Impact of a spinal cord injury in employment: a cross-sectional study in a Portuguese population

Abstract

Background: Patients who have sustained a spinal cord injury (SCI) frequently face a fundamental change in their employment situation, as the demands of their previous job often exceed their remaining physical abilities. Aim: To study which factors associated with the SCI may influence the employment status. Design: Descriptive cross-sectional study. Setting and population: Seventy-three individuals who had sustained a SCI, admitted in our Rehabilitation Center in 2015. Intervention: Not applicable. Methods: Besides clinical information, a telephone questionnaire was applied in 2019 to the patients, in order to identify demographic and injury-related status, functionality (FIM, SCIM-III, nFAC scales), and work-related information. The data was analyzed in SPSS Statistics® version 26, using χ2 test for categorical variables and t test for independent samples between continuous and categorical variables. Results: The employment rate after SCI was 27.8%. The need of a caregiver showed a significant relationship with not being employed (p<0.001), consisting in an independent determinant for employment (OR 5.38). Return-to-work was associated with higher functional scores, lower mean age values (p<0.001), previous higher education level (p<0.001), and pre-injury intellectual job (p=0.009). Conclusion and clinical rehabilitation impact: The employment rate and factors influencing return-to-work were in line with those available in literature. Additionally, we consider that the “need of a caregiver” is essential in the evaluation of a SCI patient, as it gives a clearer understanding of the patients’ work ability (participation domain), in contrast with functional scores, best suited in the activity domain of the International Classification of Functioning Disability and Health.

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Abbrevations: SCI, spinal cord injury; ICF, International
Classication of Functioning, Disability and Health; FIM, Functional
Independence Measure; SCIM-III, Spinal Cord Independence
Measure;
Introduction
Work is as important part of an individual’s life. Not only can it
provide an income but it also gives the opportunity to interact with
others, improving self-esteem and overall life satisfaction.1 Individuals
who have suered a spinal cord injury (SCI) are often faced with a
change in their job situation, because the demands of their pre-injury
job often surpass their remaining physical capabilities.2
Employment remains one of the most important studied topics
since the early 50’s, when the importance of returning-to-work
after SCI was acknowledged.3 The employment rates after SCI vary
internationally, because of discrepancies between countries, Health
and Social politics and studies’ denition of employment,4 ranging
widely from 11.5 to 74%.5–7
The International Classication of Functioning, Disability and
Health (ICF), has become the unifying framework for Physical and
Rehabilitation Medicine, as function is an intertwine of the domains
body functions and structures, activities and participation, and
environmental and personal factors. The ICF has the potential to
contribute importantly to the quality of rehabilitation care delivery,
considering all its domains.8 Work belongs in the participation
domain, and their factors should be considered.
In order to understand the factors that inuence employment status
in this population, we must ask why some SCI individuals are more
often employed than others. Several aspects have been identied to
interfere with the ability to return to work. Some cannot be modied
(e.g. level of injury, or sex) while others can be modiable (e.g.
education level, health status, or work skills). Being male, sustain a
less severe injury, having a higher functional independence, the SCI at
a younger age, a higher education level, and a previously non-manual
job tends to be associated with an increased chance of employment.9–13
The aim was to study which factors (socio-demographic,
educational, associated with the spinal cord injury and work related)
might later inuence the employment status.
Materials and methods
This article was written according to the STROBE guidelines for
observational studies.14
Int Phys Med Rehab J. 2022;7(1):6‒10. 6
©2022 Ferro et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which
permits unrestrited use, distribution, and build upon your work non-commercially.
Impact of a spinal cord injury in employment: a
cross-sectional study in a Portuguese population
Volume 7 Issue 1 - 2022
Inês Ferro,1 César Pires,1 Pedro C Sá,1 Xénia
Verraest,1 Paulo Margalho,2 Filipe Carvalho,3
Jorge Lains4
1Resident in Physical and Rehabilitation Medicine, Centro de
Medicina de Reabilitação da Região Centro, Rovisco Pais, Tocha,
Portugal
2Senior consultant in Physical and Rehabilitation Medicine,
Director of the Spinal Cord Injury department, Centro de
Medicina de Reabilitação da Região Centro, Rovisco Pais, Tocha,
Portugal
3Consultant in Physical and Rehabilitation Medicine, Centro de
Medicina de Reabilitação da Região Centro,Rovisco Pais, Tocha,
Portugal
4Senior consultant in Physical and Rehabilitation Medicine,
Centro de Medicina de Reabilitação da Região Centro, Rovisco
Pais, Tocha, Portugal
Correspondence: Inês Ferro, Resident in Physical and
Rehabilitation Medicine, Centro de Medicina de Reabilitação
da Região Centro, Rovisco Pais, Rua da Fonte Quente, Tocha,
Portugal, 3060-586, Tel +351 919873391,
Email
Received: December 28, 2021 | Published: January 07, 2022
Abstract
Background: Patients who have sustained a spinal cord injury (SCI) frequently face a
fundamental change in their employment situation, as the demands of their previous job
often exceed their remaining physical abilities.
Aim: To study which factors associated with the SCI may inuence the employment status.
Design: Descriptive cross-sectional study.
Setting and population: Seventy-three individuals who had sustained a SCI, admitted in
our Rehabilitation Center in 2015.
Intervention: Not applicable.
Methods: Besides clinical information, a telephone questionnaire was applied in 2019
to the patients, in order to identify demographic and injury-related status, functionality
(FIM, SCIM-III, nFAC scales), and work-related information. The data was analyzed in
SPSS Statistics® version 26, using χ2 test for categorical variables and t test for independent
samples between continuous and categorical variables.
Results: The employment rate after SCI was 27.8%. The need of a caregiver showed a
signicant relationship with not being employed (p<0.001), consisting in an independent
determinant for employment (OR 5.38). Return-to-work was associated with higher
functional scores, lower mean age values (p<0.001), previous higher education level
(p<0.001), and pre-injury intellectual job (p=0.009).
Conclusion and clinical rehabilitation impact: The employment rate and factors
inuencing return-to-work were in line with those available in literature. Additionally,
we consider that the “need of a caregiver” is essential in the evaluation of a SCI patient,
as it gives a clearer understanding of the patients’ work ability (participation domain),
in contrast with functional scores, best suited in the activity domain of the International
Classication of Functioning Disability and Health.
Keywords: Spinal cord injury, employment, comprehensive rehabilitation
International Physical Medicine & Rehabilitation Journal
Research Article Open Access

Impact of a spinal cord injury in employment: a cross-sectional study in a Portuguese population 7
Copyright:
©2022 Ferro et al.
Citation: Ferro I, Pires C, C Sá P, et al. Impact of a spinal cord injury in employment: a cross-sectional study in a Portuguese population. Int Phys Med Rehab J.
2022;7(1):6‒10. DOI: 10.15406/ipmrj.2022.07.00294
Study design and participants
This is a cross-sectional study. We included adult SCI individuals
that were inpatients in our facility (Rehabilitation Center of the
Central Region of Portugal–Rovisco Pais) in 2015, and that at the
time of questionnaire (August 2019) were alive, contactable, capable
and willing to participate in the study. We excluded those who were
dead, not contactable or not willing to participate in the study. This
dened our study sample size.
Statement of ethics
This study design was conducted according to Good Clinical
Practice guidelines and the Declaration of Helsinki. Our study
protocol was previously approved by the Committee of Ethics for
Health of our Rehabilitation Center. Informed consent was obtained
from all patients prior to the questionnaire application. Each patient
was assigned with a random alphanumeric code and no personal
traceable information was collected, in order to guarantee total data
concealment and anonymity.
Data gathering, setting and variables
The data gathering fell into two parts. The rst part included
the collection of data from the les of the SCI patients admitted in
2015 in our Rehabilitation Center. Sex, educational level (primary,
secondary, tertiary), age at injury and at questionnaire (in years),
lesion type (paraplegia or tetraplegia), cause (traumatic or non-
traumatic), and severity (complete or incomplete), need of a caregiver
and functionality at discharge (evaluated by Functional Independence
Measure (FIM), Spinal Cord Independence Measure (SCIM-III) and
the modied Functional Ambulation Categories (nFAC)) were used as
socio-demographic and injury-related stratication variables. Pre-SCI
job status information was also collected from the patient admission
les.
The second part of the data gathering consisted in the application
of a telephone questionnaire that we elaborated before august 2019.
The patients or their family members/caregivers were contacted, and
if they accepted, the questionnaire was applied. The questionnaire
aimed to identify present injury-related status, conrm education
level, functional status regarding ambulation (nFAC), and post-SCI
work-related information.
Concerning the education level at the moment of injury, we chose
to divide it in: primary (7 to 12years), secondary (13 to 17 years)
and tertiary levels (above 18 years). Main pre- and post-injury job
titles were divided into two groups, “manual” and “intellectual” jobs,
by two researchers independently. Any disagreements between the
two researchers were resolved by discussion and, when necessary,
arbitrated by a third researcher.
Data analysis
Data were analyzed by IBM SPSS Statistics® software version 26.
Data are presented as mean ± standard deviation (SD) for continuous
variables or frequency and percent for count variables. Evidence of a
statistical dierence was accepted at an α<0.05.
Demographic, injury-related characteristics and socioeconomic
variables are presented for the total sample. In order to identify
dierences between groups (return to work and not return to work),
Pearson’s chi-squared (χ2) test or exact Fisher test were used for
categorical variables and Student t test for independent samples
between continuous and categorical variables.
Results
Participants
One hundred and ve patients were admitted in 2015 in the spinal
cord injury ward in our Rehabilitation Center. Sixteen individuals
were dead by the time of questionnaire. The remaining 89 patients
were all contactable, and 73 were considered for this study after
the application of inclusion and exclusion criteria (16 refused to
participate).(Figure 1).
Descriptive data
The general characteristics of this study sample are presented in
Table 1. Participants (n=73) were mostly male (80.8%), had a mean age
at injury of 47.16±16.69 years old, and at the time of questionnaire of
54.86±15.44 years old. Fifty-seven patients (78.1%) were paraplegic
and 16 (21.9%) were tetraplegic. Fifty-two (71.2%) had an incomplete
lesion and 21 patients (28.8%) had a complete SCI. Fifty-one (69.9%)
had a traumatic injury, and 22 (30.1%) a non-traumatic SCI. As for the
mean functional scores, FIM was 100.43±25.08, nFAC 2.83±2.93 and
SCIM-III 63.99±22.85. Regarding the need of a caregiver, 44 (60.3%)
answered yes, while 29 (39.7%) answered no. Out of our sample, after
SCI 21 were employed and 52 weren’t.
Table 1 Characteristics of the study sample
Participants Return to work
(n = 73) Yes (n = 21) No (n = 52) p
Parameters n % n % n %
Sex
Female 14 19.2 3 15 11 21.2 0.541*
Male 59 80.8 18 85 41 78.8
Age (years) mean (SD) mean (SD) mean (SD)
At injury 47.16(±16.69) 34.75(±15.41) 51.48(±14.63) <0.001**
At questionnaire 54.86(±15.44) 44.50(±14.40) 58.44(±13.98) 0.001***
Type of injury
Paraplegia 57 78.1 19 90.5 38 73.1 0.128*
Tetraplegia 16 21.9 2 9.5 14 26.9
Cause of injury
Traumatic 51 69.9 16 76.2 35 67.3 0.577****
Non-traumatic 22 30.1 5 23.8 17 32.7
Severity of injury
Complete lesion 21 28.8 5 23.8 16 30.8 0.586****

Impact of a spinal cord injury in employment: a cross-sectional study in a Portuguese population 8
Copyright:
©2022 Ferro et al.
Citation: Ferro I, Pires C, C Sá P, et al. Impact of a spinal cord injury in employment: a cross-sectional study in a Portuguese population. Int Phys Med Rehab J.
2022;7(1):6‒10. DOI: 10.15406/ipmrj.2022.07.00294
Participants Return to work
(n = 73) Yes (n = 21) No (n = 52) p
Incomplete lesion 52 71.2 16 76.2 36 69.2
Functionality scales mean (SD) mean (SD) mean (SD)
FIM 100.43(±25.0) 106.58(±28.40) 98.83(±23.51) 0.249**
N_FAC 2.83(±2.93) 3.55(±3.28) 2.61(±2.76) 0.225**
SCIM-III 63.99(±22.85) 73.22(±21.27) 61.63(±22.08) 0.057**
Need of a caregiver
Ye s 44 60.3 6 28.6 38 73.1 <0.001****
No 29 39.7 15 71.4 14 26.9
Education level
Primary (7-12 years) 17 23.3 1 4.8 16 30.8 <0.001*
Secondary (13-17 years) 40 54.8 9 42.8 31 59.6
Tertiary (>18 years) 16 21.9 11 52.4 5 9.6
* Exact Fisher test
** Student t test for independent samples
*** Non-parametric test for independent samples
**** Chi-square test
Table Continued...
Socio-demographic factors
Although this sample had a high percentage of male patients
(80.8%), there was no statistical dierence between sex and return to
work status (p = 0.541).
Lower mean age at injury and at questionnaire exhibited a
statistically signicant dierence concerning return to work (p<0.001
and p=0.001, respectively). At the time of injury, the mean age of
those employed were 34.75±15.41 years, and of those not working
were 51.48±14.63 years. At the time of the questionnaire, the mean
age of those employed were 44.50±14.40 years, and of those not
working were 58.44±13.98 years.
Injury related factors
From our paraplegic population (n=57), 19 were employed after
SCI and 38 weren’t. Considering the tetraplegic population (n=16), 2
returned to work after SCI, while 14 didn’t. Despite these results, we
found no statistically signicant dierences between return to work
and type of injury (p=0.128).
As for the cause of injury, 16 of the 51 traumatic injuries returned to
work, while 5 of the 22 non-traumatic injuries returned to work. There
was also no statistically signicant dierence between mechanism of
injury and return to work (p=0.577). There was also no relationship
between age and mechanism of injury (p=0.971 at the time of injury
and p=0.935 ate the time of questionnaire), showing no interference
of age in our previous results.
Sixteen patients who returned to work had an incomplete lesion
(76.2%), and 5 a complete lesion (23.8%). Also, from the patients
who didn’t return to work, 16 had a complete lesion (30.8%) and 36
an incomplete lesion (69.2%). We found no statistically signicant
dierences between return to work and the severity of injury in this
population (p=0.586).
The majority of patients who returned to work mentioned no need
of a caregiver (n=15, 71.4%), while the opposite was seen in the group
who didn’t return to work (n=38, 73.1%). There was a statistically
signicant dierence found (p<0.001) between these variables.
Those who returned to work had higher mean functional scores
at discharge: mean FIM scores were 106.58±28.40 for those who
returned to work and 98.83±23.51 for those who didn’t return to work;
SCIM-III scores were 73.22±21.27 for those who returned to work
and 61.63±22.08 for those who didn’t return to work; nFAC scores
were 3.55±3.28 for those who returned to work and 2.61±2.76 for
those who didn’t return to work. Despite this, we found no statistically
signicant dierence among these three scales at discharge and present
employment status (FIM with p=0.249, SCIM-III with p=0.057,
nFAC with p=0.225). In addition, at the time of the questionnaire,
we asked about the current ambulation status, using nFAC (Table
2). The mean nFAC scale score (and SD) at questionnaire for those
who were employed after SCI was 3.65±3.23, while for those who
weren’t employed was 2.27±2.62, with no statistical signicance
found (p=0.099).
Table 2 nFAC at questionnaire and present employment status
nFAC at questionnaire p
Mean (SD)
Returned to work 3.65 (3.23) 0.099*
Didn’t return to work 2.27 (2.62)
* Student t test for independent samples
In order to explore the actual impact of functionality, a linear
regression was performed for mean functional scores, and a binary
logistic regression was performed for the need of a caregiver
(categorical variable). The correlation between mean functional
scores and employment status was low (MIF=R 0.104; SCIM-III=R
0.170; nFAC at injury=R 0.121; nFAC at questionnaire =R 0.193).
In contrast, there was a high correlation between the need of a
caregiver and employment status (OR 5.38), making it an independent
determinant of employment in our study.
Education and previous work-related factors
The biggest parcel of our population had a secondary level
education (54.8%), followed by primary level (23.3%) and tertiary
level education (21.9%). Considering those who returned to work, 11
patients (52,4%) belonged to the tertiary level education at the time
of injury, 9 (42.8%) had a secondary level education and 1 (4.8%)
a primary level education. Of the 52 patients who did not return to
work, only 5 (9.6%) had a tertiary level education, 16 (30.8%) had
a primary level education, and 31 (59.6%) had a secondary level
education. The level of education and present employment status
showed a statistically signicant dierence (p<0.001).
As showed in Table 3, previous to the SCI, 2 patients were students
(2.74%), 52 were employed (71.23%), and 19 were retired (26.03%).

Impact of a spinal cord injury in employment: a cross-sectional study in a Portuguese population 9
Copyright:
©2022 Ferro et al.
Citation: Ferro I, Pires C, C Sá P, et al. Impact of a spinal cord injury in employment: a cross-sectional study in a Portuguese population. Int Phys Med Rehab J.
2022;7(1):6‒10. DOI: 10.15406/ipmrj.2022.07.00294
Of the 52 patients reporting pre-SCI employment, 39 worked in a
manual job (75%) and 13 in an intellectual job (25%).
Table 3 Frequency distribution of the reported pre- and post-SCI employment
status
Employment status
Before SCI After SCI
n % n %
Employment status
Student 2 2.74 0 0
Employed 52 71.23 21 28.8
Retired 19 26.03 35 71.2
After SCI, and by the time of questionnaire, only 21 patients
returned to work (28,8%) and 52 were retired (71.2%). From the
previously non-retired population (n=54), after SCI 32 retired, 3 were
in the process of retirement (2 of those were still working), and 19
were not retired and still working. Out of the 21 patients who were
employed after SCI, 11 had a manual job and 10 an intellectual job
(Table 4). As for those who didn’t return to work, 28 previously had a
manual job (90.3%) and 3 had an intellectual job (9.7%). The previous
work category inuenced the return-to-work rate in our sample, with
a statistical dierence (p = 0.007) – those with an intellectual job had
higher return to work rates (10 in 13 patients, in contrast with 11 in 28
patients who previously had a manual job).
Table 4 Previous work category and present employment status
Manual Intellectual p
n (%) n (%)
Returned to work 11 (52.4) 10 (47.6) 0.007*
Didn’t return to work 28 (90.3) 3 (9.7)
*Chi-square test
Figure 1 Patient selection for this study.
Discussion
This study provides a snapshot to contextualize employment
within about four years after sustaining a SCI and being an inpatient in
a Rehabilitation Center in Portugal. The majority of our sample (n=52,
71.23%) was employed by the time of injury. However, less than a
third (n=21, 28.8%) were employed at the time of questionnaire. This
is in line with the employment rates internationally reported.5,6 We
found no National data on employment in this particular population.
Several factors have been identied in the literature to interfere
with the ability to return to work after an event like a SCI. A
comprehensive understanding of employment following SCI is
critical to restoring community reintegration. The Spinal Cord Injury
Research Evidence (SCIRE) professional project is a known resource
for current and credible information, in review format, regarding
multiple aspects of SCI patients. According to SCIRE, studies suggest
that being male, being younger at the time of injury, higher education
level pre-injury (being that people with tertiary education prior to
injury were up to 8 times more likely to be employed post-SCI),
having a lower physical demand job pre-injury are non-modiable
personal factors that positively inuence employment opportunities
after SCI. In contrast, a higher and more severe the injury are non-
modiable factors that negatively inuence employment after SCI.
Higher functional independence is a modiable factor that positively
inuences employment opportunities after SCI.15,16
Most of our results are in line with those in the literature, some
of them with statistical signicance. However, there are some data,
like sex, which does not. Women with a disability are less likely to be
employed in most developed economies.4 More than eighty percent of
our sample were males, but the distribution between sexes and return
or not to work were similar, showing no statistical signicance.
Individuals who sustained an SCI and returned to work tended to be
younger (either at the time of injury and at the time of questionnaire),
have a higher education level pre-injury, and have an intellectual job
before SCI (versus a manual one), with statistically signicant results.
Higher education level increases the chances to remain employed
after SCI.10,17 Intellectual jobs could have a better chance of being
employed after SCI than manual jobs, due to more job autonomy and
perhaps exibility, making it easier to continue working in the same
profession despite the reduction in physical ability.11
Plus, and as previously mentioned, patients who returned to work
have a tendency to have non-traumatic, incomplete and paraplegic
injury characteristics but, in our sample, we did not nd signicant
statistical dierences.
No characteristics of the SCI by itself showed statistical
signicance, although most patients who returned to work were
paraplegic, had an incomplete lesion, and a non-traumatic etiology, as
denoted in some studies.5,13,16
Regarding functionality, higher mean scores were seen in patients
who did return to work, in all three scales considered, as represented
in the literature.10 However, we cannot assume an association, as none
showed a signicant statistical dierence. Interestingly, the need of
a caregiver was associated with a lower return to work rate, with
statistical signicance, meaning there was an association between
independence and employment status post-SCI. The International
Classication of Functioning Disability and Health (ICF) is a widely
used classication of health and health-related domains, describing
body functions and structures, activities and participation, and a list
of environmental and personal factors.8 Considering the dierent
dimensions in the ICF, work belongs in the “Participation” domain,
as functional limitation belongs in the “Activity” domain. In this line
of thought, the authors consider that these functional metrics were,
perhaps, not adequate in order to establish this functionality impact
(return to work). We propose that the “need of a caregiver” may
additionally be considered in the evaluation of the SCI patient, as it
gives as a clearer understanding of our patients’ participation ability
- return to work. This fact may explain why, in our results, functional
scales had no statistical signicance while the need of a caregiver did.
Plus, when we evaluated a possible correlation, the need of a caregiver
showed to be an independent determinant for the employment status.

Impact of a spinal cord injury in employment: a cross-sectional study in a Portuguese population 10
Copyright:
©2022 Ferro et al.
Citation: Ferro I, Pires C, C Sá P, et al. Impact of a spinal cord injury in employment: a cross-sectional study in a Portuguese population. Int Phys Med Rehab J.
2022;7(1):6‒10. DOI: 10.15406/ipmrj.2022.07.00294
One of the limitations of this manuscript is the fact that this is an
observational study with cross-sectional data, and lacks longitudinal
follow-up, only allowing us to identify associations between
variables, not causal relationships. Although our response rate was
high (69.5%), our data only comprised individuals who were once
inpatients in a Rehabilitation Center from Portugal, and may not be
representative for all people with SCI in Portugal. Additionally, the
fact that only previous inpatients from a Rehabilitation Center were
enrolled in this study is a selection bias, as tendentiously they have a
more severe presentation, and employment estimates in the outpatient
population may dier.
Conclusion
The employment rate found in our study was in line with the
international literature. There is no information specically about the
Portuguese population.
Despite improvements and innovations in technology, robotics,
environmental designs, the attenuation of prejudices and the job
opportunities, employment rates for those with SCI have changed
very little over the last 30-40 years.15 This reveals the complexity of
the process of returning to work and the diverse contexts regarding
health and social politics in dierent countries.
ICF is a widely used classication of health and health-related
domains. Work ability belongs in the “participation” domain.
Therefore, the authors propose that the “need of a caregiver” may be
considered in the evaluation of the SCI patient, as it gives a clearer
understanding of our patients’ participation capability (return to
work), in contrast with functional scale scores, that are best suited in
the “activity” domain.
Employment after SCI showed no signicance with injury etiology
or mean scores in functional scales. It showed to be associated with
higher functional scores, no need of a caregiver (an independent
determinant), lower mean age values (with a statistically signicant
dierence), previous higher level of education (with a statistically
signicant dierence), and previous professional category (manual
versus intellectual job, also with a statistically signicant dierence).
A comprehensive multidisciplinary rehabilitation program,
focused on education, vocational goals, improvement in functionality,
and community and environmental access is essential for the success
of employment outcomes, with the goal of maximizing patients’
activity and participation, minoring their personal and environmental
barriers, contemplating the ICF reasoning.
Conicts of interest
The authors certify that there is no conict of interest with
any nancial organization regarding the material discussed in the
manuscript.
Funding
No sponsor or funding was required to develop this study.
Author’s contribution
All authors contributed equally to the manuscript, and read and
approved the nal version of the manuscript.
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