Psychological variables associated with employment following spinal cord injury: a meta-analysis

Effect of Exercise on Mental Health and Health-related Quality of Life in Adults With Spinal Cord Injury: A Systematic Review and Meta-analysis

OBJECTIVES

To determine the effect of exercise interventions on mental health and health-related quality of life (HRQoL) in individuals with SCI.

DATA SOURCES

We searched Embase, CINAHL, Medline, PsychINFO, and SPORTDiscus from inception to September 2023.

STUDY SELECTION

We included randomized controlled trials that (1) involved participants ≥18 years old with a SCI; (2) administered an exercise intervention; and (3) measured subjective well-being, psychological well-being, social well-being, and/or HRQoL as outcomes. We reported standardized means differences (d) with a 95% confidence interval (CI), assessed the risk of bias by using the Revised Cochrane Risk-of-bias Tool for Randomized Trials (RoB 2), and the certainty of the evidence using GRADE.

DATA SYNTHESIS

Nineteen studies (797 participants, mean age <65 years in every study) were included. Exercise improved overall well-being (d=0.494; 95% CI 0.268, 0.720; low certainty evidence), subjective well-being (d=0.543; 95% CI 0.270, 0.816; low certainty evidence), psychological well-being (d=0.499; 95% CI 0.193, 0.805; low certainty evidence), social well-being (d=0.452; 95% CI 0.151, 0.752; low certainty evidence), and HRQoL (d=0.323; 95% CI 0.072, 0.574; low certainty evidence). Four serious adverse events probably attributable to the interventions were reported in 3 studies.

CONCLUSIONS

Exercise interventions can improve well-being and HRQoL in adults with SCI <65 years of age. Additional research is needed to determine effectiveness in adults ≥65 years of age.

Relationship between employment and quality of life and self-perceived health in people with spinal cord injury: an international comparative study based on the InSCI Community Survey

STUDY DESIGN

Cross-sectional study.

OBJECTIVES

Work-related disability is common in persons with spinal cord injury (SCI). The aims of this study are to examine the associations of employment with self-perceived health (SPH) and quality of life (QoL) across 22 countries and to explore the covariates around employment and SPH and QoL.

SETTING

Community.

METHODS

We analyzed 9494 community-dwelling persons with SCI aged 18-65. We performed an adjusted regression and path analysis. The independent variable was 'employment' and the dependent variables were two single items: QoL (very poor to very good) and SPH (excellent to poor). Covariates included the Gross Domestic Product (GDP), education, time since SCI, age, gender, years of employment after SCI, SCI level (paraplegia, tetraplegia), and completeness of SCI.

RESULTS

Participants' mean age was 47, 74% were male, and 63% had paraplegia. We found an association between employment and QoL and SPH. While the magnitude of the effect of employment on QoL did not differ across GDP quartiles, its perceived effect on QoL was found to be significant in the highest GDP quartile. Employment was predictive of good SPH in two GDP quartiles (Q1 and Q4), but significant across all quartiles when predicting poor perceptions, with the magnitude of effect varying significantly.

CONCLUSIONS

Employment is closely related to QoL and SPH depending on the GDP. We may positively influence the QoL and SPH in the SCI population to promote better employment outcomes by considering the infrastructure and economy.

Spinal cord injury and work challenges: an analysis of paid work status and pathways of return to work in Brazil

DESIGN

Retrospective cohort study.

OBJECTIVES

To investigate paid work status and return to work (RTW) pathways after spinal cord injury (SCI).

SETTING

SARAH Network of Rehabilitation Hospitals.

METHODS

Participants were adults with traumatic SCI, aged between 18 and 60 years at the time of the injury, admitted between 2000 and 2017. In the first stage, socio-demographic, injury-related, and functional status data were collected from medical records. In the second stage, data on paid work, means of mobility, driving ability, return to study, ability to work, and satisfaction with the work status were collected through an online survey conducted between January and March 2020.

RESULTS

A total of 154 participants were included in the sample. Of these, 90% were working at the time of SCI and 23% were engaged in paid work at the time of the study. Three RTW pathways were identified among those who were working at the time of the injury and: did not return to work (78%); returned to a different occupation (12%) and returned to the same occupation (9%). Number of post-injury complications, returning to study, good work ability, and satisfaction with the work status were predictors of paid work. The model's adjusted coefficient was 56.5% (p = 0.001).

CONCLUSION

Working-age people with SCI who underwent rehabilitation in Brazil had a low rate of paid work. Fewer complications at the time of the injury, returning to study, good ability to work and greater satisfaction with the work status increased the likelihood of being engaged in paid work.

Can targeted job-information for adults with spinal cord dysfunction be effectively delivered online? A pilot study

OBJECTIVE

To pilot a novel email-based information package (Work and SCI) for job-seekers with an acquired spinal cord injury (SCI) or spinal cord dysfunction (SCI/D).

STUDY DESIGN

Prospective, non-randomized, repeated measures trial.

SETTING

Community dwelling cohort in Australia.

PARTICIPANTS

Five people with SCI (mean age 46.4 years, SD = 10.2; 4 female) initially reviewed Work and SCI. Twenty-four with SCI/D subsequently enrolled, of whom 16 (mean age 46.4 years, SD = 11.1; 7 female), completed the intervention.

INTERVENTION

Intervention participants accessed Work and SCI over a 4-week period.

OUTCOME MEASURES

Individual changes in pre-post scores for the My Vocational Situation Scale, Job Procurement Self-Efficacy Scale, Patient Health Questionnaire-9 and Life Orientation Test-Revised were examined.

RESULTS

Reliable change in pre-post scores across outcomes were reported by 38% (n = 6) of participants. Favorable comments on the Work and SCI resource were provided in addition to suggestions for improvement.

CONCLUSIONS

Preliminary data suggest that Work and SCI may help to establish vocational interests among job-seekers with a SCI/D, however further work is needed to enhance participant compliance. This might include moderator support to promote and maintain participation. A controlled design will also help to identify factors that influence engagement with the Work and SCI resource.

Work and SCI: a pilot randomized controlled study of an online resource for job-seekers with spinal cord dysfunction

STUDY DESIGN

A prospective, parallel randomized controlled trial (RCT).

OBJECTIVES

To test the preliminary effects of an online resource targeted to job-seekers with spinal cord injury or disorder (SCI/D), and to determine the feasibility of proceeding to a full-scale RCT.

SETTING

A community cohort in Australia.

METHODS

Forty-eight adults (M = 42 years, SD = 10.95, 27 males) were randomized to receive 4-weeks access to the Work and SCI resource (n = 25) or to a wait-list control group (n = 23). The Work and SCI intervention involved six stand-alone learning modules which provided job-searching and career-planning information through text, videos, and interactive activities. Self-report measures were administered at baseline and after 4 weeks: Job Procurement Self-Efficacy Scale (JSES), Life Orientation Test-Revised (LOT-R), and Patient Health Questionnaire-9 (PHQ-9).

RESULTS

Online usage data identified high uptake of the Work and SCI resource, although study attrition was problematic. Intention-to-treat analyses failed to reach statistical significance, whereas complete data revealed a significant interaction effect for optimism (LOT-R).

CONCLUSION

Further research to develop and enhance Work and SCI is indicated. Remediable strategies to optimize recruitment and statistical power in a future definitive RCT are discussed.

SPONSORSHIP

This project was funded by the auDA Foundation (project 16019).

The meaning of work after spinal cord injury: a scoping review

STUDY DESIGN

Scoping review.

OBJECTIVES

To explore the meaning of work after spinal cord injury (SCI) in existing literature.

METHODS

Arksey and O'Malley's widely used methodological framework for scoping reviews was used to guide this review. Studies involving adults with SCI, conducted using qualitative methods, and published in peer reviewed literature were identified based on key terms and searches in three databases (CINAHL, MEDLINE, PsycINFO). Further search steps included checking citations in identified articles and citation tracking for other relevant articles and reviews. Reported qualitative data were then thematically analysed to generate themes.

RESULTS

Twelve studies were included. Three themes were identified across these studies that describe the meanings of work after spinal cord injury: re-developing a sense of self, re-establishing place in the community and regaining economic self-sufficiency.

CONCLUSIONS

The varied meanings of work after SCI identified in this review may be used in rehabilitation programs to explore ideas about work, the types of work they wish to pursue, and the ways in which work may be meaningful for people with SCI, so as to identify individually and contextually relevant work. Taking account of meaning in ICF based models of work participation could enhance patient-centred approaches in SCI rehabilitation.

Longitudinal study of social participation and well-being among persons with spinal cord injury and their partners (pro-WELL)

PURPOSE

Social participation is an important determinant of well-being. Among persons with disabilities, and with spinal cord injury (SCI) in particular, opportunities for social participation are restricted and may impact well-being. The longitudinal pro-WELL study aims to investigate associations of 2 major domains of social participation with well-being: (1) availability and quality of close social relationships and (2) acting in core social roles (eg, paid work). The joint inclusion of persons with SCI and their partners is a major innovative aspect of this study enabling an in-depth analysis of interpersonal dynamics in coping with disability.

PARTICIPANTS

Pro-WELL is a nested project of the Swiss Spinal Cord Injury Cohort Study (SwiSCI) and involves community-dwelling persons aged 30-65 with SCI and their partners living in Switzerland. Baseline data were collected from mid-2015 to early 2016 by telephone interviews and questionnaires. The first and second follow-up assessments are scheduled with a 6 months interval.

FINDINGS TO DATE

The baseline sample consists of 133 persons with SCI and their partners. We provide an overview of baseline characteristics and well-being and describe recruitment outcomes and participation rates. A comprehensive non-response analysis demonstrates adequate representation of the source population with negligible selection bias regarding sociodemographic and lesion characteristics.

FUTURE PLANS

The prospective data collection and analysis of month 6 and 12 assessments are ongoing and tests of the main research hypotheses will be performed. Findings will be disseminated through peer-reviewed journals and scientific conferences. A workshop and a newsletter on study findings are proposed to feed back findings to participants and other stakeholders.

Labor Market Integration of People with Disabilities: Results from the Swiss Spinal Cord Injury Cohort Study

Objectives

We aimed to describe labor market participation (LMP) of persons with spinal cord injury (SCI) in Switzerland, to examine potential determinants of LMP, and to compare LMP between SCI and the general population.

Methods

We analyzed data from 1458 participants of employable age from the cross-sectional community survey of the Swiss Spinal Cord Injury Cohort Study. Data on LMP of the Swiss general population were obtained from the Swiss Federal Statistical Office. Factors associated with employment status as well as the amount of work performed in terms of full-time equivalent (FTE) were examined with regression techniques.

Results

53.4% of the participants were employed at the time of the study. Adjusted odds of being employed were increased for males (OR = 1.73, 95% CI 1.33–2.25) and participants with paraplegia (OR = 1.78, 95% CI 1.40–2.27). The likelihood of being employed showed a significant concave relationship with age, peaking at age 40. The relation of LMP with education was s-shaped, while LMP was linearly related to time since injury. On average, employment rates were 30% lower than in the general population. Males with tetraplegia aged between 40 and 54 showed the greatest difference. From the 771 employed persons, the majority (81.7%) worked part-time with a median of 50% FTE (IRQ: 40%-80%). Men, those with younger age, higher education, incomplete lesions, and non-traumatic etiology showed significantly increased odds of working more hours per week. Significantly more people worked part-time than in the general population with the greatest difference found for males with tetraplegia aged between 40 and 54.

Conclusions

LMP of persons with SCI is comparatively high in Switzerland. LMP after SCI is, however, considerably lower than in the general population. Future research needs to show whether the reduced LMP in SCI reflects individual capacity adjustment, contextual constraints on higher LMP or both.

Impact of Health Behaviors and Health Management on Employment After SCI: Psychological Health and Health Management

Objective: The purpose of this study was to examine the relationship between employment and psychological health and health management as described by individuals with spinal cord injury (SCI) who were employed at least once following injury. Methods: A qualitative approach used 6 focus groups at 2 sites with 44 participants who were at least 10 years post SCI. All had been employed at some point since injury. Heterogeneous and homogeneous groups were delineated based on specific characteristics, such as education, gender, or race. Group sessions followed a semi-structured interview format with questions about personal, environmental, and policy related factors influencing employment following SCI. All group sessions were recorded, transcribed, and coded into conceptual categories to identify topics, themes, and patterns. Inferences were drawn about their meaning. NVivo 10 software using the constant comparative method was used for data analysis. Results: Narratives discussed the relationship between employment and psychological and emotional health and health management. Four themes were identified: (1) adjustment and dealing with emotional reactions, (2) gaining self-confidence, (3) preventing burnout, and (4) attitudes and perspectives. Most themes reflected issues that varied based on severity of injury as well as stage of employment. Conclusions: Individuals with SCI who are successful in working following injury must determine how to perform the behaviors necessary to manage their health and prevent emotional or physical complications. The emotional consequences of SCI must be recognized and addressed and specific behaviors enacted in order to optimize employment outcomes.

Psychosocial correlates of depression following spinal injury: A systematic review

OBJECTIVES

Spinal cord injury (SCI) studies have identified a range of psychosocial risk and protective factors for depression post-injury. This study presents the first systematic and quantitative review of this body of research.

METHODS

Twenty-four studies (N=3172 participants) were identified through electronic database searches. Studies were evaluated according to recommended guidelines on Strengthening the Reporting of Observational Studies in Epidemiology (STROBE). The significance and magnitude of the relationships between standardised measures of depression and psychosocial outcome were examined using Pearson's effect size r, 95% confidence intervals and fail-safe Ns. Effect sizes were categorised according to the ICF psychosocial domains.

RESULTS

STROBE ratings indicated discrepancies in procedural detail and statistical analyses. Individual personal variables including affective feelings, and thoughts and beliefs specific to SCI demonstrated the strongest relationship with depression self-ratings. Life satisfaction, disability acceptance, environmental supports and community participation had a medium to strong association, helping to reduce vulnerability to depression. Longitudinal studies revealed that symptoms of depression continued to impact on psychosocial outcome up to 10 years post-injury, although this was based on limited data.

CONCLUSIONS

Assessment of psychosocial factors in the acute stages of SCI rehabilitation can inform evidence-based interventions to treat and manage depressive symptomatology in the short to longer-term. Future studies would benefit from adopting a unified approach to the measurement of depression post-SCI to help inform targeted treatment.

Exercise promotes motor functional recovery in rats with corticospinal tract injury: anti-apoptosis mechanism

Studies have shown that exercise interventions can improve functional recovery after spinal cord injury, but the mechanism of action remains unclear. To investigate the mechanism, we established a unilateral corticospinal tract injury model in rats by pyramidotomy, and used a single pellet reaching task and horizontal ladder walking task as exercise interventions postoperatively. Functional recovery of forelimbs and forepaws in the rat models was noticeably enhanced after the exercises. Furthermore, TUNEL staining revealed significantly fewer apoptotic cells in the spinal cord of exercised rats, and western blot analysis showed that spinal cord expression of the apoptosis-related protein caspase-3 was significantly lower, and the expression of Bcl-2 was significantly higher, while the expression of Bax was not signifiantly changed after exercise, compared with the non-exercised group. Expression of these proteins decreased with time after injury, towards the levels observed in sham-operated rats, however at 4 weeks postoperatively, caspase-3 expression remained significantly greater than in sham-operated rats. The present findings indicate that a reduction in apoptosis is one of the mechanisms underlying the improvement of functional recovery by exercise interventions after corticospinal tract injury.

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.

Return to Work Practices and Research with Spinal Cord Injury: An Australian Perspective

Post-injury return to work (RTW) is an important rehabilitation outcome regardless of injury type. With Spinal Cord Injury (SCI), the odds of successful RTW are lower than for the general population of work-injured. Australians living with a SCI have a higher RTW rate than many other developed countries, including the United States. Important influences on relatively higher post-injury RTW rates in the Australian context include its universal disability care policy, Australia's suite of no-fault accident insurance systems that allow for multi-faceted rehabilitation services to be provided to eligible individuals in addition to appropriate rewards for rehabilitation service providers. A combination of these systemic factors is important when delivering comprehensive rehabilitation services to those with catastrophic injuries, such as SCI. The empirical evidence on drivers of successful RTW post SCI is, however, limited in comparison to the evidence on interventions for enhanced coping following SCI. Future studies could consider the relative merits of specific RTW interventions with SCI contrasting policy and capitation systems as well as utilising study designs that take into account pre-morbid work participation and secondary health conditions.