Relationships between environmental factors and participation in adults with traumatic brain injury, stroke, and spinal cord injury: a cross-sectional multi-center study

The study of ableism in population health: a critical review

Over the past three decades, health equity has become a guiding framework for documenting, explaining, and informing the promotion of population health. With these developments, scholars have widened public health's aperture, bringing systems of oppression sharply into focus. Additionally, some researchers in disability and health have advocated for utilizing socially grounded frameworks to investigate the health of disabled people. Yet, naming ableism, much less operationalizing it for the empirical study of health, remains scant. This paper critically reviews the study of ableism as a social determinant of disabled people's health within population health research. First, we provide an orientation to the present state of this literature by looking to the past. We briefly trace a history of traditional approaches to studying disability and health and alternatives that have emerged from critiques of the individualized lens that has dominated this work. Next, we delineate the operation of ableism across social levels. We characterize how ableism has been studied in population health in terms of levels of analysis (intrapersonal, interpersonal, institutional, and structural) and measures of interest. To conclude, we discuss hinderances to and promising avenues toward population health research that advances health equity for disabled people.

A Digital Intervention to Promote Self-Management Self-Efficacy Among Community-Dwelling Individuals With Stroke: Pilot Randomized Controlled Trial

BACKGROUND

Digital interventions provided through smartphones or the internet that are guided by a coach have been proposed as promising solutions to support the self-management of chronic conditions. However, digital intervention for poststroke self-management is limited; we developed the interactive Self-Management Augmented by Rehabilitation Technologies (iSMART) intervention to address this gap.

OBJECTIVE

This study aimed to examine the feasibility and initial effects of the iSMART intervention to improve self-management self-efficacy in people with stroke.

METHODS

A parallel, 2-arm, nonblinded, randomized controlled trial of 12-week duration was conducted. A total of 24 participants with mild-to-moderate chronic stroke were randomized to receive either the iSMART intervention or a manual of stroke rehabilitation (attention control). iSMART was a coach-guided, technology-supported self-management intervention designed to support people managing chronic conditions and maintaining active participation in daily life after stroke. Feasibility measures included retention and engagement rates in the iSMART group. For both the iSMART intervention and active control groups, we used the Feasibility of Intervention Measure, Acceptability of Intervention Measure, and Intervention Appropriateness Measure to assess the feasibility, acceptability, and appropriateness, respectively. Health measures included the Participation Strategies Self-Efficacy Scale and the Patient-Reported Outcomes Measurement Information System's Self-Efficacy for Managing Chronic Conditions.

RESULTS

The retention rate was 82% (9/11), and the engagement (SMS text message response) rate was 78% for the iSMART group. Mean scores of the Feasibility of Intervention Measure, Acceptability of Intervention Measure, and Intervention Appropriateness Measure were 4.11 (SD 0.61), 4.44 (SD 0.73), and 4.36 (SD 0.70), respectively, which exceeded our benchmark (4 out of 5), suggesting high feasibility, acceptability, and appropriateness of iSMART. The iSMART group showed moderate-to-large effects in improving self-efficacy in managing emotions (r=0.494), symptoms (r=0.514), daily activities (r=0.593), and treatments and medications (r=0.870), but the control group showed negligible-to-small effects in decreasing self-efficacy in managing emotions (r=0.252), symptoms (r=0.262), daily activities (r=0.136), and treatments and medications (r=0.049). In addition, the iSMART group showed moderate-to-large effects of increasing the use of participation strategies for management in the home (r=0.554), work (r=0.633), community (r=0.673), and communication activities (r=0.476). In contrast, the control group showed small-to-large effects of decreasing the use of participation strategies for management in the home (r=0.567), work (r=0.342, community (r=0.215), and communication activities (r=0.379).

CONCLUSIONS

Our findings support the idea that iSMART was feasible to improve poststroke self-management self-efficacy. Our results also support using a low-cost solution, such as SMS text messaging, to supplement traditional therapeutic patient education interventions. Further evaluation with a larger sample of participants is still needed.

TRIAL REGISTRATION

ClinicalTrials.gov 202004137; https://clinicaltrials.gov/study/NCT04743037?id=202004137&rank=1.

Efficacy of rehabilitation interventions evaluated in common neurological conditions in improving participation outcomes: A systematic review

OBJECTIVE

Modern clinical rehabilitation practice aligned to the International Classification of Functioning, Disability and Health and the Convention on the Rights of Persons with Disabilities highlights the importance of attention to participation in the rehabilitation formulation. This systematic review investigates the efficacy of rehabilitation interventions evaluated in common neurological disorders reported to influence participation outcomes.

DATA SOURCES

PubMed, Web of Science and PsycINFO databases were searched from inception to 25 April 2023. Only randomised controlled trials were considered for inclusion.

REVIEW METHODS

The data were extracted by two independent reviewers in the following categories: characteristics of the included study publications, description of intervention and outcome measures.

RESULTS

A total of 1248 unique article records were identified through the databases. Twenty-eight randomized controlled trials were included with 15 publications having participation as a primary outcome measure. Articles were related to multiple sclerosis (N = 4), spinal cord injury (N = 2), stroke (N = 16) and traumatic brain injury (N = 6). Four publications showed significant differences in pre- and post-intervention within experimental groups. All four articles described participation as primary outcome measure.

CONCLUSION

There is a limited evidence of the identified rehabilitation interventions to improve participation in common neurological conditions. However, there was a paucity of articles involving individual with Parkinson's disease that met the inclusion criteria.

A Biopsychosocial Framework for Apathy Following Moderate to Severe Traumatic Brain Injury: A Systematic Review and Meta-analysis

Apathy, the deficit of goal-directed behaviour, is well recognised as one of the most debilitating syndromes after moderate-to-severe traumatic brain injury (TBI). However, mechanisms underlying apathy, or at least factors associated with apathy, are sporadically reported. Based on a biopsychosocial framework, this systematic review and meta-analysis synthesised evidence regarding neurobiological, socio-environmental and individual factors associated with apathy. Our searches identified 21 studies satisfying inclusion and exclusion criteria. Results showed that the majority of work has focused on cognitive dysfunction, TBI-related factors, demographic variables and psychological correlates of apathy, while evidence for neural substrates and socio-cultural and premorbid aspects is scant. Overall, the current literature suggests that TBI-related and patient demographic factors did not contribute to apathy after TBI, whereas complex neurocognitive alterations, socio-environmental and cultural factors as well as patients' self-related factors may be important components. The evidence points to the multifaceted interplay of certain biopsychosocial contributors to apathy and suggests future investigations of more complex behavioural traits, cultural elements and pre-injury levels to better characterise the aetiology of this detrimental impairment after TBI.

Family experiences of the management of challenging behaviours after traumatic brain injury in the acute hospital setting

PURPOSE

This study explored experiences of the management of challenging behaviours after traumatic brain injury (TBI) in the acute hospital setting from the perspectives of family members.

MATERIALS AND METHODS

A qualitative, interpretive phenomenological approach was adopted involving semi-structured interviews with 10 family members. Interviews were transcribed and analysed using thematic analysis, with Ecological Systems Theory applied as a guiding framework to discuss findings and implications for practice.

RESULTS

Four primary themes were identified: 1) The hospital environment; 2) Hospital staffing; 3) Identifying and preventing triggers, and 4) Family support and information.

CONCLUSIONS

This qualitative study highlights the need for further information, education, and support to families of patients with TBI in the acute setting. Further research investigating the implementation of best practice approaches for managing challenging behaviours practice in acute settings is needed to overcome the barriers of the hospital environment, inexperienced and inconsistent staffing, and difficulties identifying triggers within the acute hospital setting, experienced by families. Approaches for family involvement in behaviour management strategies, and facilitation of communication for people with TBI in the acute setting requires exploration.

Biopsychosocial factors of quality of life in individuals with moderate to severe traumatic brain injury: a scoping review

PURPOSE

Individuals with moderate to severe traumatic brain injury (TBI) experience changes in their quality-of-life (QOL) post-injury. Given the vast literature that exists about QOL after TBI, a scoping review was performed to identify the different biopsychosocial factors that affect a person's QOL after a moderate to severe TBI.

METHODS

A scoping review was conducted using the following electronic databases: MEDLINE, CINAHL, Embase, and PsycINFO. Terms relating to TBI and QOL were used.

RESULTS

There were 7576 articles obtained from the databases, resulting in 535 full-text articles. Ultimately, 52 articles were extracted, which consisted of biopsychosocial QOL factors after TBI. The biopsychosocial factors of QOL after TBI included 19 biological factors (i.e., sex, TBI severity, cognition), 16 psychological factors (i.e., depression, self-efficacy, coping styles), and 19 social factors (i.e., employment, social participation, social support). Factors such as fatigue, self-awareness, transition, and discharge from hospitals are known issues in TBI literature but were minimally reported in studies in this review, identifying them as potential gaps in research.

CONCLUSION

Identifying biopsychosocial factors relating to QOL after TBI can enable health services to develop targeted rehabilitation programs for individuals with TBI.

Comparison of Informational and Educational Resource Provision for Individuals Living With Traumatic Brain Injury Based on Language, Nativity, and Neighborhood

OBJECTIVE

To examine a resource provision program for individuals living with moderate-to-severe traumatic brain injury (TBI), using a comparison of the resources provided across social differences of language, nativity, and neighborhood.

SETTING

The Rusk Rehabilitation TBI Model System (RRTBIMS) collects data longitudinally on individuals from their associated private and public hospitals, located in New York City.

PARTICIPANTS

A total of 143 individuals with TBI or their family members.

DESIGN

An observational study of relative frequency of resource provision across variables of language, nativity, and neighborhood, using related-samples nonparametric analyses via Cochran's Q test.

MAIN MEASURES

Variables examined were language, place of birth, residence classification as medically underserved area/population (MUA), and resource categories.

RESULTS

Results indicate that US-born persons with TBI and those living in medically underserved communities are provided more resources than those who are born outside the United States or reside in communities identified as adequately medically served. Language was not found to be a factor.

CONCLUSION

Lessons learned from this research support the development of this resource provision program, as well as guide future programs addressing the gaps in health information resources for groups negatively impacted by social determinants of health (SDoH). An approach with immigrant participants should take steps to elicit questions and requests, or offer resources explicitly. We recommend research looking at what interpreter strategies are most effective and research on SDoH in relation to the dynamic interaction of variables in the neighborhood setting.

Establishing the measurement properties of the Residential Environment Impact Scale (Version 4.0)

BACKGROUND

Developed as an environment assessment informed by the Model of Human Occupation, the Residential Environment Impact Survey considered the physical, social and activity features of the environment, evaluating the impact of the environment on resident's quality of life. Clinicians reported that the Residential Environment Impact Survey was a useful tool; however, it had not been structured to be a measurement tool and did not have established psychometric properties.

AIMS/OBJECTIVES

This study examines the psychometric properties of the restructured Residential Environment Impact Scale Version 4.0 (REIS), which measures the level of environment support provided to residents.

MATERIAL AND METHODS

The REIS was completed across residential sites for people with complex mental health needs. A many facets Rasch analysis was conducted to establish the reliability and validity of the REIS.

RESULTS

The REIS demonstrated reasonable psychometric properties, with items demonstrating internal scale validity and scale items following an expected pattern of increasingly challenging environment support.

CONCLUSIONS AND SIGNIFICANCE

Initial evidence suggests that the REIS provides a valid and reliable measure of environment support, providing a detailed assessment of how physical, social and activity elements of the environment support or inhibit participation and can be applied across a range of living environments.

The role of self-efficacy in community reintegration among persons with traumatic spinal cord injury in South Africa

OBJECTIVES

To assess perceived levels of community reintegration, and examine whether self-efficacy relates to community reintegration among persons with a TSCI.

DESIGN

A cross-sectional exploratory survey.

SETTINGS

Cape Metropolitan Area. Western Cape Province, South Africa.

PARTICIPANTS

A hundred and eight (108) conveniently selected community-dwelling adults between the ages of 19 and 71 years old, who sustained a TSCI more than 1-year post-injury.

OUTCOMES MEASURES

Community Integration Measure (CIM) and the Moorong Self-Efficacy (MSES).

RESULTS

The CIM score ranged between 10 and 50 with an overall mean score of 31.48; SD = 12.5. CIM item 10 "I have something useful and productive to do in this community" was the least scored by participants (M = 2.50, SD = 1.4). Multivariate analysis demonstrated that social functioning factor of self-efficacy, accommodation type, and level of injury were the only variables influencing perceived community reintegration that explained 47.3% of the total variance, of which social functioning factor of self-efficacy was the strongest predictor that alone explained 33% of the variance in the model after controlling for the influence of accommodation and the level of injury.

CONCLUSION

Community reintegration achieved by individuals with a TSCI in this study is generally low. Individuals' perceptions about community reintegration are affected by the community in which one lives. Self-efficacy plays a major role in community reintegration following a TSCI. However, reintegration is largely dependent on social functioning rather than the activity of daily living factors of self-efficacy.

Living in a reshaped reality: Exploring social participation and self-identity after TBI

Individuals with a moderate to severe traumatic brain injury (TBI) experience substantial changes in their life. This constructivist grounded theory study aimed to develop an explanatory model that explores the impact of changes in social participation and self-identity after sustaining a TBI. Sixteen participants with moderate to severe TBI (mean age = 49.8, 69% male) were recruited, and were on average 16.4 years post-injury (SD = 10.4). Data from semi-structured interviews were analysed thematically. An overarching theme of "living in a reshaped reality" was identified, which depicted how changes in social participation and self-identity influenced ongoing experiences with TBI. Three main themes were generated: (1) "there's nothing that's the same" highlighted the daily challenges individuals faced post-injury, (2) "rebuilding and restarting" described how individuals with TBI navigated through their unfamiliar reality, and (3) "embrace it and run with it" explored participants' reactions towards life with a TBI. An explanatory model was developed, consisting of the overarching theme ("living in a reshaped reality") with the three integrated themes. Future research and clinical practices can build on this understanding to develop programmes to help individuals address their needs in post-injury life.

Poststroke activity engagement in community dwellers: Association with illness perceptions and perceived environment

OBJECTIVES

To investigate whether individuals' poststroke activity engagement is associated with their perceptions of stroke, as well as their perceptions of physical and social environment.

DESIGN

Cross-sectional study.

SETTING

Participants were recruited from eight rehabilitation settings in Beijing, China.

PARTICIPANTS

A total of 202 dyads of community dwellers with stroke and their primary caregivers.

MAIN MEASURES

Activity engagement measured by the Assessment of Life Habits; stroke individuals' and caregivers' illness perceptions measured by the Stroke-Specific Illness Perceptions Questionnaire - Revised; and stroke individuals' perceived social and physical environment measured by the Social Support Survey and abbreviated Neighborhood Environment Walkability Scale.

RESULTS

A total of 202 dyads of individuals with stroke and their caregivers participated in the study with mean ages of 61.3 (8.3) and 52.6 (11.6), respectively. On average, stroke individuals scored 7.61 (1.42) on the daily activities subscale, indicating that they completed personal level activities without assistance but with some difficulty. They scored 6.21 (2.21) on the social roles subscale, suggesting that individuals completed societal level activities with assistive devices and with some difficulty. Illness perceptions correlated significantly with personal level activity engagement (change in R-squared = 0.029; p = 0.049), and perceived accessibility and heterogeneity correlated significantly with societal level activity engagement (change in R-squared = 0.025; p = 0.011).

CONCLUSIONS

Poststroke activity engagement is associated not only with stroke individuals' performance skills but also with their perceptions of stroke, and how they perceive their physical environment. The findings may assist clinicians' decision making when developing comprehensive, targeted interventions for improving activity engagement and maximizing recovery after stroke.

Predictive role of modifiable factors in stroke: an umbrella review

BACKGROUND

A growing number of meta-analyses reviewed the existing associations between modifiable factors and stroke. However, the methodological quality of them and quality of evidence remain to be assessed by validated tools. Thus, this umbrella review was conducted to consolidate evidence from systematic reviews and meta-analyses of cohort studies investigating the association between modifiable factors and incidence of stroke.

METHODS

PubMed, Web of Science, Embase, Wanfang and China National Knowledge Infrastructure databases for systematic reviews and meta-analyses of cohort studies from inception until March 2021. Assess the methodological quality of systematic reviews 2 was used to evaluate the methodological quality of each included published meta-analysis. Excess significance test was used to investigate whether the observed number of studies (O) with nominally significant results ('positive' studies, p<0.05) was larger than the expected number of significant results (E). Statistically significant (p<0.05) associations were rated into five levels (strong, highly suggestive, suggestive, weak and no) using specific criteria. Sensitivity analyses were performed.

RESULTS

2478 records were identified through database searching. At last, 49 meta-analyses including 70 modifiable factors and approximately 856 801 stroke cases were included in the present review. The methodological quality of three meta-analyses was low, while others were critically low. Evidence of walking pace was strong. High suggestive evidence mainly included total meat, processes meat, chocolate, sodium, obesity, pulse pressure, systolic blood pressure, diastolic blood pressure, sleep duration and smoking. Suggestive evidence mainly included dietary approaches to stop hypertension (DASH) diet, vitamin C, magnesium, depression and particulate matter 2.5. After sensitivity analyses, evidence of DASH diet, magnesium and depression turned to weak. No publication bias existed, except only one study which could be explained by reporting bias.

DISCUSSION

Diet with rich macronutrients and micronutrients, healthy dietary patterns and favourable physical, emotional health and environmental management should be promoted to decrease the burden of stroke.

PROSPERO REGISTRATION NUMBER

CRD42021249921.

Strengthening Community Participation by People With Disabilities in Community-Based Group Homes Through Innovative Action Research

In the US and beyond, a paradigm shift is underway toward community-based care, motivated by changes in policies, payment models and social norms. A significant aspect of this shift for disability activists and policy makers is ensuring participation in community life for individuals with disabilities living in residential homes. Despite a U.S. government ruling that encourages community participation and provides federal and state funding to realize it, little progress has been made. This study builds on and integrates the expanded model of value creation with relational coordination theory by investigating how the resources and relationships between care providers, adults with disabilities, family members, and community members can be leveraged to create value for residents through meaningful community participation. The purpose of our community case study was to assess and improve the quality of relationships between stakeholder groups, including direct care staff and managers, residents, family members, and the community through an action research intervention. This study took place in a residential group home in a Northeastern US community serving adults with disabilities from acquired brain injury. A pre-test post-test design was used and quantitative assessments of relational coordination were collected through electronic surveys, administered at baseline, and post-intervention. Direct care staff, supervisors, the house manager, and nursing staff completed the survey. Qualitative data were collected through focus groups, change team meetings, and key informant interviews. Direct care staff formed a change team to reflect on their baseline relational coordination data and identified the weak ties between direct care staff, family members, and the community as an area of concern. Staff chose to hold a community-wide open house to provide an opportunity to foster greater understanding among staff, residents, family, and community members. The change team and other staff members coordinated with local schools, business owners, town officials, churches, and neighbors. The event was attended by 50 people, about two-thirds from the community. Following the intervention, there was an increase in staff relational coordination with the community. While statistical significance could not be assessed, the change in staff RC with the community was considered qualitatively significant in that real connections were made with members of the community both directly and afterwards. Despite a small sample size, a residential setting where management was favorable to initiating staff-led interventions, and no comparison or control group, our small pilot study provides tentative evidence that engaging direct care staff in efforts to improve relational coordination with community members may succeed in building relationships that are essential to realizing the goal of greater participation in community life.

Measurement Feedback System for Intensive Neurorehabilitation after Severe Acquired Brain Injury

Outcome of acquired brain injury (ABI) and the potential for neurorehabilitation are subject to distinct heterogeneity between patients. Limited knowledge of the complex constellation of determinants at play interferes with the possibility to deploy precision medicine in neurorehabilitation. Measurement Feedback Systems (MFS) structure clinical data collection and deliver the measurement results as feedback to clinicians, thereby facilitating progress monitoring, promoting balanced patient-centered discussion and shared decision making. Accumulation of clinical data in the MFS also enables data-driven precision rehabilitation medicine. This article describes the development and implementation of a MFS for neurorehabilitation after ABI. The MFS consists of specialized measurement tracks which are developed together with representatives of each discipline in the multidisciplinary team. The MFS is built into a digital platform that automatically distributes measurements among clinicians, at predetermined time points during the inpatient treatment, outpatient treatment and follow-up. The results of all measurements are visualized in individual patient dashboards that are accessible for all clinicians involved in treatment. Since step-wise implementation, 124 patients have been registered on the MFS platform so far, providing an average of more than 200 new measurements per week. Currently, more than 15,000 clinical measurements are captured in the MFS. The current overall completion rate of measurements is 86,4%. This study shows that structured clinical assessment and feedback is feasible in the context of neurorehabilitation after severe ABI. The future directions are discussed for MFS data in our Health Intelligence Program, which aims at periodic care evaluation and the transition of neurorehabilitation care towards precision medicine.

Understanding the priorities in life beyond the first year after stroke: Qualitative findings and non-participant observations of stroke survivors and service providers

ABSTRACTLong-term unmet health needs are associated with a lower quality of life in stroke survivors. Survivors' priorities in living their lives and health professionals' recognition influence survivors' perceptions of their needs. From the perspectives of survivors and service providers, this study investigated survivors' long-term priorities for continuing their lives after stroke. A qualitative study was conducted with a convenience sample of 40 stroke survivors and a purposive sample of 11 providers who had worked with survivors for more than five years and were currently managers of community-based stroke care services or leaders of volunteer groups. Following the survivors' interviews, non-participant observations of a random day's activities were conducted. Data were transcribed verbatim. Survivors' and providers' data were analyzed separately and then together thematically. Five themes emerged: healing the mind in order to move forward, optimizing adaptations and maintaining physical function, living a safe and cost-effective life, returning to work, and giving back to society. Community-based services can be improved to offer more at-home, technology-supported psychological and self-management interventions, barrier-free and one-stop services, and opportunities for employment and volunteering. It would be worthwhile to invest in conducting public education to promote social inclusion and strengthening collaboration between academic and community organizations.

Goal Attainment in an Individually Tailored and Home-Based Intervention in the Chronic Phase after Traumatic Brain Injury

Traumatic brain injury (TBI) is a heterogeneous condition with long-term consequences for individuals and families. Goal-oriented rehabilitation is often applied, but there is scarce knowledge regarding types of goals and goal attainment. This study describes goal attainment in persons in the chronic phase of TBI who have received an individualized, SMART goal-oriented and home-based intervention, compares goal attainment in different functional domains, and examines indicators of goal attainment. Goal attainment scaling (GAS) was recorded in the intervention group (n = 59) at the final session. The goal attainment was high, with 93.3% increased goal attainment across all goals at the final session. The level of goal attainment was comparable across domains (cognitive, physical/somatic, emotional, social). Gender, anxiety symptoms, self-reported executive dysfunction, and therapy expectations were indicators of goal attainment. These results indicate a potential for the high level of goal attainment in the chronic phase of TBI. Tailoring of rehabilitation to address individual needs for home-dwelling persons with TBI in the chronic phase represents an important area of future research.

Factors that influence the participation of individuals with deafblindness: A qualitative study with rehabilitation service providers in India

Evidence to inform rehabilitation service delivery for individuals with deafblindness, especially in the Indian context, is inadequate. Rehabilitation professionals often find it challenging to design rehabilitation interventions that promote participation for those with deafblindness. Therefore, our purpose was to understand the contextual factors that influence the participation of individuals with deafblindness in India from the perspectives of those who are involved in providing rehabilitation services to them. Using the International Classification of Functioning, Disability, and Health (ICF) as a framework, we conducted two focus group discussions with 16 rehabilitation service providers in India. We used a content analysis approach to examine the data. Rehabilitation service providers perceived participation barriers to be linked primarily to the social environment. Specifically, participants identified four major factors acting as barriers, including (a) lack of awareness about deafblindness; (b) negative attitudes and stigma associated with disability; (c) lack of access to resources such as assistive technology and interpreter support; and (d) communication challenges associated with severe impairments. Facilitators include accessibility of the built environment for multisensory impairments, affordable technology, provision of an interpreter and personal support worker, and training on deafblindness for professionals. The participation of individuals with deafblindness could be enhanced by identifying and removing environmental barriers and improving knowledge about deafblindness among rehabilitation professionals for proper identification, assessment, and access to rehabilitation services.

Adult sports-related traumatic spinal injuries: do different activities predispose to certain injuries?

OBJECTIVE

Sports injuries are known to present a high risk of spinal trauma. The authors hypothesized that different sports predispose participants to different injuries and injury severities.

METHODS

The authors conducted a retrospective cohort analysis of adult patients who experienced a sports-related traumatic spinal injury (TSI), including spinal fractures and spinal cord injuries (SCIs), encoded within the National Trauma Data Bank from 2011 through 2014. Multiple imputation was used for missing data, and multivariable linear and logistic regression models were estimated.

RESULTS

The authors included 12,031 cases of TSI, which represented 15% of all sports-related trauma. The majority of patients with TSI were male (82%), and the median age was 48 years (interquartile range 32-57 years). The most frequent mechanisms of injury in this database were cycling injuries (81%), skiing and snowboarding accidents (12%), aquatic sports injuries (3%), and contact sports (3%). Spinal surgery was required during initial hospitalization for 9.1% of patients with TSI. Compared to non-TSI sports-related trauma, TSIs were associated with an average 2.3-day increase in length of stay (95% CI 2.1-2.4; p < 0.001) and discharge to or with rehabilitative services (adjusted OR 2.6, 95% CI 2.4-2.7; p < 0.001). Among sports injuries, TSIs were the cause of discharge to or with rehabilitative services in 32% of cases. SCI was present in 15% of cases with TSI. Within sports-related TSIs, the rate of SCI was 13% for cycling injuries compared to 41% and 49% for contact sports and aquatic sports injuries, respectively. Patients experiencing SCI had a longer length of stay (7.0 days longer; 95% CI 6.7-7.3) and a higher likelihood of adverse discharge disposition (adjusted OR 9.69, 95% CI 8.72-10.77) compared to patients with TSI but without SCI.

CONCLUSIONS

Of patients with sports-related trauma discharged to rehabilitation, one-third had TSIs. Cycling injuries were the most common cause, suggesting that policies to make cycling safer may reduce TSI.

Physical activity and sedentary behavior in people with spinal cord injury: Mitigation strategies during COVID-19 on behalf of ACSM-EIM and HL-PIVOT

People with spinal cord injury (SCI) face unique challenges during the COVID-19 pandemic, including greater risk of poor COVID-19-related outcomes, increased social isolation, and restricted access to important services. Furthermore, COVID-19 related restrictions have decreased already low levels of physical activity (PA) in this population. Therefore, the purpose of this commentary is to: 1) address the impact of COVID-19 on PA and sedentary behavior (SB) in people with SCI; 2) provide potential SB reduction strategies to guide future research; and 3) provide recommendations to increase PA and reduce SB on behalf of the American College of Sports Medicine Exercise is Medicine (ACSM-EIM) and Healthy Living for Pandemic Event Protection (HL-PIVOT) using a social-ecological model targeting the individual-, social environment-, physical environment-, and policy-level determinants of behavior in people with SCI.

Community Integration After Traumatic Brain Injury and Related Factors: A Study in the Nepalese Context

Introduction

Community integration is an essential component for rehabilitation among traumatic brain injury (TBI) survivors, which yields positive outcomes in terms of social activities, community participation, and productive work. A factor that usually facilitates community integration among TBI survivors is social support, whereas physical environment and fatigue are most often found as barriers.

Objectives

This study aimed to (1) describe the level of community integration, fatigue, physical environment, and social support of persons after TBI, and (2) examine the relationship between community integration and these three factors.

Methods

This is a descriptive correlational study. One hundred and twenty TBI survivors living in the communities of Province Number Three, Nepal were enrolled using the stratified sampling technique. The data were collected using the Community Integration Questionnaire, Modified Fatigue Impact Scale, Craig Hospital Inventory of Environmental Factors, and the Multidimensional Scale of Perceived Social Support. Descriptive statistics and Pearson's correlation were used to analyze the data.

Results

Community integration, fatigue, and physical environment showed a moderate level, while social support revealed a high level. Fatigue was significantly correlated with overall community integration, whereas physical environment was found to correlate with two subscales of community integration, home integration and productive activities.

Conclusion

To enhance the level of community integration among TBI survivors, health care providers, in particular rehabilitation nurses and community nurses, should plan and implement strategies such as follow-up appointments or continued rehabilitation at home.

Essential Elements That Contribute to the Recovery of Persons With Severe Mental Illness: A Systematic Scoping Study

Introduction: There is an increasing emphasis on recovery-oriented care in the design and delivery of mental health services. Research has demonstrated that recovery-oriented services are understood differently depending on the stakeholders involved. Variations in interpretations of recovery lead to challenges in creating systematically organized environments that deliver a consistent recovery-oriented approach to care. The existing evidence on recovery-oriented practice is scattered and difficult to apply. Through this systematic scoping study, we aim to identify and map the essential elements that contribute to recovery outcomes for persons living with severe mental illness. Methods: We used the Arksey & O'Malley framework as our guiding approach. Seven key databases (MEDLINE, PubMed, CINAHL/EBSCO, EMBASE, ProQuest, PsycINFO, and Google Scholar) were searched using index terms and keywords relating to recovery and severe mental illness. To be included, studies had to be peer-reviewed, published after 1988, had persons with severe mental illness as the focal population, and have used recovery in the context of mental health. The search was conducted in August 2018 and last updated in February 2020. Results: Out of 4,496 sources identified, sixty (n = 60) sources were included that met all of the selection criteria. Three major elements of recovery that emerged from the synthesis (n = 60) include relationships, sense of meaning, and participation. Some sources (n = 20) highlighted specific elements such as hope, resilience, self-efficacy, spirituality, social support, empowerment, race/ethnicity etc. and their association with the processes underpinning recovery. Discussion: The findings of this study enable mental health professionals to incorporate the identified key elements into strategic interventions to facilitate recovery for clients with severe mental illness, and thereby facilitate recovery-oriented practice. The review also documents important gaps in knowledge related to the elements of recovery and identifies a critical need for future studies to address this issue.

Rasch Analysis of Social Attitude Barriers and Facilitators to Participation for Individuals with Disabilities

OBJECTIVES

To develop item banks of social attitude barriers and facilitators to participation and validate them with established instruments.

DESIGN

We used the Rasch model to identify misfitting items and rating scale problems, calibrate items, and develop KeyForms and short forms. Correlations between the Social Attitude Barriers and Facilitators item banks with the Patient-Reported Outcomes Measurement Information System (PROMIS) Social Health domain and National Institutes of Health Toolbox Emotional Battery Social Relationships domain were computed to evaluate convergent and divergent validity.

SETTING

Community-dwelling individuals traveled to 3 academic medical centers for testing.

PARTICIPANTS

Participants (N=558) who had a primary impairment of stroke, spinal cord injury, or traumatic brain injury (mean age, 47.0±16.0y) completed 31 social attitude facilitator and 51 barrier items using a 5-point rating scale.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Item banks to measure social attitude barriers and facilitators for individuals with disabilities.

RESULTS

After combining the "never" and "rarely" rating scale categories, 30 Facilitator items fit the Rasch model and demonstrated person reliability of 0.93. After collapsing the "never" and "rarely" rating scale categories, 45 Barrier items fit the Rasch model and demonstrated person reliability of 0.95. Ceiling and floor effects were negligible for both item banks. Facilitators and Barriers item banks were negatively correlated, and these banks were moderately correlated with PROMIS and Toolbox measures, providing evidence of convergent and divergent validity.

CONCLUSIONS

Findings support the reliability and validity of the Social Attitude Facilitators and Barriers item banks. These item banks allow investigators and clinicians to measure perceptions of social attitudes, providing information that can guide individual interventions to reduce barriers and promote facilitators. Moderate correlations between the Social Attitude banks and PROMIS and Toolbox variables provide support for the measurement and theory of environmental influences on social health and participation.

Ecological Momentary Assessment of Social Interactions: Associations With Depression, Anxiety, Pain, and Fatigue in Individuals With Mild Stroke

OBJECTIVES

To examine real-time relationships between social interactions and poststroke mood and somatic symptoms in participants' daily environments.

DESIGN

Prospective observational study using smartphone-based ecological momentary assessment (EMA) surveys 5 times a day for 2 weeks. Multilevel models were used to analyze data for concurrent and lagged associations.

SETTING

Community.

PARTICIPANTS

Adults (N=48) with mild stroke.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

EMA measures of self-appraisal of social interactions (confidence, satisfaction, and success), as well as mood (depression and anxiety) and somatic (pain and fatigue) symptoms.

RESULTS

In concurrent associations, increased depressed mood was associated with reduced ratings of all aspects of social interactions. Fatigue was associated with reduced ratings of social satisfaction and success. In lagged associations, increased anxious mood preceded increased subsequent social confidence. Higher average social satisfaction, confidence, and success were related to lower momentary fatigue, anxious mood, and depressed mood at the next time point. Regarding clinicodemographic factors, being employed was concurrently related to increased social interactions. An increased number of comorbidities predicted higher somatic, but not mood, symptoms at the next time point.

CONCLUSIONS

This study provides preliminary evidence of dynamic relationships between social interactions and somatic and mood symptoms in individuals with mild stroke. Interventions to not only address the sequelae of symptoms, but also to promote participation in social activities in poststroke life should be explored.

Environmental Barriers Experienced by People With Spinal Cord Injury Across 22 Countries: Results From a Cross-Sectional Survey

OBJECTIVES

To investigate the experience of environmental barriers by people with spinal cord injury (SCI) across 22 countries. Specific aims were to describe and compare the prevalence of environmental barriers experienced across countries, and to analyze determinants of environmental barriers at individual and country level.

DESIGN

Cross-sectional community survey.

PARTICIPANTS

Individuals (N=12,591) living with SCI in the community.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Nottwil Environmental Factors Inventory-Short Form.

RESULTS

Most barriers were experienced in relation to accessibility, climate, transportation, finances, and state services. More severe barriers were experienced in settings with lower gross domestic product (GDP), which especially refers to medical supplies (gamma=-0.38; P<.001) and finances (gamma=-0.37; P<.001) in this study. However, in a multivariable negative binomial regression using within-between estimation of the number of barriers experienced on the selected predictors, the effect of GDP was reversed when it was adjusted for covariates. On the individual level, the number of experienced barriers decreased with better mental health and greater self-care ability. People with low income, with paraplegia, complete lesions, and more health problems reported more barriers. On the country level, fewer barriers were reported in countries with higher average age, better mental health, and greater self-care ability, as well as in those with a higher percentage of traumatic SCI, paraplegia, and complete lesions. More barriers were reported in countries with a higher percentage of married individuals, lower average household income, higher average time since injury, higher mean vitality scores, and greater income inequality.

CONCLUSIONS

Study participants reported a significant number of environmental barriers, many of which are modifiable. Complementary interventions are recommended. Within and between country effects of covariates sometimes pointed in different directions, suggesting that countries with a different composition of SCI population also differed in environmental contexts.

Developing a Facilitators Scale in the Context of Travel: ReTRIP

Objective

To develop a scale for measuring factors that facilitate participation of people with spinal cord injury (SCI) in travel-related activities: Removing Travel Restrictions Influencing Participation (ReTRIP).

Design

A mixed-method approach where in the qualitative phase, items were developed and written based on results of interviewers with different stakeholder groups and in the quantitative phase, survey data were collected to examine the psychometric properties of the scale.

Setting

Home, work, and community settings.

Participants

People living with SCI, caregivers or family members, therapists, travel professionals (N=333).

Interventions

None.

Main Outcome Measures

An 11-item ReTRIP scale that measures the facilitators that enhance the travel participation of people with SCI.

Results

In the qualitative phase of the study, 5 categories of travel facilitators were identified based on semistructured in-depth interviews with 83 respondents from 4 stakeholder groups. Initial items of the ReTRIP scale were written based on the travel facilitators identified. Items in the scale were then revised based on results of cognitive interviews and an expert panel review. In the quantitative phase, a total of 250 patients enrolled in a Spinal Cord Injury Model System were systematically selected to report their experience with each travel facilitator. Item-response theory-based Rasch analysis revealed that the 11-item ReTRIP has acceptable psychometric properties, containing 2 main dimensions: industry-oriented facilitators (6 items) and self-oriented facilitators (5 items).

Conclusions

The 11-item ReTRIP scale demonstrates promising psychometric properties, allowing researchers and clinicians to potentially use self-reported environmental factors that are beneficial for people's participation in travel after SCI to properly design client-centered interventions. Future studies using a larger sample are needed to validate the scale.

The association between volition and participation in adults with acquired disabilities: A scoping review

Background/objective

Physical, cognitive and psychological factors such as self-efficacy and motivation affect participation in populations with acquired disabilities. Volition is defined as a person's motivation for participating in occupation. The concept of ‘volition’ expands similar concepts and theories, which focus mostly on cognitive processes that influence motivation. Although volition seems to affect participation, the association between these two concepts has not been examined in populations with acquired disabilities. This scoping review explored this association.

Methods

The literature review used a structured five-stage framework, according to predefined inclusion and exclusion criteria. Seven electronic databases (CINAHL, PsycINFO, PubMed, Web of Science, SCOPUS, The Cochrane Library-Wiley, OTseeker) and Google Scholar were searched for relevant articles, published in English from January 2001 to May 2018.

Results

A total of 18 articles, relating to populations with various diagnoses were included. Two directly examined volition and participation and showed a positive association between them. Other articles discussed the effect of participants’ chronic condition on their volition and participation, the effect of volition on participation, or the effect on participation of an intervention addressing volition.

Conclusions

An acquired disability affects both volition and participation, and volition seems to affect participation among people with acquired disabilities. Few articles showed positive effects of interventions that addressed clients' volition, on participation. Further research should include additional health conditions and types of literature, to better understand the association between these concepts. This understanding will contribute to the development of occupational therapy interventions that emphasise volition, in order to improve participation outcomes.

National Institutes of Health Toolbox Emotion Battery: Application of Summary Scores to Adults With Spinal Cord Injury, Traumatic Brain Injury, and Stroke

OBJECTIVE

To examine the validity of factor analytically based summary scores that were developed using the National Institutes of Health Toolbox Emotion Battery (NIHTB-EB); (ie, psychological well-being, social satisfaction, negative affect) normative sample in individuals with neurologic conditions.

DESIGN

Cross-sectional, observational cohort.

SETTING

Community.

PARTICIPANTS

A total of 1036 English-speaking adults from the National Institutes of Health Toolbox (NIHTB) normative project and 604 community-dwelling adults with neurologic conditions including spinal cord injury (SCI n=209), traumatic brain injury (TBI n=184), and stroke (cerebrovascular accident [CVA] n=211) (N=1640).

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

The NIHTB-EB.

RESULTS

A series of univariate analyses comparing summary scores across the 4 groups (SCI, TBI, CVA, normative group) were conducted to identify group differences. Base rates (defined as >1 SD toward the problematic direction) were also identified. The normative group demonstrated better emotional functioning characterized by greater social satisfaction and psychological well-being (normative group > SCI, TBI, CVA; P's <.0001), and less negative affect (normative group < SCI, P=.016; normative group < TBI, P<.001; normative group < CVA; P=.034) compared with each neurologic group. Using base rates to identify problematic emotions for the 3 summary scores, there were higher rates of problematic emotions on all 3 summary scores for the neurologic groups compared with the normative group.

CONCLUSIONS

The NIHTB-EB summary scores demonstrate an increased prevalence of problematic emotions among individuals with 3 neurologic conditions, and might be useful for identifying individuals with similar conditions and potentially in need of psychological support.

Return to work predicts perceived participation and autonomy by individuals with stroke

Purpose: Participation in activities of everyday life is seen as main goal of rehabilitation after a stroke and return to work is an important factor to consider for the substantial number of persons having a stroke at working age. The current study aims to investigate whether returning to work would predict self-perceived participation and autonomy in everyday life after a stroke, from a long-term perspective.Materials and methods: Persons with first-ever stroke at age 18-63 years in 2009-2010, Gothenburg, were included. As 5-year follow-up, the Impact on Participation and Autonomy questionnaire was sent out, investigating self-perceived participation/autonomy in five levels, and work status was investigated from national sick-absence registers. Prediction of work on participation/autonomy was investigated with logistic regression.Results: A total of 109 participants (49%) responded to the questionnaire. The majority (69-94%) perceived very good participation/autonomy in all domains and 59% were working 5 years after stroke. Working was a significant predictor of high participation/autonomy in all domains of the questionnaire.Conclusions: Being able to return to work after a stroke seems to be important for self-perceived participation/autonomy. This emphasizes the importance of work-oriented information and rehabilitation after a stroke at working age.Implications for rehabilitationThe current study shows that the majority report high self-perceived participation and autonomy in everyday life and 59% are working 5 years after a stroke in working age.To work 5 years after a stroke was a significant predictor for self-perceived participation and autonomy in everyday life.Since stroke is becoming more common among working age persons and work seem important for perceived participation and autonomy, to optimize the return to work by for instance work-oriented information and vocational rehabilitation is important.

Understanding the Changing Health Care Needs of Individuals Aging With Spinal Cord Injury

Background: Individuals over age 65 are projected to account for over 20% of the general population by 2030. This trend is reflected in an increase in the age of individuals sustaining traumatic spinal cord injury (SCI). Based on current evidence, there is concern regarding the needs of older individuals aging with SCI and current health care services. Research is limited regarding factors that contribute to health status and treatment outcomes associated with aging 5 or more years post SCI. Objective: The purpose of this qualitative study was to explore changing health care needs of individuals aging with SCI and their caregivers and to identify the environmental supports and barriers to achieving long-term health and treatment outcomes. Methods: This was a phenomenological study utilizing semi-structured interviews. Inclusion criteria were age greater than 60 years old and 5 years post SCI. Between October 2014 and January 2016, 41 individuals with SCI and eight caregivers participated in the semi-structured interviews. Emergent themes and quotations were noted and analyzed using established methods. Triangulation was used to establish rigor and trustworthiness. Results: Data analysis of the interviews revealed four themes (health literacy, health services, changes with age, and environment) and 10 subthemes. Conclusion: Rehabilitation programs should consider the health literacy of older individuals with SCI and their caregivers. Similarly, these programs should be designed to allow them to identify and utilize resources in solving barriers to everyday participation. Further investigation is required to examine the macro-environmental influences (systems and policies) on the changing health care needs of individuals aging with SCI.

Using the ICF to Identify Contextual Factors That Influence Participation of Persons With Deafblindness

OBJECTIVE

To identify and describe the contextual factors that influence the participation of people with deafblindness in India.

DESIGN

Qualitative study, using directed content analysis approach and the International Classification of Functioning, Disability and Health (ICF) as a framework to analyze the data.

SETTING

Community and social participation settings.

PARTICIPANTS

Community-dwelling individuals with deafblindness (N=16). Age ranges from 18-45 years.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Personal and environmental factors that influence the participation of individuals with deafblindness using the ICF framework.

RESULTS

Results indicate that the age of onset and nature of impairment (deafblindness) and willingness to explain the condition (functional consequences of deafblindness) emerged as important personal factors. Access to resources such as assistive technology, social support, and deafblind-specific services were found to be enablers of participation. Lack of services, systems, and policies specific to deafblindness along with negative societal attitude toward disability were highly perceived environmental barriers that influence participation of people with deafblindness in India.

CONCLUSIONS

Professionals must acknowledge aspects of the environment in conducting assessments and delivering interventions and understand the dynamic interactions between environment of the individual and his/her concurrent vision and hearing impairments. Approaches to enable participation require rehabilitation professionals to work with those with deafblindness to advocate for removal of environmental barriers and ensure provision of appropriate resources from the government to facilitate their participation. Social policy and government must ensure emphasis on awareness about deafblindness, access to deafblind-specific services, positive societal attitude, and opportunities for full participation for people with deafblindness in society.

Barriers to physical activity in university students with disabilities: Differences by sociodemographic variables

BACKGROUND

Despite the positive effects of regular physical activity (PA), university students with disabilities are less active than their able-bodied peers, which could be due to the wide range of barriers to PA that these individuals face across all social ecological levels.

OBJECTIVE

To identify the barriers to PA experienced by university students with disabilities at the different social ecological levels and to examine the differences in these barriers by sociodemographic variables.

METHODS

The reduced Spanish version of the Barriers to Physical Activity Questionnaire for People with Mobility Impairments was administered to a sample of 1219 Spanish university students with disabilities. Non-parametric tests were performed to examine the differences in the barriers experienced by sociodemographic variables.

RESULTS

The most important barriers were intrapersonal (e.g. fatigue, pain, lack of motivation), followed by organizational ones (e.g. lack of adapted programs, economic cost). At the interpersonal level, the inactivity of friends and family were the main barriers. Potholes in the streets or other public spaces were found to be the most important barriers at the community level. Significant differences were found in barriers by sex, age, disability grade, congenital-acquired disability and disability type. The groups most affected by the barriers were, in general, those with multiple disabilities and higher disability grade.

CONCLUSIONS

The results indicate the need for PA promotion programs to be implemented for university students with disabilities addressing the most important barriers found at each social ecological level, as well as the differences identified by sociodemographic variables.

Quality of life among individuals with rugby-related spinal cord injuries in South Africa: a descriptive cross-sectional study

OBJECTIVES

Rugby-related spinal cord injuries (SCIs) are rare but life altering and traumatic events. Little is known about the long-term consequences and outcomes of players who have sustained these injuries. This study investigated current quality of life (QoL) and factors associated with QoL, among individuals with rugby-related SCI in South Africa, by using the International Classification of Functioning, Disability and Health (ICF) framework.

DESIGN

Descriptive cross-sectional study.

SETTING

Rugby-related SCI population of South Africa, as captured in the BokSmart/Chris Burger Petro Jackson Players' Fund database.

PARTICIPANTS

Ninety (n=90) of the 102 eligible players on the database agreed to participate in the study.

MAIN OUTCOME MEASURE

The relationship between QoL, as measured with the WHO Quality of Life questionnaire (WHOQOL-BREF) and specific independent variables (demographic information, level of independence and participation in various activities and life roles) was investigated. Variables that were significantly associated with QoL in bivariate analyses were included in multiple linear regression analyses.

RESULTS

The mean score and SD of the WHOQOL-BREF was 15.1±2.3 arbitrary units. Participation (an ICF framework construct) and income were significantly associated with overall QoL (p<0.001). Participation was the only variable significantly associated with all QoL subdomains (p<0.001). Additionally, number of health concerns, type of healthcare (public vs private) and level of education were significantly associated with various QoL domains (p<0.001).

CONCLUSIONS

On average, these individuals with rugby-related SCI presented with higher QoL scores than other comparable SCI studies. However, lower levels of participation and income, certain levels of education, increased health concerns and use of public healthcare were associated with lower levels of QoL. Sporting bodies have a responsibility to optimise player welfare, by acting on the modifiable factors associated with QoL.

Perceived influence of intrinsic/extrinsic factors on participation in life activities after spinal cord injury

BACKGROUND

Various types of limitations on community participation are experienced by people with spinal cord injury (SCI).

OBJECTIVES

To determine: 1) the perceived influence of six intrinsic/extrinsic factors (i.e. physical impairment, emotional condition, thinking skills, environment, lack of assistance, discrimination) on participation in 26 life activities, 2) if this influence varied based on extent of participation, and 3) if personal or environmental characteristics influenced perceptions.

METHODS

Secondary analysis of a cohort (SCI Community Survey, n = 1508) using the SCI Person-Perceived Participation in Daily Activities Questionnaire. Frequency tables, Fisher's exact tests and correspondence analyses.

RESULTS

Respectively, 79.6% and 38.5% of respondents perceived that their physical impairment and the natural and/or built environment were the main factors that limited participation across all activities. Considering participation between three groups (no participation; less than wanted; as much as wanted), significant differences (p < 0.001) of perceptions were observed in 65% of the combinations (26 activities x 6 factors). The hypothesis that respondents who did not participate would perceive the highest proportion of limitations was confirmed in 41% of the combinations. Perceived influence of the intrinsic/extrinsic factors on participation was not significantly influenced by other personal or environmental characteristics.

CONCLUSION

A majority of people with SCI perceived that their participation is limited by one or more of intrinsic/extrinsic factors. Perceptions regarding which factors influence participation differ between activities and these perceptions appear related to the extent of participation suggesting that those who actively participate could be the most sensitive to limitations in certain activities.