care

ability should be able and should be expected to go

to work’. Munroe was also one of the first researchers

who maintained that rehabilitation of all patients

paralysed as the result of a SCI was possible.

Since then, the development in rehabilitation of

persons with spinal cord injuries in many countries

has been specialized and organized with multiprofes-

sional teams. Advances in acute care and rehabilita-

tion of SCI have resulted in considerably improved

longevity in this group. During the past decades,

there has been an increased focus on outcomes that

impact the lives of people living with SCI in the

community.

In 2001, the World Health Organization (WHO)

introduced The International Classification of Func-

tioning, Disability and Health (ICF), which de-

scribes health by including the aspect ‘participation

in activities’ [2]. Among the most important ‘parti-

cipation activities’ for adults, is the participation in

productive work. Many societies expect people to

work, and being employed is regarded as a key

indicator to social integration. Since new incidents of

SCI often hit young adults, return to work (RTW)

Correspondence: Ingeborg Beate Lidal, Department of Research, Sunnaas Rehabilitation Hospital, 1450 Nesoddtangen, Norway and Sunnaas Rehabilitation

Hospital, Faculty Divison, Ulleval University Hospital, University of Oslo, pb 1130 Blindern, 0318 Oslo, Norway. Tel: þ47 66 96 90 00.

Fax: þ47 66 91 25 76. E-mail: ingeborg.lidal@sunnaas.no

Disability and Rehabilitation, September 2007; 29(17): 1341 – 1375

ISSN 0963-8288 print/ISSN 1464-5165 online ª 2007 Informa UK Ltd.

DOI: 10.1080/09638280701320839

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and employment is of particular importance. Much

attention has been dedicated to obtaining work after

SCI during the past decades because of the

psychological, social, financial and political implica-

tions [3]. Among the most important consequences

of being employed, is the association of employment

with better self-esteem, higher life satisfaction, and

sense of well-being [4].

The aim of this review was to present recent

(2000 – 2006) results on RTW outcomes and em-

ployment for persons with SCI. This review also

focuses on studies analysing the effect of various

variables on RTW and employment outcomes after

SCI. Indicators positively affecting RTW as well as

factors found to trouble employment after SCI are

presented. Finally, recommendations of future re-

search directions are discussed.

Search strategy

A systematic review of the literature from the years

2000 – 2006 was performed in the seven databases,

PubMed/Medline, AMED (Allied and Complemen-

tary Medicine), (ISI) Web of Science, EMBASE,

CINAHL, PsycInfo and Sociological abstracts data-

base using database-specific search strategies. The

keywords ‘spinal cord injuries’, ‘spinal cord dis-

order’, ‘spinal cord lesion’, or ‘spinal cord disease’

were cross-indexed with ‘employment’, ‘return to

work’, ‘occupation’, or ‘vocational’. The references

were selected according to the relevance of their

content.

We limited our selection of publications to full-

length articles in English. Out of a total of approxi-

mately 270 hits, 69 references from PubMed/Medline

were used, additionally 17 references from AMED,

four references from (ISI) Web of Science, six

references from EMBASE, 12 references from

CINAHL, two from PsycInfo, and no references

from the Sociological abstracts databases. Thirteen

references were found elsewhere.

Employment and return-to-work-rates after

spinal cord injury

Since the study by Munroe, there have been several

studies focusing on employment and RTW after

SCI. Most investigations have revealed that the

number of persons obtaining work after injury

remains low. In a previous review, Athanasou et al.

[5] found employment rates (1976 – 1992) from 11%

to 69%. Yasuda et al. [6] more recently reviewed

RTW in persons with SCI, and stressed that the

variability in employment estimates is dependent

upon study methodology and different operational

definitions of employment being used. It is important

to place employment rates in the context of the

characteristics of the study’s sample design and

methods. The results presented in the current paper

show that most studies use a narrow definition of

employment, i.e., work for pay or self-employed.

However, broader definitions of employment are

used as well, and include homemaker and students.

Another matter of importance when estimating

RTW rates is time since injury [3,7,8]. There is a

tendency for the number of persons returning to

work progress over the years after injury. In a

longitudinal study by Krause and Broderick [9],

employment outcomes clearly improved over a 25-

year period, as the employment rates increased,

satisfaction with employment improved, and there

was greater stability in terms of tenure at the current

job. When considering all persons with SCI, it has

been suggested (1999) that approximately 30% are

working at any given point in time [10]. In those who

remain unemployed after the first decade after SCI

onset, the hope to enter into work seems to decline

[11]. Research has also concluded that individuals

with disabilities, including SCI, are experiencing a

sharper decline in employment in their later years

than those without disabilities [12]. The decline

seems to begin around the 40s age decade for

persons with disabilities, in contrast to the 50s and

60s age decade for able-bodied.

Table I presents recent studies with RTW as the

main topic. In persons working at injury onset,

the return to paid employment ranged from

21% to 67% after injury. It seems that relatively

few persons return to their pre-injury job [7].

Tomassen et al. [13] determined that the majority

of individuals in their study, returned to a less

physically demanding work. Schonherr et al. [14 –

16] reported that individuals who changed to a new

employer needed more time to resume work, but

seemed more satisfied with the same employer.

Further, 65% of their study sample experienced the

job situation satisfying, but several negative experi-

ences and unmet needs were reported. Many

unemployed persons thought they were capable of

working.

Table II presents investigations with employment

outcomes in SCI as the main topic (but where the

main topic of the paper is not RTW) including both

individuals who were employed and individuals who

were not employed at injury. The estimates of

persons with SCI gainfully employed range from

11.5% to 74%. Murphy and Young [21] seem to

have used a broader definition of employment, and

they found that the average proportion of available

time spent in employment was 62%. Another two

studies used a broad definition of employment, and

they reported employment rates of 29.5% and 47%,

respectively [22,23]. Individuals who sustained SCI

during childhood or adolescence seem to have higher

1342 I. B. Lidal et al.

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Tab

leI.

Su

mm

ary

of

rece

nt

stu

die

s(2

00

0–

20

06

)w

ith

retu

rnto

wo

rk(R

TW

)as

mai

nto

pic

inin

div

idu

als

wit

hsp

inal

cord

inju

ry(S

CI)

.

Au

tho

r(s)

,ye

ar,

nat

ion

alit

yP

arti

cip

ants

Age

(yea

rs)

Tim

esi

nce

inju

ry

Lev

elan

dex

ten

to

f

SC

ID

esig

nS

ign

ifica

nt

ou

tco

me

Jan

get

al.

[8]

20

05

,

Tai

wan

a

16

9(6

5%

par

tici

pat

ion

),

trau

mat

icS

CI.

Reh

abilit

atio

n1

98

9–

20

02

,8

7%

mal

es

39

(ran

ge

18

–6

0)

At

leas

t1

year

16

%co

mp

lte

tra

14

%in

com

pl

tetr

a

51

%co

mp

lp

ara

19

%in

com

pl

par

a

Cro

ss-s

ecti

on

al4

7%

emp

loye

d;

14

7p

erso

ns

wer

eem

plo

yed

pre

-in

jury

,

and

75

of

thes

ew

ere

emp

loye

dat

the

tim

eo

f

the

stu

dy.

Ed

uca

tio

nan

d

fun

ctio

nal

ind

epen

den

ce

wer

eas

soci

ated

wit

hw

ork

Sch

on

her

ret

al.

[14

–1

6]

20

04

–2

00

5(3

arti

cles

usi

ng

the

sam

em

ater

ial)

,

the

Net

her

lan

dsa

57

(res

po

nse

of

83

%),

trau

mat

icS

CI;

91

%m

ales

Age

atS

CI

33

(SD

11

),

ran

ge

18

–5

9

84

mo

nth

s(S

D2

9),

ran

ge

29

–1

40

mo

nth

s

10

%co

mp

lte

tra

30

%in

com

pl

tetr

a

35

%co

mp

lp

ara

25

%in

com

pl

par

a

Des

crip

tive

anal

ysis

of

dat

afr

om

am

aile

d

qu

esti

on

nai

re

60

%h

ada

job

atth

eti

me

of

asse

ssm

ent;

67

%o

fth

ose

wo

rkin

gat

the

tim

eo

fth

e

SC

Ire

turn

edto

wo

rk.

Hig

her

edu

cati

on

alle

vel

ind

icat

or

of

bei

ng

emp

loye

d.

Po

siti

ve

exp

ecta

tio

ns

of

the

pat

ien

t

was

aco

mp

lex

bu

tst

ron

g

ind

icat

or

of

succ

essf

ul

rein

tegra

tio

n

Yo

un

get

al.

[17

]2

00

4,

So

uth

east

ern

Au

stra

lia

a

19

2(7

9.7

%p

arti

cip

atio

n),

emp

loye

dp

erso

ns

exp

erie

nci

ng

atr

aum

atic

SC

I1

99

0–

19

96

,8

8%

mal

es

39

.45

(SD

13

.78

)

4.3

0ye

ars

(SD

2.2

9)

15

.6%

com

pl

tetr

a

34

.9%

inco

mp

l

tetr

a

21

.4%

com

pl

par

a

28

.1%

inco

mp

lp

ara

Cro

ss-s

ecti

on

alw

ith

sem

i-st

ruct

ure

d

inte

rvie

wb

yp

ho

ne

or

inp

erso

n

Agri

cult

ure

wo

rker

sh

ad

sign

ifica

nt

hig

her

rate

of

RT

Wth

ano

ther

ind

ust

ry

wo

rker

s:6

1.7

%vs

.

41

.1%

.O

vera

ll4

6.6

%

emp

loye

dat

inte

rvie

w

Kra

use

[7]

20

03

,U

SA

a2

59

,tr

aum

atic

SC

I,82

%

mal

es.

All

had

wo

rked

at

som

eti

me

po

stin

jury

46

.5A

vera

ge

23

.7ye

ars

56

%te

tra

Cro

ss-s

ecti

on

alsu

rvey

Ave

rage

4.8

year

sfr

om

inju

ryu

nti

lfi

rst

po

stin

jury

job

,an

dth

ein

terv

alw

as

gre

ates

tin

per

son

sw

ith

tetr

aple

gia

.O

nly

17

%o

f

the

par

tici

pan

tsre

turn

ed

toth

eir

pre

-in

jury

job

;

71

%w

ere

emp

loye

dat

the

tim

eo

fth

est

ud

y.

(con

tinued

)

Return to work following spinal cord injury: a review 1343

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Tab

leI.

(Con

tinued

).

Au

tho

r(s)

,ye

ar,

nat

ion

alit

yP

arti

cip

ants

Age

(yea

rs)

Tim

esi

nce

inju

ry

Lev

elan

dex

ten

to

f

SC

ID

esig

nS

ign

ifica

nt

ou

tco

me

Yav

uze

r&

Erg

in[1

8]

20

02

,

Tu

rkey

a

70

,5

6%

mal

es3

4.0

(ran

ge

16

–5

4)

Med

ian

30

mo

nth

s

(ran

ge

13

–7

2

mo

nth

s)

7co

mp

lte

tra

4in

com

pl

tetr

a

27

com

pl

par

a

32

inco

mp

lp

ara

Cro

ss-s

ecti

on

al

tele

ph

on

e

qu

esti

on

nai

re

Bef

ore

SC

I:6

5%

emp

loye

d;

11

%h

ou

sew

ives

;4

%

reti

red

;4

%u

nem

plo

yed

.

Med

ian

tim

eto

RT

W

afte

rd

isch

arge:

17

5d

ays

(ran

ge

26

–5

20

).O

fth

ose

emp

loye

db

efore

SC

I

36

%re

turn

edto

wo

rk,

50

%lo

stth

eir

job

and

14

%re

tire

d

Ch

apin

&K

ewm

an[1

9]

20

01

,U

SA

a

6em

plo

yed

men

mat

ched

wit

h6

un

emp

loye

dm

en

55

0(r

ange

30

–4

9)

Em

plo

yed

aver

aged

8ye

ars,

un

emp

loye

d

aver

aged

7ye

ars

sin

cein

jury

4p

airs

wit

hp

ara

1p

air

wit

hte

tra

1p

air

inw

hic

hth

e

emp

loye

dm

an

was

tetr

aan

dth

e

un

emp

loye

dp

ara

Aq

ual

itat

ive

stu

dy,

sem

i-st

ruct

ure

d

inte

rvie

ws

Fac

tors

asso

ciat

edw

ith

emp

loym

ent

wer

e

op

tim

ism

,se

lf-e

stee

m,

ach

ieve

men

to

rien

tati

on

,

role

mo

del

s,m

on

etar

y

ince

nti

ves,

dis

ince

nti

ves,

acce

ssan

d

acco

mm

od

atio

n

Hes

set

al.

[20]

200

0,

US

Aa

Init

ial

31

75

,tr

aum

atic

SC

I

wh

ow

ere

emp

loye

dat

the

tim

eo

fth

eS

CI.

Aft

er

excl

usi

on

,n¼

18

57

atye

ar

1,

n¼

148

6at

year

2,

n¼

11

77

atye

ar3

.

18

–6

51,

2,

and

3ye

ars

po

stin

jury

Mo

tor

ind

exsc

ore

sP

rosp

ecti

veP

red

icto

rso

fR

TW

(see

Tab

leII

I);

21

%w

ork

ing

atfi

rst

and

seco

nd

year

po

stin

jury

,2

3%

wo

rkin

g

inth

eth

ird

year

To

mas

sen

etal

.[1

3]

20

00

,

Th

eN

eth

erla

nd

sa

23

4,

trau

mat

ican

d

no

n-t

rau

mat

ic,

83

%m

ales

all

emp

loye

dat

inju

ry

40

.0(S

D

11

.7)

4.5

year

s(S

D1

.8)

0–

2ye

ars

11

%

2–

4ye

ars

34

%

4–

6ye

ars

29

%

46

year

s26

%

22

%co

mp

lte

tra

20

%in

com

pl

tetr

a

29

%co

mp

lp

ara

29

%in

com

pl

par

a

Su

rvey

.In

terv

iew

.

Qu

alit

ativ

ean

alys

is

37

%re

turn

edto

wo

rk

po

stin

jury

.L

ow

erag

e,

mal

egen

der

,h

igh

er

edu

cati

on

,lo

wer

inte

nsi

ty

of

wo

rkp

re-i

nju

ry,

retr

ain

ing

and

hig

her

Bar

thel

Ind

exw

ere

rela

ted

wit

ha

hig

her

rate

of

reem

plo

ymen

taf

ter

SC

I.

aW

ork

ing

for

pay

(nar

row

defi

nit

ion

of

emp

loym

ent)

;te

tra,

tetr

aple

gia

;p

ara,

par

aple

gia

;co

mp

l,co

mp

lete

SC

I;in

com

pl,

inco

mp

lete

SC

I;S

D,

stan

dar

dd

evia

tio

n.

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adult employment rates than do persons with adult-

onset SCI.

Personal significance

Productive work is one of the cornerstones of

adulthood [34] and an ingredient of a successful

and meaningful life. Employment means a lot to

independent adult living, independent functioning,

socialization, self-esteem, and in many countries also

to financial independence including access to health

insurance. There is an overall agreement that being

employed, part-time or full-time, influences life

satisfaction and well-being positively [4,6,33,

38,39], and persons with SCI who are not working

report lower overall satisfaction and lower satisfac-

tion with job opportunities and income [40]. Hess

et al. [4] revealed that individuals who were

employed reported significantly fewer depressive

symptoms than individuals who were not employed.

Employment is also attended with higher level of

activity, fewer medical treatments and a better overall

adjustment. Wise et al. [41] found that perceptions

of general health, lifestyle, and endurance, as well as

several factors associated with activity tolerance,

were significantly associated with employment status

in persons with SCI. Krause and Broderick [25]

concluded that locus of control, and to a lesser

degree, personality, were clearly related to post-

injury employment.

Social significance of employment

in spinal cord injury

DeVivo [42] studied (1997) direct costs of SCI in the

USA, but also described indirect costs such as lost

wages, fringe benefits, productivity and leisure time.

It was claimed that, depending on age, injury level,

educational level, and several other factors, the

indirect costs often exceed direct costs. The loss of

work after SCI has significant socioeconomic im-

plications. McKinley et al. [43] wrote that high

unemployment rates in persons with SCI in the USA

lead to significant state and federal expenses includ-

ing the cost of lost tax contributions and the direct

cost of benefits issued. The unemployment rate in

many countries are at a high level, and some studies

report that people with disabilities are among

those experiencing most difficulty in finding employ-

ment [44]. Boschen et al. [32] suggested that

adjustment after SCI can be aided through educa-

tion, involvement in productive activity, including

employment, and participation in social and leisure

activities. An improvement of the RTW rates would

have significant implications for the disbursement of

social security disability benefits and insurance

funds.

Indicators associated with RTW and

employment after spinal cord injury

Table III summarizes factors found to influence

employment and barriers to work, as well as reasons

for unemployment in individuals with SCI. The

Table shows factors described in the review by

Yasuda et al. [6] and factors found in the present

review of the literature, 2000 – 2006. The results are

similar. More detailed information concerning med-

ical problems and employment was achieved through

the present review. Anderson and Vogel [33] and

Vogel et al. [45] studied adults with paediatric-onset

injury, and found that pressure ulcers, serious urinary

tract infections, spasticity, respiratory problems and

hospitalizations were related to employment status.

Medical complications were seen more often in the

unemployed. Chen et al. [46] maintained that

pressure ulcer was more common in the unemployed.

Cutajar and Roberts [47] wrote that there was ‘no

significant association between pressure sore occur-

rence and whether or not the individual was

employed. However, it showed a statistically signifi-

cant association between unemployment and pres-

sure sores severe enough to lead to hospitalisation’.

Barriers to employment

Fiedler et al. [35] maintained that individuals with

SCI who were employed did not perceive severe

barriers. In the unemployed, however, transportation

was ranked as the number one barrier. Transporta-

tion barriers for persons with SCI is a challenge to

community reintegration including access to em-

ployment [52]. Kiyono et al. [51] wrote that ‘driving

ability is an important factor that allows individuals

with tetraplegia to participate in work’. Krause [11]

found that factors being reasons for unemployment

were related to energy, health, or health considera-

tions, and the reported barriers generally increased

across the age cohorts. The importance of encoura-

ging individuals injured later in life to consider

employment options rather than to allow them to see

their vocational life as completed, was underlined.

Liese et al. [53] found for Utah residents,

including individuals with SCI that the most

common barriers to employment were health and

physical limitations, lack of work experience, and

lack of sufficient education or training. Among other

frequently reported barriers were physical or archi-

tectural barriers, discrimination by employers, loss of

benefits such as Social Security or Medicare,

negative societal attitudes, and problems with trans-

portation. Another study [55], using qualitative

method, described challenges related to work faced

by African-American men. These included work-

place inaccessibility, employment disincentives (loss

Return to work following spinal cord injury: a review 1345

Dis

abil

Reh

abil

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

SUN

Y S

tate

Uni

vers

ity o

f N

ew Y

ork

at S

tony

Bro

ok o

n 10

/25/

14Fo

r pe

rson

al u

se o

nly.

Tab

leII

.S

um

mar

yo

fre

cen

tst

ud

ies

(200

0–

20

06

)w

ith

‘em

plo

ymen

to

utc

om

es’

asm

ain

top

icin

ind

ivid

ual

sw

ith

spin

alco

rdin

jury

(SC

I).

Au

tho

r(s)

,ye

ar,

nat

ion

alit

yP

arti

cip

ants

Age

(yea

rs)

Tim

esi

nce

inju

ryL

evel

and

exte

nt

of

SC

IM

ain

top

icD

esig

nS

ign

ifica

nt

ou

tco

me

Pfl

aum

etal

.[2

4]

20

06

,U

SA

a

20

14

3,

trau

mat

ic

SC

I,8

2%

mal

es

Mea

n3

7M

ean

4ye

ars

52

%te

tra

49

%A

ISA

Post

inju

ryem

plo

ymen

t

rate

san

dw

ork

life

exp

ecta

ncy

Lo

ngit

ud

inal

.In

cep

tio

n

coh

ort

stu

dy

Agre

ater

likel

iho

od

of

bei

ng

emp

loye

din

any

giv

enye

arw

asas

soci

ated

wit

hyo

un

ger

age,

wh

ite

race

,h

igh

ered

uca

tio

n

leve

l,b

ein

gm

arri

ed,

a

no

n-v

iole

nt

cau

seo

f

inju

ry,p

arap

legia

,A

ISD

,

lon

ger

tim

ep

ost

inju

ry,

bei

ng

emp

loye

dat

inju

ry

and

du

rin

gth

ep

revi

ou

s

po

stin

jury

year

Kra

use

&

Bro

der

ic[2

5]

20

06

,U

SA

a

13

91

,tr

aum

atic

SC

I,7

4%

mal

es

Ave

rage

41

.6A

vera

ge

9.7

year

s

55

%te

tra

Rel

atio

nsh

ipo

fp

erso

nal

ity

and

locu

so

fco

ntr

olw

ith

emp

loym

ent

ou

tco

mes

Su

rvey

27

%cu

rren

tly

emp

loye

d,

44

%h

adw

ork

edat

som

e

tim

ep

ost

inju

ry.

Lo

cus

of

con

tro

l,an

dto

less

er

deg

ree,

per

son

alit

y,w

as

clea

rly

rela

ted

top

ost

-

SC

Iem

plo

ymen

t

Kra

use

&T

erza

[26]

20

06,

US

Aa

61

5(a

tota

l

of

75

9

resp

on

den

ts

ou

to

f1

03

2;

61

5m

etth

e

incl

usi

on

crit

eria

)

trau

mat

icS

CI,

67

%m

ales

Age

atth

e

tim

eo

fth

e

stu

dy

43

.0

(ran

ge

23

–9

3)

17

.8ye

ars

(ran

ge

3–

50

)

56

%te

tra

Ear

nin

gs

and

spin

alco

rd

inju

ries

Cro

ss-s

ecti

on

ald

ata

fro

m

ano

ngo

ing

lon

git

ud

inal

stu

dy

43

%w

ere

gai

nfu

lly

emp

loye

d.

Fac

tors

asso

ciat

edw

ith

emp

loym

ent

stat

us

wer

e

mal

egen

der

,n

on

-Afr

ican

Am

eric

anra

ce,

you

nger

age

atth

est

ud

y,

par

aple

gia

,am

bu

lato

ry,

mo

reye

ars

sin

cein

jury

,

and

hig

her

edu

cati

on

al

leve

l.H

igh

erco

nd

itio

nal

earn

ings

wer

eo

bta

ined

by

men

,n

on

-Afr

ican

Am

eric

ans,

and

tho

se

wit

ha

colleg

ed

egre

e

(con

tinued

)

1346 I. B. Lidal et al.

Dis

abil

Reh

abil

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

SUN

Y S

tate

Uni

vers

ity o

f N

ew Y

ork

at S

tony

Bro

ok o

n 10

/25/

14Fo

r pe

rson

al u

se o

nly.

Tab

leII

.(C

onti

nued

).

Au

thor(

s),

year

,

nat

ion

alit

yP

arti

cip

ants

Age

(yea

rs)

Tim

esi

nce

inju

ryL

evel

and

exte

nt

of

SC

IM

ain

top

icD

esig

nS

ign

ifica

nt

ou

tco

me

An

der

son

etal

.

[27

]2

00

6,

US

Aan

d

Can

ada

a

16

6w

ho

ann

ual

ly

com

ple

ted

3

con

secu

tive

inte

rvie

ws,

69

%m

ales

29

(ran

ge

24

–3

6).

(In

clu

sio

n:

18

or

you

nger

atin

jury

)

14

.3ye

ars

(SD

4.0

).

14

.7ye

ars

(SD

5.1

)

64

%te

tra

Tra

nsi

tio

nto

adu

lth

ood

amo

ng

per

son

sw

ith

pae

dia

tric

-on

set

SC

I.

Sta

bilit

yo

fo

utc

om

es

ove

rti

me

Lo

ngit

ud

inal

stu

dy.

Tel

eph

on

ein

terv

iew

san

d

two

follo

w-u

pin

terv

iew

s

64

%em

plo

yed

atth

efi

rst

inte

rvie

w,

of

wh

ich

83

%

con

tin

ued

tob

e

emp

loye

d.

Fac

tors

asso

ciat

edw

ith

stab

le

wo

rk:

fem

ale

gen

der

,

wh

ite

race

,in

dep

end

ent

livi

ng,

CH

AR

Tm

ob

ilit

y,

and

cogn

itiv

e

ind

epen

den

ce

Val

ton

enet

al.

[23

]2

00

6,

Sw

eden

and

Fin

lan

db

18

2w

ith

SC

I,

73

.6%

mal

es.

Ad

dit

ion

ally

48

had

men

ingo

-

mye

loce

le

44

.7(m

ean

age

atin

jury

30

.5)

n¼

45

51

0ye

ars;

n¼

56

10

–2

0

year

s;

n¼

31

42

0ye

ars

47

.2%

tetr

aT

ost

ud

yin

jury

-rel

ated

and

ind

ivid

ual

fact

ors

as

pre

dic

tors

of

wo

rkin

per

son

sw

ith

trau

mat

ic

and

con

gen

ital

SC

I

Cro

ss-s

ecti

on

al

qu

esti

on

nai

rest

ud

y

Th

eem

plo

ymen

tra

tew

as

47

%in

per

son

sw

ith

trau

mat

icS

CI.

Th

eri

sk

of

no

n-p

arti

cip

atio

nin

wo

rkw

ash

igh

er

(alt

ho

ugh

no

t

sign

ifica

ntl

y)in

men

no

t

atw

ork

atth

eti

me

of

inju

ry.

Neu

rolo

gic

alle

vel

and

amb

ula

tory

stat

us

did

no

taf

fect

wo

rk

par

tici

pat

ion

insu

bje

cts

wit

htr

aum

atic

SC

I

Mea

de

etal

.[2

8]

20

06

,U

SA

a

43

6,

74

%m

ales

43

.8(S

D

12

.0)

10

.8ye

ars

(SD

7.9

)

54

%te

tra

of

tho

sew

ho

wer

e

un

emp

loye

d

52

%te

tra

of

tho

sew

ho

wer

e

par

t-ti

me

emp

loye

d

58

%te

tra

of

tho

sew

ho

wer

e

full-t

ime

emp

loye

d

To

des

crib

eth

e

rela

tio

nsh

ipb

etw

een

wo

rkin

ten

sity

,p

erso

nal

and

inju

ry-r

elat

ed

fact

ors

and

the

reso

urc

es

typ

ical

lyas

soci

ated

wit

h

emp

loym

ent

Ret

rosp

ecti

ve,

cro

ss-

sect

ion

al

34

%w

ere

emp

loye

dfu

ll-

tim

e,8

%w

ere

emp

loye

d

par

t-ti

me,

58

%w

ere

un

emp

loye

dat

the

tim

e

of

the

surv

ey.

Em

plo

ymen

tin

ten

sity

was

asso

ciat

edw

ith

age,

year

ssi

nce

inju

ry,

race

,

edu

cati

on

,an

d

dep

end

ents

livi

ng

at

ho

me

(con

tinued

)

Return to work following spinal cord injury: a review 1347

Dis

abil

Reh

abil

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

SUN

Y S

tate

Uni

vers

ity o

f N

ew Y

ork

at S

tony

Bro

ok o

n 10

/25/

14Fo

r pe

rson

al u

se o

nly.

Tab

leII

.(C

onti

nued

).

Au

tho

r(s)

,ye

ar,

nat

ion

alit

yP

arti

cip

ants

Age

(yea

rs)

Tim

esi

nce

inju

ryL

evel

and

exte

nt

of

SC

IM

ain

top

icD

esig

nS

ign

ifica

nt

ou

tco

me

Mu

rph

y&

Yo

un

g[2

1]

20

05

,

So

uth

east

ern

Au

stra

lia

b

59

25,

trau

mat

ic

SC

I.7

1%

wh

ite,

29

%

Afr

ican

Am

eric

an,

81

.9%

mal

es

32

.84

(SD

12

.55

)

Dat

a

collec

ted

at

year

s1

,5

,

10

,1

5an

d

20

afte

r

SC

I

15

.6%

com

pl

tetr

a

24

.6%

inco

mp

lte

tra

33

.9%

com

pl

par

a

26

.0%

inco

mp

lp

ara

Issu

eso

fem

plo

ymen

tan

d

race

inS

CI

Ret

rosp

ecti

vean

dcr

oss

-

sect

ion

al

Rac

ial

dis

par

itie

sin

emp

loym

ent

rate

s.1

1.5

%

wo

rkin

gat

1ye

ar,

18

.7%

at5

year

s,2

2%

at1

0

year

s,22

.2%

at15

year

s,

22.9

%at

20

year

sp

ost

-

inju

ry

Mea

de

etal

.[3

]

20

04

,U

SA

a

28

9,

trau

mat

ic

SC

I,w

ho

fou

nd

emp

loym

ent

po

stin

jury

,

86

.2%

mal

es.

Su

bgro

up

of

57

7

42

.18

(SD

0.4

9).

Incl

usi

on

16

–6

5

16

1m

on

ths

(SD

12

3).

Incl

usi

on

at

leas

t1

8

mo

nth

s

18

.5%

com

pl

tetr

a

31

.6%

inco

mp

lte

tra

28

.3%

com

pl

par

a

21

.2%

inco

mp

lp

ara

To

det

erm

ine

the

rela

tio

nsh

ipb

etw

een

sele

cted

dem

ogra

ph

ic,

inju

ry,

and

psy

cho

logic

al

char

acte

rist

ics

and

the

exte

nt

of

emp

loym

ent

afte

rS

CI

Cro

ss-s

ecti

on

alm

aile

d

surv

eyp

ackag

e

Of

tho

sew

ho

had

wo

rked

at

som

eti

me

po

stin

jury

,th

e

aver

age

pro

po

rtio

no

f

avai

lab

leti

me

spen

tin

emp

loym

ent

was

62

%.

Pre

dic

tors

for

hig

her

emp

loym

ent

wer

em

ale

gen

der

and

po

siti

vew

ork

atti

tud

e

An

der

son

etal

.

[29

]2

00

4,

US

Aan

d

Can

ada

a

26

5,

67

%m

ales

Mea

n2

7.8

(SD

3.5

).

Incl

usi

on

:

51

8at

inju

ry,

mea

n

13

.9

13

.5ye

ars

(SD

4.7

)

59

%te

tra

61

%A

ISA

Ad

ult

ou

tco

mes

of

pae

dia

tric

-on

set

SC

I

Str

uct

ure

din

terv

iew

,cr

oss

-

sect

ion

al

57

%em

plo

yed

.C

om

par

ed

wit

hm

atch

edco

mm

un

ity

con

tro

ls,

sub

ject

sw

ere

less

likel

yto

live

ind

epen

den

tly,

be

mar

ried

,h

ave

child

ren

,

or

be

emp

loye

d

Mu

rph

yet

al.

[30

],2

00

3,

So

uth

east

ern

Au

stra

lia

a

45

9(7

3%

par

tici

pat

ion

),

trau

mat

icS

CI,

85

%m

ales

39

.6(S

D

11

.2).

Incl

usi

on

16

–6

5

13

6m

on

ths

(SD

11

5).

Incl

usi

on

at

leas

t1

8

mo

nth

s

47

%p

ara

48

%co

mp

l

To

inve

stig

ate

the

infl

uen

ceo

f

dem

ogra

ph

ic,

inju

ryan

d

psy

cho

logic

al

char

acte

rist

ics

on

the

lab

or

forc

est

atu

so

f

peo

ple

wit

hS

CI

Cro

ss-s

ecti

on

alp

rim

ary

self

-rep

ort

surv

ey

47

%em

plo

yed

atth

eti

me

of

the

stu

dy.

Lev

elo

f

seco

nd

ary

sch

oo

lin

g,

the

un

der

takin

go

ftr

ain

ing

or

edu

cati

on

po

stin

jury

,

tim

esi

nce

inju

ry,

Ch

ance

RL

OC

*,

Inte

rnal

RL

OC

**

and

Wo

rk

Att

itu

de

sign

ifica

ntl

y

con

trib

ute

dto

pre

dic

tio

n

(con

tinued

)

1348 I. B. Lidal et al.

Dis

abil

Reh

abil

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

SUN

Y S

tate

Uni

vers

ity o

f N

ew Y

ork

at S

tony

Bro

ok o

n 10

/25/

14Fo

r pe

rson

al u

se o

nly.

Tab

leII

.(C

onti

nued

).

Au

tho

r(s)

,ye

ar,

nat

ion

alit

yP

arti

cip

ants

Age

(yea

rs)

Tim

esi

nce

inju

ryL

evel

and

exte

nt

of

SC

IM

ain

top

icD

esig

nS

ign

ifica

nt

ou

tco

me

Fra

nce

sch

ini

etal

.[2

2]

20

03

,It

aly

b

14

6,

71

.2%

mal

es

Mea

nag

e3

7.8

(SD

14

.9)

6.1

year

s

from

dis

char

ge

(ran

ge

3–

10)

36

.3%

tetr

a

63

.7%

par

a

Fra

nkel

scal

e:

A¼

44

.6%

B¼

2.7

%

C¼

13

%

D¼

39

.7%

To

asse

ssth

eo

utc

om

e

afte

rS

CI

(mort

alit

y,

stat

eo

fh

ealt

h,

occ

up

atio

n,

mo

bilit

y,

auto

no

my,

soci

alan

d

par

tner

rela

tio

nsh

ips,

QoL

),an

dto

dem

ogra

ph

ic–

clin

ical

dat

a

Mu

ltic

ente

red

follo

w-u

p

wit

hce

ntr

aliz

edd

ata

collec

tio

n.

29

.5%

of

pat

ien

tsw

ere

emp

loye

d(o

fw

ho

m

35

.8%

wer

en

ot

pai

d

wo

rker

s)

Ben

aven

teet

al.

[31

]2

00

3,

Sp

ain

a

90

resp

on

den

ts

(ou

to

f24

3,

i.e.

,3

7%

par

tici

pat

ion

),

72

.2%

mal

es,

75

.5%

trau

mat

icS

CI

17

.7%

51

8;

56

.7%

19

–4

0;

25

.6%

44

0

5ye

ars

Th

e9

0re

spo

nd

ents

wer

e

43

.3%

cerv

ical

47

.8%

tho

raci

c

8.9

%lu

mb

ar

48

.9%

com

pl

To

asse

ssth

ed

egre

eo

f

dis

abilit

ysh

ow

nb

y

pat

ien

tsw

ith

SC

I5

year

s

po

st-S

CI

Mai

led

qu

esti

on

nai

re.

12

.4%

did

som

ekin

dof

pai

djo

bat

follo

w-u

p.

Bei

ng

you

nger

atin

jury

(54

0ye

ars)

,h

avin

gle

ss

seve

rein

jury

,h

igh

Bar

thel

Ind

ex,

hig

h

edu

cati

on

alle

vel

and

edu

cati

on

po

stin

jury

wer

ep

red

icto

rsfo

rR

TW

Bo

sch

enet

al.

[32

],2

00

3,

Can

ada

b

Co

nve

nie

nce

sam

ple

of

10

0,

75

%m

ales

.

Qu

alit

ativ

e

sub

sam

ple

n¼

34

Ave

rage

40

Bet

wee

n

1ye

aran

d

5ye

ars

po

st-

dis

char

ge

58

tetr

a

42

par

a

39

com

pl

61

inco

mp

l

Lo

ng-t

erm

adju

stm

ent

and

com

mu

nit

yre

inte

gra

tio

n

Cro

ss-s

ecti

on

al.

Qu

esti

on

nai

res.

Qu

anti

tati

vean

d

qu

alit

ativ

e

met

ho

do

logy

36

%em

plo

yed

afte

rS

CI.

Th

ere

spo

nd

ents

fou

nd

it

dif

ficu

ltto

ob

tain

emp

loym

ent

bec

ause

of

the

inst

abilit

yo

fh

ealt

h,

len

gth

of

tim

eit

takes

to

com

ple

teta

sks

and

envi

ron

men

tal

bar

rier

s.

Fo

rp

rod

uct

ivit

yst

atu

s,

incl

ud

ing

emp

loym

ent,

age

ato

nse

t,in

jury

com

ple

ten

ess

and

hig

hes

t

edu

cati

on

alle

vel

was

imp

ort

ant

(con

tinued

)

Return to work following spinal cord injury: a review 1349

Dis

abil

Reh

abil

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

SUN

Y S

tate

Uni

vers

ity o

f N

ew Y

ork

at S

tony

Bro

ok o

n 10

/25/

14Fo

r pe

rson

al u

se o

nly.

Tab

leII

.(C

onti

nued

).

Au

tho

r(s)

,ye

ar,

nat

ion

alit

yP

arti

cip

ants

Age

(yea

rs)

Tim

esi

nce

inju

ryL

evel

and

exte

nt

of

SC

IM

ain

top

icD

esig

nS

ign

ifica

nt

ou

tco

me

An

der

son

&

Vo

gel

[33]

20

02

,U

SA

and

Can

adaa

19

5,

trau

mat

ic

and

no

n-

trau

mat

ic,

54

%m

ales

Mea

nag

e:2

9

(ran

ge

24–3

7)

Incl

usi

on

:

51

8at

inju

ry

Mea

nti

me

sin

ce

inju

ry:

15

year

s,

(ran

ge

7–

28

)

65

%te

tra

Em

plo

ymen

to

utc

om

eso

f

adu

lts

wh

osu

stai

ned

SC

Ias

child

ren

or

ado

lesc

ents

Str

uct

ure

din

terv

iew

51

%em

plo

yed

.P

red

icto

rs

of

emp

loym

ent

wer

e

edu

cati

on

,co

mm

un

ity

mo

bilit

y,fu

nct

ion

al

ind

epen

den

ce,

dec

reas

ed

med

ical

com

plica

tio

ns

Yo

un

g&

Mu

rph

y[3

4]

20

02

,A

ust

ralia

and

US

Aa

17

0,

88

.2%

mal

es

Mea

nag

e

36.7

8

(SD

10

.85

)

53

.3%

tetr

aT

oex

plo

rean

dd

escr

ibe

a

mea

sure

of

reh

abilit

atio

n

effe

ctiv

enes

sb

ased

on

cogn

itiv

eb

ehav

iou

ral

theo

ry

Inte

rvie

ws,

bo

thst

ruct

ure

d

op

en-

and

close

d-e

nd

ed

qu

esti

on

s.T

he

par

tici

pan

tsal

soto

ld

thei

rst

ori

esin

thei

ro

wn

wo

rds

48

%in

pai

dem

plo

ymen

tat

inte

rvie

w,

of

tho

se7

1%

sati

sfied

wit

hth

eir

ou

tco

me.

An

um

ber

of

peo

ple

felt

that

they

wer

e

un

der

-em

plo

yed

.T

he

maj

ori

tyo

fp

eop

len

ot

work

ing

exp

ress

eda

des

ire

tob

ew

ork

ing

Fie

dle

ret

al.

[35]

20

02

,U

SA

a

97

,8

2%

mal

esM

ean

age

38

.8

(SD

11

.6),

ran

ge

18

–

65

6.6

year

s(S

D

6.0

).

Incl

usi

on

:

min

imu

m1

year

po

stin

jury

19

%co

mp

lte

tra

20

%in

com

pl

par

a

35

%co

mp

lp

ara

26

%in

com

pl

par

a

Per

ceiv

edb

arri

ers

to

emp

loym

ent

Su

rvey

.P

erso

nal

ho

me

inte

rvie

ws

33

%em

plo

yed

,2

6%

un

emp

loye

dan

dlo

okin

g

for

wo

rk,

32%

un

emp

loye

dan

dn

ot

loo

kin

gfo

rw

ork

,9

%

stu

den

ts.

Lac

ko

f

tran

spo

rtat

ion

was

the

nu

mb

ero

ne

bar

rier

amo

ng

the

un

emp

loye

d

Kra

use

[11

]

20

01

,U

SA

a

38

1,

64

%m

ales

,

trau

mat

icS

CI.

All

un

emp

loye

d

Mea

nag

e4

3

(SD

10

.5).

Incl

usi

on5

65

17

year

s

(SD

8.5

)

60

%te

tra

Agei

ng

and

self

-rep

ort

ed

bar

rier

sto

emp

loym

ent

inp

erso

ns

no

tem

plo

yed

Th

ep

arti

cip

ant

sam

ple

was

taken

fro

ma

lon

git

ud

inal

stu

dy

of

agei

ng

afte

rS

CI.

Su

rvey

All

un

emp

loye

d.

Age

at

inju

ryon

set

and

year

s

sin

cein

jury

wer

eb

oth

rela

ted

toan

incr

ease

in

bar

rier

sto

emp

loym

ent,

mo

stof

wh

ich

wer

ed

ue

tod

eclin

ing

hea

lth

(con

tinued

)

1350 I. B. Lidal et al.

Dis

abil

Reh

abil

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

SUN

Y S

tate

Uni

vers

ity o

f N

ew Y

ork

at S

tony

Bro

ok o

n 10

/25/

14Fo

r pe

rson

al u

se o

nly.

Tab

leII

.(C

onti

nued

).

Au

tho

r(s)

,ye

ar,

nat

ion

alit

yP

arti

cip

ants

Age

(yea

rs)

Tim

esi

nce

inju

ryL

evel

and

exte

nt

of

SC

IM

ain

top

icD

esig

nS

ign

ifica

nt

ou

tco

me

Tas

iem

ski

etal

.

[36]

20

00

,

UK

a

45

,8

0%

mal

esA

ge

atti

me

of

inju

ry:

62

.2%

18

–

30

;3

1.1

%

31

–4

0;

6.7

%4

1–

50

46

.7%

tetr

a

53

.3%

par

a

Lev

els

of

spo

rtin

g/

recr

eati

on

alac

tivi

ties

,

edu

cati

on

and

emp

loym

ent

inS

CI.

To

asse

ssif

invo

lvem

ent

in

spo

rtre

crea

tio

nw

as

asso

ciat

edw

ith

hig

her

leve

lso

fed

uca

tio

nan

d

emp

loym

ent

Ap

ilo

tp

ost

alq

ues

tio

nn

aire

87

%em

plo

yed

atin

jury

;

33

%em

plo

yed

atth

e

tim

eo

fth

est

ud

y,2

9%

bei

ng

full-t

ime.

No

sign

ifica

nt

corr

elat

ion

bet

wee

nsp

ort

/rec

reat

ion

and

edu

cati

on

/

emp

loym

ent

Cre

we

[37

]2

00

0,

US

Aa

50

,8

6%

mal

esM

edia

n4

72

2–

45

year

s6

2%

fun

ctio

nal

lyco

mp

l

tetr

a

A2

0-y

ears

lon

git

ud

inal

per

spec

tive

on

the

voca

tio

nal

exp

erie

nce

so

f

per

son

sw

ith

SC

I

Inte

rvie

ws

in1

974

and

19

94

usi

ng

lon

git

ud

inal

qu

esti

on

nai

re

19

94

:5

8%

wo

rkin

gfu

ll-

tim

ean

d1

6%

wer

e

wo

rkin

gp

art-

tim

e.

Fac

tors

that

con

trib

ute

d

toth

evo

cati

on

al

acco

mp

lish

men

tso

fth

is

sam

ple

incl

ud

ew

ork

exp

erie

nce

s,

com

pre

hen

sive

reh

abilit

atio

nse

rvic

es,

and

wo

rket

hic

aW

ork

ing

for

pay

(nar

row

defi

nit

ion

of

emp

loym

ent)

;bW

ork

ing

for

pay

and

incl

ud

ing

stu

den

tsan

d/o

rh

om

emak

er(b

road

defi

nit

ion

of

emp

loym

ent)

;te

tra,

tetr

aple

gia

;p

ara,

par

aple

gia

;co

mp

l,

com

ple

teS

CI;

inco

mp

l,in

com

ple

teS

CI;

SD

,st

and

ard

dev

iati

on

;A

IS,

AS

IAIm

pai

rmen

tS

cale

;A

SIA

,A

mer

ican

Sp

inal

Inju

ryA

sso

ciat

ion

(In

tern

atio

nal

Neu

rolo

gic

alS

tan

dar

ds

for

Cla

ssifi

cati

on

of

Sp

inal

Co

rdIn

jury

);C

HA

RT

,C

raig

ho

spit

alas

sess

men

tan

dre

po

rtin

gte

chn

iqu

e.*C

han

ceR

LO

C(R

ehab

ilit

atio

nL

ocu

so

fC

on

tro

l)m

easu

res

the

exte

nt

tow

hic

ho

ne

bel

ieve

sth

atre

hab

ilit

atio

n

ou

tco

me

isa

mat

ter

of

fact

,lu

cko

rch

ance

.**In

tern

alR

LO

C(R

ehab

ilit

atio

nL

ocu

so

fC

on

tro

l)m

easu

res

the

exte

nt

tow

hic

ho

ne

bel

ieve

sin

tern

alfa

cto

rsar

ere

spo

nsi

ble

for

reh

abilit

atio

no

utc

om

e.

Return to work following spinal cord injury: a review 1351

Dis

abil

Reh

abil

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

SUN

Y S

tate

Uni

vers

ity o

f N

ew Y

ork

at S

tony

Bro

ok o

n 10

/25/

14Fo

r pe

rson

al u

se o

nly.

of medical or other ‘benefits’), racial and disability

discrimination, political challenges such as budget

cuts that impact critical programmes, and bureau-

cratic challenges including competence, responsive-

ness and effectiveness of services from agencies.

The effect of workplace characteristics on the

employment of persons with SCI and employers

who fail to provide accommodations has also been

discussed as important factors. Unemployment has

been linked to workplace discrimination [56].

Chan and Man [54] concluded: ‘. . . people with

SCI have to make extra efforts to overcome

difficulties in re-employment. The enhancement of

the rehabilitation program during early hospitaliza-

tion, the promotion of positive thinking, modifica-

tion of the vocational rehabilitation (VR) program,

and a review of the current social policy may assist

these clients to overcome the barriers that they face

during the re-employment process’.

Employment status as predictor of other

outcomes

Persons who sustain SCI are at risk of numerous

secondary medical conditions in addition to psycho-

logical challenges and changes in activity possibili-

ties. Many studies have been examining risk factors

for the occurrence of various medical complications

as well as the relationship between different variables

on perceived life satisfaction, quality of life, psycho-

logical health, and other outcomes after SCI. The

effect of employment status has often been taken into

consideration as a possible predictor of the outcome.

Table IV is an overview of recent research that

reveals employment status as an influencing factor

on the outcome. Employment has been positively

related to better community integration in persons

with SCI [3,57]. Further, many recent studies

confirm earlier findings suggesting that quality of

life and life satisfaction in general is better in persons

with SCI who are working; however, Schonherr et al.

did not find better life satisfaction in employed

participants [3,15,38,39,58 – 60].

Other studies with employment outcomes

Table V summarizes other studies from the period

2000 – 2006 that included employment data in

individuals with SCI. McMahon et al. [56] con-

cluded that employment discrimination is still very

real for many persons with SCI in the USA, although

persons with SCI have a right to non-discrimination

in employment practices that is guaranteed by the

ADA (Americans with Disability Act). The authors

found that allegations of discrimination against

people with SCI occurred more often in the Services

and the Public Administration industries, more often

among small employers, and more often among

employers located in the South.

Martz [67] concluded that the future time orienta-

tion of the group with active community roles was

significantly higher than that of the group with non-

active community roles (i.e., retired or unemployed).

Muraki et al. [68] revealed that among the six

factors age, smoking, level of physical activity,

occupation, level of SCI and period since SCI,

the level of SCI and physical activity are the

most important factors in determining physical

work capacity in wheelchair-dependent males after

SCI.

In a study on chronic pain after SCI, 33.6% of

persons employed reported frequent pain interfer-

ence with work. The pain interference was more

likely when individuals suffered from several differ-

ent types of pain, were older at injury, had an

education level at or below high school, and

experienced anxiety [69].

RTW interventions and special projects

Vocational rehabilitation programmes and supported

employment services

In many countries, VR seems to be well incorporated

in the organization of rehabilitation after SCI, and

special programmes that are geared towards improv-

ing employment outcomes in persons with disabil-

ities, have been developed [8,103,104]. Adequate

and appropriate vocational planning and rehabilita-

tion has been stressed [105]. ‘Good vocational

assessment and rehabilitation programs must place

their customers at the centre of the employment

process and allow them to choose their own

vocational direction’ [106]. Targett and Wehman

[107] listed the following characteristics of quality

RTW programmes: (i) an organizational climate and

culture that supports anyone who wants to work,

encourages success, and focuses on work as an

outcome; (ii) practical assistance is provided to

facilitate the person’s job search rather than requiring

the person to go through many steps in a process

prior to job seeking, like skills training; (iii) emphasis

on the job seeker’s personal preferences, existing

strengths, and belief in the power of workplace

supports; (iv) rapid assistance is provided when one

wants to work; one does not have to be ‘work ready’

and assessment focuses on person-centred ap-

proaches to determine employment strengths and

interest; (v) flexible and individualized support

including ongoing support if needed – rather than

giving one kind or level of support to all, assess-

ment of support needs is ongoing in the natural

environment; and (vi) the idea that the best way

for a person to learn about vocational preferences is

1352 I. B. Lidal et al.

Dis

abil

Reh

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Dow

nloa

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from

info

rmah

ealth

care

.com

by

SUN

Y S

tate

Uni

vers

ity o

f N

ew Y

ork

at S

tony

Bro

ok o

n 10

/25/

14Fo

r pe

rson

al u

se o

nly.

Table III. Summary of factors found to influence return to work (RTW) and employment including a list of barriers found to obstacle

employment after spinal cord injury (SCI).

Described in review by Yasuda [6]

2002

Described in recent literature

2000 – 2006

Demographic factors

and education/

employment

Gender Gender was not associated with

RTW, but the type of work. Men

more likely to be in paid

employment, women more likely

to be homemaker, student or

volunteer

Male gender predictor of RTW

[13,26], but other studies found

that women were more

frequently employed [27,33].

Hess did not find gender to be a

predictive variable [20]

Age at onset of SCI Older age at injury negatively

associated with postinjury

employment. Highest

employment rate was for those

injured before the age of 18

(69%). Those injured between

the ages 46 and 61 were least

likely to RTW

The younger the individuals were

at injury, the more likely they

were to RTW [8,13,20,31]. In a

Dutch study, the same

association was not found, but

their sample was relatively small

and young [14]. Recently it was

documented that age at injury

was a predictor of work

participation in male gender

only [23]

Marital status Being married influenced

employment positively [24].

Marital status was found to be

an important predictor of RTW

in year 1 and 2 after SCI, but

not at year 3 [8,20]

Race/ethnicity Caucasians more likely to be

working than minorities

Whites/non-minorities more likely

to be employed than non-whites

[3,20,24,27,29,33,48]

Education Level of education consistently

reported to be positively

correlated to RTW

Higher level of education reported

to be positively correlated to

RTW [8,13,14,20,24,26,33].

Persons who increased their

years of education after SCI

onset enhanced their

employment opportunities

[7,13]

Pre-injury employment.

Type of job. Physical

intensity of job pre-

injury

Lack of suitable jobs. Persons with

less physically intense

occupation pre-injury were more

likely to RTWa [13]

Being employed at injury and

during the previous postinjury

year was associated with greater

likelihood of being employed in

any given year [24]. Persons

who returned to their pre-injury

job reported a shorter interval

between injury and RTW [7].

Another study showed that

persons with less physically

intense occupation pre-injury

were more likely to RTWa [13]

(Vocational) retraining Vocational training after injury was

positively associated with

employment [8,13]; however

not significantly in one study

[14]

Injury related factors Time since injury More successful employment

outcomes in persons who have

lived more years since injury

Employment rates increase with

time postinjury [3,9,24,49].

Increase in barriers to

employment with years since

injury [11]

Injury severity/level of

impairment. Motor

Index Score (MIS)

Some studies found a link between

injury severity with employment,

and other studies did not. Not

clear relationships between the

Lower ASI motor score in

unemployed, i.e., more severe

impairment. Persons with

paraplegia more likely to be

(continued)

Return to work following spinal cord injury: a review 1353

Dis

abil

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from

info

rmah

ealth

care

.com

by

SUN

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Uni

vers

ity o

f N

ew Y

ork

at S

tony

Bro

ok o

n 10

/25/

14Fo

r pe

rson

al u

se o

nly.

Table III. (Continued).

Described in review by Yasuda [6]

2002

Described in recent literature

2000 – 2006

degree of impairment and ability

to work. Persons with tetraplegia

were less likely to obtain work,

but equally able to sustain

employment. Higher MIS

appears to be a significant

predictor of RTWa [20]

employed than persons with

tetraplegia [24,26,33,50].

Higher MIS appears to be a

significant predictor of RTWa

[20]. Persons with more severe

injuries are disadvantaged in

terms of the amount of time it

takes to RTW [7]. Injury

severity also reported to be an

obstacle to work participation

[23]

Functional

independence.

Barthel Index (BI)

More functional independence

positively associated with

employment [33,50]. Higher BI

was related to higher RTW rate

[8,13,31]

Cause of injury SCI after gunshot-wounds are less

motivated to seek employment

than those with other injury

aetiology

SCI after medical, and/or surgical

causes were more likely to be

employed than were those with

other aetiologies. Violence

aetiology associated with

unemployment [33]

Physical and

psychological

health

Health. Medical

complications

Health was a major limiting factor

to employment

Poor health was reported as a

reason for not working [23], and

it was reported more frequently

with increasing age [11].

Decreased medical

complications was a primary

predictor of employment [33]

Pain Neuropathic pain was a predictor

of work participation in male

gender only [23]

Fatigue Fatigue as a reason for

unemployment was reported

more frequently with increasing

age [11]

Pressure ulcers Relationship between pressure

sore occurrence and whether the

person was employed [33]

Urinary function.

Urinary tract

infection

To remain dry was not related to

employment [14]. Serious

urinary tract infections as a

complication was significantly

more common in unemployed

[33]

Spasticity Spasticity as a complication was

significantly more common in

unemployed [33]

Respiratory problems Respiratory problems as a

complication was significantly

more common in unemployed

[33]

Psychiatric disease The presence of mental disorders

is a strong risk factor for non-

participation in work [23]

Psychological factors Psychological factors related to

RTW after SCI [21]. Positive

expectations of reintegration in

work were associated with

successful reintegration in work

[14]. Positive work attitude a

(continued)

1354 I. B. Lidal et al.

Dis

abil

Reh

abil

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nloa

ded

from

info

rmah

ealth

care

.com

by

SUN

Y S

tate

Uni

vers

ity o

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ew Y

ork

at S

tony

Bro

ok o

n 10

/25/

14Fo

r pe

rson

al u

se o

nly.

by working in real jobs, is embraced and job

termination is not viewed as a failure but as an

opportunity to find a better career match or move to

a better job.

Fougeyrollas et al. [108] state that the possibility

for working is dependent on the extent of balance

between personal care, mobility, familial responsi-

bilities, etc. Then the ‘work’ is influenced by

Table III. (Continued).

Described in review by Yasuda [6]

2002

Described in recent literature

2000 – 2006

predictor of employment [21].

Optimism, self-esteem,

achievement orientation,

positive role models affected

employment [19]

Community mobility Greater community mobility was a

primary predictor of

employment [33]

Independent living Independent living was

significantly associated with

employment [33]

Barriers (most

frequent reported)

to work; reasons for

unemployment

Transportation Transportation to and from work is

important for ensuring the

individual’s self-determination

in employment

Independent driving associated

with employment [8,19,33,51].

Transportation was frequently

rated as the main reason for

unemployment [35,52,53]. In a

focus group study, the subjects

did not report transportation as

an obstacle [54]

Physical limitations Not physically capable of working

[11,53]. Physical impairment

limited the consideration and

initiative of seeking jobs [54]

Lack of work experience Lack of work experience reported

as a reason for unemployment

[53]

Lack of (sufficient)

education or training

Reported as a reason for

unemployment [53]. Can’t do

same jobs [11]

Architectural barriers.

Accessibility.

Workplace

characteristics

Lack of sanitary supplies and lack

of adjusted work or specific

adaptations. Lack of

accommodation [14 – 16,19,53]

Discrimination by

employers

Discrimination by employers

reported as a reason for

unemployment [53,54]

Loss of benefits such as

Social Security or

Medicare. Financial

disincentives

Economically aspects have been

reported to be a reason for not

seeking job/unemployment

[11,19,53,54]

Societal attitudes Negative societal attitudes

reported as a reason for

unemployment [53]

Time and energy.

Perceived stress.

Motivation

Both ‘time and energy’ as well as

‘too stressful’ was reported as

barriers. Reported more

frequently with increasing age

[11]. RTW and facing the

colleagues expressed as very

stressful [54]. Lack of

motivation reported as a hinder

for work participation [23]

aIdentical reference in the review by Yasuda and the present review (‘overlap’); ASIA, American Spinal Injury Association (International

Neurological Standards for Classification of Spinal Cord Injury). AIS, ASIA Impairment Scale.

Return to work following spinal cord injury: a review 1355

Dis

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ork

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tony

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n 10

/25/

14Fo

r pe

rson

al u

se o

nly.

Tab

leIV

.S

um

mar

yof

rece

nt

stu

die

s(2

00

0–

20

06

)w

ith

emp

loym

ent

stat

us

aso

ne

pre

dic

tor

of

ou

tco

me

inin

div

idu

als

wit

hsp

inal

cord

inju

ry(S

CI)

.

Au

tho

r(s)

,ye

ar,

nat

ion

alit

yP

arti

cip

ants

Age

(yea

rs)

Tim

esi

nce

inju

ry

Lev

elan

dex

ten

to

f

SC

IM

ain

top

icM

eth

od

sO

utc

om

e

Lin

etal

.[6

1]

20

06

,

Tai

wan

Nat

ion

wid

ere

gis

try:

18

7tr

aum

atic

,

81

%m

ales

42

.97

.4ye

ars

35

%co

mp

lC

om

par

ing

psy

cho

met

ric

per

form

ance

sof

the

rati

ng

scal

e(R

S),

stan

dar

dgam

ble

(SG

),

and

tim

etr

ade-

off

Cro

ss-s

ecti

on

al.

Tel

eph

on

e

inte

rvie

w

RS

asso

ciat

edw

ith

neu

rolo

gic

al

seve

rity

,

emp

loym

ent,

edu

cati

on

alle

vel,

and

self

-car

e

abilit

y.S

G

asso

ciat

edw

ith

neu

rolo

gic

al

seve

rity

and

emp

loym

ent

An

zai

etal

.[6

2]

20

06

,C

anad

a

52

adm

itte

d1

99

4–

20

03

,45

trau

mat

ican

d7

no

n-t

rau

mat

ic,

40

mal

es

Age

atd

isch

arge:

17¼

19

–3

3ye

ars;

20¼

34

–6

6ye

ars;

16¼

67þ

year

s

19

C1

-C3

;3

3C

4;

31

AIS

A;

21

AIS

B-C

.

Incl

usi

on

:C

1-4

,

AIS

A-C

Fac

tors

infl

uen

cin

g

dis

char

ge

loca

tio

n

follo

win

gh

igh

lesi

on

SC

I

Ret

rosp

ecti

ve

med

ical

char

ts

revi

ew

Ifem

plo

yed

atth

e

tim

eo

fin

jury

the

chan

cew

as

gre

ater

tob

e

dis

char

ged

to

com

mu

nit

y

inst

ead

of

to

exte

nd

edca

re

un

its

Ch

enet

al.

[63]

20

06

,U

SA

a

16

,tr

aum

atic

and

no

n-t

rau

mat

ic,

56

%m

ales

At

leas

t1

year

.M

ean

17

.5(r

ange

1.7

–6

0.3

)

Incl

usi

on

:

41

9ye

ars

old

;

41

year

po

stin

jury

;

�2

5kg

m7

2

At

leas

t1

year

75

%p

ara

Ob

esit

yin

terv

enti

on

Un

con

tro

lled

tria

l,

bo

dy

mas

sin

dex

red

uct

ion

Em

plo

ymen

tst

atu

s

was

amo

ng

fact

ors

tod

eter

min

eth

e

succ

ess

inw

eigh

t

loss

.S

ixp

erso

ns

wer

eem

plo

yed

,

5re

tire

d,

2st

ud

ents

,an

d

3u

nem

plo

yed

Ch

enet

al.

[46]

20

05

,U

SA

33

61

,8

3%

mal

esC

urr

ent

age

31

.3

(SD

13

.6)

4.9

(SD

3.6

),ra

nge

1–

15

year

s

48

%te

tra

52

%p

ara

54

%A

ISA

Pre

ssu

reu

lcer

Mu

ltic

ente

rco

ho

rt

stu

dy

Pre

vale

nce

of

pre

ssu

reu

lcer

.

Per

son

sem

plo

yed

or

un

der

trai

nin

g

wer

ele

sslikel

yto

hav

ep

ress

ure

ulc

erth

anth

eir

cou

nte

rpar

ts

(con

tinued

)

1356 I. B. Lidal et al.

Dis

abil

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ded

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info

rmah

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care

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by

SUN

Y S

tate

Uni

vers

ity o

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ew Y

ork

at S

tony

Bro

ok o

n 10

/25/

14Fo

r pe

rson

al u

se o

nly.

Tab

leIV

.(C

onti

nued

).

Au

tho

r(s)

,ye

ar,

nat

ion

alit

yP

arti

cip

ants

Age

(yea

rs)

Tim

esi

nce

inju

ry

Lev

elan

dex

ten

to

f

SC

IM

ain

top

icM

eth

od

sO

utc

om

e

Pri

ceet

al.

[64]

20

04

,A

ust

ralia

70

mal

es,

14

fem

ales

52

.4(S

D9

.3)

28

.1ye

ars

(SD

6.3

)5

1.2

%te

tra

56

.0%

com

pl

Fac

tors

per

ceiv

edto

chan

ge

or

thre

aten

fun

ctio

nan

d

qu

alit

yo

flife

Ret

rosp

ecti

vese

lf-

rep

ort

tele

ph

on

e-

adm

inis

tere

d

qu

esti

on

nai

re

Em

plo

ymen

tw

as

amo

ng

tho

sem

ost

freq

uen

tly

per

ceiv

edto

infl

uen

cep

osi

tive

chan

ge

Yilm

azet

al.

[60]

20

04

,T

urk

ey

52

mal

esan

d8

fem

ales

,tr

aum

atic

Mal

es2

8.5

(SD

8.7

);

fem

ales

32

.2(S

D

4.6

).

Incl

usi

on

:at

leas

t1

8

Incl

usi

on

:at

leas

t2

year

s

All

par

tici

pan

ts

com

pl

AIS

A

Su

bje

ctiv

ew

ell-

bei

ng

and

the

pre

dic

tors

of

sub

ject

ive

wel

l-b

ein

g

Cro

ss-s

ecti

on

alL

ife

sati

sfac

tio

n

corr

elat

edw

ith

soci

alfu

nct

ion

s,

ph

ysic

alfu

nct

ion

s,

role

emo

tio

nal

and

MC

S*

sub

scal

eso

fS

F-3

6

FIM

,an

d

occ

up

atio

n

sub

scal

eo

f

CH

AR

T

An

der

son

etal

.[5

7]

20

03

,U

SA

a

216

,6

9%

mal

es2

8.6

(SD

3.4

)

Incl

usi

on

:5

18

at

inju

ry,

atle

ast

24

atfo

llo

w-u

p

14

.2(S

D4

.6)

57

%te

tra

Co

mm

un

ity

inte

gra

tio

n

amo

ng

adu

lts

wit

hS

CI

sust

ain

edas

child

ren

or

ado

lesc

ents

Cro

ss-s

ecti

on

al.

Str

uct

ure

d

inte

rvie

w

57

%em

plo

yed

.

Hig

her

leve

lso

f

edu

cati

on

and

bei

ng

emp

loye

d

wer

eb

oth

asso

ciat

edw

ith

gre

ater

com

mu

nit

y

inte

gra

tio

n

Pu

tzke

etal

.[3

8]

20

02

,U

SA

b

940

,7

8%

mal

es,

trau

mat

ic

36

.3(S

D1

4.9

)E

valu

ated

at1

and

2ye

ars

po

stin

jury

32

%co

mp

lp

ara

18

%co

mp

lte

tra

Pre

dic

tors

of

life

sati

sfac

tio

nP

rosp

ecti

ve,

lon

git

ud

inal

Un

emp

loym

ent

was

amo

ng

fact

ors

asso

ciat

edw

ith

risk

of

low

life

sati

sfac

tio

n

(con

tinued

)

Return to work following spinal cord injury: a review 1357

Dis

abil

Reh

abil

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nloa

ded

from

info

rmah

ealth

care

.com

by

SUN

Y S

tate

Uni

vers

ity o

f N

ew Y

ork

at S

tony

Bro

ok o

n 10

/25/

14Fo

r pe

rson

al u

se o

nly.

Tab

leIV

.(C

onti

nued

).

Au

tho

r(s)

,ye

ar,

nat

ion

alit

yP

arti

cip

ants

Age

(yea

rs)

Tim

esi

nce

inju

ry

Lev

elan

dex

ten

tof

SC

IM

ain

top

icM

eth

od

sO

utc

om

e

Led

uc

&L

epag

e

[59

]2

00

2,C

anad

a

Lis

ted

inQ

ueb

ec

Par

aple

gic

Ass

oci

atio

n.

58

7tr

aum

atic

,

80

%m

ales

10

%5

30

25

%30

–4

0

29

%41

–5

0

25

%51

–6

0

11

%4

60

37

%5

10

;2

9%

10

–

20

;3

4%

42

0

year

s.

Incl

usi

on

:at

leas

t

2ye

ars

po

stin

jury

33

%te

tra

67

%p

ara

Hea

lth

-rel

ated

qu

alit

yo

flife

afte

rS

CI

Mai

led

qu

esti

on

nai

res.

Cro

ss-s

ecti

on

al

Em

plo

yed

sub

ject

s

sho

wed

a

sign

ifica

nt

hig

her

valu

eco

mp

ared

to

the

no

n-e

mp

loye

d

for

the

eigh

tS

F-

36

scal

es,

PC

S

and

MC

S*.

31

%

emp

loye

d

An

der

son

etal

.[5

8]

20

02

,U

SA

and

Can

ada

21

6,

69

%m

ales

28

.6(S

D3

.4)

Incl

usi

on

:5

18

at

inju

ry,

atle

ast

24

year

sat

follo

w-u

p

14

.2(S

D4

.6)

57

%te

tra

64

%A

ISA

Lif

esa

tisf

acti

on

inad

ult

s

wit

hp

aed

iatr

ic-o

nse

tS

CI

Cro

ss-s

ecti

on

al.

Str

uct

ure

d

inte

rvie

w

Em

plo

ymen

tw

as

amo

ng

the

fact

ors

stro

ngly

asso

ciat

edw

ith

SW

LS

.1

12

per

son

sw

ere

emp

loye

d

Kra

use

etal

.[6

5]

20

01

,U

SA

56

0,

60

.2%

wh

ite

mal

es,

20

%w

hit

e

fem

ales

,1

5.9

%

min

ori

tym

ales

,

3.9

%m

ino

rity

fem

ales

Age

atin

terv

iew

43.6

14

.5ye

ars

57

.7%

par

a,al

lo

f

wh

om

use

da

wh

eelc

hai

rfo

r

mo

bilit

y

To

iden

tify

pro

tect

ive

beh

avio

ur

and

risk

fact

ors

asso

ciat

edw

ith

the

dev

elo

pm

ent

of

pre

ssu

re

ulc

ers

Acr

oss

-sec

tio

nal

stu

dy

Bei

ng

curr

entl

y

emp

loye

dw

as

amo

ng

fact

ors

asso

ciat

edw

ith

low

erri

sko

f

hav

ing

pre

ssu

re

ulc

erin

the

pas

t

year

Do

wle

ret

al.

[39

]

20

01

,U

SA

a

55

52

;8

0%

mal

es,

trau

mat

icS

CI

Mea

nag

e3

8.4

1,

2,

5,

10

,1

5,

and

�2

0ye

ars

32

%co

mp

lp

ara

17

%in

com

pl

par

a

22

%co

mp

lte

tra

28

%in

com

pl

tetr

a

Pre

dic

tors

of

the

SW

LS

Fo

llo

w-u

p

eval

uat

ion

s

23

%em

plo

yed

.

Em

plo

ymen

t

stat

us

was

amo

ng

the

stro

nges

t

pre

dic

tors

of

sati

sfac

tio

nw

ith

life

Pu

tzke

etal

.[6

6]

20

01

,U

SA

54

0,

79

%m

ales

,

trau

mat

icS

CI

36

.6(S

D1

4.5

)1

year

po

stin

jury

30

%co

mp

lp

ara

19

%in

com

pl

par

a

17

%co

mp

lte

tra

33

%in

com

pl

tetr

a

Pre

dic

tors

of

pai

n1

year

po

stin

jury

Pro

spec

tive

,

lon

git

ud

inal

Ind

ivid

ual

s

un

emp

loye

dat

the

tim

eo

fin

jury

wer

e

mo

relikel

yto

rep

ort

pai

n

inte

rfer

ence

aW

ork

ing

for

pay

(nar

row

defi

nit

ion

of

emp

loym

ent)

;bW

ork

ing

for

pay

and

incl

ud

ing

stu

den

tsan

d/o

rh

om

emak

er(b

road

defi

nit

ion

of

emp

loym

ent)

;te

tra,

tetr

aple

gia

;p

ara,

par

aple

gia

;co

mp

l,

com

ple

teS

CI;

inco

mp

l,in

com

ple

teS

CI;

SD

,st

and

ard

dev

iati

on

;*T

he

eigh

tS

F-3

6sc

ales

:P

hys

ical

fun

ctio

nin

g;

Ro

lefu

nct

ion

,p

hys

ical

;R

ole

fun

ctio

n,

emo

tio

nal

;S

oci

alfu

nct

ion

ing;

Bo

dily

pai

n;

Men

tal

hea

lth

;V

ital

ity;

Gen

eral

hea

lth

;P

CS

,P

hys

ical

com

po

nen

tsu

mm

ary;

MC

S,

Men

tal

com

po

nen

tsu

mm

ary;

AIS

,A

SIA

Imp

airm

ent

Sca

le.

AS

IA,

Am

eric

anS

pin

alIn

jury

Ass

oci

atio

n

(In

tern

atio

nal

Neu

rolo

gic

alS

tan

dar

ds

for

Cla

ssifi

cati

on

of

Sp

inal

Co

rdIn

jury

);F

IM,

Fu

nct

ion

alIn

dep

end

ence

Mea

sure

;C

HA

RT

,C

raig

ho

spit

alas

sess

men

tan

dre

po

rtin

gte

chn

iqu

e;S

WL

S,

Sat

isfa

ctio

nw

ith

Lif

eS

cale

.

1358 I. B. Lidal et al.

Dis

abil

Reh

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Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

SUN

Y S

tate

Uni

vers

ity o

f N

ew Y

ork

at S

tony

Bro

ok o

n 10

/25/

14Fo

r pe

rson

al u

se o

nly.

Tab

leV

.S

um

mar

yo

fo

ther

rece

nt

stu

die

s(2

00

0–

200

6)

wit

hem

plo

ymen

td

ata

inin

div

idu

als

wit

hsp

inal

cord

inju

ry(S

CI)

.

Au

tho

r(s)

,ye

ar,

nat

ion

alit

yP

arti

cip

ants

Age

(yea

rs)

Tim

esi

nce

inju

ryL

evel

and

exte

nt

of

SC

IM

ain

top

icM

eth

od

sO

utc

om

e

Ken

ned

yet

al.

[70]

20

06

,U

K,

Ger

man

y,A

ust

ria,

Sw

itze

rlan

d

35

0,

79

%m

ales

Mea

n4

9(S

D1

2.1

)M

ean

21

year

s(S

D

11

.2)

25

%co

mp

lte

tra

18

%in

com

pl

tetr

a

48

%co

mp

lp

ara

9%

inco

mp

lp

ara

To

iden

tify

un

met

nee

ds

of

peo

ple

wit

hS

CI

Qu

esti

on

nai

re5

2%

wer

ecu

rren

tly

inp

aid

or

volu

nta

ry

emp

loym

ent.

Nee

ds

inar

eas

of

occ

up

atio

n,

sexu

al

acti

vity

and

pai

n

relief

wer

ele

ast

sati

sfac

tori

ly

Kra

use

&C

oker

[49]

20

06

,U

SA

a

78

,tr

aum

atic

,8

6%

mal

es

55

.7(S

D7

.6)

35

.8ye

ars

(SD

4.7

)6

8%

tetr

a

31

%co

mp

l

Agei

ng

afte

rS

CI

Lo

ngit

ud

inal

ove

r3

dec

ades

Yea

rso

fed

uca

tio

n

chan

ged

fro

m

13

.8to

15

.6o

ver

the

30

-yea

r

per

iod

.T

he

emp

loym

ent

rate

incr

ease

d,

and

ho

urs

wo

rked

per

wee

kin

crea

sed

.

Sat

isfa

ctio

nw

ith

emp

loym

ent

incr

ease

db

etw

een

19

73

and

19

88

,

bu

td

ecre

ased

som

ewh

atb

y2

00

2

Gau

ler

etal

.[7

1]

20

06

,S

wit

zerl

and

41

,3

5m

ales

.A

ll

sust

ain

ed

par

aglid

ing

acci

den

ts

Mea

n3

9.4

atth

e

tim

eo

fS

CI

(ran

ge

18

–7

0)

Un

kn

ow

n7

4%

of

the

vert

ebra

l

frac

ture

sw

ere

loca

lize

db

etw

een

T1

1an

dL

3,

wit

ha

max

imu

mof

30

%at

L1

Par

aglid

ing

acci

den

ts:

pat

tern

of

lesi

on

san

d

the

pro

gn

ost

ic

rad

iolo

gic

alfa

cto

rsfo

r

reh

abilit

atio

n

po

ten

tial

Are

tro

spec

tive

anal

ysis

21

pat

ien

tsre

turn

ed

toth

eir

form

er

pro

fess

ion

and

pla

ceo

f

emp

loym

ent;

11

pat

ien

tsre

ceiv

ed

spec

ialize

d

trai

nin

gfo

rn

ew

job

s

(con

tinued

)

Return to work following spinal cord injury: a review 1359

Dis

abil

Reh

abil

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

SUN

Y S

tate

Uni

vers

ity o

f N

ew Y

ork

at S

tony

Bro

ok o

n 10

/25/

14Fo

r pe

rson

al u

se o

nly.

Tab

leV

.(C

onti

nued

).

Au

tho

r(s)

,ye

ar,

nat

ion

alit

yP

arti

cip

ants

Age

(yea

rs)

Tim

esi

nce

inju

ryL

evel

and

exte

nt

of

SC

IM

ain

top

icM

eth

od

sO

utc

om

e

Joh

nst

on

etal

.[7

2]

20

05

,U

SA

a

10

7,

trau

mat

icS

CI,

82

.2%

mal

es

39

.1(S

D1

1.1

6).

Incl

usi

on

:4

18

11

.36

year

s(S

D

9.5

6)

56

.4%

AIS

A

38

.7%

com

pl

tetr

a

15

.1%

inco

mp

lte

tra

37

.6%

com

pl

par

a

8.6

%in

com

pl

par

a

Hea

lth

lite

racy

(HL

)C

ross

-sec

tio

nal

surv

ey

28

%cu

rren

tly

emp

loye

d.

HL

rela

ted

top

hys

ical

hea

lth

.

Co

rrel

atio

ns

of

HL

wit

h

occ

up

atio

nw

ere

exp

lain

edas

the

effe

cto

fed

uca

tio

n

Bu

shn

ik&

Ch

arlifu

e

[73

]2

00

5,

US

Ab

63

,8

6%

mal

es,

trau

mat

icS

CI

Age

atla

stin

terv

iew

43

.2(S

D8

.4)

Tim

esi

nce

inju

ryat

last

inte

rvie

w1

8.9

year

s(S

D2

.6)

All

sub

ject

sw

ith

hig

h

tetr

a(C

1-C

4)

73

%C

4,

16

%C

3,

9%

C2

,2

%C

1

Ou

tco

mes

of

ind

ivid

ual

s

wit

hh

igh

tetr

aw

ho

wer

ein

terv

iew

edat

thre

ep

has

es

Lo

ngit

ud

inal

inte

rvie

ws

5.3

,

13.1

and

18

.9

year

saf

ter

inju

ry

Em

plo

ymen

tst

atu

s

sho

wed

a

sign

ifica

nt

chan

ge

acro

ssth

est

ud

y

ph

ases

.

Em

plo

yed

:P

has

e

1,

10

%;

ph

ase

2,

27

%;

ph

ase

3,

31

%

Jen

sen

etal

.[7

4]

20

05

,U

SA

14

7,

74

.8%

mal

es4

8.8

(SD

13

.0)

21

–

88

16

.6ye

ars

(SD

10

.4),

ran

ge

3–

57

50

%p

ara

Ch

ron

icp

ain

Cro

ss-s

ecti

on

alan

d

lon

git

ud

inal

Ap

pro

xim

atel

y

40

.1%

emp

loye

d.

Pai

nin

sen

siti

vity

inte

rfer

ence

wit

h

wo

rkb

oth

ou

tsid

e

the

ho

me

and

ho

use

wo

rk

Cu

taja

r&

Ro

ber

ts

[47

]2

00

5,

Sau

di

Ara

bia

58

par

a,m

ales

Mea

n3

3M

ean

age

ato

nse

t2

4

year

s

86

%th

ora

cic

14

%lu

mb

ar

Pre

ssu

reso

reR

etro

spec

tive

cro

ss-

sect

ion

al.

Tel

eph

on

e

inte

rvie

wo

f58

%

of

sele

cted

ind

ivid

ual

s

41

%in

wo

rk

po

stin

jury

,m

ain

ly

offi

cew

ork

Lu

nd

etal

.[7

5]

20

05

,S

wed

en

16

1,

63

%m

ales

,

52

%tr

aum

atic

Mea

n5

2(S

D1

8.2

)M

edia

n5

year

s

(ran

ge

1–

58

)

38

%te

tra

62

%p

ara

Sel

f-as

sess

men

to

fso

cial

invo

lvem

ent

Po

stal

qu

esti

on

nai

re8

7o

f1

61

resp

on

den

ts

rep

ort

edth

eir

per

cep

tio

no

f

wo

rkas

follo

ws:

23

%n

op

rob

lem

s;

44

%m

ino

r

pro

ble

ms;

33

%

seve

rep

rob

lem

s

(con

tinued

)

1360 I. B. Lidal et al.

Dis

abil

Reh

abil

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

SUN

Y S

tate

Uni

vers

ity o

f N

ew Y

ork

at S

tony

Bro

ok o

n 10

/25/

14Fo

r pe

rson

al u

se o

nly.

Tab

leV

.(C

onti

nued

).

Au

tho

r(s)

,ye

ar,

nat

ion

alit

yP

arti

cip

ants

Age

(yea

rs)

Tim

esi

nce

inju

ryL

evel

and

exte

nt

of

SC

IM

ain

top

icM

eth

od

sO

utc

om

e

Isak

sso

net

al.

[76]

20

05

,S

wed

en

13

,fe

mal

eso

nly

Ran

ge

25

–6

1W

ith

inla

st1

0ye

ars

Un

kn

ow

nW

om

en’s

per

cep

tio

no

f

chan

ges

inth

eso

cial

net

wo

rkaf

ter

SC

I.

Inte

rvie

w.

Qu

alit

ativ

e

anal

ysis

Nee

dfo

rem

oti

on

al

and

pra

ctic

al

sup

po

rtfr

om

thei

r

soci

aln

etw

ork

to

par

tici

pat

ein

occ

up

atio

n

Par

illa

etal

.[7

7]

20

05

,U

SA

28

13

wo

men

,o

f

thes

e4

22

had

hig

h

tetr

aple

gia

At

inju

ry:

33

.0(S

D

16

.5)

1ye

arp

ost

inju

ry1

5%

hig

h(C

1-C

4)

tetr

a

33

.5%

low

tetr

a

51

.5%

inju

ries

at/b

elo

w

T2

To

com

par

ew

om

en

wit

han

dw

ith

ou

th

igh

tetr

aw

ith

resp

ect

to

clin

ical

and

soci

od

emo

gra

ph

ic

char

acte

rist

ics

and

thei

rch

anges

Cas

ese

ries

fro

mth

e

NS

CIS

C

6.2

%in

the

hig

h

tetr

agro

up

and

11

.4%

inth

eo

ther

gro

up

had

ajo

bat

1-y

ear

po

stin

jury

Kra

use

&B

rod

eric

[9]

20

05

,U

SA

95

,8

3%

mal

es,

trau

mat

icS

CI

53

.8(S

D9

.2)

32

.2ye

ars

(SD

5.6

)7

0.5

%te

tra

Th

en

atu

ral

cou

rse

of

chan

ges

inac

tivi

ty

pat

tern

s,h

ealt

h

ind

icat

ors

,life

sati

sfac

tio

nan

d

adju

stm

ent

ove

rye

ars

Lo

ngit

ud

inal

surv

ey1

:L

ife

Sit

uat

ion

Qu

esti

on

nai

re.

2:

Th

eem

plo

ymen

t

rate

incr

ease

d

fro

m4

4%

to5

2%

Ch

apin

etal

.[7

8],

20

04

,U

SA

and

Can

ada

13

2,

77

%m

ales

Cu

rren

tag

e45

.82

(SD

15

.67

)

Mea

n1

5.2

1m

on

ths

(SD

11

.63

),ra

nge

1.0

8–

50

.92

mo

nth

s

(Rec

ruit

edfr

om

the

Can

adia

nP

arap

legic

Ass

oci

atio

n)

Psy

cho

met

ric

valid

atio

n

of

SW

BI

Qu

esti

on

nai

re1

9%

emp

loye

d

full-t

ime,

6%

emp

loye

d

par

t-ti

me.

Em

plo

ymen

t

stat

us

po

siti

vely

rela

ted

tofi

nan

cial

wel

l-b

ein

gan

d

ph

ysic

alw

ell-

bei

ng

sub

scal

eso

f

the

SW

BI

Kra

use

&B

rod

eric

k

[79

],2

00

4,

US

A

51

2.

Th

ere

po

rt

focu

sed

on

47

5,

sin

ceth

egro

up

of

Asi

anA

mer

ican

s

was

sub

stan

tial

ly

low

er.

Ave

rage

42

.2A

vera

ge

12

.8ye

ars

52

%te

tra,

29

.7%

com

pl

Iden

tify

gen

der

,ra

ce

and

eth

nic

dif

fere

nce

s

inS

WB

,

par

tici

pat

ion

,an

d

gen

eral

hea

lth

rati

ngs

Mu

ltis

ite,

cro

ss-s

ecti

on

al

1:

Su

bje

ctiv

ew

ell-

bei

ng,

par

tici

pat

ion

,

gen

eral

hea

lth

rati

ngs.

2:

20

.2%

wo

rkin

gfo

rp

ay.

Wh

ites

rep

ort

ed

bet

ter

SW

Bin

rela

tio

nto

emp

loym

ent

op

po

rtu

nit

ies

(con

tinued

)

Return to work following spinal cord injury: a review 1361

Dis

abil

Reh

abil

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

SUN

Y S

tate

Uni

vers

ity o

f N

ew Y

ork

at S

tony

Bro

ok o

n 10

/25/

14Fo

r pe

rson

al u

se o

nly.

Tab

leV

.(C

onti

nued

).

Au

tho

r(s)

,ye

ar,

nat

ion

alit

yP

arti

cip

ants

Age

(yea

rs)

Tim

esi

nce

inju

ryL

evel

and

exte

nt

of

SC

IM

ain

top

icM

eth

od

sO

utc

om

e

Pu

tzke

etal

.[8

0]

200

4,

US

A

20

7,

77

%m

ales

,

trau

mat

icS

CI

Mea

n3

8.9

(SD

16

.2)

atin

jury

.

Incl

usi

on

:

41

8at

inju

ry

1,

2,

4,

and

5ye

ars

po

stin

jury

21%

com

pl

tetr

a

21%

inco

mp

lte

tra

27%

com

pl

par

a

25%

inco

mp

lp

ara

6%

un

kn

ow

n

Lif

esa

tisf

acti

on

ove

r

tim

e

Pro

spec

tive

wit

h

lon

git

ud

inal

dat

a.

Str

uct

ure

d

tele

ph

on

e

inte

rvie

ws

atye

ars

1,

2,

4,

and

5

po

stin

jury

Em

plo

yed

:1

.Yea

r

13%

;2

.Yea

r1

6%

;

4.Y

ear

21

%an

d

5.Y

ear

22

%

po

stin

jury

Pra

bh

aka

&T

hak

ker

[81]

20

04

,In

dia

54

6,

38

2fe

mal

es,

16

4m

ales

Inju

red

19

84

–2

00

11

%u

sed

elec

tric

wh

eelc

hai

r

47%

use

dm

anu

al

wh

eelc

hai

r

30%

wal

ked

wit

hai

ds

22%

wal

ked

wit

ho

ut

aid

s

Ho

me

visi

tte

amF

ollo

w-u

pat

ho

me

35

.2%

go

vern

men

t

job

or

sed

enta

ry

job

;1

0%

wo

rkin

g

ash

ou

sew

ives

Tat

eet

al.[8

2]

20

04

,

US

A

30

41

,7

8.5

%m

ales

,

trau

mat

icS

CI

41

.5(S

D1

3.4

),

ran

ge

18

–8

9

9.7

year

s(S

D8

.20

),

ran

ge

1–

25

38.1

%te

tra

AIS

A,B

,C

41.2

%p

ara

AIS

A,B

,C

20.7

AIS

D

Pat

tern

so

fal

coh

ol

and

sub

stan

ceu

sean

d

abu

se

Ret

rosp

ecti

vecr

oss

-

sect

ion

al

29

.9%

emp

loye

d;

49.1

%

un

emp

loye

d;

10.7

%re

tire

d;

8.2

%st

ud

ent;

2.1

%h

om

emak

er.

Su

bst

ance

use

mo

stp

reva

len

t

amon

gst

ud

ents

and

un

emp

loye

d

Ch

arlifu

e&

Ger

har

t

[83]

20

04

,U

K

17

8,

84

.8%

mal

es5

9.4

(SD

8.2

)M

ean

36

.0ye

ars

(SD

5.9

).

Incl

usi

on

:m

inim

um

20

year

sp

ost

inju

ry

33.1

%te

tra

AIS

A,B

,C

46.1

%p

ara

AIS

A,B

,C

20.8

%A

ISD

Co

mm

un

ity

inte

gra

tio

n

inS

CI

of

lon

g

du

rati

on

Lo

ngit

ud

inal

stu

dy

CH

AR

T

occ

up

atio

nal

sco

res

dec

lin

ed

sign

ifica

ntl

yo

ver

tim

e

Al-

Jad

idet

al.

[84

]

200

4,

Sau

di

Ara

bia

57

of

12

0m

ales

6–

60

;2

1–

30

(40

.4%

);31

–4

0

(33

.3%

)

Pat

ien

tsad

mit

ted

19

82

–2

00

3

43.9

%ce

rvic

al

40.4

%th

ora

cic

Qu

alit

yo

flife

(QoL

)R

etro

spec

tive

.

Qu

esti

on

nai

re

Th

eim

po

rtan

t

fact

ors

affe

ctin

g

QoL

wer

e

fin

anci

alst

atu

s,

emp

loym

ent,

equ

ipm

ent

sup

ply

and

soci

al

iso

lati

on (c

onti

nued

)

1362 I. B. Lidal et al.

Dis

abil

Reh

abil

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

SUN

Y S

tate

Uni

vers

ity o

f N

ew Y

ork

at S

tony

Bro

ok o

n 10

/25/

14Fo

r pe

rson

al u

se o

nly.

Tab

leV

.(C

onti

nued

).

Au

tho

r(s)

,ye

ar,

nat

ion

alit

yP

arti

cip

ants

Age

(yea

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esi

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nt

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ain

top

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e

Sh

erm

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al.

[85]

20

04

,U

SA

62

,(4

3%

resp

on

den

ts),

67

.7%

mal

es,

79

%tr

aum

atic

42

11

.7ye

ars

(ran

ge

0.3

3–

35

).

14

.5%

hig

hte

tra

Fra

nkel

A,B

,C

27

.4%

low

tetr

aF

ran

kel

A,B

,C

45

.2%

par

aF

ran

kel

A,B

,C

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.9%

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nkel

D

To

com

par

eth

eim

pac

t

of

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pes

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al

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tp

eer-

men

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ng

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tner

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stm

ent

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CI

Cro

ss-s

ecti

on

al

surv

ey

Pas

tp

eer-

men

tori

ng

asso

ciat

edw

ith

hig

her

occ

up

atio

nal

acti

vity

and

life

sati

sfac

tio

n.

65

%

rep

ort

edto

be

un

emp

loye

d

McC

oll

etal

.[8

6]

20

04

,U

SA

,

Can

ada

and

En

gla

nd

Am

atch

edsa

mp

leo

f

67

mal

esan

d

67

fem

ales

Ave

rage

57

Ave

rage

33

year

s.

Incl

usi

on

:at

leas

t

20

year

s

Mal

es:

35

%p

ara

AIS

A,B

,C

44

%te

tra

AIS

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,C

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%A

ISD

;E

Fem

ales

:5

0%

par

aA

IS

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%te

tra

AIS

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,C

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%A

ISD

;E

To

iden

tify

dif

fere

nce

s

inth

eag

ein

g

exp

erie

nce

so

fm

en

and

wo

men

wit

hS

CI

Th

est

ud

yis

par

to

fa

lon

git

ud

inal

inte

rnat

ion

alst

ud

y

of

agei

ng

and

SC

I

Men

spen

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ice

as

man

yh

ou

rs

wo

rkin

gas

did

wo

men

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d

wo

men

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t

mo

reth

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ice

as

man

yh

ou

rsin

ho

mem

akin

g

task

s,3

2%

emp

loye

d

Sam

uel

sso

net

al.

[87

]2

00

4,

Sw

eden

56

;7

9%

mal

es4

9(S

D1

8)

13

.9ye

ars

(SD

10

.8)

10

0%

par

aS

hou

lder

pai

nin

par

a

wh

eelc

hai

ru

sers

Cro

ss-s

ecti

on

al

stu

dy

No

corr

elat

ion

was

fou

nd

on

sho

uld

er

pai

nan

db

od

y

fun

ctio

nan

d

emp

loym

ent.

21

(37

.5%

)h

ad

sho

uld

erp

ain

du

rin

gla

stm

on

th

Fo

rch

hei

mer

etal

.

[88

]2

00

4,

US

A

20

48

,7

7.9

%m

ales

,

trau

mat

icS

CI

41

.9(S

D1

2.7

).

Incl

usi

on

:at

leas

t18

wh

enm

ost

rece

ntl

y

inte

rvie

wed

10

.5ye

ars

(SD

8.3

)4

1.7

%p

ara

AIS

A,B

,C

36

.8%

tetr

aA

ISA

,B,C

21

.5%

AIS

D

Gen

der

dif

fere

nce

sin

com

mu

nit

y

inte

gra

tio

n

Cro

ss-s

ecti

on

al,

retr

osp

ecti

vest

ud

y

Men

mo

relikel

yto

rep

ort

bei

ng

un

emp

loye

dan

d

wo

men

mo

re

freq

uen

tly

clas

sify

ing

them

selv

esas

ho

mem

aker

s.

31

.5%

emp

loye

d

Hig

her

pro

po

rtio

n

of

wo

men

hav

ing

max

imal

sco

res

on

the

CH

AR

T

occ

up

atio

nsc

ale

(con

tinued

)

Return to work following spinal cord injury: a review 1363

Dis

abil

Reh

abil

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

SUN

Y S

tate

Uni

vers

ity o

f N

ew Y

ork

at S

tony

Bro

ok o

n 10

/25/

14Fo

r pe

rson

al u

se o

nly.

Tab

leV

.(C

onti

nued

).

Au

tho

r(s)

,ye

ar,

nat

ion

alit

yP

arti

cip

ants

Age

(yea

rs)

Tim

esi

nce

inju

ryL

evel

and

exte

nt

of

SC

IM

ain

top

icM

eth

od

sO

utc

om

e

Dra

ino

ni

etal

.

[89]

200

4,

US

Aa

51

6,

79%

mal

esM

ean

43

Mea

n1

0ye

ars

n¼

91

com

pl

tetr

a

n¼

99

inco

mp

lte

tra

n¼

13

1co

mp

lp

ara

n¼

58

inco

mp

lp

ara

(i.e

.,3

79

ou

to

fth

e

tota

lsa

mp

leo

f5

16

)

Pat

tern

so

fin

tern

etu

se

by

per

son

sw

ith

SC

I

Cro

ss-s

ecti

on

al

surv

ey

22

%w

ere

emp

loye

d;

83

%w

ith

inte

rnet

acce

ssw

ere

emp

loye

d,

17

%o

f

per

son

sw

ith

ou

t

inte

rnet

acce

ss

wer

eem

plo

yed

.

Inte

rnet

use

d

mo

stoft

enfo

r

e-m

ail,

dis

abilit

y

and

hea

lth

info

rmat

ion

,

pla

yin

ggam

es,

sho

pp

ing,

emp

loym

ent

or

voca

tio

nal

info

rmat

ion

,an

d

chat

room

s

Mar

tz[6

7]

20

03

,

US

A

31

7,

trau

mat

ican

d

no

n-t

rau

mat

ic,

86

.1%

mal

es

Mea

n5

0.7

(SD

14

.7),

ran

ge

16

–8

7

14

.1ye

ars

(SD

13

.1),

ran

ge

0–

56

AIS

A:

32

.6%

AIS

B:

11

.8%

AIS

C:

18

.1%

AIS

D:

37

.5%

Fu

ture

tim

eo

rien

tati

on

and

emp

loym

ent

in

SC

I

Mai

led

surv

ey.

Cro

ss-s

ecti

on

al

Fu

ture

tim

e

ori

enta

tio

nw

as

dif

fere

nt

bet

wee

n

per

son

sw

ith

an

acti

veco

mm

un

ity

role

(em

plo

yed

,

stu

den

to

r

volu

nte

er;

22

.5%

)

vers

us

no

n-a

ctiv

e

(un

emp

loye

do

r

reti

red

77

.5%

).3

4

per

son

sw

ork

ed

full-t

ime,

13

par

t-

tim

e,9

wer

e

volu

nte

er,

12

wer

e

stu

den

ts,

91

per

son

sw

ere

reti

red

,an

d1

25

un

emp

loye

d

(con

tinued

)

1364 I. B. Lidal et al.

Dis

abil

Reh

abil

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

SUN

Y S

tate

Uni

vers

ity o

f N

ew Y

ork

at S

tony

Bro

ok o

n 10

/25/

14Fo

r pe

rson

al u

se o

nly.

Tab

leV

.(C

onti

nued

).

Au

tho

r(s)

,ye

ar,

nat

ion

alit

yP

arti

cip

ants

Age

(yea

rs)

Tim

esi

nce

inju

ryL

evel

and

exte

nt

of

SC

IM

ain

top

icM

eth

od

sO

utc

om

e

Wo

ulle

etal

.[9

0]

20

03

,U

SA

67

,7

9%

mal

esM

edia

n(r

ange

16

–5

7)

Med

ian

3ye

ars

(ran

ge

1–

33

)

bet

wee

nin

jury

and

surg

ery

All

tetr

a(C

4–

C8

)S

atis

fact

ion

wit

hu

pp

er-

extr

emit

ysu

rger

y

Mai

led

qu

esti

on

nai

re

69

%re

po

rted

imp

rove

men

tin

occ

up

atio

n

Bo

sch

enet

al.

[32]

20

03

,C

anad

a

Co

nve

nie

nce

sam

ple

of

10

0,

75

%m

ales

Ave

rage

40

1–

6ye

ars

afte

rS

CI

58

tetr

a

42

par

a

39

com

pl

61

inco

mp

l

Lo

ng-t

erm

adju

stm

ent

and

com

mu

nit

y

rein

tegra

tio

n

Cro

ss-s

ecti

on

al.

Qu

esti

on

nai

res,

qu

anti

tati

vean

d

qu

alit

ativ

e

met

ho

do

logy

36

%em

plo

yed

po

stin

jury

Rag

hav

anet

al.

[91

]

20

03

,U

K

47

2,

76

%m

ales

,

47

0tr

aum

atic

47

(SD

14

.7)

13

year

s(S

D1

0.6

)25

%te

tra

55

%p

ara

15

%o

ther

sc

Pre

sen

ceo

fp

ress

ure

sore

s

Po

stal

qu

esti

on

nai

re

surv

ey

18

%em

plo

yed

atth

e

tim

eof

the

stu

dy

Pen

tlan

det

al.

[92

]

20

03

,C

anad

a

29

fem

ales

35

–7

0,

mea

n5

0M

ean

12

year

s

(3–

38

)

10

cerv

ical

17

tho

raci

c

2lu

mb

ar

Occ

up

atio

nal

resp

on

se

tom

id-l

ife

and

agei

ng

inw

om

enw

ith

dis

abilit

y

Qu

alit

ativ

ew

ith

focu

sgro

up

inte

rvie

wfo

llo

wed

by

key

info

rman

t

inte

rvie

ws

Wo

men

are

dea

lin

g

sim

ult

aneo

usl

y

wit

his

sues

of

the

dis

abilit

y,m

id-

life

,an

dla

ter

life

.

Age-

rela

ted

chan

ges

mea

n

they

hav

eto

relin

qu

ish

valu

ed

rule

san

d

occ

up

atio

ns.

Th

ey

feel

iso

late

d.

Th

ey

hav

efe

aro

ffu

ture

loss

esin

per

son

al

con

tro

lan

d

occ

up

atio

nal

engag

emen

t

Bu

rnet

tet

al.

[48]

20

02

,U

SA

41

76

,tr

aum

atic

,

80

.7%

mal

es,

64

.8%

no

n-

min

ori

ty(w

hit

e)

Cu

rren

tag

e3

5.9

(SD

15

.2),

ran

ge

18

–9

4

Inju

red

19

88

–9

849

.2%

par

a

50

.8%

tetr

a

Imp

act

of

min

ori

ty

stat

us

follo

win

gS

CI

Ret

rosp

ecti

ve

anal

ysis

Sig

nifi

can

t

dif

fere

nce

s

bet

wee

n

min

ori

ties

and

no

n-m

ino

riti

esin

emp

loym

ent

stat

us

atin

jury

.A

gre

ater

pro

po

rtio

n

of

min

ori

ties

was

un

emp

loye

dan

d

had

less

than

a

hig

hsc

ho

ol

edu

cati

on (con

tinued

)

Return to work following spinal cord injury: a review 1365

Dis

abil

Reh

abil

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

SUN

Y S

tate

Uni

vers

ity o

f N

ew Y

ork

at S

tony

Bro

ok o

n 10

/25/

14Fo

r pe

rson

al u

se o

nly.

Tab

leV

.(C

onti

nued

).

Au

tho

r(s)

,ye

ar,

nat

ion

alit

yP

arti

cip

ants

Age

(yea

rs)

Tim

esi

nce

inju

ryL

evel

and

exte

nt

of

SC

IM

ain

top

icM

eth

od

sO

utc

om

e

Tat

e&

Fo

rch

hei

mer

[93]

20

02

,U

SA

20

8(1

36

reh

abilit

atio

n

pat

ien

ts,

incl

ud

ing

SC

I,7

2ca

nce

r

pat

ien

ts),

SC

I

pat

ien

tsw

ere

70

%

mal

es

SC

Ip

atie

nts

:m

ean

36

(SD

13

)

6ye

ars

(SD

3)

Qu

alit

yo

flife

,life

sati

sfac

tio

nan

d

spir

itu

alit

y

Cro

ss-s

ecti

on

al

surv

ey

25

%em

plo

yed

of

the

SC

Ip

atie

nts

Vo

gel

etal

.[4

5]

20

02

,U

SA

21

6,

69

%m

ales

28

.6(S

D3

.4)

14

.2ye

ars

(SD

4.6

)57

%te

tra

Ad

ult

sw

ith

pae

dia

tric

-

on

set

SC

I,im

pac

to

f

med

ical

com

plica

tio

ns

Cro

ss-s

ecti

on

al.

Tel

eph

on

e-

inte

rvie

w

Th

eco

mp

lica

tio

ns

mo

stsi

gn

ifica

ntl

y

asso

ciat

edw

ith

un

emp

loym

ent

wer

ese

vere

UT

I,

pre

ssu

reu

lcer

s,

spas

tici

ty,

and

resp

irat

ory

com

plica

tio

ns

Har

ker

etal

.[9

4]

20

02

,C

anad

a

Co

mm

un

ity-

resi

din

g

wit

hS

CI

on

the

19

92

mai

lin

glist

of

the

Can

adia

n

Par

aple

gic

Ass

oci

atio

n–

On

tari

oD

ivis

ion

.

44

0tr

aum

atic

,

74

.3%

mal

es

39

.69

(SD

11

.76

).

Incl

usi

on

16

–6

5

12

.3ye

ars

(SD

9.8

9)

Incl

usi

on

:at

leas

t

1-y

ear

po

stin

jury

5.5

%co

mp

lte

tra

48

.1%

inco

mp

lte

tra

4.9

%co

mp

lp

ara

41

.6%

inco

mp

lp

ara

Co

mp

aris

on

of

ind

epen

den

tlivi

ng

ou

tco

mes

follo

win

g

trau

mat

icb

rain

inju

ry

and

spin

alco

rdin

jury

Cro

ss-s

ecti

on

al.

Mai

led

surv

ey

7.3

%fu

llti

me

emp

loye

d;

5.0

%p

art

tim

e

emp

loye

d

(Ap

pen

dix

A,

p.1

02

);

26

%in

full

or

par

t-ti

me

emp

loym

ent

(tex

t,p

.9

7)

Cav

igel

liet

al.

[95

]

20

02

,S

wit

zerl

and

54

,7

6%

mal

esw

ith

par

a,97

%m

ales

wit

hlo

wer

lim

b

amp

uta

tio

n

33

(SD

11

.1)

Un

kn

ow

nP

ara

Eff

ect

of

reh

abilit

ativ

e

pro

ced

ure

so

nth

e

soci

oec

on

om

ic

ou

tcom

e

Ret

rosp

ecti

ve

com

par

iso

n

Th

eav

erag

e

du

rati

on

for

resu

mp

tio

nof

emp

loym

ent

is2

year

sw

ith

ou

t

sign

ifica

nt

dif

fere

nce

bet

wee

nth

etw

o

gro

up

so

fp

atie

nts

Hu

ges

etal

.[9

6]

20

01

,U

SA

64

wo

men

44

.6(S

D1

1.7

)M

ean

12

.0ye

ars

(SD

10

.8).

Incl

usi

on

:at

leas

t

2ye

ars

(CH

AR

TM

ob

ilit

y

Sca

le,

mea

n7

1.5

,

SD

22

.8)

Dep

ress

ion

and

wo

men

wit

hS

CI

Inte

rvie

win

a

clin

ical

sett

ing.

Cro

ss-s

ecti

on

al

76

.6%

un

emp

loye

d.

Sin

gle

and

un

emp

loye

d

wo

men

wer

em

ore

likel

yto

be

clas

sifi

edas

dep

ress

ed (con

tinued

)

1366 I. B. Lidal et al.

Dis

abil

Reh

abil

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

SUN

Y S

tate

Uni

vers

ity o

f N

ew Y

ork

at S

tony

Bro

ok o

n 10

/25/

14Fo

r pe

rson

al u

se o

nly.

Tab

leV

.(C

onti

nued

).

Au

tho

r(s)

,ye

ar,

nat

ion

alit

yP

arti

cip

ants

Age

(yea

rs)

Tim

esi

nce

inju

ryL

evel

and

exte

nt

of

SC

IM

ain

top

icM

eth

od

sO

utc

om

e

Wid

erst

rom

-No

ga

etal

.[6

9]

20

01

,

US

A

21

7,

75

.1%

mal

es,

trau

mat

icS

CI

39

.0(S

D11

.0).

Incl

usi

on

:4

18

old

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tinued

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Return to work following spinal cord injury: a review 1367

Dis

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Reh

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Dow

nloa

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from

info

rmah

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care

.com

by

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1368 I. B. Lidal et al.

Dis

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Dow

nloa

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from

info

rmah

ealth

care

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by

SUN

Y S

tate

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f N

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Return to work following spinal cord injury: a review 1369

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at S

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/25/

14Fo

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nly.

environmental factors interacting with personal

factors, both at the organic level, i.e., severity of

injury, urinary tract infections, pressure ulcers, etc.,

and reduction in capabilities (physical or mental

disabilities) related to locomotion, changing posi-

tions, manual activities, voluntary body parts move-

ment, proprioceptive functions, self-esteem,

adaptation to situations, sociability, sense of respon-

sibility, and self-affirmation. Other relevant personal

factors are age, gender, race, familial situation,

circumstances of trauma, life history, education,

work experience, and personal goals. ‘Work’ is also

influenced by physical environmental factors, facil-

itators as well as obstacles. They divided environ-

mental factors into three levels.

Microsystemic. The productive tasks and physical and

social work setting required by the job. Here use of

assistive devices and accommodations in the work

situation, e.g., specific human supports, supervision,

continuous vocational training may be needed.

Interfaces such as voice control of computers, easy

physical access to any tool required, speaker phones

may be used.

Mesosystemic. The contextual factors that determine

the accomplishment of the life habits required by the

work situation, i.e., some handicap situations are

created by the community mesosystem. This may

include physical accessibility of the built environ-

ment, values and attitudes of the human resources

department, access to assistive devices, availability

of training and opportunities on equal terms, etc.

In addition should there be effective home-care

services, accessible home, effective and adapted

transportation, access to urban and rural locations,

etc.

Macrosystemic. The environmental societal variables

that in general influence the labour market, i.e.,

unemployment, types of available jobs, legislation.

They concluded that the environmental variables are

very important in determining the possibilities for

accomplishment of the social participation in ‘work’.

Finally, they offered the hypothesis ‘that the socio-

political will of the government to reduce or

eliminate restrictions in work participation among

people with SCI is as important or is perhaps more

important than their organic impairments and

functional limitations’.

Targett et al. [104,109] describe how a tailored

‘Supported Employment’ approach may be used to

assist individuals with SCI to circumventing barriers

and obtain paid work in the community: an employ-

ment specialist plays multiple roles in assisting

individuals with disabilities with securing and main-

taining employment. The concept is based on the

individualization of services to support persons with

disabilities in their vocational pursuits. Roessler

[110] wrote that on-going job maintenance services

from a career development specialist in rehabilitation

hold great promise for improving the job retention

rates of employees with SCI. King et al. [111]

presented a collaborative approach for returning

clients with new SCI to work, the Marcus Commu-

nity Bridge Program. Teams of Bridge staff are

assigned to different geographical areas of the USA,

and assist clients in their plans to RTW. The

employment rate of clients enrolled in Bridge was

17% at the first anniversary of their discharge from

inpatient rehabilitation, and the percentage of clients

returning to school or training was 31.6%. Weh-

meyer et al. [103] have been studying the impact of

The Self-Determined Career Development Model to

enable VR counsellors and others to support VR

consumers to self-regulate problem solving to enable

them to set career job goals, and design, implement

and evaluate progress toward their goal(s). The

authors conclude that the model could increase VR

consumers’ capacity to self-direct problem-solving

and goal-setting activities related to getting a job.

Personal assistant services is another possibility to

help individuals with disabilities to go to school,

volunteer, obtain employment, and participate in

social and recreational activities [112]. It has also

been suggested that in the USA, the ‘Ticket to Work’

and the Work Incentives Improvement Act

(TWIAA) is an essential tool for individuals

with SCI who are interested in returning to work

quickly after injury [113]. TWIAA permits indivi-

duals to earn money for a period and retain benefits

status, as long as they are able to prove financial

need.

A significant number of persons with SCI seem

to be interested in receiving vocational services,

especially with finding a new job skill and assis-

tance with finding a job [114]. However, problems

have been reported with being able to afford

the service, not having access to the service, and

not knowing how to obtain it. Individuals who

receive vocational service are more likely to be non-

Whites.

Telework, technical devices/assistive technology

including computer technology and its importance

associated with employment in SCI

Many persons with disabilities need home-based

employment options if they are to participate in the

competitive labour market. Bricout [115] proposed

an analytic framework of readiness to telework (work

conducted from a remote location using Information

and Communication Technologies, ICT) in order to

integrate existing knowledge about telework with

1370 I. B. Lidal et al.

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relevant RTW knowledge about people with SCI.

Telework permits home-based work, as a strategy for

RTW for individuals with SCI. The advantages of

home-based telework include less dependency on

community accessibility, or transportation, less focus

on physical limitations, medical complications,

decreased self-efficiency, employer biases, and stress.

Barriers to telework were described, i.e., concerns

about start-up and maintenance costs, employee

supervision, security, and safety, social and profes-

sional isolation.

‘Computer and Internet technology have far-

reaching possibilities for facilitating many aspects of

life in persons with disabilities’ [89]. Drainoni et al.

showed differences in Internet access based on

sociodemographics, particularly among subjects with

less education and among African-Americans and

Hispanics with SCI. Generally, RTW related to Web

accessibility for persons with SCI seems to be little

studied.

Advancement of assistive technology has played an

important role in enhancing RTW for persons with

SCI. McKinley et al. [43] concluded that assistive

technology can help persons with SCI to compen-

sate for functional limitations, overcome barriers

to employability, enhance technical capacities and

computer utilization, and improve ability to compete

for gainful employment and enhance their qua-

lity of life. Computer technology can overcome

mobility and functional limitations and enable re-

employment. An example is the head movement

image (HMI)-controlled mouse, ‘which improves

the input speed in comparison with the infrared-

controlled mouse [116]. People with disabilities

need only wear the headset and move their heads

to control freely the movement of the mouse cursor.

Rodger and de Jonge [117] carried out a qualitative

study exploring the perspectives of 11 technology

users with cervical SCI who worked in paid employ-

ment. The study aimed to identify barriers and

supports to effective technology use at work. Among

barriers reported by the participants were being

unaware of or having limited access to information

and resources, uncertainty about technology and

how to use it, cost, the need for funds to upgrade

technology, and technology-induced pain and dis-

comfort. Recently, a study examined associations

between assistive technology cost, underwriting,

ownership, use, employment, and employer accom-

modations for two groups (civilian and veteran) of

working age adults with SCI or dysfunction [118].

Their initial findings indicated that assistive technol-

ogy is important for employment success of indivi-

duals with SCI or dysfunction. Devices identified as

important to work were 3.5 times more expensive

than other devices. Self-employed persons incurred

the greatest assistive technology costs.

Spinal cord injury and employment

outcomes in less-industrialized countries

and in developing countries

As far as our search strategy was successful, there is a

lack of reports on employment and SCI in less-

industrialized and developing countries presented at

the WHO and the World Bank websites. In general

there is a smaller number of studies on SCI from

less-industrialized and developing countries, espe-

cially follow-up studies [119]. Considering the high

national unemployment rates, poverty and cultural

differences in most of these countries, it is under-

standable that there is little information on the

employment conditions for persons with SCI. In

2000 the report ‘Disability issues, trends and

recommendations for the World Bank’ claimed that

‘Employment statistics for people with disabilities are

virtually non-existent in developing countries’ [120].

Further, the report ‘Disability, poverty and schooling

in developing countries’ concluded that disability is

associated with long-run poverty in the sense that

children with disabilities are less likely to acquire the

human capital that will allow them to earn higher

incomes’. Levy et al. [121] described in 1998 that the

fraction employed was only 13% out of 136 SCI

patients in a study from Zimbabwe, and most of the

participants spent their day doing ‘nothing’. In the

report ‘Implementation of the United Nations

standard rules on the equalization of opportunities

for persons with disabilities’ from the Inter-country

meeting for the Eastern Mediterranean Region in

Egypt 2006, it was maintained that ‘the social stigma

associated with disability makes it common for family

members to ‘‘hide’’ family members with disabilities

and to restrict their access to education, rehabilita-

tion services and job opportunities’ [122]. In August

2006, WHO and the United Nations presented the

‘Convention on the rights of persons with disabilities’

to promote, protect and ensure the full and equal

enjoyment of all human rights by persons with

disabilities [123]. It covers a number of key areas,

including education and employment.

Conclusion

This review confirms that there are still ongoing high

unemployment rates in individuals with SCI. The

most successful RTW is seen in persons injured at a

younger age, with less severe injuries, and with

higher functional independence. It has been shown

that, on average, the interval between injury onset

and the RTW is relatively long, and employment

rates improve with years after injury. Among the

most frequent self-reported barriers to employment

identified were problems with transportation, health

and physical limitations, lack of work experience,

Return to work following spinal cord injury: a review 1371

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lack of sufficient education or training, physical or

architectural barriers, discrimination by employers,

and loss of benefits. There is a tendency for persons

with SCI to discontinue working at a younger age

than non-disabled populations. Different interven-

tions to help people obtain and/or sustain employ-

ment after injury have been developed. There are

special challenges related to education and employ-

ment possibilities in persons with SCI or with other

disabilities living in less-industrialized and develop-

ing countries.

Recommendations for the future

According to this review of the literature many

factors have the potential to influence RTW and

employment in individuals with SCI. In looking

towards the future, further research needs to focus

on self-reported reasons of discontinuing employ-

ment and barriers to work. There are few long-

itudinal studies of employment in persons with SCI,

and longitudinal studies are recommended to

achieve a more complete picture of the employment

situation in samples of SCI. As Bricout [115]

suggested is there a need for research in telework,

as this issue has been well elucidated in the non-

disabled population but not among individuals with

SCI. Further, RTW related to web accessibility has

been little studied in SCI populations outside the

USA, and is a topic to explore in future research.

The employment conditions for persons with dis-

abilities including SCI in less-industrialized and

developing countries have been little studied, and is

a challenge for future research.

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