Impact of demographic and medical factors on satisfaction with life after spinal cord injury: a normative study

Life satisfaction 18 months and 10 years following spinal cord injury: results from a New Zealand prospective cohort study

PURPOSE

To examine the life satisfaction outcomes after spinal cord injury (SCI) and to identify the factors associated with life satisfaction at 18 months and 10 years post-SCI in New Zealand (NZ).

METHODS

Adults (16-64 years) were recruited between 2007 and 2009 from NZ's two spinal units following first admission for SCI. Interviews at 6 months, 18 months, and 10 years post-SCI examined demographic, physical, psychosocial, economic, and environmental characteristics. Multivariable regression models were used to identify predictors of life satisfaction at each timepoint.

RESULTS

Overall, 118 people participated at 6 months, 103 at 18 months, and 63 at 10 years post-SCI. Pre-SCI, 90% of participants were satisfied with life, 67% were satisfied at 18 months, and 78% at 10 years. At 18 months post-SCI, participants who reported: never or sometimes using a wheelchair, no problems with self-care, no problems with anxiety or depression, no/lesser disability, or fewer secondary health conditions (SHCs) at 6 months post-SCI were more likely to be satisfied (p < 0.05), compared to those without these characteristics. Participants who experienced considerable disability at 6 months post-SCI were 22% less likely to be satisfied 10 years post-SCI compared to those experiencing no/lesser disability (p = 0.028).

CONCLUSIONS

A higher proportion of participants were satisfied at both 18 months and 10 years post-SCI than not satisfied. To improve the likelihood of satisfaction with life, increased focus on reducing disability and providing supports for those using wheelchairs, experiencing anxiety/depression or problems with self-care, and effects of SHCs are promising for future potential interventions.

The role of mindfulness in quality of life of persons with spinal cord injury: a cross-sectional study

BACKGROUND

Quality of life is considered the most overarching psychosocial adaptation outcome following the rehabilitation of persons with spinal cord injury. Literature suggests that the quality of life of persons with spinal cord injury is determined by many personal and psychological factors, including mindfulness. This study aimed to identify the direct and indirect effect of mindfulness on the quality of life of persons living with spinal cord injury.

METHODS

Participants consisted of 231 members of three spinal cord injury organizations in the United States: United Spinal Association, North American Spinal Cord Injury Consortium, and Paralyzed Veterans of America-Wisconsin Chapter. The participants completed a set of standardized self-report questionnaires in an online Qualtrics survey. A hierarchical regression analysis was performed to identify the contribution of mindfulness to quality of life, controlling for sociodemographic and injury-related factors. A serial mediation analysis was performed to examine the indirect effect of mindfulness on quality of life.

RESULTS

In the hierarchical regression analysis, sociodemographic and injury-related factors (i.e., age, gender, race, marital status, education, employment, level and completeness of injury, comorbidities, frequency of hospitalization, pain intensity, and functional limitation) and mindfulness explained 59% variance on quality of life of the participants with spinal cord injury. Mindfulness uniquely contributed to the higher quality of life above and beyond sociodemographic and injury-related variables. In the serial mediation analysis, pain and functional limitation did not significantly mediate the relationship between mindfulness and quality of life. However, the indirect effects of mindfulness on functional limitation and quality of life through pain were significant.

CONCLUSION

The findings underscore the vital role of mindfulness in improving the quality of life of persons with spinal cord injury. Implications of these findings for future research and clinical practice are discussed.

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

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

30 Years After the Americans with Disabilities Act: Perspectives on Employment for Persons with Spinal Cord Injury

The Americans with Disabilities Act, passed in 1990, represented landmark legislation and led to significant improvements in accessibility, such as prohibiting discrimination based on disability in public life, including employment. Now 30 years later, however, employment rates for persons with disabilities, including spinal cord injury, remain low. This article discusses why employment is so important for persons with spinal cord injury and challenges that remain. Presented are previously unpublished employment data from a nationally representative US sample. Finally, the state of the art of vocational rehabilitation, including models proven to facilitate this critical rehabilitation outcome, is discussed.

A study of whether individual and dyadic relations between spirituality and resilience contribute to psychological adjustment among individuals with spinal cord injuries and their family members

Objective:

To test a model of spiritual well-being and resilience among individuals with spinal cord injuries and their family members.

Design:

Prospective cross-sectional observational data were analyzed by structural equation modelling.

Setting:

Inpatient and community services at one rehabilitation hospital.

Subjects:

Individual with spinal cord injury ( n = 50) and family member ( n = 50) dyads.

Interventions:

Standard rehabilitation, both inpatient and community.

Main measure(s):

Functional assessment of chronic illness therapy – spiritual well-being scale – expanded, Connor–Davidson resilience scale, positive and negative affect scale, depression anxiety and stress scale–21, satisfaction with life scale.

Results:

Median time post-injury was 8.95 months (IQR (interquartile range) = 14.15). Individuals with spinal cord injury and family members reported high scores for both spiritual well-being (66.06 ± 14.89; 68.42 ± 13.75) and resilience (76.68 ± 13.88; 76.64 ± 11.75), respectively. Analysis found the model had acceptable fit (e.g. chi-square goodness of fit statistic = 38.789; P = .263). For individuals with spinal cord injury, spiritual well-being was positively associated with resilience which, in turn, was associated with increasing positive affect and satisfaction with life. Among family members, spiritual well-being was positively associated with resilience. Resilience was then associated with lowered levels of depression and mediated the impact of depression on satisfaction with life. Limited evidence was found for mutual dyadic links, with the only significant pathway finding that resilience in the individual with spinal cord injury was associated with increased satisfaction with life among family members.

Conclusion:

Increased spirituality and resilience make a significant contribution (both independently and in combination) to positive psychological outcomes for both individuals with spinal cord injury and their family members.

Well on wheels intervention: Satisfaction with life and health for adults with spinal cord injuries

Objective/Background: To examine how demographic and injury characteristics identify satisfaction with life (SWL), and assess the differential effects of a wellness intervention by baseline SWL groups.Design: Baseline and longitudinal analysis of a randomized controlled pilot intervention using decision tree regression and linear mixed models.Setting: Community based.Participants: Seventy-two individuals with spinal cord injury (SCI) were randomized to an intervention group (n = 39) or control group (n = 33). Participants were aged 44.1 ± 13.0 years and 13.1 ± 10.6 years post-injury. Most participants were male (n = 50; 69.4%) and had paraplegia (n = 38; 52.7%). Participants were classified as high versus low SWL at baseline using a cutoff score of 20.Interventions: The intervention aimed to increase self-efficacy, and in turn, increase engagement in health-promoting behaviors related to SWL. Six 4-hour in-person workshops were conducted over a 3-month period led by experts and peer-mentors who were available for support.Outcome measure(s): Self-efficacy for health practices, secondary condition severity, health-promoting behaviors, perceived stress, and SWL.Results: At baseline, participants with low SWL were recently injured (<4.5 years), while persons with high SWL were married and younger (<49 years old). Intervention participants with low SWL at baseline significantly improved SWL over time compared to those with high SWL (P = 0.02).Conclusion: Certain injury and demographic characteristics were associated with SWL, and intervention participants with low SWL at baseline improved their SWL over 2 years. Healthcare providers should consider time post-injury, marital status, and age in identifying individuals at risk for low SWL that may benefit from wellness interventions.

Determining priorities in functional rehabilitation related to quality of life one-year following a traumatic spinal cord injury

Context/Objective: To determine the relationship between the different functional aspects (as determined by the Spinal Cord Independence Measure) and quality of life (QOL) following a traumatic spinal cord injury (TSCI), considering clinical confounding factors.Design: Retrospective review of a prospective cohortSetting: A single Level-1 trauma center specialized in SCI careParticipants: One hundred and forty-two individuals sustaining an acute traumatic SCIInterventions: Not applicableOutcome measures: The four QOL domains as assessed by the WHOQoL-bref questionnaire 6-12 months following a TSCI.Results: Mobility subscore was the only functional aspect significantly associated with all QOL domains (physical, psychological, social and environmental). Females present better chronic social and environmental QOL when compared to males. The level of injury may also influence environmental QOL.Conclusion: Mobility training (mobility in bed, mobility with or without technical aids, transfers and stair management) should be an important part of the rehabilitation process in order to optimize chronic QOL following a TSCI.

Impact of Marital Status on 20-Year Subjective Well-being Trajectories

BACKGROUND

It is well-known that marital status has a significant impact on subjective well-being (SWB). However, research examining the long-term influence of marital status on SWB after spinal cord injury (SCI) is limited.

OBJECTIVE

To identify the relationship between marital status and SWB trajectories over time, using 20 years of longitudinal data.

METHODS

We conducted a cohort study, including 1,032 participants surveyed 5 times in 1993, 1998, 2003, 2008, and 2013. Participants were identified from outpatient records of 2 Midwestern hospitals and 1 Southeastern specialty hospital. The Life Situation Questionnaire-Revised (LSQ-R) was used to measure multiple aspects of SWB. A multilevel model was applied to analyze the 5 repeated measurements.

RESULTS

The married or cohabitating participants enjoyed the best SWB at baseline, but their home satisfaction and global satisfaction declined over time and their social isolation increased slightly. For divorced, separated, or widowed people, the negative effects of marital loss attenuated over time. For single individuals, SWB, except for environmental barriers, did not change positively over time if they remained single.

CONCLUSIONS

Using longitudinal data with 5 repeated measurements, our study showed a complicated relationship between marital and relationship status with SWB and how these relationships change over time for people with chronic SCI.

Measuring positive affect and well-being after spinal cord injury: Development and psychometric characteristics of the SCI-QOL Positive Affect and Well-being bank and short form

OBJECTIVE

To develop an item response theory (IRT)-calibrated spinal cord injury (SCI)-specific Positive Affect and Well-being (PAWB) item bank with flexible options for administration.

DESIGN

Qualitative feedback from patient and provider focus groups was used to expand on the Neurological Disorders and Quality of Life (Neuro-QOL) positive affect & well-being item bank for use in SCI. New items were created and revised based on expert review and patient feedback and were then field tested. Analyses included confirmatory factor analysis, graded response IRT modeling and evaluation of differential item functioning (DIF).

SETTING

We tested a 32-item pool at several rehabilitation centers across the United States, including the University of Michigan, Kessler Foundation, Rehabilitation Institute of Chicago, the University of Washington, Craig Hospital and the James J. Peters/Bronx Department of Veterans Affairs hospital.

PARTICIPANTS

A total of 717 individuals with SCI answered the PAWB questions.

RESULTS

A unidimensional model was observed (Confirmatory Fit Index=0.947; Root Mean Square Error of Approximation=0.094) and measurement precision was good (reliability in theta of -2.9 to 1.2 is roughly equivalent to classical reliability of 0.95 or above). Twelve items were flagged for DIF, however, after examination of effect sizes, the DIF was determined to be negligible and would have little practical impact on score estimates. The final calibrated item bank resulted in 28 retained items

CONCLUSIONS

This study indicates that the Spinal Cord Injury--Quality of Life PAWB bank represents a psychometrically robust measurement tool. Short form items are also suggested and a computer adaptive test is available.

Household income and subjective well-being after spinal cord injury: a longitudinal study

BACKGROUND

Studies regarding subjective well-being (SWB) after spinal cord injury (SCI) are increasing in recent years, but little has been contributed to the relationship between income and SWB.

OBJECTIVE

By using longitudinal data, we want to identify (1) the overall trend in SWB over a 10-year period; (2) the association between household income and SWB at baseline; (3) the variation of the trajectory of SWB over 10 years among different household income groups; and (4) the variation of change rates of SWB over 10 years among different household income groups.

METHODS

We conducted a cohort study, including 434 participants who completed 3 measurements in 1998, 2003, and 2008. They were identified from outpatient records of 2 midwestern hospitals and a southeastern specialty hospital.

RESULTS

People with lower household income experienced more life problems and less life satisfaction at the baseline measurement. During the 10-year period, their health problems and environmental barriers significantly increased compared to persons with higher income. Increasing vocational satisfaction was the only favorable change for the lower income group.

CONCLUSIONS

There were consistent disparities in SWB related to income, and these typically persisted over time. Therefore, with the exception of vocational satisfaction, few changes may be anticipated in SWB that would narrow the gap between high and low income.

Domain-specific satisfaction in adults with pediatric-onset spinal cord injuries

STUDY DESIGN

Interview using a structured questionnaire and standardized measures.

OBJECTIVES

To determine domain-specific satisfaction levels in adults with pediatric-onset spinal cord injuries (SCI), to determine factors associated with these levels of satisfaction, and to determine the relationship of domain-specific satisfaction to overall life satisfaction in this population.

SETTING

US and Canada.

METHODS

The participants were adults who sustained SCI at age 18 years or younger and were 24 years of age or older at the time of interview and did not have significant head injury. In addition to providing information about themselves, including education level, employment, marital status, and community participation, they were asked to rate their level of satisfaction in seven domains: transportation in the community, educational achievement, employment opportunities, income, social/recreational opportunities, dating opportunities, and sexual experience. They also completed the satisfaction with life scale (SWLS), the Craig handicap assessment and reporting technique, the functional independence measure, and the short-form-12 perceived health scale.

RESULTS

A total of 216 individuals were interviewed. The mean age at injury was 14 years and the mean age at interview was 29 years. From most satisfied to least satisfied, the domains were ranked in the following order: satisfaction with transportation in the community, educational achievement, social and recreational opportunities, sexual experiences, dating opportunities, job opportunities, and income. Age at interview, gender, and perceived health were identified in regression analyses as predictors of some of the domain-specific satisfactions, but the primary predictive factors were in the area of participation. Neither severity of neurologic impairment nor level of functional independence were predictors for any of the domains. Satisfaction in each of the domains was significantly associated with SWLS and satisfaction with dating, job opportunities, education, and income were identified as predictive factors in a regression analysis.

CONCLUSIONS

Dating opportunities, job opportunities, and income are the three domains in which adults with pediatric-onset SCI are least satisfied and those domains have a significant impact on overall satisfaction.

Racial Disparities in Depression and Life Satisfaction After Spinal Cord Injury: A Mediational Model

PURPOSE: To identify the relationship of race and gender with 3 aspects of life satisfaction and depressive symptoms after spinal cord injury (SCI), evaluating the extent to which socioeconomic factors mediate any observed relationships. METHODS: Adults with traumatic SCI of at least 1-year duration (N = 1,549) were identified through a Southeastern United States SCI Model System of care, and cross-sectional survey data were collected at a Southeastern United States medical university. Three aspects of life satisfaction (home life satisfaction, vocational satisfaction, global satisfaction) were measured using 20 satisfaction items from the Life Situation Questionnaire-Revised. The Older Adult Health and Mood Questionnaire measured depressive symptoms. MANCOVA assessed mediation of socioeconomic status between race and life satisfaction and depression. RESULTS: Home life satisfaction and vocational satisfaction were significantly related to race, with White participants scoring higher than Black participants during the first stage of the regression. However, socioeconomic factors mediated the relationships such that race was no longer significant after considering economic factors. Race was significantly associated with global satisfaction after adjusting for socioeconomic factors. Depression was not significantly related to race. Gender was unrelated to all study outcomes. Of the socioeconomic mediators, family income was a significant predictor of each outcome, whereas education was only predictive of vocational satisfaction. CONCLUSION: Socioeconomic factors are important mediators of the relationship between race and certain aspects of life satisfaction among persons with SCI. Family income and, to a lesser extent, education should be considered when evaluating race differences in life satisfaction after SCI.

Returning to work after spinal cord injury: exploring young adults' early expectations and experience

PURPOSE

The study sought to explore experience and expectations about paid work among young adults on sick leave after spinal cord injury (SCI).

METHOD

Eight participants with traumatic SCI, who were 20-34 years of age, and had not yet returned to work 1-5 years post-injury, were interviewed. Selection was made with purposive sampling. Data were analysed using a constant comparative method.

RESULTS

Four main themes emerged as relevant: 'finding your way to an everyday life where work is possible', 'at the crossroads, expectations of work through education', 'expectations of paid work as part of a desired future life' and 'expectations of finding a solution within oneself or with help from others'. The findings reveal high expectations of work ability but at the same time difficulties to plan for return to work and lack of support in this process.

CONCLUSIONS

The participants represent a vulnerable group in vocational rehabilitation due to their young age and recent injury. Without formal training or suitable work experience, they need tailored work support as part of their general rehabilitation.

Goal striving and maladaptive coping in adults living with spinal cord injury: associations with affective well-being

OBJECTIVE

The current study examined how goal engagement and two coping strategies (self-blame and denial) hypothesized to prevent successful disengagement relate to affective well-being among adults with a functional disability.

METHOD

Ninety-nine community-dwelling adults (23 to 76 years old, 66 men) with spinal cord injury participated in structured interviews assessing affective well-being using the Positive and Negative Affect Scale (Watson, Clark, & Tellegen, 1988); goal engagement using a modified version of the Optimization, Primary, and Secondary Control Scale (Heckhausen, Schulz, & Wrosch, 1998); and self-blame and denial using items from Carver's (1997) Brief COPE Inventory.

RESULTS

Greater goal engagement was significantly associated with positive but not negative affect. Greater use of self-blame and denial coping was associated with lower positive affect for older adults and higher negative affect across the age range.

IMPLICATIONS

Men's adjustment to spinal cord injury: the unique contributions of conformity to masculine gender norms

Men constitute 82% of the approximately 250,000 people in the United States living with a spinal cord injury. Unfortunately, however, little is known about the impact of men's adherence to gender norms on their adjustment to such injuries. The present investigation examined the utility of masculine norms in explaining variance in depression beyond that accounted for by commonly identified predictors of men's adjustment following spinal cord injury. As hypothesized, results suggested that men's adherence to masculine norms accounted for unique variance in their depression scores beyond that contributed by social support, environmental barriers/access, and erectile functioning. Respondents who adhered to norms stressing the primacy of men's work demonstrated lower rates of depression, whereas those who conformed to norms for self-reliance demonstrated higher depression scores. The authors discuss future research directions and potential psychotherapeutic strategies for working with men with spinal cord injuries.

The associations between life satisfaction and health-related quality of life, chronic illness, and health behaviors among U.S. community-dwelling adults

The primary purpose of this article was to examine the associations between life satisfaction level and health-related quality of life (HRQOL), chronic illness, and adverse health behaviors among adults in the U.S. and its territories. Data were obtained from the 2005 Behavioral Risk Factor Surveillance System, an ongoing, state-based, random-digit telephone survey of the noninstitutionalized U.S. population aged >or=18 years. An estimated 5.6% of U.S. adults (about 12 million) reported that they were dissatisfied/very dissatisfied with their lives. As the level of life satisfaction decreased, the prevalence of fair/poor general health, disability, and infrequent social support increased as did the mean number of days in the past 30 days of physical distress, mental distress, activity limitation, depressive symptoms, anxiety symptoms, sleep insufficiency, and pain. The prevalence of smoking, obesity, physical inactivity, and heavy drinking also increased with decreasing level of life satisfaction. Moreover, adults with chronic illnesses were significantly more likely than those without to report life dissatisfaction. Notably, all of these associations remained significant after adjusting for sociodemographic characteristics. Our findings showed that HRQOL and health risk behaviors varied with level of life satisfaction. As life satisfaction appears to encompass many individual life domains, it may be an important concept for public health research.

Return to work following spinal cord injury: a review

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Psychological impact of sports activity in spinal cord injury patients

OBJECTIVE

To investigate whether sports activity is associated with better psychological profiles in patients with spinal cord injury (SCI) and to evaluate the effect of demographic factors on psychological benefits.

METHODS

The State-Trait Anxiety Inventory, Form X2 (STAI-X2), the Eysenck Personality Questionnaire for extraversion (EPQ-R (E)) and the questionnaire for depression (QD) were administered in a cross-sectional study of 137 males with spinal cord injury including 52 tetraplegics and 85 paraplegics. The subjects were divided into two groups according to sports activity participation (high frequency vs no sports participation). Moreover, multiple regression analysis was adopted to investigate the influence of demographic variables, such as age, educational level, occupational status and marital status, on psychological variables.

RESULTS

Analysis of variance revealed significant differences among the groups for anxiety (STAI-X2), extraversion (EPQ-R (E)) and depression (QD). In particular, SCI patients who did not practice sports showed higher anxiety and depression scores and lower extraversion scores than sports participants. In addition, with respect to the paraplegics, the tetraplegic group showed the lowest depression scores. Following multiple regression analysis, only the sports activity factor remained as an independent factor of anxiety scores.

CONCLUSION

These findings demonstrate that sports activity is associated with better psychological status in SCI patients, irrespective of tetraplegia and paraplegia, and that psychological benefits are not emphasized by demographic factors.

Stability of transition to adulthood among individuals with pediatric-onset spinal cord injuries

BACKGROUND/OBJECTIVE

Cross-sectional studies have provided information about the outcomes of adults with pediatric-onset spinal cord injuries (SCIs), but there has been no information about the stability of those outcomes over time. The purpose of this study was to assess the stability of independent living, employment, and life satisfaction and to determine factors associated with stable, successful outcomes.

METHODS

Structured interviews of individuals who had sustained an SCI at age 18 years or younger and were 24 years or older at first interview. The primary standardized measures used include the Functional Independence Measure, Craig Handicap Assessment and Recording Technique (CHART), Short-Form 12 measure of perceived health, and the Satisfaction with Life Scale.

RESULTS

One hundred sixty-six individuals had 3 consecutive annual interviews. Mean age at interview was 29 years (range, 24-36 years). Of this group, 64% lived independently at the first interview, and 90% of those continued to live independently; 64% were employed at first interview, of which 83% continued to be employed; and 48% reported life satisfaction at the first interview, and 84% of these continued to be satisfied. Factors most closely associated with stable independent living were CHART subscales of physical independence, mobility, and occupation. Factors associated with stable employment were sex, race, independent living, CHART mobility, and cognitive independence. Factors associated with stable life satisfaction were CHART occupation subscale and fewer pressure ulcers.

CONCLUSIONS

Many individuals with pediatric-onset SCI achieve successful, stable adult outcomes. The factors associated with that success can help us improve rehabilitation for future patients.

Burden of support for partners of persons with spinal cord injuries

STUDY DESIGN

Cross-sectional survey.

OBJECTIVES

(1) To describe the support given to persons with spinal cord injuries (SCI) by their partners, (2) to describe the perceived burden of support by partners and (3) to examine predictors of perceived burden of support.

SETTING

The Netherlands.

METHODS

All members of the Dutch patients organisation DON (N = 1004) and their caregivers, if applicable, were invited. Physical disability of the person with SCI was measured using the Barthel Index (BI). A number of secondary conditions, other practical problems and psychosocial problems were recorded. Partner support was described using a list of ADL-support, other practical support and emotional support. Burden of support was measured by a six-item measure (Cronbach's alpha 0.92), Nonparametric descriptive statistics and correlations were used. Linear regression was used to identify predictors of caregiver burden.

RESULTS

Responses were obtained from 461 persons with SCI. Of 265 couples, patient as well as partner data were available. Mean age of the partners was 49.4 years (SD 12.2) and 69.8% were women. Mean BI of the persons with SCI was 12.3 (SD 4.7) on a 0-20 scale and 60.4% were seriously disabled (BI < 15). Most partners provided various kinds of support. ADL-support and other practical support were given much more often by partners of persons with serious disability, but less difference was seen regarding emotional support. Professional (paid) support was obtained by 45.3% of all couples. Perceived burden of support was high in 24.8% of partners of persons with serious disabilities against 3.9% of partners of persons with minor disabilities. Significant predictors of caregiver burden were (in order of importance) the amount of ADL support given, psychological problems of the patient, partner age, partner gender, BI score and time after injury (total explained variance 47%).

CONCLUSION

A substantial proportion of partners of persons with SCI suffer from serious burden of support. Prevention of caregiver burnout should be part of the lifelong care for persons with SCI.

Aging with spinal cord injury

The years after SCI may be associated with acceleration of the aging process because of diminished physiologic reserves and increased demands on functioning body systems. Clinicians with expertise in the treatment and prevention of SCI-specific secondary complications need to collaborate with gerontologists and primary care specialists and need to invest in the training of future physicians to ensure a continuum of accessible, cost-effective, and high-quality care that meets the changing needs of the SCI population. Managed care payers often do not adequately cover long-term disability needs to prevent secondary SCI-specific complications. In this era of increasing accountability, evidence-based clinical practice guidelines are needed to document scientific evidence and professional consensus to effectively diagnose, treat, and manage clinical conditions; to reduce unnecessary testing and procedures; and to improve patient outcomes. Longitudinal research is needed to minimize cohort effects that contribute to misinterpretation of cross-sectional findings as representative of long-term changes in health and functioning. However, longitudinal studies confound chronologic age, time since injury, and environmental change. Thus, time-sequential research, which controls for such confounding effects, is essential, as is research on the effects of gender,culture, and ethnicity. If we consider how much progress has been made over the past 50 years with respect to SCI mortality related to infectious disease, we can expect to achieve even greater progress against the effects of aging in the next 50 years. Recent developments in molecular biology regarding growth and neuro-trophic factors are bringing us closer to the goal of repairing the damaged spinal cord. The challenge remains for rehabilitation professionals to provide the most comprehensive and holistic approach to long-term follow-up, with an emphasis on health promotion and disease prevention, to postpone functional decline and enhance QOL.

Overview of adult outcomes in pediatric-onset spinal cord injuries: implications for transition to adulthood

OBJECTIVE

To provide an overview of the adult outcomes of individuals with pediatric-onset spinal cord injuries (SCIs) and the implications of those findings for transition to adulthood.

METHOD

Structured interview including standardized measures.

PARTICIPANTS

Individuals who sustained SCI at < or = 18 years of age and were > or = 24 years of age at interview; matched community controls.

OUTCOME MEASURES

A structured interview including demographics and medical complications. Standardized measures include the Functional Independence Measure, Craig Handicap Assessment and Reporting Technique (CHART), Short Form-12 (SF-12), and Satisfaction with Life Scale (SWLS).

RESULTS

Of 265 individuals interviewed (mean age at injury, 13.9 years; mean age at follow-up, 27.8 years), 67% were males, 87% were white, and 59% had tetraplegia. Results showed that 32% had a college degree, 57% were employed, 65% were living independently, and 20% were married; the median income was 12,000 dollars. Compared with controls, subjects were less likely to live independently, be married, have children, or be employed. They showed significantly less community participation, significantly lower life satisfaction, and significantly lower perceived physical health. Multiple regression analyses were conducted for 5 outcomes (independent living, employment, income, CHART total, and SWLS), using demographic factors, impairment, medical complications, use of street drugs, and functional independence as independent variables. Functional independence and education were significantly associated with all five outcomes. Illegal drug use was associated with independent living, employment, and SWLS. Race was associated with employment and CHART. Medical complications were associated with CHART and SWLS. Gender was only associated with living independently, and age at injury was only associated with SWLS. Level of injury was not associated with any of the outcomes.

CONCLUSIONS

Adults with pediatric-onset SCI have adult outcomes that are below the level of their peers. These results have implications for improving the transition to adulthood for future patients with pediatric-onset SCI.

A Study of Spirituality and Life Satisfaction Among Persons with Spinal Cord Injury

The purpose of this study was to investigate the relationship of spirituality and life satisfaction among persons with spinal cord injury. A nationwide sample of 230 persons with long-term spinal cord injury completed the Satisfaction With Life Scale (SWLS), the Quality of Life Index (QLI), and a demographic data form. Data analysis also indicated that there was a significant positive correlation between life satisfaction and psychological/spiritual factors of the QLI instrument. Nurses are mandated by the International Council of Nurses, the Joint Commission on Accreditation of Healthcare Organizations, and the Patient's Bill of Rights (Maddox, 2001) to provide spiritual care for clients. Rehabilitation nurses have the opportunity to support spirituality and life satisfaction as we assist our clients with disabilities to redefine their lives and explore new life opportunities.

Aging with spinal cord injury: Changes in selected health indices and life satisfaction11No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated

OBJECTIVES

To document the impact of age, age at injury, years postinjury, and injury severity on changes over time in selected physical and psychosocial outcomes of people aging with spinal cord injury (SCI), and to identify the best predictors of these outcomes.

DESIGN

Retrospective cross-sectional and longitudinal examination of people with SCI.

SETTING

Follow-up of people who received initial rehabilitation in a regional Model Spinal Cord Injury System.

PARTICIPANTS

People who meet the inclusion criteria for the National Spinal Cord Injury Database were studied at 5, 10, 15, 20, and 25 years postinjury.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Number of pressure ulcers, number of times rehospitalized, number of days rehospitalized, perceived health status, satisfaction with life, and pain during the most recent follow-up year.

RESULTS

The number of days rehospitalized and frequency of rehospitalizations decreased and the number of pressure ulcers increased as time passed. For the variables of pressure ulcers, poor perceived health, the perception of pain and lower life satisfaction, the best predictor of each outcome was the previous existence or poor rating of that same outcome.

CONCLUSIONS

Common complications of SCI often herald the recurrence of those same complications at a later point in time, highlighting the importance of early intervention to prevent future health and psychosocial difficulties.

Quality of life in spinal cord injured individuals and their caregivers during the initial 6 months following rehabilitation

Addressing quality of life (QOL) issues in the spinal cord injured (SCI) population is imperative as the majority survive their initial injury and longevity now approaches that of the general population. The purpose of this mixed method, descriptive, longitudinal feasibility study was to describe and compare QOL in 10 adult SCI individuals and their family caregivers (FCs) during the initial 6 months following rehabilitation. Instruments used were the SF-36 and two horizontal visual analog scales, one for pain and one for QOL. Participants completed the instruments and a face-to-face in-depth interview at 1-, 3-, and 6-months following inpatient rehabilitation. SCI individuals reported low physical function, role physical (RP), and role emotional (RE) scores on the SF-36, while reporting high general health (GH), mental health and social functioning on the SF-36. FCs reported lower RP, GH and vitality scores, while reporting higher physical functioning and RE scores. On the visual analog scales, persons with SCI reported lower QOL while FCs reported more pain at 3 and 6 months. This study suggests that more work is needed to identify interventions which could enhance QOL during the transition from rehabilitation to home for SCI individuals and their FCs.

Satisfaction with medical rehabilitation after spinal cord injury

STUDY DESIGN

Retrospective.

OBJECTIVE

To predict satisfaction with medical rehabilitation.

SUMMARY OF BACKGROUND DATA

While spinal cord injury (SCI) patient satisfaction with life and community services has been investigated, satisfaction with medical rehabilitation has not.

METHODS

Information submitted to the Uniform Data System for Medical Rehabilitation (1998-2001) by 134 hospitals/rehabilitation facilities in the United States (n = 6,205 patients with SCI) was examined. Predictors were sociodemographic variables, Case Mix Groupings (CMG) (401-505, 5001), length of stay, rehospitalization, follow-up therapy, and health maintenance. Satisfaction was assessed at a mean of 92.2 days (SD 11.9 days) postdischarge. Data were analyzed according to who reported the outcome (patient, n = 3,858 or family/other, n = 1,869). Statistical modeling was conducted using logistic regression.

RESULTS

High overall satisfaction was reported (94%). Significant predictors for the patient report data were CMG and rehospitalization. Compared with CMG 5001 (short stay, <3 days), patients in CMGs 401/2/3 and 501/2/3/4/5 had a 54% to 74% lower likelihood of being dissatisfied. Rehospitalized patients had a higher likelihood of dissatisfaction (odds ratio 2.3, 95% confidence interval 1.7 to 3.2). Significant predictors for the family/other report data were CMG (compared to CMG 5001, CMGs 401/2, 403, and 501/2 had a 70% lower likelihood of dissatisfaction), rehospitalization (odds ratio 1.7, 95% confidence interval 1.1-2.5), and marital status (married = 50% lower likelihood of dissatisfaction, 95% confidence interval 0.26-0.96).

CONCLUSIONS

Satisfaction with medical rehabilitation services following SCI is related to functional abilities, rehospitalization, and marital status. Slightly different results were found for whether satisfaction was rated by the patient or family/other. The complex relationships among satisfaction, patient demographics, and functional status require continued examination.

Race: predictor versus proxy variable? Outcomes after spinal cord injury

OBJECTIVE

To examine the impact of race on acute, rehabilitation, and long-term outcomes after spinal cord injury (SCI).

DESIGN

Two case control studies (study 1: acute and rehabilitation outcomes, study 2: long-term outcomes) in which white and nonwhite individuals were matched case for case on multiple demographic, medical, and geographic characteristics with the rationale being that a case-control methodology would increase the internal validity of the design, thereby increasing confidence in the assertion that any between-group differences observed may be specifically attributed to race.

SETTING

Data drawn from the Spinal Cord Injury Model Systems. Institutional practice and general community.

PARTICIPANTS

Study 1: 187 pairs of individuals, study 2: 158 pairs of matched individuals.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Outcome measures assessed included economic (eg, cost of care), treatment-related (eg, length of hospital stay), functional (eg, FIM instrument), and medical (eg, number of medical complications) variables, as well as self-reported life satisfaction, level of handicap, and mental and physical health.

RESULTS

In study 1, none of the outcome measures differed significantly across racial groups. Similarly, study 2 failed to indicate significant differences in any of the outcome variables across racial groups, with the exception that nonwhites were at increased risk of greater self-reported handicap in the area of mobility. Power analyses indicated these finding were not merely the result of inadequate power.

CONCLUSION

For the outcomes assessed in studies 1 and 2, race appeared to act primarily as a proxy for other variables (eg, injury severity, age, educational achievement), which in turn may be associated with poor outcome after SCI. Theoretical implications and recommendations are discussed.

Predictors of life satisfaction: a spinal cord injury cohort study

OBJECTIVE

To determine unique demographic, medical, perceived health, and handicap predictors of life satisfaction 2 years after spinal cord injury (SCI), as well as the predictors of change in life satisfaction from year 1 to year 2.

DESIGN

Prospective predictive study performed by using longitudinal data from 18 Spinal Cord Injury Model Systems.

SETTING

University physical medicine and rehabilitation department.

PARTICIPANTS

Adults with traumatic onset SCI (N = 940) evaluated at 1 and 2 years' postinjury.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Satisfaction with Life Scale (SWLS) 2 years post-SCI.

PREDICTOR VARIABLES

demographic characteristics, impairment and disability classifications, and 1 year post-SCI measures of life satisfaction (SWLS), medical complications, self-perceived health (Medical Outcomes Study 12-Item Short-Form Health Survey), and extent of handicap (Craig Handicap Assessment and Reporting Technique).

RESULTS

The factors uniquely associated with an increased risk of lower self-reported life satisfaction at year 2 post-SCI included being male and unemployed, with poor perceived health, decreased mobility, and decreased social integration. After controlling for year 1 estimates of life satisfaction (ie, examining change in life satisfaction), only mobility and perceived health were uniquely related to life satisfaction 2 years post-SCI.

CONCLUSION

Mobility and perceived health appear to be the consistent predictors of life satisfaction at year 2 post-SCI, as well as change in satisfaction from year 1 to year 2. Because both factors are amenable to change, they are reasonable targets of intervention programs. Identifying specific mechanisms of perceived health and mobility associated with life satisfaction should be an important area of continued research.