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.     

Objective measures of neighborhood environment and self-reported physical activity in spinal cord injured men

Liang H, Tomey K, Chen D, Savar NL, Rimmer JH, Braunschweig CL. Objective measures of neighborhood environment and self-reported physical activity in spinal cord injured men.

Objectives

To assess the relationship between objective neighborhood environment and self-reported physical activity (PA) and between PA and obesity-related risk factors in people with spinal cord injury (SCI).

Design

A cross-sectional study.

Setting

Urban university.

Participants

Men with SCI (N=131), 20 to 59 years old, at least 1 year postinjury and using wheelchair for mobility most of the time.

Interventions

Not applicable.

Main Outcome Measures

Metabolic syndrome (abdominal obesity, elevated blood pressure, glucose, triglycerides, and low-high density lipoprotein cholesterol) and high C-reactive protein (CRP), as well as total PA metabolic equivalent score.

Results

Lower PA was associated with higher prevalence rate for elevated triglycerides, metabolic syndrome, and high CRP. Compared with those in low PA tertile, those in high PA tertile had significantly lower odds for elevated triglycerides (odds ratio [OR]=.19; 95% confidence interval [CI], .04–.80), metabolic syndrome (OR=.15; 95% CI, .03–.66) and high CRP (OR=.17; 95% CI, .04–.71) while adjusting for relevant factors. In crude analysis, lower PA was associated with neighborhood environmental characteristics including shorter distance to nearest transit stops, smaller mean block area, greater number of transit stops, high vacant housing, and higher neighborhood crime rate. In multivariate analysis higher total crime was the only risk factor significantly associated with lower PA level. Those living in higher crime rate neighborhoods had 86% lower odds of having greater than median PA level (OR=.14; 95% CI, .04–.49) than their counterparts.

Conclusions

In men with SCI, lower PA is independently associated with having elevated triglycerides, metabolic syndrome, and high CRP. Additionally, lower PA is associated with higher neighborhood crime rate.     

The experiences of physical rehabilitation in individuals with spinal cord injuries: a qualitative thematic synthesis

Purpose: The purpose of this thematic synthesis review was to identify and synthesise published qualitative research on the perspectives of individuals with spinal cord injuries with respect to physical rehabilitation interventions.

Materials and methods: The peer-reviewed literature was searched across seven databases and identified abstracts were independently screened by two reviewers. A thematic synthesis methodology was used to code and synthesise the results from the included studies.

Results: In total, 7233 abstracts were identified; 31 articles were selected for inclusion, representing 26 physical rehabilitation interventions. The methodological quality of studies was moderate (Standards for Reporting Qualitative Research mean?±?standard deviation?=?14.39?±?3.61). The four main themes developed were: (1) Benefits of physical rehabilitation, (2) Challenges of physical rehabilitation, (3) Need for support, and (4) Issue of control.

Conclusions: This qualitative thematic synthesis provides key insights into the experiences of individuals with spinal cord injuries who received physical rehabilitation. Recommendations for practice, based on the findings, include creating a diverse, encouraging, and educational physical rehabilitation experience with supportive staff who focus on communication and person-centred care.

• Implications for Rehabilitation

• Physical rehabilitation provides psychological as well as physical benefits to people with spinal cord injuries, including motivation, hope, improved self-confidence, and acceptance.

• Challenges identified during physical rehabilitation for people with spinal cord injuries, such as comparisons, negative emotions, recovery expectations, and slow progress, should be addressed by healthcare professionals to ensure person-centred care.

• People with spinal cord injuries identified a need for support from health care professionals, family, and friends, as well other people with spinal cord injuries.

• There is an issue of control in physical rehabilitation for people with spinal cord injuries, which can result in a fight with oneself or with healthcare professionals to regain the control that has been lost.

     

Out-patient rehabilitation programme for spinal cord injured patients: Evaluation of the results on motor FIM score

Purpose. The aim of this study was to evaluate an out-patient attention programme based on a short in-patient phase followed by an out-patient interdisciplinary rehabilitation programme.

Methods. A prospective quasi-experimental before-and-after study was carried out; a phase 2 trial. The study population consisted of 42 patients who met the inclusion criteria. The Functional Independence Measurement (FIM) was the main outcome, and the American Spinal Injury Association (ASIA) motor scores and morbidity the secondary ones. The intervention was a two-phase goal-based interdisciplinary programme which consisted of a hospital and an ambulatory phase. After an evaluation upon admission to hospital, follow-up was carried out 1, 3, 6, 12 and 18 months later.

Results. Initially, 208 patients were evaluated and only 42 completed the study. The in-patient phase was short (average: 13.5 days) and the out-patient phase lasted 18 months. Motor FIM scores progressively increased from 25/91 up to 69/91 (p < 0.01). Some 25% of the patients had pressure sores at 1 month, and 11.9% still had them after 18 months. Pain was the most frequent complication, in 80% of patients by the third month. Urinary and fecal continence improved during follow-up (74% at 18 months and 81.1% at 12 months, respectively).

Conclusions. Good functional evolution of SCI patients and low morbidity can be obtained with a low-cost out-patient rehabilitation programme. Such a programme must emphasize patient and family education concerning self-care and possible SCI complications.     

Acupuncture for chronic shoulder pain in persons with spinal cord injury: a small-scale clinical trial

OBJECTIVE: To determine the efficacy of acupuncture in the treatment of chronic musculoskeletal shoulder pain in subjects with spinal cord injury (SCI). DESIGN: Randomized, double blind (participants, evaluator), placebo (invasive sham) controlled trial. SETTING: Clinical research center. PARTICIPANTS: Seventeen manual wheelchair-using subjects with chronic SCI and chronic musculoskeletal shoulder pain. INTERVENTIONS: Participants were randomly assigned to receive 10 treatments of either acupuncture or invasive sham acupuncture (light needling of nonacupuncture points). MAIN OUTCOME MEASURE: Changes in shoulder pain intensity were measured using the Wheelchair User's Shoulder Pain Index. RESULTS: Shoulder pain decreased significantly over time in both the acupuncture and the sham acupuncture groups (P=.005), with decreases of 66% and 43%, respectively. There was no significant difference between the 2 groups (P=.364). There was, however, a medium effect size associated with the acupuncture treatment. CONCLUSIONS: There appears to be an analgesic effect or a powerful placebo effect associated with both acupuncture and sham acupuncture. There was a medium treatment effect associated with the acupuncture, which suggests that it may be superior to sham acupuncture. This observation, along with the limited power, indicates that a larger, more definitive randomized controlled trial using a similar design is warranted.     

肠道综合物理疗法对不完全性脊髓损伤患者便秘的影响

目的：通过3种方法的对比观察肠道综合物理疗法对不完全性脊髓损伤患者便秘的影响。方法：选取符合入组条件的不完全性脊髓损伤患者30例,随机分为A、B、C 3组各10例。在常规干预的基础上,A组进行生物反馈电刺激治疗,B组进行肠道运动疗法治疗,C组进行肠道综合物理疗法（生物反馈电刺激结合肠道运动疗法）的治疗,治疗前后比较神经源性肠道功能障碍（NBD）评分量表、Wexner便秘评分量表、便秘患者生活质量量表评分（PAC-QOL）、便秘患者症状自评量表评分（PAC-SYM）、乳果糖及开塞露用量、肛门直肠测压等指标,分析评估疗效。结果：治疗4周后,3组的NBD、Wexner便秘,PAC-QOL及PAC-SYM评分均较治疗前有明显减少（P<0.01）,乳果糖及开塞露用量均较治疗前有明显减少(P<0.01),肛门收缩压较治疗前有明显增加(P<0.01),直肠容量感觉阈值较治疗前有明显减少(P<0.05),肛门静息压治疗前后差异无统计学意义;治疗后,C组各项量表评分、乳果糖及开塞露用量均较A、B组有明显减少(P<0.05),A、B组间差异无统计学意义,直肠测压各项指标3组间比较差异无统计学意义。结论：3种方法均可改善不完全脊髓损伤患者的便秘症状,肠道综合物理疗法比单独生物反馈电刺激及肠道运动疗法对不完全性脊髓损伤后便秘的改善作用更显著。     

自体骨髓间质干细胞移植联合神经营养因子及综合康复治疗脊髓损伤

目的:探讨自体骨髓间质干细胞移植联合神经营养因子及综合康复治疗脊髓损伤的疗效和安全性。方法:经91例脊髓损伤患者知情同意并签署知情同意书后,给予自体骨髓间质干细胞移植联合神经营养因子及综合康复治疗。治疗前后按美国脊髓损伤学会评分标准评分,同时进行神经电生理和影像学方面的对比分析。治疗后每3个月随访1次,随访1年。结果:91例脊髓损伤患者术后美国脊髓损伤学会评分的平均数较术前提高,其中41例出现运动、感觉、影像学、神经电生理方面的不同改善;32例出现不同程度的运动、感觉、神经电生理方面的改善;12例出现神经电生理方面的改善;6例无变化。1例严重复合伤患者出现并发症,经积极治疗无效死亡。在随后的1年随访中,除2例失访外,其余患者均有不同程度进一步恢复的趋势,无明显不良反应发生。结论:自体骨髓间质干细胞移植联合神经营养因子及综合康复治疗可部分促进脊髓损伤的恢复,改善神经功能,是一种中西医结合治疗脊髓损伤安全有效的新策略,有临床推广应用价值。     

Outpatient spinal cord injury rehabilitation: managing costs and funding in a changing health care environment

Purpose. To examine the literature describing the cost of outpatient rehabilitation for patients with spinal cord injury (SCI) as well as the effect of funding type on cost and outcome. A SCI rehabilitation planning and funding model is presented that calls for structured assessment of the client's economic environment, with follow through to promote full access to funding for rehabilitation plans.

Method. Literature review of specific outpatient rehabilitation intervention costs and effect of funding type, followed by development of a funding model to improve access to available funding for SCI rehabilitation.

Results. There is insufficient economic data to draw conclusions about the relationship between an individual's rehabilitation needs and access to appropriate funding for outpatient rehabilitation. Consequently, health providers and payers need to adopt an approach that will improve consistency of payment decisions and access to necessary funding for rehabilitation.

Conclusions. A model for a more formal approach to: (a) Assessment of a client's economic environment; (b) use of evidence-based SCI rehabilitation; and (c) use of available financial resources should promote better access to appropriate rehabilitation following SCI.     

Outpatient spinal cord injury rehabilitation: Managing costs and funding in a changing health care environment

Purpose. To examine the literature describing the cost of outpatient rehabilitation for patients with spinal cord injury (SCI) as well as the effect of funding type on cost and outcome. A SCI rehabilitation planning and funding model is presented that calls for structured assessment of the client's economic environment, with follow through to promote full access to funding for rehabilitation plans.

Method. Literature review of specific outpatient rehabilitation intervention costs and effect of funding type, followed by development of a funding model to improve access to available funding for SCI rehabilitation.

Results. There is insufficient economic data to draw conclusions about the relationship between an individual's rehabilitation needs and access to appropriate funding for outpatient rehabilitation. Consequently, health providers and payers need to adopt an approach that will improve consistency of payment decisions and access to necessary funding for rehabilitation.

Conclusions. A model for a more formal approach to: (a) Assessment of a client's economic environment; (b) use of evidence-based SCI rehabilitation; and (c) use of available financial resources should promote better access to appropriate rehabilitation following SCI.     

Influence of hand cycling on physical capacity in the rehabilitation of persons with a spinal cord injury: a longitudinal cohort study

Valent LJ, Dallmeijer AJ, Houdijk H, Slootman HJ, Post MW, van der Woude LH. Influence of hand cycling on physical capacity in the rehabilitation of persons with a spinal cord injury: a longitudinal cohort study.

Objective

To investigate the influence of hand cycling on outcome measures of physical capacity during and after rehabilitation in persons with paraplegia and tetraplegia in The Netherlands.

Design

A longitudinal cohort study with measurement moments at the start (t1) and end (t2) of clinical rehabilitation and 1 year after discharge (t3). Hand cycle use was assessed by means of questionnaires at t2 and t3.

Setting

Eight rehabilitation centers in The Netherlands.

Participants

Subjects (N=162) with a recent spinal cord injury.

Interventions

All subjects followed the regular rehabilitation program.

Main Outcome Measures

Peak oxygen uptake (Vo₂peak) and peak power output (POpeak) determined in a handrim wheelchair peak exercise test, peak muscle strength of the upper extremities, and pulmonary function.

Results

A significantly larger increment in Vo₂peak, POpeak, and elbow extension strength was found in subjects with paraplegia during clinical rehabilitation. No such effect was found in subjects with tetraplegia. In the postrehabilitation period, no influence of hand cycling on any outcome measure was found in subjects with paraplegia or subjects with tetraplegia.

Conclusions

After correction for baseline values and confounders, regular hand cycling (once a week or more) appeared to be beneficial for improving aerobic physical capacity in persons with paraplegia during clinical rehabilitation. The small and heterogeneous study groups may have hampered the finding of positive results of hand cycling in persons with tetraplegia.     

The effect of motivational interviewing on physical activity level among older adults: a systematic review and meta-analysis

Abstract

Aim: To determine the reported effect of randomized controlled trials (RCTs) using Motivational Interviewing (MI) to advance physical activity among older adults.

Methods: We searched for RCTs in MEDLINE, EMBASE, CINAHL, AgeLine, PsycINFO and Cochrane Library from inception until March, 2019. Identified trials that used MI for improving physical activity in community-dwelling older adults (≥65?years).

Results: From 5616 citations identified from the search, we included three trials (four publications). There was no evidence of a significant difference between the effect of MI and usual care on physical activity in older adults (Standard Mean Difference (SMD) -0.02, 95% Confidence Interval (CI) 0.05 to 0.46, I² 16%; 3 trials; 84 participants).

Conclusion: There is insufficient evidence to support the effect of MI on improving physical activity among older adults. There is a need for more high quality trials to show that MI is beneficial in older adults who are physically inactive.     

Narrative environments and the capacity of disability narratives to motivate leisure-time physical activity among individuals with spinal cord injury

Abstract

Purpose: Few individuals with spinal cord injury (SCI) engage in the recommended amount of leisure time physical activity (LTPA). Yet little is known about how, and why, active individuals engage in specific types of LTPA. This study explored how a unique narrative environment and disability narratives motivated individuals with SCI to engage in LTPA. Method: Fourteen individuals with SCI from a physical activity program participated in approximately hour-long interviews. Interviews were then subjected to a narrative analysis. Results: Individuals who used a restitution narrative (n?=?6) were motivated to engage in functional LTPA because of the desire to maintain the body and restore the past self. The individual who used the chaos narrative (n?=?1) preferred solitary LTPA as exposure to others with SCI was a constant reminder of the lost, pre-injury self. Individuals who used a quest narrative (n?=?7) explored LTPA options that fit with their interests; these individuals were open to new types of LTPA, such as sport and outdoor recreation. Conclusion: The plot of three disability narratives can all motivate the pursuit of LTPA; however, not all types of LTPA are seen as equal. LTPA interventions can be enhanced through the lessons learned from this unique type of environment.

• Implications for Rehabilitation

• Despite individuals’ views about their disability, they can still be motivated to engage in routine LTPA.

• Different theoretical determinants, such as health or social benefits, hold different relevance for LTPA among individuals with differing disability narratives.

• The environment provided by practitioners can therefore elicit some stories of SCI while stifling others. Open narrative environment will attract individuals to listen and maintain involvement in LTPA.

     

不同时相点移植的皮肤源性前体细胞在损伤脊髓中的存活数量及其机制

目的:观察不同时相点移植的皮肤源性前体细胞(skin-derived precursors,SKPs)在损伤脊髓中的存活数量并探讨其可能的机制。方法:分离雄性大鼠SKPs,Allen法制备雌性大鼠中度脊髓挫伤模型,伤后即刻、1d、3d、7d和14d取损伤脊髓匀浆离心取上清液,酶联免疫吸附法测定上清液中白介素-1(IL-1)和血小板源性生长因子(platelet-derived growth factor,PDGF)的含量,然后观察上清液、IL-1和PDGF对SKPs增殖和凋亡的影响。上述同样的时相点将DAPI标记的SKPs经局部注射到损伤脊髓处,移植后14d取材采用针对Y染色体的实时定量PCR检测脊髓中SKPs含量,BBB法评价大鼠功能恢复情况。结果:IL-1可抑制SKPs的增殖活性,促进其凋亡;而PDGF的作用相反。损伤3d后脊髓的提取液培养中IL-1的浓度最高,7d的PDGF浓度最高,7d的脊髓提取液对SKPs促增殖活性最高。伤后7d移植组损伤脊髓局部存活的SKPs数量最多,功能恢复也最好。结论:中度挫伤脊髓损伤后7d移植SKPs存活率最高,对功能恢复的作用最强,其可能机制与损伤脊髓局部表达的细胞因子有关。     

Etiology and incidence of rehospitalization after traumatic spinal cord injury: a multicenter analysis

OBJECTIVES: To examine the frequency and reasons for rehospitalization in persons with acute traumatic spinal cord injury (SCI) during follow-up years and to examine the association between rehospitalization and demographics, neurologic category, payer sources, length of stay (LOS), discharge motor FIM instrument score, and discharge residence. DESIGN: Survey design with analysis of cross-sectional data. SETTING: Model Spinal Cord Injury Systems (MSCIS) centers. PARTICIPANTS: Data for 8668 persons with SCI from 16 MSCIS centers entered in the National Spinal Cord Injury Statistical Center database between 1995 and 2002. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: MSCIS Forms I and II were used to identify the annual incidence, medical complications, and etiologies of rehospitalizations reported at 1-, 5-, 10-, 15-, and 20-year follow-ups. RESULTS: The leading cause of rehospitalization was diseases of the genitourinary system, including urinary tract infections (UTIs). Diseases of the respiratory system tended to be more likely in patients with tetraplegia (C1-8 American Spinal Injury Association [ASIA] grades A, B, C); whereas patients with paraplegia (T1-S5 ASIA grades A, B, C) were more likely to be rehospitalized for pressure ulcers. The rate of rehospitalization was significantly higher at year 1, 5, and 20 for those who were discharged to a skilled nursing facility after acute rehabilitation. Lower motor score using the FIM was predictive of rehospitalization (P=.000). The average LOS per rehospitalization at the year-5 follow-up was approximately 12 days, which is lower than in past MSCIS reports. CONCLUSIONS: Despite improvements in SCI medical management, rehospitalization rates remain high, with an increased incidence in conditions associated with the genitourinary system (including UTIs), respiratory complications (including pneumonia), and diseases of the skin (including pressure ulcers). Acutely injured patients need close follow-up to reduce morbidity and rehospitalizations.     

Provider-identified barriers and facilitators to implementing a supported employment program in spinal cord injury

Purpose: In a 5-year study, individual placement and support (IPS) significantly increased employment rate of United States Veterans with spinal cord injury (SCI), a historically underemployed population. In a follow-up study, data on barriers and facilitators to IPS implementation were identified.

Methods: Over 24?months of implementation, 82?key medical and vocational staff underwent semi-structured interviews (n?=?130). Interviews were digitally recorded and qualitatively analyzed (ATLAS.ti v0.7) using a constant comparative method to generate themes.

Results: Some barriers to implementation occurred throughout the study, such as Veterans’ lack of motivation and providers’ difficulty integrating vocational and medical rehabilitation. Other barriers emerged at specific stages, for example, early barriers included a large geographic service area and a large patient caseload, and late barriers included need for staff education. Facilitators were mostly constant throughout implementation and included leadership support and successful integration of vocational staff into the medical care team.

Conclusions: Implementation strategies need to be adjusted as implementation progresses and matures. The strategies that succeeded in this setting, which were situated in a real-world context of providing IPS as a part of SCI medical care, may inform implementation of IPS for other populations with physical disabilities.

• Implications for Rehabilitation

• Key facilitators to IPS in SCI implementation are integrating vocational staff with expertise in IPS and SCI on clinical rehabilitation teams and providing leadership support.

• Ongoing barriers to IPS in SCI include patient specific and program administration factors such as caseload size and staffing patterns.

• Varying implementation strategies are needed to address barriers as they arise and facilitate successful implementation.

     

《国际功能、残疾和健康分类康复组合》对创伤性脊髓损伤恢复期患者康复疗效和成本效益的初步报告

目的:采用ICF康复组合(ICF-RS)评价脊髓损伤患者的功能状况,初步分析康复疗效与成本效益关系.方法:15例创伤性脊柱脊髓损伤(TSCI)恢复期患者进行为期2周的集中康复训练,通过ICF-RS评估患者的功能改善情况,记录康复医疗支出.结果:TSCI恢复期患者最常见的身体功能障碍主要为b730肌肉力量、b640性功能...     

Psychosocial factors associated with physical activity in ambulatory and manual wheelchair users with spinal cord injury: a mixed-methods study

Purpose: To identify psychosocial factors which explain lower levels of leisure time physical activity (LTPA) in persons with spinal cord injury (SCI) who are ambulatory relative to those who use manual wheelchairs. Method: For the quantitative study component, 347 adults with SCI (78% male; M age?=?47.7) completed baseline measures of LTPA attitudes, subjective norms, perceived behavioural control and intentions. Six months later, LTPA was assessed. The qualitative component involved semi-structured interviews with six ambulant adults with SCI (five male, M age?=?52.8) addressing LTPA experiences with an emphasis on barriers and facilitators. Results: Ambulatory individuals had poorer attitudes towards LTPA than chair users (p?=?0.004). Their attitudes had significant indirect effects on LTPA, through intentions. Perceived behavioural control was a significant negative predictor of LTPA. Qualitative analysis revealed three themes: an underestimated disability, low wheelchair skill self-efficacy and experiencing chronic pain. Conclusions: Poorer attitudes towards LTPA may partially explain why ambulatory individuals are less active. The qualitative and quantitative data suggest ambulators are an often-overlooked subgroup in need of targeted resources to enhance their attitudes, wheelchair skill self-efficacy and awareness of LTPA opportunities.

• Implications for Rehabilitation

• Rehabilitation practitioners must be sensitive to the unique needs of spinal cord injured individuals who are ambulatory, and tailor physical activity promotional strategies to suit the needs of this distinct group.

• Lack of wheelchair skills is a participation barrier for ambulators; ambulators should be introduced to activities that do not require wheelchair use, such as swimming, hand-cycling and adapted forms of circuit training.

• Strategies that encourage wheelchair skill development in non-wheelchair using ambulators, may increase physical activity opportunities for this segment of the spinal injured population.

     

The influence of secondary conditions on job acquisition and retention in adults with spinal cord injury

Meade MA, Forchheimer MB, Krause JS, Charlifue S. The influence of secondary conditions on job acquisition and retention in adults with spinal cord injury.

Objective

To examine the associations of job acquisition and job retention to secondary conditions, hospitalizations, and nursing home stays for adults with spinal cord injury (SCI).

Design

Retrospective analysis of longitudinal data from multicenter study.

Setting

Community setting.

Participants

Two samples of adults participating in the SCI Model Systems; the first sample consisted of persons who reported being unemployed at follow-up (n=9501); the second sample consisted of those who reported working at follow-up (n=5,150).

Interventions

Not applicable.

Main Outcome Measures

Job acquisition (change from not working at 1 anniversary of injury to working at the following data collection) and job retention (maintenance of work between 2 assessment periods).

Results

Discrete time hazard modeling was used to assess how secondary conditions affect job acquisition. After controlling for the effects of demographic and injury characteristics, hospitalizations within the last 12 months were associated with decreased chance of having obtained employment. Hierarchic logistic regression analyses were used to examine job retention. Hospitalizations and the presence of PUs were associated with lower odds of job retention once demographic and injury characteristics were controlled. Secondary conditions from the previous assessment period were not significantly related to either job acquisition or job retention after the variance from demographic and injury characteristics and current secondary conditions were controlled.

Conclusions

Hospitalization, as well as a limited number of secondary conditions, were associated with reduced odds of both job acquisition and job retention among adults with SCI. Interventions that can prevent secondary conditions and reduce the need for hospitalizations may be beneficial in improving employment for this population.