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 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.     

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.     

Perceived Exercise Barriers and Odds of Exercise Participation Among Persons With SCI Living in High-Income Households

Objective:

To define the prevalence of and the degree to which exercise barriers decrease odds of exercise participation among persons with SCI reporting annual household income greater than $50,000.

Method:

In this cross-sectional study, 180 individuals completed a Web survey of personal characteristics and exercise barriers. Over half (n=89) reported annual household incomes greater than $50,000. Chi-square and Mann-Whitney U identified personal characteristic differences between exercisers and nonexercisers. Odds ratios (OR) determined barriers that decreased odds of exercise participation. Significance was set at α < 0.05.

Results:

Eighty-seven percent of respondents were currently exercising (n=61). No differences discriminated exercisers and nonexercisers by gender, age, race, age at injury, injury level or completeness, education level, and total comorbidities or medications. A higher percentage of exercisers were full-time employed or married. Nonexercisers reported more barriers (4.9 ± 2.4 vs 2.21 ± 1.8). Only one barrier was highly prevalent and impactful (lack of motivation). The most impactful barrier, “too lazy to exercise,” was the 9th most prevalent barrier (14%). Persons reporting this as a barrier were 19 times less likely to be exercising.

Conclusion:

Among high-income households, highly prevalent barriers may not decrease odds of exercise participation. Knowledge and psychological barriers had the greatest impact on odds of exercise participation.     

The Effect of Total Knee Replacement on Employment in Patients Under 60 Years of Age

INTRODUCTION

The effect of primary total knee replacement on the employment status of 56 patients under 60 years of age was examined at a mean follow-up of 64 months.

PATIENTS AND METHODS

A total of 56 primary total knee replacements performed on patients under the age of 60 years by two surgeons between 1996 and 2003 were retrospectively assessed by postal questionnaire. Patients were selected from databases held at Holly House and Newham Hospital NHS Trust.

RESULTS

Overall, 97.5% of patients who were employed before their operation, returned to their previous work. However, in patients not working prior to total knee replacement none were employed after their operation.

CONCLUSIONS

Total knee replacement may be a valuable tool to help some patients to continue working but may not affect patients who are already unemployed.     

Vocational Rehabilitation in Spinal Cord Injury: What Vocational Service Activities Are Associated with Employment Program Outcome?

Background:

Designing effective vocational programs for persons with spinal cord injury (SCI) is essential for improving return to work outcome following injury. The relationship between specific vocational services and positive employment outcome has not been empirically studied.

Objective:

To examine the association of specific vocational service activities as predictors of employment.

Method:

Secondary analysis of a randomized, controlled trial of evidence-based supported employment (EBSE) with 12-month follow-up data among 81 Veteran participants with SCI.

Results:

Primary activities recorded were vocational counseling (23.9%) and vocational case management (23.8%). As expected, job development and employment supports were the most time-consuming activities per appointment. Though the amount of time spent in weekly appointments did not differ by employment outcome, participants obtaining competitive employment averaged significantly more individual activities per appointment. Further, for these participants, job development or placement and employment follow-along or supports were more likely to occur and vocational counseling was less likely to occur. Community-based employment services, including job development or placement and employment follow-along or supports as part of a supported employment model, were associated with competitive employment outcomes. Office-based vocational counseling services, which are common to general models of vocational rehabilitation, were associated with a lack of employment.

Conclusions:

Vocational services that actively engage Veterans with SCI in job seeking and acquisition and that provide on-the-job support are more likely to lead to employment than general vocational counseling that involves only job preparation.     

Online support for individuals with spinal cord injuries: An ethnographic investigation

Background

Although social support is an important protective factor for individuals with spinal cord injuries (SCIs), individuals often encounter significant barriers to obtaining support after experiencing a SCI. It has been suggested that the Internet may serve to help individuals with disabilities overcome common barriers in obtaining support, yet research examining the efficacy of Internet-based support for individuals with SCI has been mixed.

Objective

To develop a more nuanced understanding of how individuals with SCI can or might use the Internet for support.

Design

Using an ethnographic approach, we conducted semi-structured interviews with nine individuals with SCI to explore perceived needs and barriers to information-seeking and online support.

Setting

Participants were recruited from Veterans Administration medical center outpatient and inpatient units providing specialty care to individuals with SCIs and from a community SCI Center of Excellence.

Results

Individuals with SCI gain emotional, problem-focused, and reciprocal support from online sources.

Conclusions

Online resources can provide important opportunities for social support for individuals with SCI.     

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.     

Cheerleading injuries: A narrative review of the literature

Background:

With its increase in participation rate and complex stunts and gymnastic-like maneuvers, cheerleading injuries are on the rise.

Objective:

A structured narrative review of the literature was performed to discover the status of the literature on a growing yet under recognized sport. Cheerleading injuries are described in terms of distribution, etiology, and prevention.

Methods:

A literature search was conducted. The articles were then reviewed and included based on broad criteria set out by the author.

Results:

The search produced 87 articles related to cheerleading injuries or articles with a mention of cheerleading. A total of 26 articles were included in this review based on the inclusion criteria. The most common injury experienced by a cheerleader is an ankle ligament sprain.

Summary:

The recognition of cheerleading as a sport and a mandatory reporting database are needed along with further research for injury prevention strategies to be implemented.     

Comparison between open and arthroscopic acromioplasties: evaluation of absenteeism

Objective

To evaluate the rate of absenteeism from work in patients who had undergone open or arthroscopic acromioplasty.

Design

A retrospective case series.

Setting

A university hospital.

Patients

Eighteen patients with excellent results after open acromioplasty performed by one orthopedic surgeon and 20 patients with excellent results after arthroscopic acromioplasty performed by another orthopedic surgeon.

Main Outcome Measure

The time between operation and return to work.

Results

There were no statistical differences between the two techniques with respect to the return to work, age, sex and type of work. The overall time off work averaged 203 days (range from 42 to 840 days) for the arthroscopic group compared with 144 days (range from 60 to 540 days) for the open group.

Conclusions

Open acromioplasty, a safe and reliable procedure for the general orthopedic surgeon, is associated with a shorter, though not significant, delay in return to work than the arthroscopic technique.     

It’s All of the Above: Benefits of Working for Individuals with Spinal Cord Injury

Background:

The majority of research on employment among persons with spinal cord injury (SCI) focuses on the employment rate at a given point in time to the exclusion of quality employment outcomes.

Objective:

To identify the employment outcomes of greatest importance as defined by those with SCI who have worked since injury.

Methods:

A qualitative approach was used with 6 focus groups at 2 sites (Minnesota and Georgia). Participants (N = 44) were a minimum of 10 years after injury and had been employed at some point after SCI. We identified participants through a 40-year longitudinal study of SCI and a community resource. A combination of homogeneous (race/ethnic minority group, female group) and heterogeneous groups were convened. A semi-structured interview format queried participants about personal, environmental, and policy-related factors that impacted obtaining, maintaining, and advancing in employment.

Results:

Seven overlapping themes were identified under the 2 broad categories of compensation and subjective well-being: (1) salary and what it can support, (2) health insurance and other fringe benefits, (3) promotions and recognition, (4) social connection and support, (5) job satisfaction and enjoyment from working, (6) making a difference and helping others, and (7) psychological and emotional health.

Conclusion:

The results indicate several common themes among persons with SCI who have successful employment histories, suggesting that the benefits of employment are multifaceted and go beyond monetary compensation.     

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.     

Analysis of reporting return to work in studies comparing open with endoscopic carpal tunnel release: A review of randomized controlled trials

BACKGROUND:

In studies comparing open with endoscopic carpal tunnel release, return to work (RTW) is often cited as a primary outcome.

OBJECTIVE:

The present study assessed the reporting of RTW and evaluated its usefulness in studies comparing these two methods of carpal tunnel release.

METHODS:

A computerized search was conducted to find randomized controlled trials that compared open with endoscopic carpal tunnel release, with RTW as an outcome measure. The factors that were compared across the studies included definition of RTW, units quantifying RTW, measures of hand function, patients’ type of employment, worker’s compensation or insurance status, patients’ handedness, unilateral or bilateral carpal tunnel release, and use of rehabilitation.

RESULTS:

Fifteen studies met the inclusion criteria for the present systematic review. Of the 15 studies reviewed, there were seven definitions of RTW. All studies defined whether the patients underwent unilateral or bilateral carpal tunnel release but there was variability in the calculation of RTW when bilateral releases were performed. The impact of worker’s compensation or insurance, type of work, handedness and rehabilitation were inconsistently addressed as factors affecting RTW.

CONCLUSIONS:

Although RTW ideally reflects function and recovery, it is inadequately measured and reported. The present review revealed that, in studies comparing open carpal tunnel release with endoscopic carpal tunnel release, there is lack of uniformity in reporting RTW, which may contribute to the inconclusive results for RTW. Future research needs to ensure that RTW is used in a consistent manner.     

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.     

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.     

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.     

Predictors of missed appointments in prospective hand surgery research

Background

Missed research appointments may bias the outcome of prospective clinical trials if the participants that miss appointments differ in important ways from those that do not. The purpose of this study was to determine the predictors of missed research appointments in patients enrolled in clinical trials.

Methods

We retrospectively evaluated 665 participants enrolled in ten prospective clinical trials conducted at our outpatient office between 2001 and 2010. Demographic data (sex, race, date of birth, date of enrollment, age at enrollment, educational level, and work status), study coordinator, and study type were analyzed for association with missed a research appointment in bivariate and multiple logistic regression analyses.

Results

One hundred and forty-four (21.7 %) participants missed research appointments during their follow-up. There were no statistical differences between those who missed appointments and those who did not, regarding sex, race, and age at enrollment. Educational level and work status were independent predictors of missed appointments.

Conclusions

This study suggests that educational level and work status are predictors of missed appointments in prospective clinical research.     

FIRST BRAZILIAN CONSENSUS ON MULTIMODAL TREATMENT OF COLORECTAL LIVER METASTASES. MODULE 1: PRE-TREATMENT EVALUATION

Background

: Liver metastases of colorectal cancer are frequent and potentially fatal event in the evolution of patients with these tumors.

Aim

: In this module, was contextualized the clinical situations and parameterized epidemiological data and results of the various treatment modalities established.

Method:

Was realized deep discussion on detecting and staging metastatic colorectal cancer, as well as employment of imaging methods in the evaluation of response to instituted systemic therapy.

Results

: The next step was based on the definition of which patients would have their metastases considered resectable and how to expand the amount of patients elegible for modalities with curative intent.

Conclusion

: Were presented clinical, pathological and molecular prognostic factors, validated to be taken into account in clinical practice.     

Coping and Participation in Youth With Spinal Cord Injury

Background:

Coping and participation are important adjustment outcomes of youth with spinal cord injury (SCI). Research addressing how these outcomes are related is limited.

Objective:

This cross-sectional study examined relationships between coping and participation in youth with SCI.

Method:

Youth ages 7 to 18 years were recruited from 3 hospitals specializing in rehabilitation of youth with SCI. The Kidcope assessed coping strategies, and the Children’s Assessment of Participation and Enjoyment (CAPE) examined participation patterns. Point biserial and Pearson correlations assessed relationships among variables, and hierarchical multiple regression analyses examined whether coping significantly contributed to participation above and beyond significant demographic and injury-related factors.

Results:

The sample included 294 participants: 45% female, 65% Caucasian, 67% with paraplegia. Mean age was 13.71 years (SD = 3.46), and mean duration of injury was 5.39 years (SD = 4.49). Results indicated that higher levels of social support and lower levels of self-criticism predicted higher participation in informal activities, lower levels of social withdrawal predicted participation in informal activities with a greater diversity of individuals, lower levels of blaming others predicted higher enjoyment of informal activities, and higher levels of cognitive restructuring predicted participation in formal activities with a greater diversity of individuals and in settings further from home.

Conclusion:

Results suggest higher levels of social support and cognitive restructuring and lower levels of self-criticism, social withdrawal, and blaming others predicted favorable participation outcomes. Interventions for youth with SCI that encourage higher levels of positive coping strategies and lower levels of negative and avoidant strategies may promote positive participation outcomes.