Access to vocational counselling, educational or job training has often been mentioned as a key issue to enable return to work after SCI (Jang et al. 2005; Jongbloed et al. 2007; Lidal et al. 2007). However very few studies have empirically tested strategies to increase job opportunities and most reports we found were either case series or observational studies. Various strategies were described through case studies suggesting successful return to work and job retention. These individualized strategies addressed activities of daily living and mobility needs, job accommodation including workplace support and employer’s needs and concerns. In this section intervention studies that examine which strategies lead to return to work are reviewed. 

Table 5: Interventions for enhancing employment post-SCI

Discussion

This review suggests there is a profound lack of high-level evidence studies which have a focus on work and employment-related interventions. Only one randomized controlled study was found addressing a specific factor (access to trained service dogs) suggesting an improvement in psychosocial status such as those that involve self-esteem, internal locus of control, and psychological well being. Results of the same study also revealed other benefits of having trained service dogs including a decrease in needed assistance time by either a professional assistant, family or friends increase in school attendance and part-time employment, and increase in social participation and community integration such as interaction and use of public transportation (Allen and Blascovich 1996).

Other studies included case series and observational studies. These studies examined employment outcomes of people with SCI who received various vocational rehabilitation services. One study (Inge et al. 1998) suggests that people enrolled in a program using person-centered planning tools to identify the needs and to direct the job search might gain employment but the workplace support greatly varied- from minor to intensive support. Another study (King et al., 2004) described a modified case management approach to return people with SCI to work. Comparing their preliminary results with those of the U.S. Model Systems, it appears that the program is successful for increasing return to educational training but not to work. Marini et al. (2007) suggest that people with SCI registered in state vocational rehabilitation agencies and receiving job placement services are likely to have a higher employment rate. Likewise, Jellinek and Harvey (1982) supported the conclusion of higher employment rate in individuals with SCI who had access to on-site professional counsellors for vocational / educational rehabilitation in addition to state vocational rehabilitation agency only. They concluded that the vocational or educational placement was as high as 78% among those who had on-site vocational or educational services. In their sample of 169 people (49% engaged in gainful employment), Jang et al. (2005) found that fifty percent of the employed had received vocational training, compared with only 28% of the unemployed. Jongbloed (2007) also found that employment re-training and education were identified as important contributors to success. However, her participants stated that services and information were perceived as difficult to access

Two other studies could be associated to vocational interventions. Wang et al. (2002) compared a group of persons with SCI receiving a multimodal 6-month training course to a group without specific training. They found that individuals with paraplegia had higher employment rate which meant that employment depended on the level of injury. Hansen et al. (2007) interviewed male participants with SCI in a work rehabilitation program which included physical conditioning, vocational training, and work placements. Less than half were employed in a similar or identical job as their previous employment and only about a quarter of those who used a wheelchair returned to work. Overall, the studies included in this review investigated different types of interventions and used different measures to assess the interventions. Although this may limit the generalizability of the outcomes, there is evidence in general supporting the use of interventions to enhance employment post-SCI.

• There is level 1 evidence (Allen and Blascovich 1996) that suggests a service dog improves integration and participation in school and employment and decrease the number of hours of paid assistance after the first year.
• There is level 5 (Jellinek and  Harvey 1982) and level 4 evidence (Marini et al. 2008) that on-site vocational rehabilitation counselling during inpatient rehabilitation can increase employment rates.
• There is level 4 evidence (Marini et al. 2008) that use of job placement services may help individuals with SCI find employment.
• There is level 4 evidence (Inge et al. 1998) suggesting that person-centred planning tools facilitate employment.
• There is level 4 evidence (King et al. 2004) that case management programs increase return to educational training, but not to work.
• There is level 5 evidence from 4 studies (Wang et al. 2002; Jang et al. 2005; Jongbloed et al. 2007; Hansen 2007;) that receiving vocational training increases the likelihood of employment.

• People with SCI may benefit from vocational rehabilitation in the process of job placement and work reintegration.
• There is a dearth of high quality research in vocational (re) training. Consequently, conclusions are mostly based on evidence from observational studies or case studies.
• Continuous support to the employee and employer before and after vocational placement might lead to a successful return to work and job retention.