Psychosocial Outcomes Among Youth with Spinal Cord Injury and Their Primary Caregivers

Background:

Past research has found youth with disabilities to experience poor psychosocial outcomes, but little is known about factors related to psychosocial health among youth with spinal cord injury (SCI).

Objective:

To describe psychosocial health among youth with SCI, examine relationships between psychosocial outcomes and demographic and injury-related factors, and examine relationships between aspects of psychosocial health. Youth activity, participation, quality of life (QOL), coping, anxiety and depression, and caregiver mental health were included.

Methods:

Data were collected as part of a prospective study of 420 youth with SCI ages 1-18 and their primary caregivers. Activity data were also presented from a study developing a computerized adaptive testing (CAT) platform with 226 youth with SCI ages 8-21.

Results:

Although relationships varied by factor, youth outcomes were related to youth age, sex, age at injury/injury duration, and level/extent of injury. Caregiver mental health related to child age and age at injury. Further, relationships were uncovered between aspects of psychosocial health: aspects of youth mental health were related to youth participation and QOL, youth coping was related to youth mental health, participation, and QOL, and caregiver mental health was related to child mental health and QOL.

Conclusion:

Psychosocial outcomes relate to each other and vary by child and injury-related factors and should be understood in a comprehensive, developmental context. Identifying best measures of activity and psychosocial functioning among youth with SCI and understanding factors related to their psychosocial health is critical to improving outcomes for the pediatric-onset SCI population.     

Obstacles to community participation among youth with spinal cord injury

Objective

Examine caregiver-report of obstacles to community participation for youth with spinal cord injury (SCI), and explore relationships between obstacles and child, caregiver, and community characteristics.

Design

Two hundred and one primary caregivers of youth with SCI ages 7–17 years were interviewed at three pediatric SCI centers within a single-hospital system. Caregivers answered an open-ended question assessing obstacles to youth participation. A mixed-methods approach was incorporated, where qualitative methods analyzed caregiver-reported obstacles, and exploratory multivariate analyses examined relationships between obstacles and demographic variables.

Results

Caregivers were primarily mothers (74%), married (69%), employed (54%), had college experience (67%), and lived in small towns (55%). Youths'' mean age was 12.60 years at interview and 7.19 years at injury, 70% had paraplegia, and 55% had complete injuries. Analyses revealed that youth participation was limited by obstacles across six domains: community, disability-related, practical concerns, child-internal, social, and other. Child, caregiver, and community characteristics were related to overall report of obstacles, and report of community obstacles, disability-related obstacles, and practical concerns. Caregiver college experience and small town living predicted overall report of obstacles. Having a child injured at a younger age, caregiver college experience, and small town living predicted community obstacles. Having a child with an incomplete injury and recent medical complication predicted disability-related obstacles. Caregiver employment predicted practical concerns.

Conclusion

Youth from small towns, those injured younger, those with incomplete injuries, and those experiencing recent medical complications may need additional supports and resources to maximize participation. Clinicians should work with caregivers to identify and problem-solve obstacles to youth participation.     

Functional electrical stimulation cycling in youth with spinal cord injury: A review of intervention studies

Context

Preliminary research suggests that functional electrical stimulation cycling (FESC) might be a promising intervention for youth with spinal cord injury (SCI).

Objective

To review the evidence on FESC intervention in youth with SCI.

Methods

Systematic literature searches were conducted during December 2012. Two reviewers independently selected titles, abstracts, and full-text articles. Of 40 titles retrieved, six intervention studies met inclusion criteria and were assessed using American Academy for Cerebral Palsy and Developmental Medicine Levels of Evidence and Conduct Questions for Group Design.

Results

The study results were tabulated based on levels of evidence, with outcomes categorized according to the International Classification of Functioning, Disability, and Health framework. Evidence from the six included studies suggests that FESC is safe for youth with SCI, with no increase in knee/hip injury or hip displacement. Results from one level II randomized controlled trial suggest that a thrice weekly, 6-month FESC program can positively influence VO₂ levels when compared with passive cycling, as well as quadriceps strength when compared with electrical stimulation and passive cycling.

Conclusions

FESC demonstrates limited yet encouraging results as a safe modality to mitigate effects of inactivity in youth with SCI. More rigorous research involving a greater number of participants is needed before clinicians can be confident of its effectiveness.     

Relationship of nursing education and care management inpatient rehabilitation interventions and patient characteristics to outcomes following spinal cord injury: The SCIRehab project

Objective

To investigate associations of nursing bedside education and care management activities during inpatient rehabilitation with functional, participation, and quality-of-life outcomes for patients with traumatic spinal cord injury (SCI).

Methods

In a prospective observational study, data were obtained by means of systematic recording of nursing activities by registered nurses (RNs), chart review and patient interview.

Results

Greater patient participation in nursing activities is associated with better outcomes. More time spent by RNs in coordination with other members of the care team, consultants and specialists, along with participation in physician rounds (team process) is associated with patient report of higher life satisfaction and higher CHART mobility at the one-year injury anniversary; more time providing psychosocial support is associated with higher CHART mobility and occupation scores and with greater likelihood of working or being in school at the anniversary. More time spent providing education about specific care needs is associated with several outcomes but not as consistently as might be expected.

Conclusion(s)

Higher levels of patient participation in nursing care activities is associated with multiple better outcomes, and hence, nurses should promote active patient participation during all aspects of care and interactions between themselves and patients with SCI. Time spent providing psychosocial support of patients and their families should be evaluated to ensure that other necessary education or care management interventions are not minimized.

Note

This is the seventh of nine articles in the SCIRehab series.     

Do risk perceptions explain sex differences in community integration and participation after spinal cord injury?

Objective

To describe how men and women with spinal cord injury (SCI) rate the risks posed by a set of everyday activities measured using the Risk Inventory for persons with Spinal Cord Injury (RISCI), and to examine whether sex differences are related to community integration and participation.

Design

Cohort study.

Setting

Metropolitan Detroit.

Participants

One hundred and forty community-dwelling white and African-American men and women with SCI.

Outcome measures

RISCI scores, community integration, and level of and satisfaction with community participation.

Results

Study participants were just over age 40 years, and had been living with SCI for 10.8 years. One-third were women and 40% were African-American. Results showed women with SCI had higher RISCI scores (perceived more dangers) on every item on the RISCI Scale (P < 0.001). The items perceived to hold greatest risk were revealing personal information to others, going on a blind date, and going for a roll (“walk”) alone after dark. Women with higher RISCI scores reported lower community integration (P < 0.05) and lower levels of and lower satisfaction with community participation (P < 0.01). For men, however, RISCI scores were mainly unrelated (except for community integration) to participation measures.

Conclusion

More research is needed to determine whether the levels of risk perceived by women are warranted and whether a sense of vulnerability for women with SCI is unnecessarily limiting their chances at “a good life” after injury.     

Psychosocial outcomes among youth with spinal cord injury by neurological impairment

Objective

Examine psychosocial outcomes of youth with spinal cord injury (SCI) as a function of neurological level (paraplegia/tetraplegia) and severity (American Spinal Injury Association (ASIA) Impairment Scale (AIS)).

Design

Survey research.

Setting

Three pediatric SCI specialty centers in the USA.

Participants

Youth with SCI ages 5–18 with neurological impairment classifications of: tetraplegia AIS ABC (tetraplegia ABC), paraplegia AIS ABC (paraplegia ABC), or AIS D.

Outcome Measures

Children''s Assessment of Participation and Enjoyment, Pediatric Quality of Life Inventory, Revised Children''s Manifest Anxiety Scale, and Children''s Depression Inventory.

Results

Three hundred and forty youth participated; 57% were male; 60% were Caucasian, 21% Hispanic, 7% African-American, 2% Native American, and 3% reported “other”. Their mean age was 8.15 years (standard deviation (SD) = 5.84) at injury and 13.18 years (SD = 3.87) at interview. Ninety-six youth (28%) had tetraplegia ABC injuries, 191 (56%) paraplegia ABC injuries, and 53 (16%) AIS D injuries. Neurological impairment was significantly related to participation and quality of life (QOL). Specifically, youth with paraplegia ABC and AIS D injuries participated in more activities than youth with tetraplegia ABC (P = 0.002; P = 0.018, respectively) and youth with paraplegia ABC participated more often than youth with tetraplegia ABC (P = 0.006). Youth with paraplegia ABC reported higher social QOL than youth with tetraplegia ABC (P = 0.001) and AIS D injuries (P = 0.002). Groups did not differ regarding mental health.

Conclusion

Interventions should target youth with tetraplegia ABC, as they may need support in terms of participation, and both youth with tetraplegia ABC and AIS D injuries in terms of social integration.     

The SCIRehab project: treatment time spent in SCI rehabilitation. Psychology treatment time during inpatient spinal cord injury rehabilitation

Background

Rehabilitation psychologists are integral members of spinal cord injury (SCI) rehabilitation teams.

Objective

To describe specific information regarding types and intensity of treatments delivered by rehabilitation psychologists to patients with various levels of SCI.

Methods

Utilizing a taxonomy of psychological interventions as a framework, rehabilitation psychologists documented time spent on specific psychology interventions for each interaction they had with 600 patients with traumatic SCI at 6 inpatient SCI rehabilitation centers. Associations of patient and injury characteristics with time spent on various psychological interventions were examined using ordinary least squares stepwise regression models.

Results

Psychologists focus the majority of the time they spend with patients with SCI on psychotherapeutic interventions of processing emotions, emotional adjustment, and family coping, while educational efforts focus mostly on coping and adjusting to the new injury. There was wide variation in the amount of time spent on psychotherapeutic and psychoeducational interventions; patient, injury, and clinician characteristics explained little of the variation in time spent.

Conclusions

Variations observed in psychological treatment delivery mirror real-world human complexity and clinical experience; they are not explained well by patient and injury characteristics and set the stage for future analyses to associate treatments with outcomes.     

Facilitators and Barriers to Employment Among Veterans with Spinal Cord Injury Receiving 12 Months of Evidence-Based Supported Employment Services

Background:

Return to work is associated with positive rehabilitation outcomes for persons with spinal cord injury (SCI); however, more research is needed on vocational support for persons with disabilities seeking employment.

Objective:

The association between facilitators and barriers of employment and employment outcome was examined among Veterans with SCI who participated in an evidence-based supported employment (EBSE) program.

Methods:

Using a mixed-methods, nested case-control design, data on facilitators and barriers to employment were extracted from qualitative interviews and quantitative measures administered in person to 34 Veterans with SCI who completed 12 months of an EBSE program. Participants who did (case) and did not (control) obtain competitive employment were matched on time since SCI. Facilitators and barriers to employment were compared between the groups.

Results:

Self-report measures administered at baseline were examined; there were no statistically significant factors that predicted employment outcomes after 12 months of EBSE program participation. Qualitative interview data revealed program-specific facilitators and Veteran characteristics that were associated with employment outcomes.

Conclusions:

Qualitative data illustrate how the integration of the vocational rehabilitation specialist on the medical team is helpful for addressing identified disability-specific barriers, including practical matters such as transportation and caregiving schedules, to facilitate employment outcomes.     

Relationship of speech-language pathology inpatient rehabilitation interventions and patient characteristics to outcomes following spinal cord injury: The SCIRehab Project

Background/objective

Describe associations of patient characteristics and speech–language pathology (SLP) interventions provided during impatient rehabilitation for spinal cord injury (SCI) to outcomes at discharge and 1-year post-injury.

Methods

Speech–language pathologists at six inpatient rehabilitation centers documented details of treatment provided. Least squares regression modeling was used to predict outcomes at discharge and 1-year injury anniversary. Cognitive, participation, and mood outcomes for a subsample of patients with traumatic brain injury (TBI) and cognitive-communication limitations (CCLs) were examined.

Results

SLP treatment factors explain a small amount of variation in cognitive Functional Independence Measure (FIM), participation, and mood. Variation explained by treatment factors for cognitive outcomes at the time of discharge increased when the patient group was more homogeneous (patients with TBI and CCLs). More time in SLP cognitive-communication interventions had a negative relationship, while longer length of stay was positive. The added explanatory power was not seen for similar outcomes at 1-year post-injury.

Conclusion

Patients with SCI who have the greatest need for interventions to address cognitive limitations due to TBI receive the most SLP cognitive-communication treatment and show the greatest amount of improvement during rehabilitation. Their cognitive functioning remained impaired at discharge; this likely accounts for the consistent finding that more hours of SLP cognitive-communication treatment is associated with lower cognitive FIM scores at discharge. Future research on individuals with dual SCI and TBI should include more comprehensive assessment of individual differences in cognitive performance in order to better examine the complex relationships between SLP treatments and outcomes.

Note

This is the fifth of nine articles in this SCIRehab series.     

Examining implicit bias of physicians who care for individuals with spinal cord injury: A pilot study and future directions

Context

Despite evidence that healthcare providers have implicit biases that can impact clinical interactions and decisions, implicit bias among physicians caring for individuals with spinal cord injury (SCI) has not been examined.

Objective

Conduct a pilot study to examine implicit racial bias of SCI physicians and its association with functioning and wellbeing for individuals with SCI.

Design

Combined data from cross-sectional surveys of individuals with SCI and their SCI physicians.

Setting

Four national SCI Model Systems sites.

Participants

Individuals with SCI (N = 162) and their SCI physicians (N = 14).

Outcome measures

SCI physicians completed online surveys measuring implicit racial (pro-white/anti-black) bias. Individuals with SCI completed questionnaires assessing mobility, physical independence, occupational functioning, social integration, self-reported health, depression, and life satisfaction. We used multilevel regression analyses to examine the associations of physician bias and outcomes of individuals with SCI.

Results

Physicians had a mean bias score of 0.62 (SD = 0.35), indicating a strong pro-white/anti-black bias. Greater physician bias was associated with disability among individuals with SCI in the domain of social integration (odds ratio = 4.80, 95% confidence interval (CI) = 1.44, 16.04), as well as higher depression (B = 3.24, 95% CI = 1.06, 5.41) and lower life satisfaction (B = −4.54, 95% CI= −8.79, −0.28).

Conclusion

This pilot study indicates that SCI providers are susceptible to implicit racial bias and provides preliminary evidence that greater implicit racial bias of physicians is associated with poorer psychosocial health outcomes for individuals with SCI. It demonstrates the feasibility of studying implicit bias among SCI providers and provides guidance for future research on physician bias and patient outcomes.     

Relationship of occupational therapy inpatient rehabilitation interventions and patient characteristics to outcomes following spinal cord injury: The SCIRehab Project

Background/objective

Describe associations of occupational therapy (OT) interventions delivered during inpatient spinal cord injury (SCI) rehabilitation and patient characteristics with outcomes at the time of discharge and 1-year post-injury.

Methods

Occupational therapists at six inpatient rehabilitation centers documented detailed information about treatment provided. Least squares regression modeling was used to predict outcomes at discharge and 1-year injury anniversary for a 75% subset; models were validated with the remaining 25%. Functional outcomes for injury subgroups (motor complete low tetraplegia and motor complete paraplegia) also were examined.

Results

OT treatment variables explain a small amount of variation in Functional Independence Measure (FIM) outcomes for the full sample and significantly more in two functionally homogeneous subgroups. For patients with motor complete paraplegia, more time spent in clothing management and hygiene related to toileting was a strong predictor of higher scores on the lower body items of the self-care component of the discharge motor FIM. Among patients with motor complete low tetraplegia, higher scores for the FIM lower body self-care items were associated with more time spent on lower body dressing, manual wheelchair mobility training, and bathing training. Active patient participation during OT treatment sessions also was predictive of FIM and other outcomes.

Conclusion

OT treatments add to explained variance (in addition to patient characteristics) for multiple outcomes. The impact of OT treatment on functional outcomes is more evident when examining more homogeneous patient groupings and outcomes specific to the groupings.

Note

This is the third of nine articles in the SCIRehab series.     

Outcomes of social work and case management services during inpatient spinal cord injury rehabilitation: The SCIRehab project

Objective

To investigate associations of social work/case management (SW/CM) services during inpatient rehabilitation following spinal cord injury (SCI) and patient characteristics with outcomes.

Design

Prospective observational cohort of individuals with SCI receiving inpatient rehabilitation.

Setting

Six inpatient rehabilitation centers.

Participants

1032 individuals with traumatic SCI.

Interventions

Not applicable.

Main outcome measure(s)

Type of residence at the time of rehabilitation discharge. Employment/school status, presence of a pressure ulcer, Patient History Questionnaire, Satisfaction with Life Scale, Craig Handicap Assessment and Reporting Technique (CHART) subscales, and rehospitalization at 1-year post-injury.

Results

The intensity of specific SW/CM services is associated with multiple outcomes examined. More sessions dedicated to discharge planning for a home discharge and financial planning were associated positively with more discharge to home, while more sessions focused on planning for discharge to a location other than home, e.g. nursing home or long-term acute care facilities, have negative associations with societal participation outcomes (CHART Social Integration, Occupation, and Mobility scores) as well as with residing at home at the time of the 1-year injury anniversary.

Conclusion(s)

The intensity and type of SW/CM services are associated with outcomes at rehabilitation discharge and at 1-year post-injury. Discharge to home may require assistance from SW/CM in the area of discharge planning and financial planning, while discharge to non-home residence demands directed SW/CM services for such placement.

Note

This is the eighth of nine articles of this SCIRehab series.     

Relationship of therapeutic recreation inpatient rehabilitation interventions and patient characteristics to outcomes following spinal cord injury: The SCIRehab project

Objective

To investigate associations of therapeutic recreation (TR) interventions during inpatient rehabilitation for patients with traumatic spinal cord injury (SCI) with functional, participation, and quality of life outcomes.

Methods

In this prospective observational study, data were obtained from systematic recording of TR services by certified TR specialists, chart review, and patient interview.

Results

TR interventions, including exposure to community settings and leisure activities, add to the variance explained (in addition to the strong predictors of injury classification, admission motor Functional Independence Measure (FIM), and other patient characteristics) in outcomes at the time of rehabilitation discharge (FIM, discharge to home) and at the 1-year injury anniversary (FIM, working or being in school, residing at home, and societal participation as measured by the Craig Handicap Assessment and Reporting Technique (CHART)). They also are associated with less rehospitalization and less pressure development after discharge. In addition, more time spent in specific TR activities during rehabilitation is associated with more participation in the same type of activities at the 1-year injury anniversary.

Conclusion(s)

Greater participation in TR-led leisure skill and community activities during rehabilitation is a positive predictor of multiple outcomes at rehabilitation discharge and the 1-year injury anniversary demonstrating that TR activities are associated with a return to a productive and healthy life after SCI. Further research should focus on the impact of TR on longer-term outcomes to determine whether relationships continue or change as persons continue to adapt to their life after SCI.

Note

This is the fourth of nine articles in the SCIRehab series.     

Team size in spinal cord injury inpatient rehabilitation and patient participation in therapy sessions: The SCIRehab Project

Context/objective

Rehabilitation teams generally are described as consisting of a single representative of 6–8 disciplines, but research suggests that the number of individuals involved may be much larger. This study aimed to determine the size of teams in spinal cord injury (SCI) rehabilitation, and the effect of team size on patients'' active participation in their treatment sessions.

Design

Prospective observational study.

Setting

Six SCI rehabilitation centers.

Participants

A total of 1376 patients with traumatic SCI admitted for first rehabilitation.

Interventions

Not applicable.

Outcome measures

Number of treatment sessions, by discipline and overall clinician rating of active participation of the patient; Treatment Concentration Index (TCI) calculated as Σp_k² (where p refers to the proportion of treatment sessions delivered by team member k).

Results

The average patient was treated by 39.3 different clinicians. The numbers were especially high for physical therapy (mean: 8.8), occupational therapy (7.2), and nursing (16.1). TCI was 0.08 overall; it varied by discipline. TCI was negatively correlated with length of stay, except for psychology. Participation ratings were minimally affected by the number of sessions the patient and the therapist had worked together.

Conclusions

In SCI rehabilitation, teams are at least as large as suggested by previous research. However, this may not mean lack of familiarity of patient and therapist with one another, or alternatively, the possibly weak therapeutic alliance does not affect the patients'' active participation in their sessions. Further research is needed to determine whether there are negative effects on rehabilitation outcomes.     

Relationship of psychology inpatient rehabilitation services and patient characteristics to outcomes following spinal cord injury: The SCIRehab Project

Context and objective

To evaluate the effects of psychological interventions on rehabilitation outcomes, including residence and functional status at discharge, and residence, school attendance, or employment, and physical, social, occupational, and mobility aspects of participation 1 year after spinal cord injury (SCI).

Design

Prospective observational cohort study.

Setting

Six inpatient rehabilitation facilities in the United States.

Participants

Inpatients with SCI 12 years of age and older.

Interventions

Usual rehabilitation care.

Outcome measures

Functional Independence Measure at rehabilitation discharge and 1-year injury anniversary; discharge destination and residence at 1-year anniversary; Craig Handicap Assessment and Reporting Technique, Diener Satisfaction with Life Scale, Patient Health Questionnaire, employment or school attendance, rehospitalization, and occurrence of a pressure ulcer at 1-year anniversary.

Results

More time in psycho-educational interventions was associated with better function, discharge to home, home residence at 1 year, and the absence of pressure ulcers at 1 year. More psychotherapeutic sessions focusing on processing emotions and/or locus of control were associated with poorer function at discharge and 1 year, less physical independence and community mobility, lower satisfaction with life, and the presence of pressure sores at 1 year.

Conclusions

Psychological services are an important component of comprehensive medical rehabilitation and tailored to patient needs and readiness to benefit from rehabilitation. Services focused on remediating deficits tend to be associated with negative outcomes, while services intended to foster adjustment and growth tend to be associated with favorable outcomes. Further research is needed to determine the optimal type and timing of psychological services during inpatient rehabilitation based on individuals'' strengths and vulnerabilities.

Note

This is the sixth in this third series of SCIRehab articles.     

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.     

Effects of Adult Romantic Attachment and Social Support on Resilience and Depression in Individuals with Spinal Cord Injuries

Background:

Spinal cord injury (SCI) can cause psychological consequences that negatively affect quality of life. It is increasingly recognized that factors such as resilience and social support may produce a buffering effect and are associated with improved health outcomes. However the influence of adult attachment style on an individual’s ability to utilize social support after SCI has not been examined.

Objective:

The purpose of this study was to examine relationships between adult romantic attachment perceived social support depression and resilience in individuals with SCI. In addition we evaluated potential mediating effects of social support and adult attachment on resilience and depression.

Methods:

Participants included 106 adults with SCI undergoing inpatient rehabilitation. Individuals completed measures of adult attachment (avoidance and anxiety) social support resilience and depression. Path analysis was performed to assess for presence of mediation effects.

Results:

When accounting for the smaller sample size support was found for the model (comparative fit index = .927 chi square = 7.86 P = .01 β = -0.25 standard error [SE] = -2.93 P < .05). The mediating effect of social support on the association between attachment avoidance and resilience was the only hypothesized mediating effect found to be significant (β = -0.25 SE = -2.93 P < .05).

Conclusion:

Results suggest that individuals with SCI with higher levels of attachment avoidance have lower perceived social support which relates to lower perceived resilience. Assessing attachment patterns during inpatient rehabilitation may allow therapists to intervene to provide greater support.     

Environmental barriers and subjective health among people with chronic spinal cord injury: A cohort study

Objective

Although previous studies have found environmental barriers to be associated with social participation and life satisfaction after spinal cord injury (SCI), few studies exist reporting their effects on subjective health after SCI. Our purpose was to identify the prevalence of perceived environmental barriers and their effects on subjective health in persons with chronic SCI who completed two repeated measurements during a 5-year longitudinal study.

Design

This is a prospective cohort study. Environmental barriers were measured at baseline by the Craig Hospital Inventory of Environmental Factors-Short Form. Subjective health was measured at baseline and 5-year follow-up by days of physical and mental health not good. Other control variables included sex, race, age at injury, years since injury, and injury severity at baseline.

Setting

Data were collected at a specialty hospital and analyzed at a medical university in the Southeastern USA.

Participants

A total of 1635 participants completed both baseline and follow-up surveys.

Results

Twenty per cent of participants reported at least one policy barrier, 46% at least one physical and structural barrier, 22% at least one attitudinal and support barrier, 26% at least one barrier to services and assistance, and 13% at least one barrier at work or school. After controlling for sex, race, age at injury, years since injury, and injury severity, the physical and structural barriers, and services and assistance barriers measured at baseline significantly predicted subjective physical and mental health measured at follow-up.

Conclusion

Environmental barriers are prevalent among people with chronic SCI. They are important predictors for future subjective health.     

An examination of the psychometric properties of the community integration questionnaire (CIQ) in spinal cord injury

Objective

To examine the psychometric properties of the Community Integration Questionnaire (CIQ) in large samples of individuals with spinal cord injury (SCI).

Design

Longitudinal 12-month survey study.

Setting

Nation-wide, community dwelling.

Participants

Adults with SCI: 627 at Time 1, 494 at Time 2.

Interventions

Not applicable.

Outcome measures

The CIQ is a 15-item measure developed to measure three domains of community integration in individuals with traumatic brain injury: home integration, social integration, and productive activity. SCI consumer input suggested the need for two additional items assessing socializing at home and internet/email activity.

Results

Exploratory factor analyses at Time 1 indicated three factors. Time 2 confirmatory factor analysis did not show a good fit of the 3-factor model. CIQ scores were normally distributed and only the Productive subscale demonstrated problems with high (25%) ceiling effects. Internal reliability was acceptable for the Total and Home scales, but low for the Social and Productive activity scales. Validity of the CIQ is suggested by significant differences by sex, age, and wheelchair use.

Conclusions

The factor structure of the CIQ was not stable over time. The CIQ may be most useful for assessing home integration, as this is the subscale with the most scale stability and internal reliability. The CIQ may be improved for use in SCI by including items that reflect higher levels of productive functioning, integration across the life span, and home- and internet-based social functioning.