Return to work with SCI

In Australia, among those work-injured, general RTW rates of approximately 70% post-injury have been reported (Australian Institute for Primary Care, 2006; Campbell Research, 2012), with lower RTW rates of between 31% and 47% experienced by people with SCI (King, Waghorn, Lloyd, McLeod, McMah & Leong, Reference King, Waghorn, Lloyd, McLeod, McMah and Leong2006; Murphy & Young, Reference Murphy, Young, Craig and Tran2008). However, wide variations in post-SCI employment rates have been reported across the developed nations. Whereas in Europe a median rate of 48% has been reported, RTW rates post-SCI in North America have rarely surpassed 30% (Young & Murphy, Reference Young and Murphy2009). System characteristics of insurance schemes, income-protection arrangements, along with socio-economic characteristics of different countries, exert a strong influence on the RTW rates achieved and/or reported. In addition there are differences in how RTW is defined across jurisdictions. In particular, RTW reporting guidelines are mostly social policy-driven and as such, data on work participation indicators other than formal employment status may not be routinely collected. For example, the Australian Workers Compensation benefit schemes typically define RTW based on information relating to the first day of reporting at the workplace post injury (Vermeulen, Anema, Schellart, Mechelen & Beek, Reference Vermeulen, Anema, Schellart, van Mechelen and van der Beek2010). Such point-in-time assessment is commonly used, as it is simple to extract information about the first day of workplace presence by the employee post-injury, although data related to sustained RTW may be more useful to managers and rehabilitation practitioners. In Australian workers’ compensation, durable RTW is assessed, and is defined as work continuation for seven to nine months post workplace re-engagement (Campbell Research, 2012). Point-in-time RTW reporting has the obvious limitation of inflating the success rate in cases where an individual returns to the workplace but subsequently withdraws from labour-force participation. However, such point-in-time focus is encouraged by the fact that insurance or welfare systems rarely provide adequate payments for individualised post-placement or post-RTW services (Campbell Research, 2012).

Nonetheless, the SCI literature consistently reports low RTW rates (King et al., Reference King, Waghorn, Lloyd, McLeod, McMah and Leong2006; Murphy & Young, Reference Murphy, Young, Craig and Tran2008; Young & Murphy, Reference Young and Murphy2009). More recently, psychological factors and attributes have been implicated in this process, considered to explain a significant amount of variance in post-injury employment status (Ottomanelli & Lind, 2009; Kent & Dorstyn, Reference Kent and Dorstyn2014; Murphy, Young, Brown & King, Reference Murphy, Young, Brown and King2003). This includes heightened risk of post-traumatic stress disorder from the trauma of experiencing a SCI (McFarlane & Bryant, Reference McFarlane and Bryant2007), which, in turn, can impede RTW success and other post-injury participation outcomes. A recent meta-analysis established the prevalence estimate of depression diagnosis after SCI to average between 18.7 and 22.2%, or to occur in at least a fifth of the cases (Williams & Murray, Reference Williams and Murray2015). Depression and anxiety, both of which are compounded by the neurological effects of SCI such as fatigue and neuropathic pain, are also prevalent in persons with SCI. The co-occurrence of depression and anxiety with SCI may represent further complications to RTW (Craig et al., Reference Craig and Kennedy2012; Craig, Tran, Lovas & Middleton, Reference Craig, Tran, Lovas and Middleton2008; Kent & Dorstyn, Reference Kent and Dorstyn2014; Elliot & Kennedy, Reference Elliott and Kennedy2004). It follows that improvements in psychological well-being may lead to improved chances of employment post rehabilitation.

Contextualising Post-Injury Vocational Rehabilitation Services in Australia

Australia's 23 million people have full access to high-quality hospital-based medical and physical rehabilitation, regardless of RTW prospects (Duckett & Willcox, Reference Duckett and Willcox2011). However, vocationally-relevant assessments are not commonly supported within the traditional biomedical model of rehabilitation (Middleton et al., Reference Middleton, Murphy and Johnson2014). This is primarily due to the distinctive features of the Australian post-injury vocational system. Worker's compensation streams rehabilitation services and approves eligible service providers through authorisations within a highly specified worker's compensation scheme. Nearly all vocational and RTW services are apportioned post-discharge to clients covered under workers’ compensation or motor vehicle accident insurance (Duckett & Willcox, Reference Duckett and Willcox2011; Workcover SA, Reference Workcover2011), even though authorities such as Waddell and Aylward (Reference Waddell and Aylward2005) maintain that occupational management must proceed in tandem with clinical management of the work-injured if chronic work incapacity is to be avoided. Persons with spinal cord injuries not covered by the major no-fault workers’ compensation or motor vehicle accident insurance schemes receive vocational preparation and return to work services from a patchwork of federal government approved public, private, and non-profit Disability Employment Service (DES) providers (Australian Government Productivity Commission, 2011; Byrnes & Lawn, Reference Byrnes and Lawn2013). There are more than 100 such DES contractors operating across Australia serving over 1,000 metropolitan and rural locations. This coverage does not usually meet the full range of vocational rehabilitation services needed by those living with SCI, hence DES rehabilitation may focus on social integration rather than labour force participation (Harrison & Allen, Reference Harrison and Allen2003).

The RTW service context for SCI may change with the advent of the 2013 National Disability Insurance Scheme (NDIS). The NDIS will provide individually funded packages to support individuals with permanent physical, sensory or intellectual disability. This includes funding support for activities to facilitate RTW, such as personal attendant care in the workplace, aids and equipment to maximise the person's functional independence and transport to and from work as required (Australian Commonwealth Government, 2013). The NDIS should facilitate improved RTW rates of those with SCI when fully funded – particularly via services that assist with mobility and transportation issues. This prospective NDIS support would contrast the current biomedical rehabilitation approach, which gives little salience to vocational preparation as an index of successful rehabilitation service delivery (see Murphy, Reference Murphy2009a). Indeed, individuals served in a strictly biomedical model are typically discharged home with limited understanding of their chances of successful participation in gainful and productive employment (see Fadyl & McPherson, Reference Fadyl and McPherson2010).

Types of High Prospect RTW Interventions for those living with SCI

RTW is founded on the following empirically-based principles: 1) early assessment and intervention; 2) a focus on the workplace; individualised services that are coordinated, accountable, and results-oriented; 3) active worker participation in plan development and implementation; and 4) employer engagement in prevention as well as rehabilitation (Murphy & Swerissen, Reference Murphy and Swerissen2006). Despite these useful guiding principles, there remains a need to improve inter-sectoral links between rehabilitation health service providers, vocational placement services, employers and participants in order to enhance return-to-work outcomes following SCI (Harrison & Allen, Reference Harrison and Allen2003; King et al., Reference King, Waghorn, Lloyd, McLeod, McMah and Leong2006).

In the Australian context, inter-sectoral RTW coordination could be facilitated by the Heads of Workers’ Compensation Authorities (for the workers’ compensation insurance industry) and Disability Employment Australia (for the public services), each of which employ rehabilitation consultants and case managers to provide networked services with a supposedly RTW or employment focus. Within this case-mix model, service inefficiencies due to a delay in case decisions or flow with manual case management may result (Harrison & Allen, Reference Harrison and Allen2003). However, communication systems exist to enable seamless inter-sector RTW services. This includes the coordinated use of telecommunication technology, namely Internet-mediated services, in vocational rehabilitation to enable the contemporaneous delivery of vocational services alongside traditional physical rehabilitation SCI services. Indeed, telecommunication-based vocational services have been shown to be cost-effective and well accepted by consumers with disability (Schmeler, Schein, McCue & Betz, Reference Schmeler, Schein, McCue and Betz2009). However, despite its potential, the use of virtual reality technology to support RTW services for individuals with SCI remains largely aspirational, although a handful of SCI researchers are starting to develop VR services that involve Internet-based applications (see Murphy, Reference Murphy2013).

RTW rates for those living with SCI could be improved further by using more responsive assessment tools, or outcome measures that provide information about relevant personal and environmental assets that facilitate work participation (see also Mpofu et al., Reference Mpofu, Madden, Athanasou, Manga, Gitchel, Peterson, Chou, Toriello, Bishop and Rumrill2012; Murphy, Middleton, Quirk et al., Reference Murphy2009). One pertinent personal attribute important to RTW is resilience, or the ability to adjust successfully and persist in goal attainment efforts (Craig, Reference Craig and Kennedy2012). Assessment of resilience within a VR context might include the following aspects: (a) actual or perceived risks and barriers to successful outcomes (e.g., investigating risks of chronic fatigue and neuropathic pain following SCI and its relation to vocational status); (b) investigating cycles of failure (e.g., cycles of unsuccessful job interviews or of employment cessation in the injured and reasons why); (c) the establishment and maintenance of protective factors such as self-esteem and self-efficacy beliefs even after frequent job-application failures; and (d) opening up of opportunities, such as vocational opportunities (see also Kilic, Dorstyn & Guiver, Reference Kilic, Dorstyn and Guiver2013; Kent & Dorstyn, Reference Kent and Dorstyn2014; Rutter, Reference Rutter1987). This assessment framework goes beyond the traditional deficit model typically used in SCI rehabilitation or one in which clinical assessment predominately focuses on the risk factors that contribute to poor psychological adjustment post-injury (Craig, Reference Craig and Kennedy2012; Middleton & Craig, Reference Middleton, Craig, Craig and Tran2008) and gives priority to addressing potentialities for work participation including job retention (see also Murphy & O'Hare, Reference Murphy, O'Hare, Giessen and Harder2011).

Research Directions on RTW with SCI

Studies of post-injury interventions for those living with SCI are limited (see Trenaman, Miller, Escorpizo et al., Reference Trenaman, Miller and Escorpizo2014) and, where present, have tended to focus on the pre-vocational stage. This includes studies that have examined interventions to enhance resilient coping with SCI rather than RTW outcomes per se. For instance, Kennedy, Duff, Evans and Beedie (Reference Kennedy, Duff, Evans and Beedie2003) demonstrated that a brief group-based psychological intervention, Coping Effectiveness Training (CET), significantly reduced rates of depression and anxiety compared with those of a matched SCI inpatient control group – however these researchers did not extend the assessments taken to include any measurement of vocational achievement. Similarly, Craig et al., (Reference Craig, Hancock, Dickson and Chang1997) conducted a non-randomised controlled trial on the effectiveness of cognitive behaviour therapy (CBT) for people with SCI. CBT was shown to enhance significantly the life quality of the SCI participants, significantly reduce prevalence of depressive mood and anxiety, improve coping and adjustment expectations, reduce hospital admissions, and reduce medication intake. Improvements were numerous and enduring, registering at two years and six years post treatment (Craig et al., Reference Craig, Hancock, Chang and Dickson1998; Craig et al., Reference Craig, Hancock, Chang and Dickson1999).

Although it can be reasonably argued that improvements in well-being (e.g., lowered depressive mood and anxiety, enhanced adaptive expectations about the future) will lead to improved chances of employment post-rehabilitation, it is important to recognise that improved psychological ‘adjustment’ does not translate directly to improved vocational performance (see Murphy, Reference Murphy and T. Berkovsky2009b). For instance, pre-morbid functioning may mediate the relationship between resilient coping following SCI and RTW, whereby individuals with significant pre-injury work participation will likely have successful RTW outcomes compared with peers with lower pre-injury participation. RTW research is therefore needed that builds on and broadens resilience based models of coping with SCI and its vocational sequelae (Craig, Reference Craig and Kennedy2012). Specifically, evidence is needed on psychological interventions that target issues such as depression and that make for higher RTW prospects post-SCI. Such evidence could explain RTW success rates beyond predictions based on the physical-functional limitations and impairment associated with the injury as well as on influential, but essentially unchangeable, demographic characteristics, as dominates the extensive reports of Krause and colleagues (see, for example, Krause et al., Reference Krause, Kewman and DeVovo1999).

Effects of capitation systems on RTW

An examination of outcome studies that have compared the rehabilitation achievements of those individuals with traumatic SCI with insurance entitlements, against the achievements of those similarly-injured but without compensation, can be used to yield one index of the effectiveness of the rehabilitation provided to both groups. For instance, MacKenzie et al. (Reference Mackenzie, Morris and Jurkovich1998) reported that those with Workers Compensation entitlements returned to work at a significantly lower rate than did those with no insurance cover (Relative Risk Ratio of .40). Similarly, in the study of Zelle et al. (Reference Zelle, Brown and Panzica2005), those with workers compensation entitlements were 70% more likely to have withdrawn from labour force participation (C.I. 1.14–2.83). Within a sample of North Americans living with SCI, Bell (Reference Bell2002) found that receiving disability benefits, including workers’ compensation, following SCI decreased the probability of working post-injury, and increased the number of years post-injury before a RTW was attempted by an average of 2.5 years. Further research is needed on subgroups of SCI with compensation that choose work participation, in order to partial out effects of compensation systems on RTW with SCI. Findings from the related research would clarify the role of compensation per see in RTW considerations beyond perceived compensation-oriented work disincentives.

Limitations of research on RTW for those living with SCI

Post-SCI vocational rehabilitation research and practice is constrained by the low study enrolments, consequent upon the low incidence of SCI in the general population (estimated at between 14 and 22 per million in Australia; O'Connor & Cripps, Reference O'Connor and Cripps1997). The relatively low incidence of SCI potentially places would- be participants at risk for ‘research participation burnout’ from repeated requests for study participation. Improved inter-sectoral links between rehabilitation providers, employers and participants for RTW, as previously discussed, could potentially increase data set networking for research purposes. Inter-sectoral collaboration would also support longitudinal studies to address long term RTW outcomes with more reliable tracking of labour force participation post-discharge. Currently, there is scarcely any research based on the inter-sectoral collaboration effects on RTW among those living with SCI. A more general problem with research in the field is the scarcity of high quality experimental studies of interventions aiming to enhance post-injury vocational achievements among those living with SCI. Trenaman et al. (Reference Trenaman, Miller and Escorpizo2014) attempted to conduct a systematic review on the topic and could locate only two relevant experimental studies.

Evidence is also required on post-SCI RTW outcomes achieved from early contact with vocational rehabilitation services. Studies with other disability populations suggest that early employee contact has positive effects on RTW outcomes (Murphy & Swerissen, Reference Murphy and Swerissen2006). However, the incremental benefits of RTW rehabilitation offered during the in-patient SCI rehabilitation phase compared with vocational interventions offered in community are still largely unknown, although results from one large, state-wide pilot study in New South Wales are promising in terms of enhanced post-injury vocational achievements (see Middleton et al., Reference Middleton, Murphy and Johnson2014). While experimental designs would provide strong evidence for specific RTW interventions (see Elliot & Kennedy, Reference Elliott and Kennedy2004; Trenaman et al., Reference Trenaman, Miller and Escorpizo2014), it is difficult to maintain comparability of groups over time given the medical complexities of SCI, including recurrent or secondary health problems seen in this population. Studies would therefore always need to address effects on RTW outcomes explained by secondary conditions following SCI, as such conditions limit labour force participation (Craig & Nicholson Perry, Reference Craig and Nicholson Perry2014).

Additional challenges for both the private and public providers of rehabilitation services arise from the use of medico-legal reports by physicians not trained in vocational rehabilitation and who may not fully understand the health benefits of being employed (see Paul & Moser, Reference Paul and Moser2009). Further challenges are posed by the recruitment practices and case management systems currently utilised by private and public providers in Australia which see widespread employment of rehabilitation consultants trained in allied health but with limited education in rehabilitation counselling, including in vocational rehabilitation.

Implications for Vocational Rehabilitation Practice and Policy

Compensation insurance policy provisions influences impact observed RTW rates for those living with disability. A disability social inclusion approach with its emphasis on full community participation (Harley, Mpofu, Scanlan, Umeasiegbu & Mpofu, Reference Harley, Mpofu, Scanlan, Umeasiegbu, Mpofu and Mpofu2015) would likely result in greater numbers of people with SCI choosing RTW rather than with reliance on compensation oriented incentives. For instance, RTW could be enhanced with a disability care approach in which work participation is interlinked with other social inclusion or life design supports (see Mpofu, Reference Mpofu2013). This would result from the fact that a disability social inclusion approach in which RTW was one of many complementary community participation outcomes would likely result in more sustained post-injury employment. Regardless of capitation systems in place, RTW (especially for those living with SCI) may be enhanced with a broader or more inclusive definition of work participation to include self-employment in the home or other choice settings. For instance, Telework via the Internet has become a mainstream option for employment and has the advantage for those living with SCI of minimising the impact of transportation and community accessibility issues (Bricout, Reference Bricout2004).

Challenges associated with adaptation and adjustment to physical disability make timing of RTW efforts particularly crucial. Early-contact, vocationally-focused rehabilitation services can be expected to enhance RTW rates (see Murphy, Reference Murphy2009a; Young, Murphy & Athanasou, Reference Young, Murphy and Athanasou1996; Middleton et al., Reference Middleton, Murphy and Johnson2014), as would support with the management of secondary health conditions commonly associated with SCI. Workers with SCI face a complex set of barriers beyond the severity or level of SCI injury (Lidal, Huynh & Biering-Sørensen, Reference Lidal, Huynh and Biering-Sørensen2007). Transportation is a major and often overlooked barrier to employment and needs to be directly addressed as part of any RTW support for those living with SCI. Integrating personal assistants (Hagglund, Clark, Mokelke & Stout, Reference Hagglund, Clark, Mokelke and Stout2004; Lidal et al., Reference Lidal, Huynh and Biering-Sørensen2007) as RTW supports could enhance sustained or durable post-injury work participation following SCI (see Ottomenelli, Reference Ottomanelli, Goetz and Suris2012). RTW services that address work access issues inclusive of transportation likely will yield improved rates of work participation than commonly observed (see also Lindquist & Lundalv, Reference Lindquist and Lundalv2012).

RTW service providers may be influenced by reimbursement systems insensitive to severity of disability, and thus may move to prioritise or ‘cream’ those cases of SCI perceived to require less support for successful transition back to the workplace (Byrnes & Lawn, Reference Byrnes and Lawn2013). To avoid creaming and premature placement of workers within incentive-based schemes, complex cases can be monitored and funded differently, allowing for the additional time, effort and resources that are needed for stable, satisfying vocational outcomes. In New South Wales, the Lifetime Care and Support Authority (LCSA) has led the way among Australian jurisdictions in providing proper levels of resource support for those with catastrophic injuries. This segmentation and triage of case worker requires similarly articulated organisational structures and processes (i.e., efficient means to direct simple cases to case coordinators, directing complex cases to triage managers with more extensive training in allied health fields as well as in rehabilitation counselling, including especially VR).