Race, employment, and spinal cord injury

A Framework for Addressing Health Disparities in Adult Neurogenic Lower Urinary Tract Dysfunction-Systematic Review and Neurogenic Bladder Research Group Recommendations

The systematic review and workshop recommendations by the Neurogenic Bladder Research Group offer a comprehensive framework for evaluating health disparities in adult neurogenic lower urinary tract dysfunction (NLUTD). The study acknowledges the multifaceted nature of health, highlighting that medical care, though critical, is not the sole determinant of health outcomes. Social determinants of health significantly influence the disparities seen in NLUTD. This report calls for a shift in focus from traditional urologic care to a broader, more inclusive perspective that accounts for the complex interplay of social, economic, and health care factors in managing NLUTD.

Factors associated with racial and ethnic disparities in chronic pain after acute traumatic injury

BACKGROUND

Chronic pain represents a substantial health burden and source of disability following traumatic injury. This study investigates factors associated with racial and ethnic disparities in chronic pain.

METHODS

Prospective, longitudinal, panel study. Seriously injured patients were recruited from two trauma centres in the Northeastern and Southwestern USA. Data from medical records and individual surveys were collected in-hospital, and at 3-month and 12-month postinjury from a balanced cohort of non-Hispanic black, non-Hispanic white and Hispanic patients. We used linear regression to estimate the associations between race and ethnicity and 3-month and 12-month pain severity outcomes. We grouped all available cohort data on factors that theoretically influence the emergence of chronic pain after injury into five temporally ordered clusters and entered each cluster sequentially into regression models. These included: participant race and ethnicity, other demographic characteristics, preinjury health characteristics, acute injury characteristics and postinjury treatment.

RESULTS

650 participants enrolled (Hispanic 25.6%; white 38.1%; black 33.4%). Black participants reported highest relative chronic pain severity. Injury-related factors at the time of acute hospitalisation (injury severity, mechanism, baseline pain and length of stay) were most strongly associated with racial and ethnic disparities in chronic pain outcomes. After controlling for all available explanatory factors, a substantial proportion of the racial and ethnic disparities in chronic pain outcomes remained.

CONCLUSION

Racial and ethnic disparities in chronic pain outcomes may be most influenced by differences in the characteristics of acute injuries, when compared with demographic characteristics and postacute treatment in the year after hospitalisation.

Pre-Hospital and Post-Hospital Quality of Care in Traumatic Spinal Column and Cord Injuries in Iran

STUDY DESIGN

A retrospective study.

OBJECTIVES

The quality of care (QoC) for spinal column/cord injury patients is a major health care concern. This study aimed to implement the QoC assessment tool (QoCAT) in the National Spinal Cord/Column Injury Registry of Iran (NSCIR-IR) to define the current state of pre- and post-hospital QoC of individuals with Traumatic Spinal Column and Spinal Cord Injuries (TSC/SCIs).

METHODS

The QoCAT, previously developed by our team to measure the QoC in patients with TSC/SCIs, was implemented in the NSCIR-IR. The pre-hospital QoC was evaluated through a retrospective analysis of NSCIR-IR registry data. Telephone interviews and follow-ups of patients with SCI evaluated the QoC in the post-hospital phase.

RESULTS

In the pre-hospital phase, cervical collars and immobilization were implemented in 46.4% and 48.5% of the cases, respectively. Transport time from the scene to the hospital was documented as <1 hour and <8 hours in 33.4% and 93.9% of the patients, respectively. Post-hospital indicators in patients with SCI revealed a first-year mortality rate of 12.5% (20/160), a high incidence of secondary complications, reduced access to electrical wheelchairs (4.2%) and modified cars (7.7%), and low employment rate (21.4%).

CONCLUSION

These findings revealed a significant delay in transport time to the first care facilities, low use of immobilization equipment indicating low pre-hospital QoC. Further, the high incidence of secondary complications, low employment rate, and low access to electrical wheelchairs and modified cars indicate lower post-hospital QoC in patients with SCI. These findings imply the need for further planning to improve the QoC for patients with TSC/SCIs.

Racial and Ethnic Inequities in the Return-to-Work of Workers Experiencing Injury or Illness: A Systematic Review

PURPOSE

Non-White workers face more frequent, severe, and disabling occupational and non-occupational injuries and illnesses when compared to White workers. It is unclear whether the return-to-work (RTW) process following injury or illness differs according to race or ethnicity.

OBJECTIVE

To determine racial and ethnic differences in the RTW process of workers with an occupational or non-occupational injury or illness.

METHODS

A systematic review was conducted. Eight academic databases - Medline, Embase, PsycINFO, CINAHL, Sociological Abstracts, ASSIA, ABI Inform, and Econ lit - were searched. Titles/abstracts and full texts of articles were reviewed for eligibility; relevant articles were appraised for methodological quality. A best evidence synthesis was applied to determine key findings and generate recommendations based on an assessment of the quality, quantity, and consistency of evidence.

RESULTS

15,289 articles were identified from which 19 studies met eligibility criteria and were appraised as medium-to-high methodological quality. Fifteen studies focused on workers with a non-occupational injury or illness and only four focused on workers with an occupational injury or illness. There was strong evidence indicating that non-White and racial/ethnic minority workers were less likely to RTW following a non-occupational injury or illness when compared to White or racial/ethnic majority workers.

CONCLUSIONS

Policy and programmatic attention should be directed towards addressing racism and discrimination faced by non-White and racial/ethnic minority workers in the RTW process. Our research also underscores the importance of enhancing the measurement and examination of race and ethnicity in the field of work disability management.

The impact of impairment, socio-demographic and environmental factors on spinal cord injury survivors' ability to return to work

BACKGROUND

Re-employment of spinal cord injury survivors (SCIS) has been positively related to better community integration. The identification of the determining factors and their impact on return to work (RTW) of SCIS would be helpful in improving the RTW rate.

OBJECTIVE

The aim of this study was to identify the factors determining RTW and explore their impact on RTW.

METHODS

An adapted Work Rehabilitation Questionnaire Self-Report questionnaire was used to elicit sociodemographic information and work-related characteristics of the participants. Sixty-eight participants with a premorbid worker status completed the questionnaires which were sent via mail, email and hand delivery. Descriptive and inferential statistical analyses were performed.

RESULTS

At the time of the survey 70.6% of the participants were not re-employed. The inferential statistical analysis indicated that time since injury and re-employment, receiving medical attention due to complications, vocational intervention, supervisor's support, family support and government support were significant factors of RTW. The results showed no significant differences in RTW by most of the sociodemographic factors. Only two percent of the participants indicated vocational planning and intentions.

CONCLUSION

The significant impact of vocational and injury characteristics suggests that vocational rehabilitation services are urgently needed to support SCIS in returning to their worker role. Returning to work is a significant outcome of SCI rehabilitation.

Factors associated with past and current employment of veterans with spinal cord injury

Objective: The purpose of this study was to examine variables predictive of post-SCI return to employment and current employment among a large cohort of veterans with Spinal Cord Injury (SCI) treated within the Veterans Health Administration (VHA) SCI System of Care.Design: Cross sectional analysis of data obtained during in-person baseline interviews and follow-up phone interviews.Setting: Seven SCI Centers within Veteran Affairs Medical Centers.Participants: 1047 veterans with SCI receiving inpatient or outpatient care in VHA.Results: Only 29.8% were employed post-SCI, 27.9% reported employment within the immediate 5 years before the baseline interview, but only 9.2% reported current employment at the time of the baseline interview. Significant predictors of current employment among these veterans with SCI included recent employment experience, history of legal problems, duration of SCI, education, and life satisfaction.Conclusions: The baseline employment rate following SCI of a large, representative sample, was 29.8%. Greater duration of SCI predicted unemployment, likely due to the older age of this population. Additional years of education promoted current and post-SCI employment, while a history of legal problems was a barrier to employment.

Health Care Disparities Add Insult to Spinal Cord Injury

The authors describe the disparities and increased risk of traumatic spinal cord injury Black Americans face because of violence. This article should serve as a realization of these inequities and as a call to action to improve the equity of rehabilitation services in this population to improve outcomes.

Early vocational rehabilitation after spinal cord injury: A survey of service users

BACKGROUND: Early vocational rehabilitation following spinal cord injury (SCI) improves return to work (RTW) outcomes, but there is limited information about who benefits from such interventions, why and in what contexts. OBJECTIVE: We aimed to describe demographic and clinical characteristics and RTW outcomes of adults with SCI who received early vocational rehabilitation. We sought to identify key mechanisms of early vocational rehabilitation. METHODS: This is a cross-sectional survey of people with SCI recruited from the New Zealand Spinal Trust Vocational Rehabilitation Service, who had sustained an SCI within the previous five years. RESULTS: Of the 37 people who responded to the survey, 54% returned to paid work (90% of whom retained their pre-injury employment). Those in autonomous roles returned to work faster with greater odds of returning to their pre-injury employer and role. Participants highlighted the importance of feeling hopeful about RTW while still in the spinal unit as a key mechanism of effect within the early vocational intervention. CONCLUSIONS: Findings suggested key mechanisms of early vocational intervention could be framed by models of hope. However, for gains to be optimised, continuity of support beyond the acute stage was suggested as an area for future research.

Quality of Life and Physical Activity of Persons with Spinal Cord Injury

The higher quality of life of people with spinal cord injury is closely related with their reintegration into the social environment. Social reintegration is a demanding and complex process, requiring individuals to become active again and acquire age-, gender-, and culture-appropriate roles and social status. It also involves independence and productive behavior as part of multiple interpersonal relationships with family, friends, and others. In order to establish whether individuals with spinal cord injury who are physically active subjectively rate their quality of life to be higher compared to those who are not, sixty-two respondents from Slovenia with spinal cord injury were interviewed. Thirty-one of them were physically active, and 31 were not. The level of injury of the responders was from Th6–Th12. The participants gave the highest assessments to their interpersonal relationships, and the lowest to their satisfaction with material prosperity. Data comparison showed that subjective estimates in all areas of quality of life are higher in respondents who were involved in physical activity after their injury. The results may encourage persons with spinal cord injury to participate more often in sports programs, and also encourage others to do so.

Return to work status in rehabilitated South Indian persons with spinal cord injury: a cross-sectional survey

STUDY DESIGN

Cross-sectional, retrospective survey.

OBJECTIVE

To find the factors influencing the return to work status (RTW) in persons with spinal cord injury (SCI).

SETTING

Tertiary care university teaching hospital, India.

METHODS

A total of 109 community-dwelling persons with SCI who had been previously rehabilitated and were residing within a 100 km radius from our rehabilitation center were recruited. The return to work status in addition to the demographic, injury, work, environment, physical, and psychosocial characteristics were self-reported via interview.

RESULTS

The return to work rate was 82%. The odds of a return to work post injury was 93 times higher for persons who reported high self-motivation when compared to persons who reported low self-motivation (OR = 93.6, 95% CI 10.5-836.6). The odds of a return to work were nine times higher for persons who reported adequate social support from the family and in the community when compared to those who reported inadequate social support (OR = 8.9, 95% CI 10.5-52.6). Other factors significantly associated with return to work status include younger age at injury, being single, lower level of lesion, vocational training, independence in self-care, and accessibility and mobility to all places.

CONCLUSION

Motivation and social support are critical to successful return to work following SCI. Comprehensive multidisciplinary rehabilitation, which targets vocational goals, improvements in individual functioning and mobility, and community access are important for successful employment outcomes.

Pre- and post-injury job type distributions of individuals with SCI in relation to structural changes in the labor market: A comparative analysis based on findings from the Swiss Spinal Cord Injury Cohort Study

Objective: To compare pre- and post-injury job type distributions of individuals with spinal cord injury (SCI) living in Switzerland.Design: Cross-sectional, self-report survey.Setting: Community.Participants: Two hundred sixty-three individuals reporting a pre- and 677 a post-injury job title in the Swiss SCI Cohort Study community survey.Interventions: Not applicable.Outcome Measures: Job titles were elicited by free-text questions and classified using the International Standard Classification of Occupations (ISCO-08). Frequencies across ISCO-08 major groups were calculated and compared to Swiss labor market statistics for 1995 and 2011.Results: Compared to pre-SCI, Professionals (16.3% vs 31.2%) and Clerical Support Workers (11.7% vs 19.1%) were more prevalent and Crafts and Related Workers (26.5% vs 5.4%) less common post-injury. Except for Clerical Support Workers, these results reflect recent structural changes in the Swiss labor market.Conclusion: The higher post-SCI prevalence of jobs predominantly requiring cognitive and communication skills compared to rather physically oriented jobs mirrors structural changes in the labor market, except for clerical jobs. Future return-to-work strategies should not primarily target the clerical sector with its diminishing job opportunities, but promote vocational re-training towards jobs requiring higher education and assistive technology to return individuals with limited cognitive resources to physically oriented jobs.

Disparities in Health Care for Black Patients in Physical Medicine and Rehabilitation in the United States: A Narrative Review

Racial health disparities continue to disproportionately affect Black persons in the United States. Black individuals also have increased risk of worse outcomes associated with social determinants of health including socioeconomic factors such as income, education, and employment. This narrative review included studies originally spanning a period of approximately one decade (December 2009-December 2019) from online databases and with subsequent updates though June 2020. The findings to date suggest pervasive inequities across common conditions and injuries in physical medicine and rehabilitation for this group compared to other racial/ethnic groups. We found health disparities across several domains for Black persons with stroke, traumatic brain injury, spinal cord injury, hip/knee osteoarthritis, and fractures, as well as cardiovascular and pulmonary disease. Although more research is needed, some contributing factors include low access to rehabilitation care, fewer referrals, lower utilization rates, perceived bias, and more self-reliance, even after adjusting for hospital characteristics, age, disease severity, and relevant socioeconomic variables. Some studies found that Black individuals were less likely to receive care that was concordant with clinical guidelines per the reported literature. Our review highlights many gaps in the literature on racial disparities that are particularly notable in cardiac, pulmonary, and critical care rehabilitation. Clinicians, researchers, and policy makers should therefore consider race and ethnicity as important factors as we strive to optimize rehabilitation care for an increasingly diverse U.S. population.

Returning to work after a hand injury: Does ethnicity matter?

Background

Hand injuries (HI) are common and may limit participation in work. The objective of this study is to examine the effect of ethnicity and other prognostic variables on return-to-work (RTW) among male manual workers after acute HI.

Methods

A cohort of 178 subjects (90 Arabs, 88 Jews) aged 22 to 65 was studied. Trained bilingual occupational therapists evaluated and interviewed the subjects, using structured validated questionnaires for evaluating personal and environmental factors, body function and structure, and activity limitation and participation restrictions. Employment status 3 months post injury was assessed by a telephone interview. To establish a predictive model for RTW, ethnicity and certain variables of the four domains mentioned above were analyzed using logistic regression analysis.

Results

A significant difference in the rate of RTW between Jews and Arabs was found (45.5% for Jews, 28.9% for Arabs, p = 0.03) three months post HI. In the univariate regression analysis, ethnicity was associated with RTW (OR = 2.05; CI: 1.10–3.81) for Jews vs. Arabs. Using a multivariate analysis, only legal counseling, educational attainment, and the severity of disability were significantly associated with RTW.

Conclusion

RTW three months post HI among manual workers is directly related to variables such as education and legal counseling and only indirectly related to ethnicity. Patients with a lower level of education and those who were engaged in legal counseling need special attention and close guidance in the process of RTW.

Differential Odds of Employment and Estimation of Earnings Among Those With Spinal Cord Injury

Our purpose was to identify demographic, educational, and injury-related characteristics associated with odds of employment and estimates of differential earnings among participants with spinal cord injury (SCI). Self-report assessments were obtained from 1,983 participants who had traumatic SCI, were 18+ years old, and less than 65 years of age. All were recruited into the current cross-sectional study from previous studies of health and aging from the Midwestern and Southeastern United States. Midwestern participants had 2.41 higher odds of employment. Older age at injury was associated with lower odds of employment. There were no sex differences in the odds of employment, but women had an estimated US$19,431 lower conditional earnings. Non-Hispanic Blacks had 69% lower odds of employment, and those working had an estimated US$12,058 lower earnings. Ambulatory participants had higher odds of employment (odds ratio [OR] = 4.66) and higher conditional earnings (US$17,277) than those with the most severe SCI. Those with 4-year or postgraduate degrees had substantially higher odds of employment (OR = 4.15, OR = 5.72, respectively) and higher conditional earnings (US$29,990, US$44,580, respectively) compared with those with a high school certificate or less. These findings underscore the importance of policies to promote the optimal quality employment outcomes for people with SCI.

An interdisciplinary approach to job matching: developing an occupation-specific job matching tool for reintegrating persons with spinal cord injury into the labor market

Purpose: To develop and pretest a comprehensive occupation- and health condition-specific job matching tool for vocational rehabilitation of persons with spinal cord injury.Materials and methods: The study design involved qualitative and quantitative steps. First, an interdisciplinary scoping review covering return-to-work, organizational and vocational psychology research was conducted to devise a conceptual job matching framework. Then, the occupation- and health condition-specific tool content was determined based on a database analysis of jobs performed by persons with spinal cord injury and focus groups with affected persons. Finally, a tool prototype was developed and pretested in a simulation exercise with vocational rehabilitation professionals.Results: The study yielded a tool prototype with matching profiles that structure the demands and characteristics of 415 occupations as well as spinal cord injury-related needs and limitations into a stable, a modifiable, and a needs-supplies dimension of person-job match. Vocational rehabilitation professionals perceived the prototype as helpful for determining target jobs for vocational retraining and for goal-oriented intervention planning.Conclusions: By comprehensively assessing the person-job match of individuals with spinal cord injury, the tool facilitates determining suitable target jobs and interdisciplinary intervention planning in vocational rehabilitation and is thus likely to promote sustainable return to work.Implications for rehabilitationJob matching is crucial for a sustainable work reintegration of persons with disabilities. However, the majority of existing job matching tools lack applicability for return to work because they are (1) not occupation-specific or rely on outdated occupational information, (2) not health condition-specific, and (3) not comprehensive with regard to the relevant aspects for determining a person-job match.Persons with spinal cord injury are a case in point for the need of job matching tools that comprehensively address occupation- and health condition-specific information.The present study responded to the shortcomings of existing job matching tools and uses vocational rehabilitation of persons with spinal cord injury as a case in point for developing a job matching tool that is both occupation- and health condition-specific at the same time.The developed tool was perceived as promising for determining suitable target jobs for vocational retraining of persons with spinal cord injury and for goal-oriented intervention planning in an interdisciplinary vocational rehabilitation setting. The tool's underlying conceptual framework may also serve as a blueprint for developing job matching tools for other types of disabilities.

Vocational Rehabilitation Awareness Among Spinal Cord Injury Male Patients in Saudi Arabia: A Brief Communication

Background: Motor vehicle accidents are the most common cause of spinal cord injury (SCI) in Saudi Arabia, mainly involving young adults. Much attention has been dedicated to obtaining work after SCI during the past decades because of the psychological, social, financial, and political implications. Since high unemployment rates pose a significant social burden due to the increase in the expenditures associated with benefits, it remains an important consideration in individuals with activity limitation after spinal cord injury. There are no current data or guidelines for community reintegration or employment rates in the spinal cord injury population in Saudi Arabia.

Objective: The objective of our study was to identify the awareness of vocational rehabilitation in individuals with spinal cord injury in Saudi Arabia.

Design and methods: This cross-sectional study was conducted in the outpatient department of the largest tertiary care rehabilitation hospital in Saudi Arabia. After obtaining informed consent, structured interviews were conducted from March 2018 through July 2018 (five months) by the primary investigator and a rehabilitation nurse The interviews were administered in a one-to-one format.

Results: One hundred and twenty-one male patients with SCI were included in the study with mean age of 35.6 ± 13.9 years. Seventy (57.9) were employed at the time of injury. The employment rate decreased significantly after injury; only 20 (16.5%) were employed, 38 (31.4%) had retired, and 11 (9.1%) patients resumed their studies.

One hundred and five (86.8%) patients received rehabilitation treatment as an inpatient. Ninety-four (77.7%) reported that they had no idea about vocational rehabilitation. Only five patients (4.1%) received services of vocational rehabilitation.

Conclusion: Vocational rehabilitation awareness among spinal cord injury male patients in Saudi Arabia is lacking. This needs to be addressed to overcome unemployment and improve the quality of life which in turn may reduce the economic burden and costs among spinal cord injury patients in Saudi Arabia.

Comparison of disability and quality of life between patients with pediatric and adult onset paraplegia

OBJECTIVE

To investigate the factors that affect disability and quality of life in patients with spinal cord injuries (SCIs) and to compare the degree of disability and quality of life in patients with SCI according to over and under 18 years of age when their injury occurred.

DESIGN

Cohort study.

SETTING

Two academic hospitals in Istanbul, Turkey.

PARTICIPANTS

Forty patients with SCI were included in this study. Group 1 included 20 patients with SCI who were younger than 18 years of age when their injury occurred, Group 2 included 20 patients who were older than 18 years of age when their injury occurred.

OUTCOME MEASURES

Patients' demographics, duration of SCI and degree of disability were assessed using the Craig Handicap Assessment and Reporting Technique (CHART). Quality of life was assessed using the World Health Organization Quality of Life Scale Short Form (WHOQOL-Bref). Depression was assessed using the Beck Depression Inventory (BDI).

RESULTS

Although there was no significant difference between the BDI scores and CHART scores of the two groups, environment domain scores in the WHOQOL-Bref were significantly higher in Group 2 than in Group 1 (P<0.05). No significant correlation was found between age of SCI onset, disease duration, ASIA scores, depression scores, total CHART scores for all patients.

CONCLUSION

Adaptation to environment was significantly better in those who suffered SCI during adulthood than in pediatric patients with SCI. Disability level was not associated with age of disease onset, disease duration, neurological status, depression level.

Racial Differences in Data Quality and Completeness: Spinal Cord Injury Model Systems' Experiences

Background: Among people with spinal cord injury (SCI), minorities experience a disproportionately higher burden of diseases. Knowledge of data quality by race/ethnicity will help better design racial health disparity research and understand potential errors/biases. Objective: To investigate racial/ethnic differences in response completeness in a longitudinal SCI database. Methods: This study included 7,507 participants (5,483 non-Hispanic whites, 1,414 non-Hispanic blacks, and 610 Hispanics) enrolled in the National SCI Database who returned for follow-up between 2001 and 2006 and were aged ≥18 years at follow-up. Missing data were defined as any missing, unknown, or refusal response to interview items. Results: The overall missing rate was 29.7%, 9.5%, 9.7%, 10.7%, 12.0%, and 9.8% for the Craig Handicap Assessment and Reporting Technique-Short Form (CHART) economic self-sufficiency subscale, CAGE questionnaire, drug use, Diener's Satisfaction with Life Scale, Patient Health Questionnaire, and pain severity, respectively. The missing rate for the CHART measure was significantly higher among non-Hispanic blacks and Hispanics than among non-Hispanic whites, after controlling for demographics, injury factors, mode of data collection, and study sites. The missing data in the other outcome measures examined were also significantly higher among non-Hispanic blacks than among non-Hispanic whites but were not significantly different between Hispanics and non-Hispanic whites. Conclusion: Our study highlights the importance of research methodology designed to improve non-response or response incompleteness, particularly in non-Hispanic blacks, as we move to reduce racial/ethnic disparities and strive to explain how and why disparities occur in the SCI population.

Factors associated with disability among middle-aged and older African American women with osteoarthritis

BACKGROUND

Middle-aged and older African American women experience disproportionate rates of functional limitations and disability from osteoarthritis (OA) compared to other racial ethnic groups; however, little is known about what factors contribute to this disparity within African American women.

OBJECTIVE

To examine factors associated with physical function and disability among African American women ages 50-80 with OA using the disablement process model.

METHODS

This descriptive study included 120 African American women with OA from the Southwestern region of the United States. Regression techniques were used to model the correlates of physical function and disability and to test a mediation model.

RESULTS

BMI and pain severity were significantly related to functional limitations. Depressive symptoms mediated the relationship between racial discrimination and disability.

CONCLUSION

Biological, intra-individual, and extra-individual factors are related to disablement outcomes in this sample of African American women, which is consistent with theory suggesting the need for treatment coupled with environmental modifications. This study can inform the development of future bio-behavioral interventions.

Differences in the Community Built Environment Influence Poor Perceived Health Among Persons With Spinal Cord Injury

OBJECTIVE

To assess the association between characteristics of the built environment and differences in perceived health among persons with spinal cord injury (SCI) using objective measures of the local community derived from Geographic Information Systems data.

DESIGN

Secondary analysis of cross-sectional survey data.

SETTING

Community.

PARTICIPANTS

Persons with chronic SCI enrolled in the Spinal Cord Injury Model Systems database (N=503). All cases were residents of New Jersey, completed an interview during the years 2000 through 2012, had a complete residential address, and were community living at the time of follow-up.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Perceived health.

RESULTS

Bivariate tests indicated that persons with SCI residing in communities with more (vs less) mixed land use and small (vs large) amounts of open space were more likely to report poor perceived health. No associations were found between perceived health and differences in the residential or destination density of the community. Adjusting for variation in demographic, impairment, quality of life, and community socioeconomic characteristics accounted for the gap in the odds of reporting poor health between persons living in areas with large versus small amounts of open space (odds ratio [OR], 0.54; 95% confidence interval [CI], 0.28-1.02). However, even after accounting for individual background differences, persons living in communities characterized by more heterogeneous land use were twice as likely to report poor health compared with persons living in less mixed areas (OR, 2.14; 95% CI, 1.12-4.08).

CONCLUSIONS

Differences in the built characteristics of communities may be important to the long-term health and well-being of persons with SCI who may have greater exposure to the features of their local area because of limited mobility. The results of this study suggest living in a community with more heterogeneous land use was not beneficial to the perceived health of persons with chronic SCI living in New Jersey. Further investigation is needed to assess if the relationships observed in this analysis are influenced by differences in infrastructure and resources across communities. Further research is also needed to investigate the role built environment plays in the long-term health and well-being of persons with SCI in other geographic locales.

Modifiable and non-modifiable factors associated with employment outcomes following spinal cord injury: A systematic review

CONTEXT

Employment rates in individuals with spinal cord injury (SCI) are approximately 35%, which is considerably lower than that of the general population. In order to improve employment outcomes a clear understanding of what factors influence employment outcomes is needed.

OBJECTIVE

To systematically review factors that are consistently and independently associated with employment outcomes in individuals with SCI, and to understand the magnitude of their influence.

METHODS

Through an electronic search of MEDLINE/PubMed, EMBASE, CINAHL, PsycINFO, Social Science Abstracts and Social Work databases, we identified studies published between 1952-2014 that investigated factors associated with employment outcomes following SCI. Exclusion criteria included: (1) reviews (2) studies not published in English (3) studies not controlling for potential confounders through a regression analysis, or (4) studies not providing an effect measure in the form of OR, RR, or HR. Data were categorized based on the International Classification of Functioning, Disability and Health framework, with each domain sub-categorized by modifiability. First author, year of publication, sample size, explanatory and outcome variables, and effect measures were extracted.

RESULTS

Thirty-nine studies met the inclusion criteria. Twenty modifiable and twelve non-modifiable factors have been investigated in the context of employment following SCI. Education, vocational rehabilitation, functional independence, social support, and financial disincentives were modifiable factors that have been consistently and independently associated with employment outcomes.

CONCLUSION

A number of key modifiable factors have been identified and can inform interventions aimed at improving employment outcomes for individuals with SCI. Future research should focus on determining which factors have the greatest effect on employment outcomes, in addition to developing and evaluating interventions targeted at these factors.

Review of cross-cultural issues related to quality of life after spinal cord injury

Quality of life (QOL) is a dynamic concept that means different things to different people, both in the general public and within the research community. Because of this, a common definition of QOL has been hard to achieve. This article reviews cross-cultural issues related to QOL research in spinal cord injury (SCI). Many factors influence QOL for persons with SCI, including observable and objective indicators and subjective self-report ones. The World Health Organization's International Classification of Function, Disability and Health is used in this article as a framework to better understand how these factors may influence QOL. A number of important steps are summarized with respect to measurement issues in QOL. A comparison between data from 2 countries (United States and Brazil) using the International SCI QOL Basic Data Set shows similarities in scores and good reliability in the Brazilian sample. Substantial, significant correlations were observed among the SCI QOL Basic Data Set items and the WHOQOL-BREF within the US sample. The article ends with a set of recommendations for the development of cross-cultural measures of QOL for use in the SCI population.

Racial and ethnic disparities in functioning at discharge and follow-up among patients with motor complete spinal cord injury

OBJECTIVE

To examine racial and ethnic differences in self-care and mobility outcomes for persons with a motor complete, traumatic spinal cord injury (SCI) at discharge and 1-year follow-up.

DESIGN

Retrospective cohort study.

SETTING

Sixteen rehabilitation centers contributing to the Spinal Cord Injury Model Systems (SCIMS) database.

PARTICIPANTS

Adults with traumatic, motor complete SCI (N=1766; American Spinal Injury Association Impairment Scale grade A or B) enrolled in the SCIMS between 2000 and 2011. Selected cases had complete self-reported data on race and ethnicity (non-Hispanic white, non-Hispanic black, or Hispanic) and motor FIM scores assessed at inpatient rehabilitation admission, discharge, and 1-year follow-up.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Functional outcomes were measured by FIM self-care and mobility scores on a 1 to 7 FIM scale, at discharge and 1-year follow-up.

RESULTS

Multiple regression models stratified by neurologic category and adjusted for sociodemographic and injury characteristics assessed racial and ethnic group differences in FIM self-care and mobility change scores at discharge and 1-year follow-up. At discharge, non-Hispanic black participants with tetraplegia and paraplegia had significantly poorer gains in FIM self-care and mobility scores relative to non-Hispanic white and Hispanic participants. At 1-year follow-up, similar FIM self-care and mobility change scores were found across racial and ethnic groups within each neurologic category.

CONCLUSIONS

Non-Hispanic white and Hispanic participants had comparatively more improvement in self-care and mobility during inpatient rehabilitation compared with non-Hispanic black participants. At 1-year follow-up, no differences in self-care and mobility outcomes were observed across racial and ethnic groups. Additional research is needed to identify potential modifiable factors that may contribute to racially and ethnically different patterns of functional outcomes observed during inpatient rehabilitation.

Race-ethnicity and poverty after spinal cord injury

Objective

Our objective was to examine the relationship between race-ethnicity and poverty status after spinal cord injury (SCI).

Study Design

Secondary analysis of existing data.

Setting

A large specialty hospital in the southeastern United States (US).

Methods

Participants were 2,043 adults with traumatic SCI in the US. Poverty status was measured using criteria from the US Census Bureau.

Results

Whereas only 14% of non-Hispanic White participants were below the poverty level, 41.3% of non-Hispanic Blacks were in poverty. Logistic regression with three different models identified several significant predictors of poverty including marital status, years of education, level of education, age, and employment status. Non-Hispanic Blacks had 2.75 greater odds of living in poverty after controlling for other factors, including education and employment.

Conclusions

We may need to consider quality of education and employment to better understand the elevated risk of poverty among non-Hispanic Blacks in the US.

Participation in organized sports is positively associated with employment in adults with spinal cord injury

OBJECTIVE

The aim of this study was to determine the association between participation in organized sports programs and employment in adults with chronic spinal cord injury.

DESIGN

This is a cross-sectional study of 149 adults with chronic spinal cord injury. Motor level and completeness of injury were confirmed by physical examination. Information related to demographics, employment, level of education, body mass index, duration of injury, participation in individually planned exercise, and participation in organized sports was obtained using a standardized questionnaire. Multivariable logistic regression analyses were used to assess factors associated with employment.

RESULTS

In univariate analyses, employment was associated with younger age (P = 0.001) and a higher level of education (P = 0.01), whereas obesity decreased the likelihood of employment (P = 0.04). Participation in organized sports approached significance (P = 0.06). In the multivariable analysis and after adjusting for age, education, and body mass index, participation in organized sports was significantly associated with employment (odds ratio, 2.4; P = 0.04). Sex, duration of injury, wheelchair use, and participation in individually planned exercise were not significantly associated with employment (P = 0.16-0.94).

CONCLUSIONS

In the adults with chronic spinal cord injury, participation in organized sports was positively associated with employment. Further studies are necessary to determine the causative nature of this association and how various factors related to sports participation may contribute.

Conducting intervention research among underserved populations: lessons learned and recommendations for researchers

Randomized controlled trials (RCTs) are considered the criterion standard in research design for establishing treatment efficacy. However, the rigorous and highly controlled conditions of RCTs can be difficult to attain when conducting research among individuals living with a confluence of disability, low socioeconomic status, and being a member of a racial/ethnic minority group, who may be more likely to have unstable life circumstances. Research on effective interventions for these groups is urgently needed, because evidence regarding approaches to reduce health disparities and improve health outcomes is lacking. In this methodologic article, we discuss the challenges and lessons learned in implementing the Lifestyle Redesign for Pressure Ulcer Prevention in Spinal Cord Injury study among a highly disadvantaged population. These issues are discussed in terms of strategies to enhance recruitment, retention, and intervention relevance to the target population. Recommendations for researchers seeking to conduct RCTs among socioeconomically disadvantaged, ethnically diverse populations are provided.

Geographic variation in participation for physically disabled adults: the contribution of area economic factors to employment after spinal cord injury

This study investigates the role of area economic characteristics in predicting employment-a key aspect of social participation for adults with physical disabilities-using data from a national registry of persons with spinal cord injury (SCI). SCI results in chronic impairment and most commonly occurs during young adulthood when working is a key aspect of the adult social role. Geocoded data were collected from two of the 14 SCI Model Systems (SCIMS) centers involved in the National SCIMS database and used to link individual-level data with area-level measures extracted from the 2000 US Census. The analysis included participants of working-age (18-64 years) and living in the community (N=1013). Hierarchical generalized linear modeling was used to estimate area-level variation in participation and the relative contribution of area-level economic indicators, adjusted for individual-level health, functioning, and background characteristics. The likelihood of employment for adults with SCI varied by area and was associated with area SES and urbanicity, but not area unemployment. These findings suggest that variation in area economic conditions may affect the feasibility of employment for persons who experience chronic physical disability during adulthood, thus limiting full participation in society.

Vulnerable Groups Living with Spinal Cord Injury

There is considerable variation in rehabilitation outcomes within the population of spinal cord-injured individuals across racial and socioeconomic groups. This suggests that the long-term health following spinal cord injury (SCI) is determined, at least in part, by group differences in exposure to advantages and disadvantages among persons living in the community. This article conceptualizes the nature of vulnerability and how increased vulnerability leads to disparities in SCI outcomes. Demographic, socioeconomic, and geographic determinants of adverse outcomes among vulnerable groups are discussed. Finally, a research model that outlines potential processes that elicit vulnerability following SCI and clinical implications is reviewed.

Long-term outcomes of adults with pediatric-onset spinal cord injuries as a function of neurological impairment

OBJECTIVE

To identify outcomes of participation, life satisfaction, and medical complications as a function of impairment in adults with pediatric-onset spinal cord injury (SCI).

METHODS

Study participants were adults who sustained SCI at age 18 years or younger and were interviewed at age 24 years or older (M = 26.9, SD = 3.5). The telephone interview included a questionnaire and several standardized measures: FIM instrument (FIM), Craig Handicap Assessment and Reporting Technique (CHART), SF-12 Health Survey, and Satisfaction with Life Scale. Using the International Standards for Neurological Classification of Spinal Cord Injury and the American Spinal Injury Association (ASIA) Impairment Scale (AIS), subjects were grouped into four impairment categories: C1-C4 ABC, C5-C8 ABC, T1-L4 ABC, and AIS D.

RESULTS

Of the 410 participants, 62% were male, 54% had tetraplegia, 70% had AIS A lesions, and average age at injury was 14 years (SD = 4.3). Of the 407 subjects who had complete neurological information, 59 had C1-C4 ABC, 140 had C5-C8 ABC, 168 had T1-L4 ABC, and 40 had AIS D lesions. The outcomes were delineated for education, employment, independent living and driving, marriage, participation, medical complications, health-related quality of life, and global life satisfaction, in addition to the ASIA motor score and FIM motor scores, for each of the four impairment groups.

CONCLUSIONS

This information should help focus interventions that facilitate positive outcomes in relationship to the severity of impairment. In addition, these data can provide a level of expectation about long-term outcomes for newly injured children and their parents.

Differences in functioning of individuals with tetraplegia and paraplegia according to the International Classification of Functioning, Disability and Health (ICF)

STUDY DESIGN

Cross-sectional, multicenter study.

OBJECTIVES

To identify and quantify the differences in functioning of individuals with tetraplegia versus paraplegia using the International Classification of Functioning, Disability and Health (ICF) as a frame of reference.

SETTING

International.

METHODS

Functional problems of 1048 participants with spinal cord injury in 16 study centers in 14 countries were recorded using ICF categories. The level of significance and odds ratios (OR) for experiencing each of these functional problems were reported for individuals with tetraplegia and paraplegia. Regression models were adjusted for age, age squared, early post-acute or long-term context, gender and for world regions.

RESULTS

Persons with tetraplegia are more at risk than persons with paraplegia to have difficulties in 36.4% categories of the component body functions. In the component body structures, 40% of the categories show significant differences. Individuals with tetraplegia indicate problems in three categories, whereas individuals with paraplegia are more likely to indicate problems in one category. Most categories indicating difficulties (56.6%) for persons with tetraplegia were found for the component activities and participation. The component with the highest congruency was the environmental factors. Overall, 3.7% categories (of the persons with tetraplegia as experienced, 2.4% of the categories as barriers, whereas 4.9% were experienced to be facilitators) obtained OR, indicating individuals with tetraplegia having more difficulties.

CONCLUSION

The logistic regression analysis identified a variety of differences in functional problems in individuals with tetraplegia compared with individuals with paraplegia. The ICF has the potential to indicate the differences in health conditions.

Employment of persons with spinal cord lesions injured more than 20 years ago

PURPOSE

The primary objective was to study factors influencing post-injury employment and withdrawal from work in persons who sustained traumatic spinal cord injury (SCI) more than 20 years ago. A secondary objective was to study life satisfaction in the same patients.

METHOD

A cross-sectional study with retrospective data of 165 SCI-patients admitted to Sunnaas Rehabilitation Hospital 1961-1982. Multiple logistic regression was used to identify predictors for obtaining work post-injury. A Cox proportional hazards regression model was used to study factors influencing early withdrawal from work, i.e. time from injury until discontinuing employment.

RESULTS

Sixty-five percent of the participants were employed at some point after the injury. Thirty-five percent still had work at the time of the survey. The odds of obtaining work after injury were higher in persons of younger age at injury, higher in males versus females, higher for persons with paraplegia versus tetraplegia, and for persons classified as Frankel D-E compared to a more severe SCI. Factors associated with shorter time from injury until discontinuing employment were higher age at injury, incidence of injury after 1975 versus before, and a history of pre-injury medical condition(s). Life satisfaction was better for currently employed participants.

CONCLUSION

The study indicates a low employment-rate in persons with SCI, even several years after injury. From the results, we suggest more support, especially to persons of older age at injury and/or with a history of pre-injury medical condition(s), to help them to obtain work and sustain employed for more years after injury.

The Relationship of Chronological Age, Age at Injury, and Duration of Injury to Employment Status in Individuals with Spinal Cord Injury

Employment status following spinal cord injury (SCI) has important implications for financial and psychosocial well-being. Several age-related variables-in particular chronological age, duration of SCI, and age at SCI onset-have been identified as being associated with employment among individuals with SCI. Cross-sectional investigations of this topic are complicated by methodological and statistical issues associated with aging and disability. The purpose of the current study was to examine the associations between three aging variables and employment status in individuals with SCI through a series of regression analyses. Six hundred twenty individuals with SCI completed a survey that included measures of demographic characteristics, pain, psychological functioning, physical functioning, fatigue, and sleep. The results indicated that chronological age and age at SCI onset were significant predictors of employment status. A significantly greater proportion of individuals aged 45-54 were employed compared to those aged 55-64 even after controlling for biopsychosocial variables. Additionally, there was a negative linear relationship between percent employed and age at SCI onset, and this relationship was not accounted for by the biopsychosocial variables. The analyses used in this study provide one method by which to disentangle the effects of different age-related variables on important SCI outcomes in cross-sectional research. Continued research in this area is needed to better understand age-related effects on employment status, which could be used to help maximize the quality of life in individuals with SCI.

A prospective study of factors influencing return to work after traumatic spinal cord injury in Taiwan

Lin M-R, Hwang H-F, Yu W-Y, Chen C-Y. A prospective study of factors influencing return to work after traumatic spinal cord injury in Taiwan.

OBJECTIVE

To examine comprehensively the effects of physical, psychologic, and sociologic characteristics on employment among persons after a traumatic spinal cord injury (SCI) in Taiwan.

DESIGN

A prospective study with follow-up telephone interviews over a 3-year period.

SETTING

To register people who had sustained an SCI, medical records of 4 hospitals were reviewed using codes of the International Classification of Diseases-9th Revision-Clinical Modifications from 806.0 to 806.9 and from 952.0 to 952.9.

PARTICIPANTS

Subjects (N=219) employed at the time of injury.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Employment status after an SCI.

RESULTS

The employment rate was 32.9%. After controlling for other variables, education level (relative rate [RR]=4.01 approximately 8.17), autonomy in transportation (RR=5.13), professional licensure (RR=1.86), and thrill and adventure-seeking trait (RR=1.12) were positively and significantly associated with employment, while subjects with more severe overall injury severity (RR=0.95), preinjury chronic conditions (RR=0.20), necessity for aids for daily living (RR=0.31), and depression (RR=0.38) were less likely to have been employed than their counterparts.

CONCLUSIONS

In addition to education level and traditional physical factors, overall injury severity and psychologic factors such as thrill and adventure seeking and depression can also influence the return to work after an SCI.

Review of critical factors related to employment after spinal cord injury: implications for research and vocational services

BACKGROUND/OBJECTIVE

Employment rates after spinal cord injury (SCI) vary widely because of discrepancies in studies' definition of employment and time of measurement. The objective of this study was to provide a comprehensive summary of the literature on employment rates, predictors of employment, and the benefits and barriers involved.

METHODS

A search using the terms spinal cord injury and employment in the databases PubMed, PsycINFO, and MEDLINE. The search included a review of published manuscripts from 1978 through 2008.

RESULTS

A total of 579 articles were found and reviewed to determine the presence of reported employment rates. Of these, 60 articles were found to include a report of employment rates for individuals with SCI. Results indicated that, in studies that examined paid employment, the average rate of any employment after SCI was approximately 35%.

CONCLUSIONS

Characteristics associated with employment after SCI include demographic variables, injury-related factors, employment history, psychosocial issues, and disability benefit status. It is recommended that researchers studying employment after SCI use common outcome measures such as competitive employment rates, duration of employment, and job tenure. Empirical evidence is lacking in regard to the most effective methods of vocational rehabilitation among this population. Evidence-based supported employment practices seem to be the most applicable model for assisting persons with SCI in restoring meaningful employment. Controlled studies are needed to test this assumption.

Personal bankruptcy after traumatic brain or spinal cord injury: the role of medical debt

OBJECTIVE

To estimate the prevalence of medical debt among traumatic brain injury (TBI) and spinal cord injury (SCI) patients who discharged their debts through bankruptcy.

DESIGN

A cross-sectional comparison of bankruptcy filings of injured versus randomly selected bankruptcy petitioners.

SETTING

Patients hospitalized with SCI or TBI (1996-2002) and personal bankruptcy petitioners (2001-2004) in western Washington State.

PARTICIPANTS

Subjects (N=186) who filed for bankruptcy, comprised of 93 patients with previous SCI or TBI and 93 randomly selected bankruptcy petitioners.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Medical and nonmedical debt, assets, income, expenses, and employment recorded in the bankruptcy petition.

RESULTS

Five percent of randomly selected petitioners and 26% of petitioners with TBI or SCI had substantial medical debt (debt that accounted for more than 20% of all unsecured debts). SCI and TBI petitioners had fewer assets and were more likely to be receiving government income assistance at the time of bankruptcy than controls. SCI and TBI patients with a higher blood alcohol content at injury were more likely to have substantial medical debts (odds ratio=2.70; 95% confidence interval, 1.04-7.00).

CONCLUSIONS

Medical debt plays an important role in some bankruptcies after TBI or SCI. We discuss policy options for reducing financial distress after serious injury.

Return to work following spinal cord injury: a review

PURPOSE

To review literature on return to work (RTW) and employment in persons with spinal cord injury (SCI), and present employment rates, factors influencing employment, and interventions aimed at helping people with SCI to obtain and sustain productive work.

METHODS

A systematic review for 2000 - 2006 was carried out in PubMed/Medline, AMED, (ISI) Web of Science, EMBASE, CINAHL, PsycInfo and Sociological abstracts database. The keywords 'spinal cord injuries', 'spinal cord disorder', 'spinal cord lesion' or 'spinal cord disease' were cross-indexed with 'employment', 'return to work', 'occupation' or 'vocational'.

RESULTS

Out of approximately 270 hits, 110 references were used, plus 13 more found elsewhere. Among individuals with SCI working at the time of injury 21 - 67% returned to work after injury. RTW was higher in persons injured at a younger age, had less severe injuries and higher functional independence. Employment rate improved with time after SCI. Persons with SCI employed ranged from 11.5% to 74%. Individuals who sustained SCI during childhood or adolescence had higher adult employment rates. Most common reported barriers to employment were problems with transportation, health and physical limitations, lack of work experience, education or training, physical or architectural barriers, discrimination by employers, and loss of benefits. Individuals with SCI discontinue working at younger age.

CONCLUSIONS

This review confirmed low employment rates after SCI. Future research should explore interventions aimed at helping people with SCI to obtain and sustain productive work.

Perceived information needs of community-dwelling persons with chronic spinal cord injury: findings of a survey and impact of race

OBJECTIVE

To examine the perceived information needs of community-dwelling individuals with chronic spinal cord injury (SCI) and to determine factors that influence these needs.

DESIGN AND PARTICIPANTS

Cross-sectional survey mailed to 620 persons with chronic SCI who completed acute inpatient rehabilitation.

RESULTS

Of 103 (17%) returned surveys, 82 contained complete information and were useable for this study. Individuals with chronic SCI (M time since injury = 7 +/- 6 years) endorsed a multitude of information needs across a broad range of domains. Participant endorsements were most commonly observed in the areas of aging (73%), research (72%), financial aid (66%), and education (63%). Independent variables expected to influence information needs, including Internet use, whether the rehabilitation specialist also served as the primary care physician, and time since injury, showed no significant effect. Race/ethnicity was found to predict perceived information needs, with nonwhite participants endorsing a significantly greater degree of needs than white participants in 11 of 23 (48%) domains.

CONCLUSIONS

Perceived information needs of community-dwelling persons with SCI are not fully met years after discharge from acute inpatient rehabilitation, which may have implications with respect to psychological adjustment. Race/ethnicity appears to exert a significant influence on the endorsement of perceived information needs, but this finding must be investigated further considering other possible mediating/moderating variables. Results must be considered in light of the relatively low response rate of eligible participants.

An overview of tissue engineering approaches for management of spinal cord injuries

Severe spinal cord injury (SCI) leads to devastating neurological deficits and disabilities, which necessitates spending a great deal of health budget for psychological and healthcare problems of these patients and their relatives. This justifies the cost of research into the new modalities for treatment of spinal cord injuries, even in developing countries. Apart from surgical management and nerve grafting, several other approaches have been adopted for management of this condition including pharmacologic and gene therapy, cell therapy, and use of different cell-free or cell-seeded bioscaffolds. In current paper, the recent developments for therapeutic delivery of stem and non-stem cells to the site of injury, and application of cell-free and cell-seeded natural and synthetic scaffolds have been reviewed.