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Page 8 of 11 Merritt et al. Neuroimmunol Neuroinflammation 2019;6:9 I http://dx.doi.org/10.20517/2347-8659.2019.15

Effectiveness of the supported employment initiative in veterans with TSCI
In 2012, a randomized multisite study investigated the effectiveness of a SE rehabilitation program in
aiding military veterans with TSCI find post-injury employment. The initial results showed that veteran
participants were 11.4 × more likely to find employment as compared to veterans without any form of
[60]
rehabilitation program . Two years later, a follow-up study was performed by the same investigators
assessing the long-term performance of the previously studied SE rehabilitation program. The results
showed that veterans were 30.8% more likely to achieve employment; however, veterans were significantly
more likely to achieve employment within the first 12 months after their TSCI compared to those who
[61]
waited longer than a year .

In the same year as the 2-year follow-up study, a cost-effectiveness analysis was performed on the
SE rehabilitation program for veterans with TSCI. Each participant received approximately 35 h of
rehabilitation services costing $1,821 on average. The costs associated with the program were then
compared to the quality of life improvement self-reported by each of the participants. The results showed
that participants in the SE rehabilitation program had marginally reduced societal costs compared to the
control group. But these results, coupled with an insignificant difference in quality of life improvement,
led to the determination that the SE rehabilitation program was not cost-effective as compared to standard
[62]
care .

Bankruptcy prevalence in those having sustained a TSCI
[63]
In the United States, the leading cause of bankruptcy is the inability to pay medical bills . A study
comparing the risk of bankruptcy before and after TSCI found that patients sustaining a TSCI have a
3.5% chance of bankruptcy in the first five years post-injury. Interestingly, those with private insurance
were twice as likely to file for bankruptcy as compared to those with Medicaid. The authors attributed
this finding to private insurance patients accruing additional debts pre-injury that they can no longer be
[64]
paid back (i.e., car, mortgage, etc.) . Race and income were also found play an important role for those
returning to work post-injury. For caucasian patients it took a median of 566 days to return to work.
However, their non-Caucasian counterparts took 1382 days to return to work, almost 2.5 times slower.
Considering income, higher income patients in the upper 75th percentile returned to work in 557 days. In
contrast, TSCI patients in the lower 25th percentile of income returned to work over 200 days later than
[58]
their higher income counterparts. Phillips et al. attributed this delay to lower paying jobs often requiring
skilled physical labor, causing an obvious barrier to TSCI patients.

Following a TSCI, patients report unemployment and financial difficulties as primary factors contributing
to unhappiness, to a greater extent than the extent of their disability. Employment gives these patients
a sense of both purpose and financial independence . Patients with greater levels of social support,
[57]
community integration and higher levels of education were more likely to gain steady employment [65,66] .
TSCI may leave patients emotionally drained and separated from their social lives . Prolonged
[67]
unhappiness can exacerbate a variety of mental illnesses, with studies showing that 18%-37% of TSCI
patients presented with signs of major depressive disorder (MDD) . Financial stressors such as job loss,
[56]
financial crisis, and inability to pay bills are found in 31.2% of those with MDD [68,69] . Patients following a
TSCI may additionally have altered decision making capabilities due to the increased incidence of MDD .
[70]

CONCLUSION
TSCI is a lifelong costly injury for both hospital systems and the patient. Fast access to decompression
surgery and early rehabilitation has been shown to improve injury outcomes. Although access to
rehabilitation can be difficult through certain forms of insurance, it is critical in TSCI care. Lack of
rehabilitation services has been associated with greater levels of comorbid secondary health conditions.