Socioeconomic and behavioral risk factors for mortality: do risk factors observed after spinal cord injury parallel those from the general USA population?

Longitudinal changes in employment, health, participation, and quality-of-life and the relationships with long-term survival after spinal cord injury

STUDY DESIGN

Cohort study.

OBJECTIVE

To identify five-year longitudinal changes in employment, health, participation, and quality-of-life outcomes (QOL) among participants with chronic spinal cord injury (SCI) and to compare the amount of change in these outcomes between those surviving and those not surviving until follow-up.

METHODS

Participants were 1157 individuals from the SCI Longitudinal Aging Study, who have completed at least two self-report assessments separated by five-year intervals. The main outcome measures were 13 indicators related to employment, health, participation, and QOL/psychosocial indicators. Survival status measured at follow-up.

RESULTS

Those who survived to follow up had a history indicating a greater likelihood of employment, better health, participation, and QOL/psychosocial indicators. Among survivors, longitudinal declines were limited to the percent employed and participation indicators, whereas those deceased by follow-up had significant undesirable changes in employment, participation, health, and QOL/psychosocial indicators. More specifically, compared to the survivors, those deceased by follow-up experienced a greater increase in hospitalizations, decreases in nights away from home, and declines in global satisfaction over the five-year interval.

CONCLUSIONS

Longitudinal declines in employment and some aspects of participation are common among long-term survivors and may be part of the natural course of outcomes after SCI. However, more dramatic increases in hospitalizations, fewer nights away from home, and declining satisfaction may be red flags for declining longevity.

Life Satisfaction Trend and Mortality After Traumatic Spinal Cord Injury: A Cohort Study

Background

Individuals with traumatic spinal cord injuries (SCIs) have lower subjective well-being and diminished longevity, yet there is a lack of research on how life satisfaction and changes in life satisfaction relate to longevity.

Objectives

To identify the relationships between survival status and life satisfaction and its changing trend over a 10-year period.

Methods

Data were taken from the SCI Longitudinal Aging Study. A cohort study of 676 adult participants with SCI completed three assessments separated by 5-year intervals. We applied the survival analyses by using person-year logistic regression models.

Results

There were 135 participants (20%) who were deceased by the end of 2019. After controlling for demographic and injury factors, life satisfaction was significantly related to survival. In the final model, having an upward trend of life satisfaction was significantly associated with lower odds of mortality, whereas a downward trend in life satisfaction was not significant.

Conclusion

Our findings demonstrate the importance of current life satisfaction and having a trend toward improving satisfaction to survival. The findings indicated the importance of psychosocial adaptation to life quality and longevity after SCI.

Social participation as a mediator of the relationships of socioeconomic factors and longevity after traumatic spinal cord injury

STUDY DESIGN

Cohort study.

OBJECTIVE

Previous research has indicated that socioeconomic factors affect longevity after traumatic spinal cord injury (SCI). Our purpose was to evaluate whether social participation mediates the relationship between socioeconomic factors and survival status after SCI.

SETTING

Medical university in the southeastern United States.

METHODS

Participants (N = 1540) met the following inclusion criteria: traumatic SCI of at least 1-year duration, minimum of 18 years of age, and having residual impairment from SCI. The main outcome measures were a) survival status as of December 31, 2019, identified by the National Death Index (NDI) search, b) socioeconomic status (SES), measured by education, employment status, and family income, and c) participation, measured by marital/relationship status, hours out of bed per day, days leaving home per week, and nights away home during the past year.

RESULTS

Thirty nine percent of participants (n = 602) were decreased by the end of 2019. Socioeconomic factors were associated with longevity controlling for demographic, injury characteristics, and health status. However, the association of SES with longevity was mediated by three social participation mobility indicators (hours out of bed, days out of house, and nights away from home), such that SES was no longer significantly related to longevity after inclusion of the participation variables.

CONCLUSIONS

Although socioeconomic factors are related to longevity, their relationship appears to be mediated by social participation mobility indicators. Intervention studies are needed to address the modifiable factors that may promote longevity, including promoting an active lifestyle.

Demographic and Health Profiles of People Living With Traumatic Spinal Cord Injury in the United States During 2015-2019: Findings from the Spinal Cord Injury Model Systems Database

OBJECTIVE

To estimate the population profile of people living with traumatic spinal cord injury (TSCI) to help evaluate health care needs of this aging population.

DESIGN

Cross-sectional study.

SETTING

SCI Model Systems (SCIMS) centers in the United States.

PARTICIPANTS

Individuals (N=20,437) who: (1) incurred a TSCI between 1972 and 2019, (2) were initially treated at one of the SCIMS centers, and (3) were alive during the period from 2015 to 2019.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Demographics, injury characteristics, health conditions, and social participation, as compared with previous estimates in 2008 and general population statistics in 2017.

RESULTS

People living with TSCI during the period from 2015-2019 (mean years since injury, 18y; 79.4% male, and 62.5% White) were older (51.6 vs 45.0y) and had a higher percentage of C1-C4 (21.9% vs 17.0%) and American Spinal Injury Association Impairment Scale D injuries (31.5% vs 26.0%) compared with the 2008 TSCI population profile. Although the proportion of people with a bachelor's degree or higher was similar between the TSCI and general US populations (30.7% vs 32.0%), the employment rate was lower in the TSCI population (24.0% vs 59.5%). People are affected by various medical problems over time post TSCI. The prevalence of pain and urinary tract infection remained high over postinjury years, at 86.1% and 52.6%, respectively. Rehospitalization and depression were most common during the first year (34.9% and 22.3%, respectively), and pressure injury was more common among those 20 years or more postinjury (>30.0%). Health conditions declined with advanced age, including self-perceived health, diabetes, and institutional residence. People who survived TSCI for years, however, had relatively good degrees of independence and social participation.

CONCLUSION

Study findings highlight the need for greater involvement of primary care providers and geriatricians in the continuity of care for SCI to promote healthy aging. Improvement in employment should also be the target in promoting social participation and quality of life.

Mortality Beyond the First Year After Spinal Cord Injury: Does Body Mass Index Matter?

OBJECTIVE

To examine the association between body mass index (BMI [calculated as weight in kilograms divided by height in meters squared]) and mortality after the first year post spinal cord injury (SCI) overall and across demographic and injury characteristics.

DESIGN

Cohort study.

SETTING

Sixteen Spinal Cord Injury Model Systems (SCIMS) centers.

PARTICIPANTS

SCIMS Database participants age 20 years or older and having a BMI assessment during the 2007-2011 wave of data collection.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

All-cause mortality rate. Life table method and log-rank test were used to estimate and compare mortality rates across BMI groups and other factors. Cox proportional hazard regression model was conducted to estimate hazard ratio (HR) and 95% confidence interval (CI).

RESULTS

A total of 2346 participants (N=2346) with SCI were classified into 1 of the 8 BMI groups: <18.5 (6.9%), 18.5-19.9 (7.3%), 20.0-22.49 (15.0%), 22.5-24.9 (18.8%), 25.0-27.49 (17.5%), 27.5-29.9 (13.2%), 30.0-34.9 (13.5%), and ≥35.0 (7.8%). Compared with people with BMI of 22.5-29.9, a higher mortality risk was observed among people with BMI<18.5 (HR, 1.76; 95% CI, 1.25-2.49), 18.5-19.9 (HR, 1.51; 95% CI, 1.06-2.15), and ≥35.0 (HR, 1.51; 95% CI, 1.11-2.07) after adjusting for confounding factors (sex, age at the time of BMI assessment, marital status, neurologic status). The U-shape BMI-mortality relationship varied by age, sex, neurologic status, and years since injury.

CONCLUSIONS

To improve life expectancy after SCI, health care professionals could focus on weight management among patients with relatively low and extremely high BMI, defined by demographic and injury-related characteristics. Future studies should explore factors that contribute to such a higher mortality after SCI, including pre-existing conditions, poor diet and/or nutrition, and cardiorespiratory fitness.

The impact of body mass index on one-year mortality after spinal cord injury

Objective: Evaluate the association between body mass index (BMI, kg/m²) and one-year mortality among people who survived the first 90 days after spinal cord injury (SCI).Design: Cohort study.Setting: Eighteen SCI Model Systems centers throughout the United States.Participants: 6640 participants (men, 79.6%; mean age, 42.8 ± 17.7y; Whites, 62.3%) who had an SCI between October 2006 and March 2017.Interventions: Not applicable.Outcome Measures: All-cause mortality and causes of death. Life table method was used to estimate mortality rates, while Cox proportional hazard model was conducted to assess the impact of BMI on mortality after adjusting for demographic and injury-related factors.Results: Based on BMI obtained during initial rehabilitation, participants were classified into underweight (4.2%), normal weight (41.2%), overweight (30.9%) and obese (23.8%) groups, and their corresponding one-year mortality rates were 2.6%, 1.8%, 3.1%, 3.5%, respectively (P = 0.002). After adjusting for potential confounding factors, people with obesity had a higher mortality risk than those with normal weight (hazard ratio, 1.51; 95% confidence interval, 1.00-2.28). The most frequent causes of death for people with obesity were infective and parasitic diseases and respiratory diseases, while respiratory diseases were the most frequent for people with other BMI statuses.Conclusion: People with obesity who incur an SCI need special attention to prevent early mortality. Future studies should explore factors that contribute to such a higher mortality after SCI, such as preexisting conditions and comorbidities. The effects of BMI on long-term mortality also deserve further investigation.

Psychological factors and risk of mortality after spinal cord injury

Objective: Identify the association of personality and purpose in life with competing risks of multiple causes of death after spinal cord injury (SCI), using data from the SCI Longitudinal Health Study. Design: Prospective cohort study with data collected in 1997-1998 and 2007-2009. Mortality status determined as of December 31, 2016. Setting: Specialty hospital in the Southeastern United States. Participants: 3070 adults with chronic (>1-year), traumatic SCI. Interventions: N/A. Outcome Measures: We examined 6 psychological factors (Purpose in Life and 5 scales of the Zuckerman-Kuhlman Personality Questionnaire) and risk of mortality due to 6 specific causes of death, building on published analyses of behavioral and health/clinical risk and protective factors. Results: There were 803 deaths. Four of the 6 psychological factors were predictive of all-cause mortality. All except 1 personality scale were related to cause-specific mortality. Psychological factors were most predictive of unintentional injury deaths. Purpose in life was protective of death due to pneumonia; whereas, Activity was protective of death due to diseases of heart and blood vessels and to unintentional injury. Sociability, Impulsive-Sensation Seeking, and Neuroticism-Anxiety were risk factors for death due to unintentional injury. Neuroticism-Anxiety was related to death due to septicemia. There were no significant psychological predictors of cancer. Conclusions: Rehabilitation professionals have a central role in promoting purpose in life as a means of increasing longevity. By assessing personality factors predictive of specific causes of mortality, those at risk may be targeted for cause-specific prevention strategies.

Employment status, hours working, and gainful earnings after spinal cord injury: relationship with pain, prescription medications for pain, and nonprescription opioid use

STUDY DESIGN

Cross-sectional self-report assessment. Econometric modeling.

OBJECTIVES

Identify the relationship of multiple pain indicators, prescription pain medication, nonprescription opioid use, and multiple indicators of quality employment among those with spinal cord injury (SCI).

SETTING

Data were collected at a medical university in the Southeastern United States (US).

METHODS

Participants included 4670 adults with traumatic SCI of at least one-year duration who were enrolled in a study of health and longevity. They were identified from three sources including a specialty hospital and two population-based state SCI surveillance systems. Econometric modeling was used for three outcome variables: employment status, hours per week spent working, and earnings.

RESULTS

Several pain parameters were significantly related to multiple employment outcomes. Prescription medication to treat pain was associated with lower odds of employment, fewer hours working, and lower conditional earnings. Nonprescription opioid use was only related to fewer hours working. Painful days, number of painful conditions, and pain intensity were all related to employment outcomes, but the pattern varied by outcome. The number of painful conditions was most consistently related to employment. Multiple demographic, injury, and educational factors were related to employment, with better outcomes among those with less severe SCI and greater educational achievements.

CONCLUSIONS

The presence of significant pain and use of either prescription pain medications or the use of nonprescription opioids may have a significant adverse effect on both the probability of employment and quality of employment. Rehabilitation and vocational professionals should routinely assess pain and associated medications in vocational and career planning.

Outcomes in socioeconomically disadvantaged patients with spinal cord injury: a systematic review

OBJECTIVEIndividuals with a spinal cord injury (SCI) in socioeconomically disadvantaged settings (e.g., rural or low income) have different outcomes than their counterparts; however, a contemporary literature review identifying and measuring these outcomes has not been published. Here, the authors' aim was to perform a systematic review and identify these parameters in the hope of providing tangible targets for future clinical research efforts.METHODSA systematic review was performed to find English-language articles published from 2007 to 2017 in the PubMed/MEDLINE, EMBASE, and SCOPUS databases. Studies evaluating any outcomes related to patients with an SCI and in a low-resource setting were included. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed, and a flowchart was created. Of the 403 articles found, 31 underwent complete review and 26 were eligible for study inclusion. According to the current study criteria, any case studies, studies in less developed countries, studies including and not separating other types of neurological disorders, studies not assessing the effects of a low-resource setting on outcomes in patients with SCI, and studies evaluating the causes of SCI in a low-resource setting were excluded.RESULTSIn SCI patients, a lower income was a predictor of death (OR 2.1, 95% CI 1.7-2.6, p = 0.0002). Moreover, secondary outcomes such as pain intensities (OR 3.32, 95% CI 2.21-4.49, p < 0.001), emergency room visits (11% more likely, p = 0.006), and pressure ulcer formation (OR 2.1, 95% CI 1.5-3.0, p < 0.001) were significantly higher in the lower income brackets. Rurality was also a factor and was significantly associated with increased emergency room visits (OR 1.5, 95% CI 1.1-2.1, p = 0.01) and lower outpatient service utilization (incidence rate ratio [IRR] 0.57, 95% CI 0.35-0.93, p < 0.05).CONCLUSIONSThe authors showed that individuals in a low-resource setting who have suffered an SCI have significantly different outcomes than their counterparts. These specific outcomes are promising targets for future research efforts that focus on improving health conditions among this population.

Health factors and spinal cord injury: a prospective study of risk of cause-specific mortality

STUDY DESIGN

Prospective cohort study.

OBJECTIVES

Identify the risk and protective factors of all-cause and cause-specific mortality among persons with traumatic spinal cord injury (SCI).

SETTING

Rehabilitation specialty hospital in the Southeastern United States.

METHODS

A prospective cohort study was conducted with 3070 adults with traumatic SCI who were a minimum of 1 year post-injury at assessment. Prospective data were collected in 1997-1998 and 2007-2010, with mortality determined as of 31 December, 2016. The deceased were classified into six categories based on underlying cause of death: septicemia, pneumonia and influenza, cancer, heart and blood vessel diseases, unintentional injuries, and all other causes. The competing risk analysis strategy applied to each of the specific causes.

RESULTS

There were a total of 803 observed deaths among the 2979 final study sample. After controlling for demographic and injury characteristics, general health, pressure ulcer history, and symptoms of infections were significantly associated with all-cause mortality. Except for cancer, they were also related with at least one of the specific causes of death, whereas orthopedic complications and subsequent injuries were unrelated to any cause.

CONCLUSIONS

Three health domains, global health, pressure ulcers, and symptoms of illness or infection, were significantly associated with mortality after SCI, and the patterns of association varied as a function of specific cause of death.

Checkpoints to Progression: Qualitative Analysis of the Personal and Contextual Factors That Influence Selection of Upper Extremity Reconstruction Among Patients With Tetraplegia

PURPOSE

Patients with tetraplegia consistently rank better use of the upper extremity as their top functional priority. Multiple case series have demonstrated that upper extremity reconstruction (UER) is well-tolerated and can produce substantial functional improvements for appropriate candidates; however, UER remains critically underutilized. The mechanisms that drive differences in provider practice and referral patterns have been studied, but comprehensive examination of the patient factors that influence UER decisions has not been performed for American patients.

METHODS

Nineteen patients with C4-8 cervical spinal injuries were selected using purposive sampling: 9 patients had undergone UER, 10 had not undergone UER. Semistructured interviews were conducted and transcripts evaluated using grounded theory methodology.

RESULTS

Our study yielded a conceptual model that describes the characteristics common to all patients who undergo UER. Patients who selected reconstruction proceeded stepwise through a shared sequence of steps: (1) functional dissatisfaction, (2) awareness of UER, and (3) acceptance of surgery. Patients' ability to meet these criteria was determined by 3 checkpoints: how well they coped, their access to information, and the acceptability of surgery. Extremely positive or negative coping prevented patients from moving from the Coping to the Information Checkpoint; thus, they remained unaware of UER and did not undergo surgery. A lack of knowledge regarding reconstruction was the strongest barrier to surgery among our participants.

CONCLUSIONS

We built a conceptual model that outlines how patients' personal and contextual factors drive their progression to UER. Moving from functional dissatisfaction to understanding that they were candidates for UER was a substantial barrier for participants, particularly those with very high and very low coping skills.

CLINICAL RELEVANCE

To improve utilization for all patients, interventions are needed to increase UER awareness. Standardizing introduction to UER during the rehabilitation process or improving e-content may represent key awareness access points.

Risk and Protective Factors for Cause-Specific Mortality After Spinal Cord Injury

OBJECTIVE

To investigate the association of multiple sets of risk and protective factors (biographic and injury, socioeconomic, health) with cause-specific mortality after spinal cord injury (SCI).

DESIGN

Retrospective analysis of a prospectively created cohort.

SETTING

Spinal Cord Injury Model Systems facilities.

PARTICIPANTS

Adults (N=8157) with traumatic SCI who were enrolled in a model systems facility after 1973 and received follow-up evaluation that included all study covariates (between November 1, 1995 and October 31, 2006).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

All-cause mortality was determined using the Social Security Death Index as of January 1, 2014. Causes of death were obtained from the National Death Index and classified as infective and parasitic diseases, neoplasms, respiratory system diseases, heart and blood vessel diseases, external causes, and other causes. Competing risk analysis, with time-dependent covariates, was performed with hazard ratios (HRs) for each cause of death.

RESULTS

The HRs for injury severity indicators were highest for deaths due to respiratory system diseases (highest HR for injury level C1-4, 4.84) and infective and parasitic diseases (highest HR for American Spinal Injury Association Impairment Scale grade A, 5.70). In contrast, injury level and American Spinal Injury Association Impairment Scale grade were relatively unrelated to death due to neoplasms and external causes. Of the socioeconomic indicators, education and income were significantly predictive of a number of causes of death. Pressure ulcers were the only 1 of 4 secondary health condition indicators consistently related to cause of death.

CONCLUSIONS

Injury severity was related to mortality due to infective disease and respiratory complications, suggesting that those with the most severe SCI should be targeted for prevention of these causes. Socioeconomic and health factors were more broadly related to a number of causes of death. Intervention strategies that enhance socioeconomic status and health may also result in reduced mortality due to multiple causes.

Emergency room visits and hospitalizations among participants with spinal cord injury

BACKGROUND

Literature examining emergency room visits (ERV) and emergency room related hospitalizations (ERH) after spinal cord injury (SCI) is limited.

OBJECTIVE

Identify (1) the annual frequency of ERV and ERH and (2) their likelihood as a function of demographic, injury, and socioeconomic characteristics.

METHODS

Participants (n = 1,579) with SCI completed mailed self-report questionnaires.

RESULTS

37% reported at least one ERV, with an average of 85 ERV per 100 participants. 19% reported at least one ERH and an average of 33 ERH annually per 100 participants. A greater likelihood of ERV was observed among non-whites, those with more severe SCI, less education, and lower income. Among those with at least one ERV, greater risk of ERH was observed among non-Hispanic whites, those with more severe SCI, lower education, and higher age.

CONCLUSIONS

ERV are common after SCI and should be accounted for when predicting SCI related expenses. Those with the most severe SCI and those in the oldest age group were most likely to be hospitalized after an ERV.

Prevalence of cigarette smoking and attempts to quit in a population-based cohort with spinal cord injury

OBJECTIVE

The purposes of this study were to assess (i) prevalence of smoking in a population-based cohort of persons with spinal cord injury (SCI), (ii) history of quit attempts and (iii) the relationship between access to health care, socioeconomic status (SES), smoking status and history of quit attempts.

STUDY DESIGN

Cross-sectional study.

SETTING

Population-based SCI cohort.

METHODS

A total of 833 adults with SCI of at least 1-year duration were identified through a population-based surveillance system. Current smoking status, attempts to quit smoking in the past year and seeking professional help to quit smoking were assessed.

RESULTS

Over one-third (35.3%) of the sample were current smokers, of whom 75.4% had ever tried to quit, and of these, only 27.9% had ever sought professional help. Those with lower SES were more likely to be current smokers, as were those with less access to health care. Access to care was positively related to likelihood of having sought professional help.

CONCLUSIONS

We found rates of smoking among persons with SCI to be well above national prevalence rates. We also found poorer access to care related to a greater likelihood of being a current smoker, had no association with trying to quit smoking, but decreased likelihood of using cessation support among those who did attempt to quit.

Is financial hardship associated with reduced health in disability? The case of spinal cord injury in Switzerland

Objective

To investigate socioeconomic inequalities in a comprehensive set of health indicators among persons with spinal cord injury in a wealthy country, Switzerland.

Methods

Observational cross-sectional data from 1549 participants of the Swiss Spinal Cord Injury Cohort Study (SwiSCI), aged over 16 years, and living in Switzerland were analyzed. Socioeconomic circumstances were operationalized by years of formal education, net equivalent household income and financial hardship. Health indicators including secondary conditions, comorbidities, pain, mental health, participation and quality of life were used as outcomes. Associations between socioeconomic circumstances and health indicators were evaluated using ordinal regressions.

Results

Financial hardship was consistently associated with more secondary conditions (OR 3.37, 95% CI 2.18–5.21), comorbidities (OR 2.88, 95% CI 1.83–4.53) and pain (OR 3.32, 95% CI 2.21–4.99), whereas mental health (OR 0.23, 95% CI 0.15–0.36), participation (OR 0.30, 95% CI 0.21–0.43) and quality of life (OR 0.22, 95% CI 0.15–0.33) were reduced. Persons with higher education reported better mental health (OR 1.04, 95% CI 1.00–1.07) and higher quality of life (OR 1.06, 95% CI 1.02–1.09); other health indicators were not associated with education. Household income was not related to any of the studied health indicators when models were controlled for financial hardship.

Conclusions

Suffering from financial hardship goes along with significant reductions in physical health, functioning and quality of life, even in a wealthy country with comprehensive social and health policies.

Risk behaviors related to cigarette smoking among persons with spinal cord injury

INTRODUCTION

Smoking, while detrimental to health in any population, has greater health implications for those with spinal cord injury (SCI) because of additional risks posed by SCI. The aims of this study were to document smoking status after SCI and to assess relationships between smoking status with injury severity and alcohol/pain medication use.

METHODS

Participants (n = 1,076) were identified from a large rehabilitation hospital in the southeastern part of the United States. Eligibility criteria included (a) traumatic SCI resulting in residual impairment, (b) adult, and (c) 1+ years postinjury. Previous and current cigarette smoking and quitting attempts were assessed. Relationships were assessed between smoking status (current, former, and never), alcohol use, and pain medication use.

RESULTS

Of participants (72% male, M age = 49.6 years, M = 16.1 years since SCI), 49.2% had never smoked, 28.2% were former smokers, and 22.6% were current smokers. Of current smokers, 39.2% attempted quitting in the past year and 77.2% had ever tried to quit. Only 29.9% of those who ever tried to quit sought professional help. Ambulatory persons, regardless of injury level, were 2.32 times more likely to be current smokers than nonambulatory persons with a high-level cervical injury. Lower socioeconomic status, binge drinking, and misuse of pain medication all predicted current smoking.

CONCLUSIONS

Smoking prevalence among persons with SCI is largely consistent with the general population. Additionally, we found smoking to be associated with other risk behaviors (binge drinking and prescription medication misuse) and differs by injury severity. Future studies should assess smoking interventions, which may differ by injury severity.

Theoretical Risk and Prevention Model for Secondary Health Conditions and Mortality After SCI: 15 Years of Research

BACKGROUND

To successfully prevent secondary health conditions (SHCs) and promote longevity after spinal cord injury (SCI), we must first understand the risk factors precipitating their occurrence and develop strategies to address these risk factors. Conceptual models may aid in identifying the nature of SHCs and guide research, clinical practice, and the development of prevention strategies.

OBJECTIVE

Our purpose is to review and refine an existing theoretical risk and prevention model (TRPM) as a means of classifying risk and protective factors for SHCs and mortality after SCI and for identifying points of intervention.

METHODS

We describe conceptual work within the field of SCI research and SHCs, including a description of the TRPM, a review of research using the TRPM, and conceptual enhancements to the TRPM based on previous research.

CONCLUSIONS

The enhanced TRPM directs research to the timing and chronicity of the SHCs and their relationship with overall health and physiologic decline. Future research should identify differences in the nature of SHCs, the extent to which they relate to risk and protective factors, and the degree to which they may be prevented with appropriate research-based strategies.