Return to Work Following Spinal Cord Injury Krislofer J. Hagglund, PhD Robert G. Frank, PhD Division of Clinical Health Psychology and Neuropsychology Department of Physical Medicine and Rehabilitation University of Missouri at Columbia Columbia, MO Return to work following spinal cord injury is achievable for many individuaL~. Interd~~ciplinary rehabilitation teams are ideally suited to facilitate an individuaL:~ efforts at overcoming the numerous barriers involved in returning to gainful, competitive employment. Many of these barriers are personspecific (i.e., education level), and multifaceted assessment and comprehensive vocational planning are suggested. Other barriers, such as economic d~\'incentives and poor access to needed services, are less easily overcome. Rehabilitation professionals are encouraged to become familiar with recent health and disability policy (i.e., Americans with Disabilities Act) and become proactive in policy formation. There is a significant need for development and testing of model programs to enhance return to work for individuaL~ with spinal cord injury. Keywords: Spinal cord injury; return to work; pr6ductive activity; functional independence

Return to work is one of the major goals of adaptation to life changes following spinal cord injury (SCI). Consequently, it should be considered an important focus of long-term, if not short-term, rehabilitation. However, interventions facilitating return to work frequently are accorded secondary status because other pressing medical problems overshadow employment during this period. This rehabilitation approach is short-sighted and may interfere with adjustment for individuals who are able to return to work soon after injury. Research has documented consistently that employment status is associated with life satisfaction 1,2 and long-term survival. 3,4 Moreover, employment is a marker of self-sufficiency and autonomy. In this article, we argue that interdisciplinary teams are ideally designed to help individuals with SCI develop programs focusing on returning to Address reprint requests to Kristofer J. Hagglund, PhD, Department of Physical Medicine and Rehabilitation, 501 Rusk Rehabilitation Center, 1 Hospital Drive, Columbia, MO 65212.

gainful employment. Realistic plans for returning to work are unlikely to be developed after acute rehabilitation. Rehabilitation professionals are challenged with promoting obtainment of the highest level of functioning given residual disability. 5 Part of this challenge involves discriminating among individuals with SCI who are likely to return to work and those who may benefit from other goals for productivity. This process is fraught with pitfalls. Directing patients toward inappropriate goals usually results in frustration, disappointment, anger, and depression. Often there is wasted time and money for the patient, the rehabilitation team, and third parties. The following case example highlights many of the problems of attempting to facilitate return to work among patients with SCI. JM was a 25-year-old male who sustained an SCI in a single-auto, roll-over MVA. Medical personnel at the scene reported no loss of consciousness, but medical records indicated his blood alcohol level was 0.21. His diagnosis was NeuroRehabil 1994; 4( 1):36-44 Copyright © 1994 by Butterworth-Heinemann

Return to Work Following Spinal Cord Injury

a C7 SCI, with a Frankel B rating. JM had no health insurance and was admitted to the rehabilitation center "Medicaid pending." JM had been employed in a small construction firm for four months before his injury. Previous jobs included work on a county road crew and siding installation. He reported a generally steady work history, locating and obtaining most of his jobs through personal contacts. JM quit school to go to work after the eleventh grade. He was an average student who obtained highest grades in vocational technology classes. He described himself as someone who worked hard and "played hard." Recreational activities included attending truck and tractor pulls, drinking beer with his co-workers after work, and going to movies and dinner with his girlfriend. At the time of his injury, JM was living with his girlfriend in a mobile home that later was modified to be accessible. JM declined counseling for his history of alcohol abuse, stating that "it wasn't a problem." JM was referred to the vocational rehabilitation counselor at the rehabilitation center about one week before discharge after he mentioned to his physician during morning rounds that he was willing to consider returning to work. The rehabilitation counselor performed an initial evaluation, but was unable to perform a complete evaluation because of a heavy case load and difficulty with scheduling. She determined that JM would benefit from a referral to the Department of Vocational Rehabilitation (DVR) for assistance in obtaining his CED. JM reluctantly agreed to return for CED classes because he was unable to identify any jobs that were appealing, even with help from his rehabilitation counselor. His attendance at CED classes was irregular, and he quit after attending only three classes. His DVR counselor closed his case soon after he was transferred to a different case manager. This case reflects barriers to return to work that are observed too often in rehabilitation settings. The barriers reflected here include job opportunities inconsistent with work experience, lower level of education, poor funding for state voca-

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tional rehabilitation systems, poor motivation or lack of readiness to return to work, and acute rehabilitation that deemphasizes vocational rehabilitation. Rehabilitation teams and patients must overcome these and other barriers if individuals with SCI are to be successful in returning to, and maintaining, gainful employment. Most treatment teams struggle with how to facilitate individual attempts to cope with the challenge oftransition from hospitalization to occupational independence. We review and integrate the literature regarding these barriers, health and rehabilitation policy (including the Americans with Disabilities Act [ADA]), and clinical practice. Trieschmann 6 thoroughly discusses the literature up to 1987 on employment after SCI, and the , reader is encouraged to examine her review. Our purpose is to update the literature review and to provide specific suggestions for rehabilitation teams to facilitate return to work efforts and guide future research in this area. However, the reader is cautioned that competitive, paid employment is only one measure of productive activity.6,7 Depending on an individual's situation, other valid indicators of adaptation include resuming academic pursuits, homemaking, volunteering, and engaging in nonpaid employment. Krause 8 points out that avocational activities as well as competitive employment are associated with good adaptation and survival. With that caveat, this article will focus almost exclusively on return-to-work issues.

PREVIOUS RESEARCH: WHAT WE HAVE LEARNED Returning to work is a feasible goal for many patients. Rates of individuals in competitive, paid employment following SCI range from 10%9 to 67%.10 The wide disparity of rates is likely due to substantial differences in study methodology, including definitions of employment, sampling techniques, type and extent of injury, and time since rehabilitation. Unfortunately, there have been few improvements in the research

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NEUROREHABILITATION / JANUARY 1994

conduct.ed since Trieschmann 6 noted that many studies suffered from important methodological weaknesses. Drawing from existing studies with adequate scientific rigor, several factors have been found to affect the likelihood of return to work. These include both person-specific (i.e., age, educational level) and environmental (i.e., economic disincentives) variables. Rehabilitation teams that are cognizant of these variables will have the most success in facilitating return to work.

Preinjury Educational Level Educational level has been found to be highly predictive of reentry into the competitive labor market following SCI.II .. 14 A recent investigation by Krause,8 involving 286 individuals with SCI, found that fewer than 3% of persons with fewer than 12 years of education were employed, whereas 72% of persons with 16 years of education were employed. Similar results were revealed for having worked at any time since injury, hours working per week, and total years worked since injury. KrauseR concluded that "individuals with fewer than 12 years of education are at a severe disadvantage vocationally." Alone, these results suggest that individuals without a high school diploma may be best served by being guided toward productive activities other than competitive employment, perhaps to further education or training.

Education and Training After Injury El Ghatit and Hanson 15 found that the amount of education obtained after injury is a better predictor of return to work than is the total amount of education. Since only 12% (approximately) of individuals return to their previous job,S return to education and/or vocational training may be the means for ultimately entering the labor market. The study by Krause s demonstrated a corresponding increase in rate of employment with increasing education beyond high school, suggesting that even for individuals with college diplomas, further education may be profitable. Persons with higher levels of education are often more easily retrained (and in a shorter period of time) in occupations that deemphasize physical abilities. Furthermore, a higher education level increases the number of job opportunities and has

been found to be associated with stronger motivation to reenter the labor market. 14

Time Since SCI Delayed return to the labor market for the sake of education and/or training is consistent with the evidence on education after injury and return to work rates. De Vivo and colleagues 16 reported that among individuals between 16 and 59 years of age included in the National SCI Statistical Center (NSCISC) data base, employment more than doubled from 2 years postinjury (12.6%) to 12 years postinjury (38.3%). Similar findings have been reported in longitudinal studies of 1117 and 15 years. 18 This research suggests that there is a natural interaction between education level and interval before to return to work following SCI. It appears that for many individuals who sustain SCI, reentry into the labor market is delayed because of a return to school to complete unfinished degrees or participate in vocational retraining. I I It is not unusual for return to competitive employment to occur several months or years after injury. This delay should not be attributed to the stage of adaptation, as t.oo often occurs, 19 but rather to the need for many individuals to make themselves competitive f

Return to work following spinal cord injury.

Return to work following spinal cord injury is achievable for many individuals. Interdisciplinary rehabilitation teams are ideally suited to facilitat...
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