Vocational rehabilitation and return to work after spinal cord injury: a scoping review of policies in the U.S. and Canada.

PURPOSE: Spinal cord injury (SCI) significantly impacts quality of life and economic independence, yet employment rates remain disproportionately low, suggesting a divergence between the legislative intent of inclusion and the clinical goal of functioning. The alignment of social policy with rehabilitation practice is essential. This study conducted a comparative scoping review of federal policies and policy-driven vocational rehabilitation (VR) strategies in the U.S. and Canada to map the evidence landscape and identify critical gaps in cross-national research.

METHODS

The PRISMA guidelines and the Arksey and O'Malley framework were used. We searched Ovid Medline, CINAHL, and Google Scholar, using COVIDENCE for the final review. Guided by the Population-Concept-Context (PCC) framework, we included English-language studies and materials that addressed federal-level policies in Canada and the U.S. related to the employment of persons with SCI.

RESULTS

Overall, 10 studies were analyzed. The literature predominantly focused on the U.S., particularly within the Veterans Health Administration (VHA) and state VR systems. A recurring barrier identified across both nations was the "benefits trap," where social protection policies create financial disincentives that affect return-to-work (RTW). On the other hand, integrated interventions such as Individual Placement and Support (IPS) and federally mandated resource allocation (e.g., for assistive technology) demonstrated superior outcomes compared to traditional models.

CONCLUSIONS

Current policy frameworks, while effective at protecting against discrimination, are often insufficient to overcome structural and financial disincentives to employment. To truly reconcile the goals of rehabilitation and inclusion, future efforts must address policy-driven barriers and prioritize funding for integrated, hospital-based vocational services that translate legal rights into employment outcomes for individuals with SCI.