Subjective well-being and severe motor impairments: the Tetrafigap survey on the long-term outcome of tetraplegic spinal cord injured persons

Theory Without Theories: Well-Being, Ethics, and Medicine

Medical ethics would be better if people were taught to think more clearly about well-being or (what I take to be the same thing) the concept of what is good for a person. Yet for a variety of reasons, bioethicists have generally paid little attention to this concept. Here, I argue, first, that focusing on general theories of welfare is not useful for practical medical ethics. I argue, second, for what I call the "theory-without-theories approach" to welfare in practical contexts. The first element of this approach is a focus on examining important and relatively uncontroversial constituents of welfare as opposed to general theories. The second key element is a framework for thinking about choice in relation to welfare, a framework I refer to as "the mild objectivity framework." I conclude with illustrations of the way in which the "theory without theories approach" can improve thinking in medicine.

The functioning of social support in long-term prevention after spinal cord injury. A qualitative study

BACKGROUND

The impact of social support on the long-term condition after a spinal cord injury (SCI) varies across studies mainly involving self-report questionnaires.

OBJECTIVE

We aimed to establish the common factors associated with social support leading individuals with an SCI to the effective prevention of secondary complications, including via adherence to medical follow-up.

METHODS

Inclusion criteria were a history of acquired SCI of any etiology, wheelchair use, and age≥18 years at the time of the study. Participants should have completed their initial rehabilitation program in France≥1 year earlier and were also enrolled according to 2 related study variables: routine medical follow-up (patients were or were not followed up) and the medically supervised reporting of a pressure ulcer after the initial rehabilitation session (0 or≥1 pressure ulcers). We performed a preparatory quantitative and qualitative literature review to identify factors affecting long-term follow-up after SCI, then adopted a narrative design with semi-structured interviews, transcribed and analyzed progressively by using qualitative analysis software.

RESULTS

We included 32 participants. We categorized our results based on the knowledge, attitudes, beliefs and practices of participants with respect to pressure ulcer prevention and long-term medical follow-up. Our narrative approach allowed us to identify 3 main domains relevant to social support: reciprocity, self-management and timing related to social support.

CONCLUSIONS

Our study showed social support as a dynamic process, a reciprocal phenomenon evolving in variations over time. These findings should be central to short- and long-term therapeutic education programs for patients and for people providing social support. Effective changes should also be implemented through the concept of the Learning Health System.

Influence of training protocols on text input speed on a computer in individuals with cervical spinal cord injury: a randomised controlled trial

STUDY DESIGN

Randomised controlled trial.

OBJECTIVES

To evaluate the impact of two different word prediction software (WPS) training protocols on text input speed (TIS) in people with tetraplegia and to determine which was the most effective.

SETTING

Rehabilitation department, Garches, France.

METHODS

Participants with neurological levels between C6 and C8 were allocated to one of three different groups. The REHAB group underwent training with an occupational therapist. The SELF group carried out a standardised home self-training with a written training guide. The CONTROL group had no training. Participants were assessed at day 15 (D15) and day 30 (D30). The primary outcome was a copying task with and without WPS (WITH and WITHOUT).

RESULTS

Forty-two participants (mean age ± SD of 39.8 ± 12) were included and 38 completed the study. At D30, the mean (95% confidence interval) difference in TIS between the CONTROL and SELF groups was 3.8 [-1.7 to 9.4] characters per minute (cpm) (p = 0.23), between the REHAB and SELF groups was 12.9 [7.4 to 18.4] cpm (p < 0.001), and between the REHAB and CONTROL groups was 9.1 [3.5 to 14.6] cpm (p < 0.001).

CONCLUSIONS

The results of this study showed that occupational therapist-supervised training improved TIS but word prediction software did not increase TIS. These results suggest that supervised training should be provided to all individuals who are prescribed with devices and systems to facilitate computer access in order to increase their TIS.

Cannabis shenanigans: advocating for the restoration of an effective treatment of pain following spinal cord injury

Cannabis is an effective treatment for pain following spinal cord injury that should be available to patients and researchers. The major argument against the rescheduling of cannabis is that the published research is not convincing. This argument is disingenuous at best, given that the evidence has been presented and rejected at many points during the political dialog. Moreover, the original decision to criminalize cannabis did not utilize scientific or medical data. There is tension between the needs of a society to protect the vulnerable by restricting the rights of others to live well and with less pain. It is clear that this 70-year war on cannabis has had little effect in controlling the supply of cannabis. Prohibition can never succeed; "it is a tyranny from which every independent mind revolts." People living with chronic pain should not have to risk addiction, social stigma, restrictions on employment and even criminal prosecution in order to deal with their pain. It is time to end the shenanigans and have an open, transparent discussion of the true benefits of this much-beleaguered medicine.

Effects of a Tailored Positive Psychology Intervention on Well-Being and Pain in Individuals With Chronic Pain and a Physical Disability: A Feasibility Trial

OBJECTIVES

To determine the feasibility, acceptability, and efficacy of a computer-based positive psychology intervention in individuals with a physical disability and chronic pain.

METHODS

Individuals with spinal cord injury, multiple sclerosis, neuromuscular disease, or postpolio syndrome and chronic pain were randomly assigned to a positive psychology or a control condition. Participants in the intervention group were instructed to practice 4 personalized positive psychology exercises. Participants in the control group were instructed to write about life details for 8 weeks. Participants completed online well-being and pain-related questionnaires at baseline, posttreatment, and at the 2.5-month follow-up, and rated treatment satisfaction at posttreatment.

RESULTS

Ninety-six participants were randomized and 68 (70%) completed follow-up assessments. Participants in the positive psychology intervention group reported significant pretreatment to posttreatment improvements in pain intensity, pain control, pain catastrophizing, pain interference, life satisfaction, positive affect, and depression. Improvements in life satisfaction, depression, pain intensity, pain interference, and pain control were maintained to the 2.5-month follow-up. Participants in the control group reported significant pretreatment to posttreatment improvements in life satisfaction, and pretreatment to follow-up improvements in pain intensity and pain control. Significant between-group differences, favoring the treatment group, emerged for pretreatment to posttreatment improvements in pain intensity and pain control. Participants were similarly satisfied with both treatments.

DISCUSSION/CONCLUSIONS

The results support the feasibility, acceptability, and potential efficacy of a computer-based positive psychology intervention for improving well-being and pain-related outcomes in individuals with physical disabilities and chronic pain, and indicate that a full trial of the intervention is warranted.

Lifestyle changes of a family caring for a 25-year-old quadriplegic man after delayed spinal cord infarction

Worldwide, 110-190 million people over the age of 15 years are estimated to live with severe disability-a physical state of being defined by the WHO as "the equivalent of disability inferred for conditions such as quadriplegia, severe depression, or blindness." Modes and qualities of disability care undoubtedly vary globally, dependent on income, health infrastructure and culture. Quadriplegia has a unique set of emotional and physical challenges that demand a great deal from care regimens and health systems. This case study examines a specific-and successful-configuration of quadriplegic care in a Druze village in the Golan and looks to the economic, geographic and sociocultural aspects of care.

Sitting tai chi improves the balance control and muscle strength of community-dwelling persons with spinal cord injuries: a pilot study

Objective. To investigate the effects of sitting Tai Chi on muscle strength, balance control, and quality of life (QOL) among survivors with spinal cord injuries (SCI). Methods. Eleven SCI survivors participated in the sitting Tai Chi training (90 minutes/session, 2 times/week for 12 weeks) and eight SCI survivors acted as controls. Dynamic sitting balance was evaluated using limits of stability test and a sequential weight shifting test in sitting. Handgrip strength was also tested using a hand-held dynamometer. QOL was measured using the World Health Organization's Quality of Life Scale. Results. Tai Chi practitioners achieved significant improvements in their reaction time (P = 0.042); maximum excursion (P = 0.016); and directional control (P = 0.025) in the limits of stability test after training. In the sequential weight shifting test, they significantly improved their total time to sequentially hit the 12 targets (P = 0.035). Significant improvement in handgrip strength was also found among the Tai Chi practitioners (P = 0.049). However, no significant within and between-group differences were found in the QOL outcomes (P > 0.05). Conclusions. Twelve weeks of sitting Tai Chi training could improve the dynamic sitting balance and handgrip strength, but not QOL, of the SCI survivors.

Relationship Between the Consumption Status of Households That Include Individuals With Physical Disabilities and Their Employment

This study investigates whether the consumption of households that include individuals with physical disabilities (IWPD) depends on the employment status of such individuals. Data from the 2012 Panel Survey of Employment for the Disabled (PSED) conducted by the Korea Employment Agency for the Disabled were used to ascertain the consumption patterns, consumption functions, income elasticity, and Engel coefficient of households that include IWPD. An independent t test was used to differentiate between employment and unemployment status. The results revealed that the consumption patterns of such households were similar to those of a typical poor household. Although these patterns did not differ according to the employment status of IWPD, the number of items in the consumption expenditure of a household that includes employed IWPD was larger than that of a household that includes unemployed IWPD. Income had a significant effect on all expenditure items. Furthermore, only savings were classified as a luxury, regardless of employment status. The analysis results of this study could enable researchers to capture the problems facing IWPD and provide greater insight into their economic status.

Health-related quality of life in children and adolescents following traumatic injury: a review

This paper comprehensively reviews the published literature investigating health-related quality of life (HRQOL) following general traumatic injury in individuals between birth and 18 years. Studies were not considered if they primarily compared medical treatment options, evaluated physical function but not other aspects of HRQOL, or focused on non-traumatic wounds. Specific injury types (e.g., burn injury) were also not included. A total of 16 studies met criteria. Participants were age 1-18 years, with 12 studies considering children 5 years of age or older. Males were overrepresented. Injury severity averaged mostly in the moderate range. HRQOL deficits were noted in injured samples in all studies except the two with the longest time to follow-up (6-11 years). Some improvement was seen 6 months to 2 years after injury. Factors associated with HRQOL deficits were investigated, with acute and posttraumatic stress disorder symptoms showing the strongest relationship. Research to date in this area is impressive, particularly the number of studies using prospective longitudinal investigations and validated measures. Challenges remain regarding methodologic differences, assessment of preinjury status, retention of participants, and management of missing data. Suggested future directions include extension of follow-up duration, utilization of pediatric self-report when possible, inclusion of younger children, and development of intervention programs.

Health technology assessment and haemophilia

Although the funding of rare diseases such as haemophilia in developing countries remains a low priority, pressures on the funding of haemophilia treatment are also emerging in developed economies affected by the global economic downturn and the other demands on health care budgets. This is leading advisory bodies and payers alike to explore the tools of Health Technology Assessment (HTAs) in deriving recommendations for reimbursement policies. In particular, the use of cost utility analysis (CUA) in deriving costs per quality adjusted life year (QALY) for different interventions is being used to rank interventions in order of priorities relative to a threshold cost per QALY. In these exercises, rare chronic disorders such as haemophilia emerge as particularly unattractive propositions for reimbursement, as the accepted methodology of deriving a CUA. For e.g. the use of prophylaxis in haemophilia leads to a range of costs/QALY which exceed the willingness to pay thresholds of most payers. In this commentary, we review the principles utilized in a recent systematic review of the use of haemophilia products carried out in Sweden as part of an HTA. We suggest that ranking haemophilia related interventions with the standard interventions of therapeutics and public health in CUA comparisons is inappropriate. Given that haemophilia treatment is a form of blood replacement therapy, we propose that such comparisons should be made with the interventions of mainstream blood transfusion. We suggest that unequivocally effective treatments such as haemophilia therapies should be assessed differently from mainstream interventions, that new methodologies are required for these kinds of diseases and that evidence of a societal willingness to support people with rare disorders needs to be recognized when reimbursement policies are developed.

Lower well-being of young Australian adults with self-reported disability reflects their poorer living conditions rather than health issues

OBJECTIVE

To determine the extent to which the lower well-being of young Australians with disabilities could be accounted for by increased rates of exposure to adversity and reduced access to personal, economic, social and community resources.

METHODS

Secondary analysis of data extracted from Waves 1 (2001) to 8 (2008) of the annual longitudinal survey of Household Income and Labour Dynamics in Australia.

RESULTS

Self-reported disability was associated with significantly lower scores on all indicators of psychological well-being. However, people self-reporting disability were more likely to be exposed to adversity and less likely to have access to a range of personal, economic, material, social and community resources. When these between-group differences in social context were controlled for, the between-group differences in psychological well-being were largely eliminated.

CONCLUSION

Our results suggest that, among younger adults in Australia, the association between disability and lower psychological well-being largely reflects their increased risk of exposure to adversity and reduced access to resources, rather than the presence of health conditions or impairments per se.

IMPLICATIONS

Public health interventions aimed at improving the well-being of young adults with a disability need to address the predominantly social determinants of well-being in this group.

Well-being and occupational rights: an imperative for critical occupational therapy

BACKGROUND

One of occupational therapy's core assumptions is that engagement in occupations influences well-being. Because occupational engagement is integral to human well-being, and because well-being is integral to human rights, this paper contends that the ability and opportunity to engage in occupations is an issue that concerns rights.

AIMS

To outline well-being and its centrality to human rights; to explore the relationships between well-being and occupation and between well-being and occupational rights; and to highlight the consequent imperative to engage in critical occupational therapy.

KEY ISSUES

The World Federation of Occupational Therapists asserts that all people have the right to participate in a range of occupations that enable them to flourish, fulfil their potential, and experience satisfaction congruent with their culture and beliefs; and further asserts the human right to equitable access to participation in occupation.

CONCLUSIONS

If occupational therapists are to take seriously their espoused commitment to enabling equitable access to participation in occupation, the inequitable conditions of people's lives will need to be addressed. Critical occupational therapy is a committed form of practice which acknowledges that well-being cannot be achieved solely by enhancing individuals' abilities, and that consequently endeavours also to address the conditions of people's lives.

Health of people with spinal cord injury in Singapore: implications for rehabilitation planning and implementation

PURPOSE

This study aimed to provide a broad overview of the health of people with spinal cord injury (SCI) in Singapore, so as to highlight areas of potential need. These areas could then guide future research and rehabilitation programme development.

METHODS

Demographic data, injury information and information about SCI-related secondary impairments, chronic conditions and their associated risk factors, medical and hospital utilisation, participation (Craig Handicap Assessment and Reporting Technique) and life satisfaction (Satisfaction with Life Scale) were collected via interviews from people living with traumatic SCI.

RESULTS

On average, participants (50 men and 5 women) were aged 48.3 ± 16.54 years and had had their SCIs for 5 years. -75% with tetraplegia. The most prevalent SCI-related secondary impairments were pain, spasms, bladder problems, bowel problems and oedema. Chronic conditions and their associated risk factors were prevalent. Participation and life satisfaction scores were lower than those reported for similar populations cross-culturally.

CONCLUSION

The study revealed several health areas that may be affecting the overall health of people with SCI in Singapore. By focusing on community reintegration and health promotion, physiotherapists and other rehabilitation professionals may augment health outcomes and improve the quality of life of this population in Singapore.

Recovery of life satisfaction in persons with spinal cord injury during inpatient rehabilitation

OBJECTIVE

To determine the course of life satisfaction of persons with spinal cord injury and its determinants during inpatient rehabilitation and up to 1 yr after discharge.

DESIGN

Prospective cohort study of 222 persons with spinal cord injury. Measurements at the start of active rehabilitation, after 3 mos, at discharge, and 1 yr after discharge. Questions about current life satisfaction and current life satisfaction compared with life satisfaction before spinal cord injury were asked and analyzed, and the sum score Life Satisfaction Total of these questions was analyzed using a multilevel regression analysis. Person and injury characteristics and secondary impairments at each measurement were analyzed as possible determinants of the Life Satisfaction Total score.

RESULTS

Estimated Life Satisfaction Total scores improved from 5.3 (SE, 0.16) at the start of active rehabilitation up to 6.5 (0.17) at discharge and remained stable (6.5; 0.16) during the first year after discharge. Significant determinants of a positive course of life satisfaction were less pain, fewer secondary impairments, and better functional status.

CONCLUSIONS

Life satisfaction already improves during inpatient rehabilitation. Functional status, pain, and secondary impairments must be treated adequately in multidisciplinary rehabilitation.

To work or not to work? The occupational trajectories of wheelchair users

PURPOSE

To throw light upon the dynamic processes which may or may not lead persons with severe motor disability to employment.

METHOD

A qualitative approach to the chronology of both the professional and non-professional occupations of wheelchair users between acquisition of the disability and the interview; this approach focuses upon actions and meanings, thus allowing the authors to identify the diverse factors which help build the occupation situation at the time of the study. The narratives of 36 wheelchair users of working age were used. The objective of the analysis was to reconstitute the occupation trajectories of the participants and hence to suggest a typology. This involved pinpointing the various actors, the external and cognitive contexts of their decisions and actions, and their consequences and related feelings.

RESULTS

The wide diversity found in the trajectories forced the authors to go beyond any simple notion of 'work versus non-work' and to focus on the quality of the individual's process of occupation appropriation. Indeed, it is possible to successfully appropriate both work and non-work situations, just as, inversely, it is possible for a person to fail to appropriate either type of situation. Analysis of this process allows one to pinpoint different types of trajectory. On the one hand, trajectories within which people appropriate their occupations--gradual, intermittent, through rupture and successive adjustment--and, on the other hand, unstable or endured occupation trajectories.

CONCLUSIONS

The findings suggest that with regard to rehabilitation practices, we should be focussing as much on the appropriation process as on return to work.

Network bridging potential in later life: life-course experiences and social network position

Objective. Much work in social gerontology has examined older adults' social connectedness, but we know little about the extent to which older adults occupy positions of power and independence in their networks. The author uses health and life-course frameworks to understand older adults' prospects of occupying bridging positions between otherwise unconnected individuals. Methods. Egocentric social network data were collected from a nationally representative sample of 3,005 older adults between the ages of 57 and 85 in 2005-2006. A series of multivariate regression analyses was used to examine how health and life-course factors relate to bridging. Results. Age is not significantly associated with bridging. However, retirees and people with poor health are less likely to have bridging potential. At the same time, widows are more likely to serve as bridges. Discussion. The discusses the need for more dialogue between social network researchers and social gerontologists to help explain older adults' bridging prospects.

GOOD HEALTH AND THE BRIDGING OF STRUCTURAL HOLES

Bridges that span structural holes are often explained in terms of the entrepreneurial personalities or rational motivations of brokers, or structural processes that lead to the intersection of social foci. I argue that the existence and use of bridges in interpersonal networks also depends on individuals' health. Poor health may make it more difficult to withstand the pressures and to execute some of the common tasks associated with bridging (e.g., brokerage). I examine this possibility using egocentric network data on over 2,500 older adults drawn from the recent National Social Life, Health, and Aging Project (NSHAP). Multivariate regression analyses show that both cognitive and functional health are significantly positively associated with bridging, net of sociodemographic and life-course controls. The relationship between functional (kinesthetic) health and bridging appears to be partially mediated by network composition, as older adults who have poorer functional health also tend to have networks that are richer in strong ties. Several potential mediation mechanisms are discussed. Cognitive function remains significantly associated with bridging net of network composition, suggesting that the inherent challenges of maintaining bridging positions may be more difficult to cope with for those who have cognitive impairments than for those who have functional impairments such as limited mobility. An alternative explanation is that cognitively impaired individuals have more difficulty recognizing (and thus strategically using) bridges in their networks. Theoretical implications and possibilities for future research are discussed.

Changes and determinants of life satisfaction after spinal cord injury: a cohort study in the Netherlands

OBJECTIVE

To determine the impact of spinal cord injury (SCI) on life satisfaction of persons with SCI 1 year after discharge of inpatient rehabilitation.

DESIGN

A cohort study. Life satisfaction before SCI was retrospectively measured at the start of active rehabilitation. One year after discharge from inpatient rehabilitation, current life satisfaction was measured.

SETTING

Eight rehabilitation centers in The Netherlands.

PARTICIPANTS

Persons (N=147) aged 18 to 65 and wheelchair-dependent at least for long distances.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

The Life Satisfaction Questionnaire.

RESULTS

Mean satisfaction with life +/- SD as a whole was 5.3+/-0 before SCI and 4.3+/-1.3 one year after inpatient rehabilitation. Sexual life, self-care, and vocational situation showed the largest impact of SCI (P<.05), whereas the social relationships domains appeared to be the least affected. Decrease of life satisfaction after SCI was larger when using the retrospective ratings than when using general population scores. Significant determinants of life satisfaction after SCI were high lesion level (beta=.31, P<.05), pain (beta=.19, P<.05), and secondary impairments (beta=.22, P<.05).

CONCLUSIONS

Life satisfaction decreased in persons with SCI. Level of lesion and suffering secondary impairments or pain were associated with low life satisfaction 1 year after discharge from inpatient rehabilitation.

Toll motorway accessibility for wheelchair users: a survey

OBJECTIVE

To identify difficulties encountered by wheelchair users who travel on toll motorways, with the goal of defining areas for improvement.

DESIGN

Survey. After observing a wheelchair user travelling on a toll motorway and using the associated services, we designed a self-questionnaire on perceptions by wheelchair users of toll motorway accessibility.

SETTING

Toll motorway and rehabilitation hospital in France.

SUBJECTS

We recruited 167 wheelchair users by advertisement and, to assess selection bias, 19 consecutive outpatients who visited our hospital's wheelchair showroom.

INTERVENTION

None.

RESULTS

Of the 186 included subjects, 91 (49%) were used to driving independently on toll motorways. Among them, only 16% used automatic toll booths and 32% reported difficulties at toll booths. Furthermore, 53% routinely asked for help at filling stations, and only 27% were aware of the availability of a free-of-charge assistance service for disabled people at some filling stations. Among the 186 toll motorway users, only 84 (45%) reported never encountering difficulties in lay-bys; 162 (87%) felt that toilet accessibility was the most important feature of lay-bys and 143 (77%) preferred the locked toilets reserved for disabled people.

CONCLUSION

Wheelchair users reported difficulties on toll motorways that could be corrected fairly easily.

Health-related quality of life in patients with spinal cord injury: review of the short form 36-health questionnaire survey

Advances in medical and rehabilitative care have increased interest in studying how different factors may affect the health-related quality of life (HRQOL) of individuals with spinal cord injury (SCI). There has been a large increase in the number of studies assessing HRQOL among persons with SCI. However, despite these advances, numerous issues remain unanswered because these studies have used a variety of methodologic approaches and assessment tools to examine how different factors have a role in predicting HRQOL in SCI populations. Therefore, standardized instruments should be used as part of this process. The Medical Outcomes Study Short Form (SF-36) was developed in order to survey health status of the general population. However, the available data on the HRQOL of individuals with SCI are currently limited. In addition, there is little information currently available on the factors that are associated with HRQOL in the SCI population and this issue remains controversial. The findings from several individual studies that used the SF-36 to assess the HRQOL of patients suffering from SCI were reviewed, and the results were interpreted with disability in mind. This review article aims to summarize the data regarding the HRQOL of individuals with SCI by using the SF-36.

Spinal Cord Injury Pain: The Influence of Psychologic Factors and Impact on Quality of Life

OBJECTIVES

To examine chronic pain prevalence in a spinal cord injury (SCI) population, and to determine the influence of psychologic factors on SCI pain and impact of SCI pain on quality of life.

METHODS

Five hundred seventy-five persons with SCI were asked to participate in the study. Demographic, SCI, and pain characteristics were obtained. The Chronic Pain Grade, anger items of the Profile of Mood States, Illness Cognition Questionnaire, Pain Coping and Cognition List, and Patient Health Questionnaire were used. General health and well-being were assessed with 0-10 scales. The influence of psychologic factors was assessed with regression analyses controlling for person and injury characteristics and pain intensity.

RESULTS

Response rate was 49%. SCI pain prevalence was high (77.1%). More internal pain control and coping, less catastrophizing, higher level of lesion, and nontraumatic SCI cause were associated with less pain intensity. More pain was associated with higher pain-related disability. Lower catastrophizing was related to better health. Less SCI helplessness and catastrophizing, greater SCI acceptance and lower anger levels were related to higher well-being. Higher levels of SCI helplessness, catastrophizing, and anger were related to higher depression levels. Pain intensity showed no independent relationships with health, well-being, and depression in the regression analyses.

DISCUSSION

Chronic SCI pain and quality of life were both largely associated with several psychologic factors of which pain catastrophizing and SCI helplessness were most important. Psychologic intervention programs may be useful for persons suffering from chronic SCI pain to improve their quality of life.

Impact of spinal cord injury on self-perceived pre- and postmorbid cognitive, emotional and physical functioning

STUDY DESIGN

Cross-sectional study with repeated measurements.

OBJECTIVES

To examine the patient's perspective of the impact of spinal cord injury (SCI) on physical, cognitive, emotional function, and quality of life (QOL).

SETTING

Australia.

METHODS

A sample of 63 patients with SCI, 32 of whom had recent injuries, and 31 with established injuries were administered the Ruff Neurobehavioral Inventory to examine patients' subjective evaluation of pre- and post-injury functioning. Current happiness levels were also evaluated using the Subjective Happiness Scale. A follow up assessment was performed 6 months later to examine changes over time.

RESULTS

A significant difference was found between perception of pre- and postmorbid function on composite Cognitive (t=5.99, df=62, P<0.001), Physical (t=11.56, df=62, P<0.001), and QOL (t=7.16, df=62, P<0.001) scales and on several of the Emotional subscales including anxiety, paranoia and suspicion, and substance abuse (P<0.001). A series of hierarchical regression analyses indicate that post-SCI pain was a significant predictor of: cognitive (R(2)=0.20, P<0.001); emotional (R(2)=0.13, P<0.004); and of QOL (R(2)=0.22, P<0.001) functioning. With the exception of a decrease in happiness (P<0.01), there were no significant changes in any measures over the 6 month time period.

CONCLUSIONS

There are significant changes in patients' perceptions of physical and cognitive functioning, and of QOL before and after SCI and some aspects of emotional functioning. Pain has a significant adverse effect on functioning. Happiness decreased slightly in the 6 months between surveys.

Preliminary reliability and validity of a Spinal Cord Injury Secondary Conditions Scale

BACKGROUND/OBJECTIVE

Although the impact of secondary conditions after spinal cord injury (SCI) on health, well being, and financial burden have been studied, there are psychometrically sound scales of secondary conditions in the extant literature. The use of such scales allows for cross-sample comparison of secondary condition prevalence rates and associations with functional, medical, and psychosocial factors. Thus, the purpose of this study was to evaluate the preliminary reliability of a SCI secondary conditions scale.

METHODS

The Spinal Cord Injury Secondary Conditions Scale (SCI-SCS) is a 16-item scale based on the Seekins Secondary Conditions Scale. Sixty-five individuals with SCI completed written surveys at 5 time-points over 2 years.

RESULTS

Internal consistency across each of the time-points exceeded 0.76; test-retest reliability ranged from 0.569 to 0.805. Convergent validity was assessed with 6 physical functioning items from the SF-12. Spearman (coefficients were all statistically significant and ranged from 0.317 (accomplished less because of health problems) to 0.644 (pain). The most prevalent secondary conditions were chronic pain, joint and muscle pain, and sexual dysfunction.

CONCLUSIONS

Preliminary testing of the SCI-SCS suggests that it is a reliable and valid scale, and further development (ie, factor analysis, item revision) and examination of validity are recommended with larger and more diverse SCI samples.

Impact of the timing, type and severity of disability on the subjective well-being of individuals with disabilities

Despite the existence of a large volume of literature on subjective well-being (SWB) of the general population, very few studies have focused on individuals with disabilities. The present study uses data on 24,036 Canadians with disabilities to investigate factors affecting their SWB. It found that SWB, measured here by level of happiness, decreases with severity of disability but is independent of the type of physical disability. Those born with a disability are likely to be happier as compared to those disabled later on in life. Per capita family income has no effect on happiness. However, unemployment decreases happiness. Happiness is found to be U shaped in age, bottoming out around 40 years of age. Some of these results vary when the sample is split according to the timing, type or severity of disability.

The impact of considering adaptation in health state valuation

Patients with chronic health conditions often rate their quality of life (QoL) significantly higher than non-patients. One explanation for this discrepancy is that non-patients focus on the negative aspects of the onset of a condition, especially the early difficulties people face when they first experience a debilitating condition, without considering that patients can adapt to it over time. To test this hypothesis, we had 359 people perform person tradeoff (PTO) elicitations in an online survey, varying whether the treatment programs under consideration saved the lives of patients (a) with pre-existing paraplegia; or (b) who would experience new onset of paraplegia. Half of each group completed an "adaptation exercise" which encouraged them to consider their own ability to emotionally adapt to negative events in general and specifically to having paraplegia. The adaptation manipulation increased the value participants placed on pre-existing paraplegia (p=0.03) and on new onset paraplegia (p=0.05), relative to saving healthy lives. Moreover, the adaptation exercise dramatically reduced the differences between evaluations of pre-existing and new onset paraplegia to values within 2% of each other. Our findings suggest that asking non-patients to do an adaptation exercise before giving QoL ratings may help close the gap in ratings between patients and citizen non-patients.

Quality of life among people with high spinal cord injury living in the community

STUDY DESIGN

An exploratory, qualitative methodology.

OBJECTIVES

To explore perceptions of quality of life (QOL) among community-dwelling people with high spinal cord injuries (SCI) and the factors they identified as contributing to, enabling or constraining the quality of their lives.

SETTING

Urban communities on Vancouver Island and in the lower mainland of British Columbia, Canada.

METHODS

Semi-structured interviews with both men (n=11) and women (n=4) with complete high SCI (C1-C4). Interpretive analysis was grounded in the themes that arose from the interview transcripts.

RESULTS

Time since injury ranged from 4 to 28 years. The mean current age was 35 years, with a range from 21 to 50 years of age. High SCI disrupted not just a body but an entire biography of plans, daily activities and valued occupations. Initially feeling helpless and useless, the participants were unanimously glad to be alive at the time of the study and several described perceptions of very high QOL. The themes which emerged from the data were over-lapping and inter-dependent and described a process of refocusing values and re-establishing a view of the self as able and valuable following injury. The three primary themes addressed issues of autonomy, the meaningful use of time, and relationships.

CONCLUSIONS

The study findings suggest that life with a high SCI can be rich and fulfilling if society is prepared to enable and support this; and that QOL outcomes might be maximized by adopting a biographical orientation to the rehabilitation process.

SPONSORSHIP

This research was funded by a University of British Columbia Graduate Fellowship, a studentship from the Rick Hansen Man in Motion Foundation and a doctoral fellowship from the Social Sciences and Humanities Research Council of Canada.

Exploring quality of life following high spinal cord injury: a review and critique

STUDY DESIGN

Review.

OBJECTIVES

To explore the concept of quality of life (QOL), critique the practice and problems of assessing QOL following spinal cord injury (SCI) and to review the findings of studies into QOL for people with SCI both below and above the level of C4.

METHODS

Relevant articles were identified from the Medline and CINAHL databases for approximately the period 1990-2003, cross-indexing 'spinal cord injury' or 'quadriplegia/tetraplegia' with 'quality of life', 'life satisfaction', 'social adjustment' or 'psychological adaptation'. This search was augmented through papers identified in reference lists. Articles were excluded if they were designed solely to examine the impact of a specific intervention upon QOL; or if they examined satisfaction with various life domains without explicitly linking these to perceptions of QOL. Papers were also accessed that addressed the philosophical and epistemological issues involved in QOL conceptions and assessment.

RESULTS

Review of the literature highlights the philosophical and methodological difficulties associated with the quantitative measurement of a qualitative experience; and with the assessment of life domains chosen by researchers. Analysis of QOL research undertaken among people with all levels of SCI demonstrates that dissatisfaction with life following injury arises primarily from social disadvantage. However, little research has been conducted specifically to ascertain perceptions of QOL among people with high SCI.

CONCLUSIONS

Ensuring the relevance of future research into QOL following high SCI requires qualitative methodology and mixed methods. Further research is needed to determine how rehabilitation professionals can act on the findings of their QOL assessments and enhance the QOL experienced by people with spinal cord injury in the context of their environments.

SPONSORSHIP

The early phase of this study was supported by: University of British Columbia Graduate Fellowship; Rick Hansen Man in Motion Foundation (studentship); Social Sciences and Humanities Research Council of Canada: doctoral fellowship.

Psychosocial Profiles of People With Pain Associated With Spinal Cord Injury

OBJECTIVES

The objectives of the study were to: (1) identify psychosocial profiles of people with pain associated with spinal cord injuries (SCI), and (2) compare the psychosocial profiles with other chronic pain syndromes.

METHODS

History questionnaires and the Multidimensional Pain Inventory (MPI) were mailed to 159 persons with chronic pain and SCIs (SCICP) and 120 (75.5%) agreed to participate.

RESULTS

Cluster analysis of MPI scores identified 2 subgroups of SCICP. One (42.5%) was characterized by high Pain Severity (PS), Affective Distress (AD), Life Interference (LI), and low Life Control (LC) similar to a previously identified cluster labeled Dysfunctional. The second (57.5%) was characterized by low PS, AD, LI, and high levels of LC and activity (GA), similar to the Adaptive Copers (AC) cluster identified in previous studies with the exception that the scores were lower on Support (S), Solicitous Responses (SR), and Negative Responses (NR) and higher on Distracting Responses (DR). Both subgroups were similar to those observed in other chronic pain syndromes (CPSs). People with SCIs differed significantly from heterogeneous chronic pain and chronic headaches in that they indicated less inference of pain with activities. They also scored lower on S. SCICP reported comparable levels of LI, LC, AD, S, SR, but greater levels of PS compared with a group of people with post-polio syndrome.

DISCUSSION

The similarities and differences between SCI and other CPSs suggest that although a general measure assessing psychosocial impact can be used across pain syndromes, it is important to use different norms for comparison of particular pain syndromes. The failure to identify a subgroup of patients characterized by low levels of S and high levels of NR, and the low SR and DR for SCICP compared with other CPSs warrants examination.

Aging, spinal cord injury, and quality of life: structural relationships

OBJECTIVE

To quantify relationships among 3 sets of factors: demographic factors, health and disability factors, and quality of life (QOL).

DESIGN

Part of a program of longitudinal research on aging and spinal cord injury (SCI) involving 3 populations: American, British, and Canadian. The present analysis uses data from the 1999 interval.

SETTING

The Canadian sample was derived from the member database of the Ontario and Manitoba divisions of the Canadian Paraplegic Association. The British sample was recruited from a national and a regional SCI center in England. The American sample was recruited through a hospital in Colorado.

PARTICIPANTS

A sample of 352 participants was assembled from 4 large, well-established databases. The sample included individuals who had incurred an SCI at least 20 years earlier, were admitted to rehabilitation within 1 year of injury, and were between the ages of 15 and 55 at the time of injury.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

A combination of self-completed questionnaires and interviews. Data included demographics, injury-related variables, health and disability-related factors, QOL, and perceptions about aging.

RESULTS

Using linear structural relationships modeling, we found that QOL was affected both directly and indirectly by age, health and disability problems, and perceptions of aging. Two surprising findings were as follows: those who experienced fewer disability-related problems were more likely to report a qualitative disadvantage in aging, and the younger members of the sample were more likely to report fatigue.

CONCLUSIONS

Fatigue is a concern because of the relationship of fatigue with perceived temporal disadvantage in aging, health problems, and disability problems. This finding highlights the need for clinical vigilance among those just beginning to experience the effects of aging.

Longitudinal outcome 6 years after spinal cord injury

STUDY DESIGN

Multicentered follow-up with centralized data collection based on retrospective study.

OBJECTIVES

To assess the outcome in a population of patients with spinal cord injury (SCI). The assessed outcomes are mortality, state of health, occupation, mobility, autonomy, social and partner relationships, quality of life (QoL), with the identification of any relation between results and demographic-clinical data.

SETTING

Two rehabilitation centers (Udine and Trevi) and a Spinal Injuries Unit (Torino).

METHODS

A total of 251 patients with SCI discharged after first hospitalization from rehabilitation facilities between 1989 and 1994 were enrolled. A questionnaire was administered by telephone.

RESULTS

During the time between discharge and follow-up, 25 out of the 251 patients had died, yielding a mortality rate of 9.96%. A total of 80 patients did not give their consent. The 146 patients' mean interval from discharge from the rehabilitation facility was 6 years. At least 25% has been hospitalized again. The descriptive analysis also shows that 29.5% of patients were working, 48.6% were able to drive, 63.7% would leave their home alone, 61% would leave home every day, 63% reported of a change in their relationships, 48.6% were happy with their love lives. Significant correlations have emerged between certain items and age: those who had a job, who could drive, were more autonomous and had a higher QoL are generally younger. Level of injury appear to be only associated with the degree of autonomy, which seems to be inferior for tetraplegic subjects. The injury's completeness and etiology do not exhibit any correlation. QoL is associated with a number of items: a higher QoL is linked to the possibility to work, especially if it is a paid job, to the ability to drive, to a good degree of autonomy, to a lack of change in the social and partner relationships, and to a satisfactory love life.

CONCLUSION

At 6 years after discharge from rehabilitations, the effects of trauma on work and social and partner relationships, domains correlated with autonomy and QoL, are evident. Further investigation by means of a prospective study over the years are therefore necessary.

Disability and a sense of community belonging. A study among tetraplegic spinal-cord-injured persons in France

This article presents a study of the identity of persons with motor impairments with regard to the community of disabled persons. The authors used the Tetrafigap survey on the long-term outcome of Tetraplegic Spinal-cord-injured (TSCI) persons, in France, to study the sense of belonging to the community of disabled persons among 1356 TSCI persons in relation to factors of social participation (both sociological and disability-related) and subjective factors (subjective well-being, social perception of disability, perceived disability). The results show that 44% of TSCI persons felt that disabled persons do not constitute a community (the "no-community" group). Of those who recognised the existence of such a community, 34% said they belonged to it (the "in-community" group) and 22% declared they did not (the "out-community" group). People in the "no-community" group tended to be more socially integrated, whilst those in the "in-community" group tended to have greater social and clinical difficulties. The "out-community" group was more diverse, being made up of both autonomous persons and dependent persons suffering from complications. Factors related to the sense of community belonging were identified using bivariate analysis and multiple logistic regression. Subjective well-being appeared to be independent of any sense of community belonging. However, the authors found a gender difference: women in the "in-community" group described themselves as having a poorer level of well-being than women in the other two groups. The results are discussed in terms of two views on the social treatment of disabilities: universalism and assimilation vs. particularism and positive identity and the growth of the disability movement.

Psychosocial predictors of physical performance in disabled individuals with chronic pain

OBJECTIVES

First, to identify what physical performance differences existed between a group of disabled individuals with chronic pain and a control group of pain-free individuals with comparable disabilities; and second, to test a psychosocial model designed to evaluate which psychosocial constructs were predictive of performance in disabled individuals with chronic pain.

DESIGN

Case-comparison study.

SETTING

Ambulatory university laboratory.

PARTICIPANTS

A community sample of 62 individuals with lower limb amputations or paraplegia, 31 with chronic pain and 31 pain-free.

INTERVENTION

Standardized lifting and wheel-turning tasks.

MAIN OUTCOME MEASURES

Static strength, endurance, lifting speed, lateral and anterior-posterior sway, and multidimensional psychosocial measures. RESULTS Disabled individuals with chronic pain had decreased endurance for both the lifting (p <0.001) and the wheel-turning (p <0.05) tasks. A psychosocial model of physical performance also was evaluated. Using confirmatory factor analysis, 31 measures were used to validate 8 theoretical constructs: emotional functioning, pain intensity, pain cognitions, physical functioning, social functioning, task-specific self-efficacy, performance outcome, and performance style. Regression analyses indicated that more than 90% of the variance in performance was predicted by psychosocial factors, with self-efficacy, perceived emotional and physical functioning, pain intensity, and pain cognitions showing the highest associations.

CONCLUSIONS

Chronic pain was found to significantly reduce the performance in individuals with lower limb amputations and paraplegia. A strong association was found between performance and psychosocial factors in disabled individuals with chronic pain. These findings extend the existing literature by validating that psychosocial models of chronic pain can be applied to the disabled population, with results similar to those of other chronic pain samples.