Rehabilitation following SCI recognizes the importance of returning to work (RTW) and the essential role employment plays in participation within a community. Remunerative employment is a vital aspect of human functioning — a concept that integrates the body functions, body structures and activities of an individual within a social context.1 Within the International Classification of Functioning, Disability and Health (ICF), work and employment make up an important element of the major life areas and include such endeavors as apprenticeships, acquiring, keeping and terminating a job, and both remunerative and non-remunerative employment.2

For persons living with the consequences of SCI, physical challenges are just one of many obstacles to be confronted as they work to rebuild their lives. Finding and securing employment presents a further challenge. Societal pressure to work is significant, and this is not diminished for those with SCI.3 Among adults, one of the most important factors (and, in turn, indicators) for reintegrating into a community is the participation in productive work.4

In one study, the average interval was found to be 4.8 years to work and 6.3 years before a patient was engaged in full-time work.

The range of employment rates seem to be relatively low among SCI patients. A number of facilitators and barriers to employment have been elaborated in multiple studies to be associated to returning to work.567 In general, these factors may be grouped into demographics, injury-related factors, physical and psychological health, and barriers to returning to work.

Those associated with an increased rate of employment included younger age, being married, higher levels of education, being employed at the time of injury, paraplegia and/or an incomplete injury, post-injury vocational training, mental and psychological health, greater functional independence, independent living and community mobility (e.g. the ability to drive).3

On the other hand, barriers to work included (in order of the most to the least frequently reported): transportation, physical limitations, a lack of work experience, a lack of sufficient education or training, architectural barriers, discrimination, loss of benefits, societal attitudes and a perceived stress or lack of motivation.3

The time interval from the injury to beginning employment often depends on a patient’s ability to work in the pre-injury job. If there is a need for vocational education and training. this time period will clearly be longer. In one study, the average interval was found to be 4.8 years to work and 6.3 years before a patient was engaged in full-time work.8

While a patient’s return to his or her pre-injury job has been found to be a key factor in successful employment following an SCI 13, only 17 percent of patients return to their pre-injury jobs.8 Among pre-injury jobs, those that are physically demanding are naturally unlikely candidates for post-injury employment.

Accordingly, SCI patients with less physically demanding jobs have been found to be more likely to return to work.7 Nevertheless, two Dutch studies have shown that within their country’s population, 60 percent of those suffering from SCI were able to reenter the workforce, demonstrating the potential for returning to work. Although a decrease in working hours occurred among a majority, 94 percent were satisfied or reasonably satisfied with their post-injury work situation.910

An understanding of the associations between facilitators and barriers and returning to work in the context of an individual patient can be a valuable tool for vocational counselors in helping to prepare SCI survivors for a return to employment.11

A vocational assessment and rehabilitation program ideally should be made available early in the rehabilitation process and center the process on the patient, allowing him or her to lead and choose the direction and focus of his or her employment.

A vocational assessment and rehabilitation program ideally should be made available early in the rehabilitation process...

The concept of supported employment is one model of a process that can help enable those with disabilities “to achieve sustainable, long-term employment and businesses to employ valuable workers.”12 To achieve higher rates of both employment among persons with SCI and the number of those who will be satisfied with their work, patient-specific interventions need to be undertaken by rehabilitation teams and include vocational counselors. Such interventions will necessarily be required to address multiple factors. (See Box 1) 3111314

Box 1 | Intervention areas for vocational counseling

Vocational counseling aims to secure employment for SCI patients and promote life satisfaction through work. Such goals involve a complex and interrelated range of targets that need to be addressed. Dealing with the following intervention areas has been demonstrated to be useful in achieving these vocational goals: 3111314

Individual educational and vocational counseling is needed to assess each patient’s own facilitating factors and barriers as well as their personal goals. Additionally, an assessment of the feasibility of specific jobs and a plan to explore vocational possibilities are necessary.

Contact with peer groups to allow for an exchange of ideas and experiences with respect to vocation and employment.

Personal care issues — how might these be managed at a workplace?

Changing employer perceptions to promote the idea of “supported employment” (see Case Study 9) and minimize discrimination.

Supported employment includes an exploration of accommodations including the accessibility of the facility, flexible work scheduling, restructuring jobs, availability and/or modification of equipment, and providing support.

Improving mobility includes both adequate transportation to and from the work-place and independent personal mobility within the workplace that may involve wheelchair accessibility.

Reducing financial disincentives to working — such disincentives can occur, for example, when financial assistance while unemployed is greater than the remuneration for employment.

As this process is undertaken, this case study will focus on the initial phase that begins an evaluation of a patient’s possibilities. This case study intends to show that the early integration of vocational counseling and training into the rehabilitative strategy is an important component for preparing patients for returning to work.