Environmental factors and their role in community integration after spinal cord injury

Exploring caregivers' perceptions of community-based service requirements of patients with spinal cord injury: a qualitative study

BACKGROUND

The incidence of spinal cord injury is increasing worldwide. Patients with spinal cord injury and their families face many difficulties during the disease course. Caregivers are more involved with these patients than anyone else, so recognizing patients' care requirements based on caregivers' opinions can facilitate care provision to these people. The purpose of this study was to explore caregivers' perceptions of the community-based services requirements of patients with spinal cord injury.

METHODS

This qualitative research was conducted in Iran from Apr 2021 to Dec 2022 using the conventional content analysis method. The participants in the study included family caregivers and providers of home care services to patients with spinal cord injury, who were selected by purposeful sampling. Data were collected by conducting 14 face-to-face interviews and analyzed based on the method proposed by Lundman and Graneheim.

RESULTS

Data analysis led to the extraction of 815 primary codes, which were organized into two themes: community reintegration (with two categories, including the need to provide a suitable social platform and lifelong care) and palliative care (with two categories, including family conference and survival management).

CONCLUSION

Social facilities and infrastructure should be modified in a way that patients with spinal cord injury can appropriately benefit from community-based care services and an independent satisfactory life. Palliative care should be continuously provided from the time of lesion development until the patient's death.

Clinical and socio-demographic determinants of community reintegration in people with spinal cord injury in eThekwini Municipality, KwaZulu-Natal province

Background

Community reintegration is a major outcome of rehabilitation after the acute phase in people with spinal cord injury (PWSCI).

Objective

To investigated clinical and socio-demographic factors determining community participation in PWSCI, living in the greater eThekwini Municipality, KwaZulu-Natal province.

Method

Our quantitative, cross-sectional study had a convenient sample of 41 PWSCI. A trained interviewer obtained socio-demographic information using a structured questionnaire. Participants completed the Reintegration to Normal Living Index (RNLI). Descriptive statistics were used in summarising the data; inferential statistics, -a t-test and analysis of variance (ANOVA) assessed the association of clinical and socio-demographic factors with the extent of community reintegration. A multiple linear regression investigated the determinants of community reintegration with the alpha level set at p = 0.05.

Results

Mean age of the participants was 41 years (s.d.: 10, range 25–66), with the majority (n = 32, 78%) being male. The mean RNLI score was 68% (s.d.: 22, range 24–100). Participants scored higher on the RNLI if they were male (mean difference [MD] 18%, 95% confidence interval [CI]: 2–34), were employed (MD 16%, 95% CI: 0–32), had a salary (MD 19%, 95% CI: 5–32) and had no muscle spasms (MD 14%, 95% CI: 1–27. Muscle spasms (p = 0.012, 95% CI: 3.85–29.05) and being female PWSCI (p = 0.010, 95% CI: −35.75 to −5.18) were significant negative predictors of community reintegration.

Conclusion

Community reintegration may be influenced by socio-economic factors. Special interventions for muscle spasms and support for women living with spinal cord injuries may enhance community reintegration.

Clinical implication

Therapists need to focus on community reintegration with female PWSCI and on returning to PWSCI to work as this was improved community reintegration.

Relationship of psychosocial factors and musculoskeletal pain among individuals with newly acquired spinal cord injury

STUDY DESIGN

Cross-sectional analysis of baseline data of a longitudinal cohort study.

OBJECTIVES

Little evidence exists on pain-related psychosocial factors in individuals with newly acquired spinal cord injury (SCI). To understand a biopsychosocial model of pain, we must first understand the presenting psychological pain-related factors at injury onset. Therefore, we assessed musculoskeletal pain and pain-related psychological constructs in a group of individuals with newly acquired SCI. We hypothesized that individuals with new SCI would report musculoskeletal shoulder pain with elevated levels of kinesiophobia and pain catastrophizing.

SETTING

Data were collected in three rehabilitation hospitals located in urban and suburban communities.

METHODS

Thirty-five individuals with newly acquired SCI participated. Demographics, Musculoskeletal Pain Survey shoulder subscale, Tampa Kinesiophobia Scale-11, Pain Catastrophizing Scale, Fear of Pain Questionnaire, Chronic Pain Coping Inventory-42, and Subjective Quality of Life Questionnaire were administered. Descriptive analysis of all measures was determined and relationships between pain and psychosocial measures determined.

RESULTS

Moderate shoulder pain existed in 40% of people with new SCI along with clinically elevated kinesiophobia, pain catastrophizing, fear of pain, and reduced quality of life. Shoulder pain was statistically associated with pain catastrophizing (ρ = 0.41, p = 0.01). Kinesiophobia positively correlated with fear of pain (ρ = 0.38, p = 0.02) with an inverse relationship to quality of life (ρ = -0.47, p = 0.01).

CONCLUSIONS

Elevated pain, and pain-related psychological characteristics, such as catastrophizing and kinesiophobia exist during the early stages after SCI. Early identification of pain-related factors can guide clinical intervention potentially ameliorating pain-linked functional impairments.

TRIAL REGISTRY

This trial is registered with ClinTrial.gov ID NCT03137394.

Association of musculoskeletal pain, fear-avoidance factors, and quality of life in active manual wheelchair users with SCI: A pilot study

Objective: Limited evidence examines the association of psychological factors, such as fear of movement and pain catastrophizing, with musculoskeletal pain patterns in active manual wheelchair users with spinal cord injury (SCI). This study investigated the relationship among musculoskeletal pain, fear avoidance factors, quality of life (QoL), activity and duration of injury in individuals with SCI. Design: Cross-sectional correlational. Setting: Community setting. Participants: Twenty-six individuals with SCI (age = 42 ± 14 years, duration manual wheelchair use = 17 ± 13 years, work/school/volunteer hours/week = 31 ± 14; recreation/sports hours/week 10 ± 12). Outcome Measures: Demographics and self-report measures including the Musculoskeletal Pain Survey (MPS), Wheelchair Users Shoulder Pain Index (WUSPI), Tampa Scale of Kinesiophobia (TSK-11), Pain Catastrophizing Scale (PCS), Fear of Pain (FPQ), Subjective Quality of Life Questionnaire (SQoL), and the Social Interaction Inventory (SII). Spearman's rho (ρ) assessed correlation among measures. Results: Strong association existed between age and duration of injury (ρ = 0.66, P < 0.001). SQoL offered a strong, direct correlation with age (ρ = 0.63, P = 0.01), duration of injury (ρ = 0.70, P = 0.001), and strong, inverse relationship with MPStotal (ρ = -0.66, P = 0.003) and MPS shoulder subscore (ρ = -0.64, P = 0.004). WUSPI demonstrated strong, inverse association with self-reported work hours (ρ = -0.52, P = 0.02) and a strong, direct relationship to PCS (ρ = 0.79, P = <0001). PCS demonstrated a strong, inverse relationship to work/school/volunteer hours (ρ = 0.71, P < 0.001) and strong association to TSK-11_total (ρ = 0.61, P = 0.001). A moderate, inverse relationship was identified for recreational/sports hours and FPQ (ρ = 0.48, P = 0.03). Conclusion: This cyclical relationship of musculoskeletal pain, reduced activity, and maladaptive psychological factors allude to interdependence of factors, supporting the multidisciplinary approach to care.

What Is the Impact of Engaging With Natural Environments Delivered Via Virtual Reality on the Psycho-emotional Health of People With Spinal Cord Injury Receiving Rehabilitation in Hospital? Findings From a Pilot Randomized Controlled Trial

OBJECTIVES

This study investigated (1) the effect of engaging with 20-minute simulated natural environments delivered via virtual reality (VR) on current mood state and (2) the effect of engaging with multiple VR sessions over a period of a week on the depressive symptoms of people with a spinal cord injury (SCI).

DESIGN

Randomized controlled trial design.

SETTING

Spinal Cord Injury Rehabilitation Unit in Australia.

PARTICIPANTS

Participants (N=24) were assigned to a group engaging in VR sessions during week 1 (group 1, n=10) or week 2 (group 2, n=14).

INTERVENTIONS

The intervention week involved participation in up to three 20-minute VR sessions over 3 consecutive days. The control condition involved regular rehabilitation practice over a week.

MAIN OUTCOME MEASURES

The Patient Health Questionnaire-8 (PHQ-8) was completed prior to the first week (T1), after the first week and prior to the second week (T2), and after the second week (T3). Current feeling states, including depressed/happy, anxious/relaxed, and not feeling good/feeling good, were rated immediately prior and after each VR session.

RESULTS

Levels of happiness, relaxation, and feeling good were significantly higher subsequent to engaging with each VR session. Between-group differences in PHQ-8 scores were significantly greater for participants who experienced the intervention during the first week compared to participants within the control group: intervention participants had significant improvements in psycho-emotional health. Within-group PHQ-8 scores were reduced for each group subsequent to experiencing the intervention; however, differences were not significant.

CONCLUSIONS

Engaging with simulated natural environments delivered via VR can favorably affect the psycho-emotional health of people with SCI receiving rehabilitation in hospital. Future research including larger samples and investigating the effect over a longer time period is required to confirm the findings presented.

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.

Heterogeneity and Its Impact on Rehabilitation Outcomes and Interventions for Community Reintegration in People With Spinal Cord Injuries: An Integrative Review

Background: Various injury characteristics such as cause, level, severity, and time since injury divide individuals with spinal cord injury (SCI) into many subgroups. The heterogeneity among individuals' injuries and personal characteristics has significant implications for SCI rehabilitation practice, specifically directed toward community reintegration, which is a key goal of rehabilitation interventions for people with disabilities. Purpose: This study aims to summarize the evidence on attributes that make the SCI population heterogeneous, the impact of these attributes on community reintegration, and the implications of heterogeneity for rehabilitation interventions directed toward optimizing community reintegration. Methods: We used an integrative review approach to conduct this study. MEDLINE, PubMed, CINAHL, EMBASE, Google Scholar, and PsycINFO were searched from inception until May 2017. Out of 670 articles retrieved, 49 provided evidence on the impact of various attributes that make SCI heterogeneous on rehabilitation outcomes related to community reintegration. Results: An array of injury-related, personal, social, and environmental factors are associated with various rehabilitation outcomes that affect community reintegration of people with SCI. There is level 1 evidence that social support, self-efficacy, and self-esteem facilitate community reintegration among people with SCI while there is level 5 evidence that presence of psychological or medical complications decreases it. There is lack of clarity on the impact of injury-related factors on community reintegration. Conclusion: This integrative review found that social support and individuals' self-efficacy can improve community reintegration of people with SCI. However, evidence regarding the impact of injury characteristics on community reintegration is still underdeveloped. Approaches directed at community reintegration should involve components of psychosocial, physical, and vocational rehabilitation while considering personal and societal aspects of an individual's life.

Predictors of functional outcomes in adults with traumatic spinal cord injury following inpatient rehabilitation: A systematic review

CONTEXT

Despite functional improvements during rehabilitation, variable functional outcomes were reported when patients with Spinal Cord Injury (SCI) return to society. Higher functioning individuals at discharge can experience a decrease in independent mobility (i.e. Motor Functional Independence Measure (mFIM) Score) by one-year follow-up. However, functional gains after discharge have also been reported and associated with recovery.

OBJECTIVE

To identify, categorize and rank predictors of mFIM score for patients with SCI following inpatient rehabilitation, both at the time of discharge and at one-year follow-up.

METHODS

Data sources included CINAHL, PubMed, ERIC, Google Scholar, and Medline for literature published from February 2000 to February 2015. Quality and risk of bias of included studies was assessed using the Risk of Bias Assessment Instrument for Prognostic Factor Studies (QUIPS). Significant predictors of mFIM score were categorized using the domains of the International Classification of Function and Disability model ICF and ranked based on how frequently they were significant predictors of mFIM score.

RESULTS

Twenty-seven predictors of mFIM score spanning the ICF domains were identified among seven studies. At discharge, variables in the Body Structure and Function domain were the most consistent predictors of mFIM score. At one-year follow-up, variables in the Activity and Participation domain were the most consistent predictors of mFIM score. Contextual factors were the least frequent predictors at both discharge and one-year follow-up.

CONCLUSION

This systematic-review assists clinicians setting realistic goals that maximize functional independence at the time of discharge and after reintegrating to society.

Environmental barriers and social participation in individuals with spinal cord injury

OBJECTIVE

The study aimed to examine the relationship between environmental barriers and social participation among individuals with spinal cord injury (SCI).

METHOD

Individuals admitted to regional centers of the Model Spinal Cord Injury System in the United States due to traumatic SCI were interviewed and included in the National Spinal Cord Injury Database. This cross-sectional study applied a secondary analysis with a mixed effect model on the data from 3,162 individuals who received interviews from 2000 through 2005. Five dimensions of environmental barriers were estimated using the short form of the Craig Hospital Inventory of Environmental Factors-Short Form (CHIEF-SF). Social participation was measured with the short form of the Craig Handicap Assessment and Reporting Technique-Short Form (CHART-SF) and their employment status.

RESULTS

Subscales of environmental barriers were negatively associated with the social participation measures. Each 1 point increase in CHIEF-SF total score (indicated greater environmental barriers) was associated with a 0.82 point reduction in CHART-SF total score (95% CI: -1.07, -0.57) (decreased social participation) and 4% reduction in the odds of being employed. Among the 5 CHIEF-SF dimensions, assistance barriers exhibited the strongest negative association with CHART-SF social participation score when compared to other dimensions, while work/school dimension demonstrated the weakest association with CHART-SF.

CONCLUSIONS

Environmental barriers are negatively associated with social participation in the SCI population. Working toward eliminating environmental barriers, especially assistance/service barriers, may help enhance social participation for people with SCI. (PsycINFO Database Record

Cross-Sectional Examination of the Associations Between Symptoms, Community Integration, and Mental Health in Multiple Sclerosis

OBJECTIVE

To determine the frequency and severity of 8 symptoms in persons with multiple sclerosis (MS) and to examine the association between these symptoms and community integration and mental health.

DESIGN

Cross-sectional survey that assessed 8 symptoms (pain, fatigue, imbalance, numbness, weakness, shortness of breath, vision loss, and memory loss), disease progression (self-report version of the Expanded Disability Status Scale), community integration, and mental health.

SETTING

Community.

PARTICIPANTS

Adults with self-reported MS who responded to a mailed survey (N=180).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The presence and intensity of symptoms were measured with a symptoms checklist. Community integration was assessed with the Community Integration Questionnaire, and mental health was measured by the Mental Health Index of the Medical Outcomes Study 36-Item Short-Form Health Survey.

RESULTS

The average number of symptoms reported was 5.07±2.18. The most common symptoms (fatigue, weakness, and imbalance) were also rated as the most severe. Not all symptoms were associated with level of disease progression or with MS subtype. Symptoms related to mobility were more likely to be associated with these variables. The 8 symptoms as a whole accounted for significant amounts of variance (range, 13%-21%) in measures of community integration and mental health, with specific symptoms making differential independent contributions to these measures.

CONCLUSIONS

This study demonstrates that most individuals with MS report a number of bothersome symptoms. Type of MS or level of progression does not tell the whole story regarding the impact of symptoms.

One size fits all? Applying theoretical predictions about age and emotional experience to people with functional disabilities

The current study examined whether commonly observed age differences in affective experience among community samples of healthy adults would generalize to a group of adults who live with significant functional disability. Age differences in daily affect and affective reactivity to daily stressors among a sample of participants with spinal cord injury (SCI) were compared with a noninjured sample. Results revealed that patterns of affective experience varied by sample. Among noninjured adults, older age was associated with lower levels of daily negative affect, higher levels of daily positive affect, and less negative affective reactivity in response to daily stressors. In contrast, among the sample with SCI, no age differences emerged. Findings, which support the model of Strength and Vulnerability Integration, underscore the importance of taking life context into account when predicting age differences in affective well-being.

Exploring Winter Community Participation Among Wheelchair Users: An Online Focus Group

The aim of this qualitative study was to gain an understanding of what people who use wheeled mobility devices (WMDs; e.g., manual and power wheelchairs, and scooters) identify as environmental barriers to community participation in cold weather climates, and to explore recommendations to overcome environmental barriers to community participation. Researchers conducted an online asynchronous focus group that spanned seven days, with eight individuals who use WMDs. Each day, participants were asked to respond to a moderator-provided question, and to engage with one another around the topic area. The researchers analyzed the verbatim data using an inductive content-analysis approach. Four categories emerged from the data: (1) winter barriers to community participation; (2) life resumes in spring and summer; (3) change requires awareness, education, and advocacy; and (4) winter participation is a right. Participants confirmed that it is a collective responsibility to ensure that WMD users are able to participate in the community throughout the seasons.

Quality of life in and after spinal cord injury rehabilitation: a longitudinal multicenter study

PURPOSE

To investigate the changes in quality of life (QOL) in persons with spinal cord injury (SCI) and their close persons during the first 2 years post injury.

METHOD

Longitudinal multiple sample multiple wave panel design. Data included 292 patients recruited from Austrian British German Irish and Swiss specialist SCI rehabilitation centers and 55 of their close persons. Questionnaire booklets were administered at 6 weeks 12 weeks 1 year and 2 years after injury to both samples.

RESULTS

Study 1 investigated the WHOQOL-BREF domains in individuals with SCI and found differences mostly in the physical domain indicating that QOL increases for persons with SCI from onset. An effect of the culture was observed in the psychological and environmental domains with higher QOL scores in the German-speaking sample. Study 2 compared individuals with SCI to their close persons and found differences in the physical environmental and social domains over time. The scores on the psychological dimension did not significantly differ between the persons with SCI and their close persons over time.

CONCLUSION

QOL measured by the WHOQOL-BREF shows that QOL changes during rehabilitation and after discharge. Apart from the physical dimension the persons with SCI and their close persons seem to experience a similar change in QOL. Further longitudinal research is suggested to clarify the mutual adjustment process of people with SCI and their close persons and to explore cultural differences in QOL between English-and German-speaking countries.

Community engagement: an essential component of well-being in older African-American adults

Active engagement in life is a critical factor for successful aging. Research indicates that community engagement is strongly associated with health and well-being in late life. However, less is understood regarding the influence of neighborhood conditions on health and well-being, particularly in older African-American adults. The current study describes a convenience sample of older African Americans (N = 501, mean age = 70.7 [range 55-95] years) living in Detroit. The specific goal is to examine the relationships between their perceptions of neighborhood conditions, level of community engagement, and their health and well-being. Survey findings reveal a sample of highly engaged older African Americans in reasonable health who perceive their neighborhoods favorably. Regression analysis results indicate that community engagement is closely associated with both neighborhood perceptions and well-being in this sample. We propose that community engagement or "participation" mediates the relationship between neighborhood conditions and well-being for older African Americans living in Detroit.

Spinal Cord Injury Community Survey: Understanding the Needs of Canadians with SCI

BACKGROUND

There is a lack of literature regarding service needs of people with SCI living in the community. Better assessment of expressed and met and unmet needs would help in the development of effective service delivery.

OBJECTIVE

From a national SCI Community Survey in Canada, the aim was to identify the most critical service needs of people living in the community at least 1 year post discharge from rehabilitation and the support they received to meet their needs.

METHOD

Data were collected mainly through a secure Web site and encompassed demographics, personal and household income, an SCI severity measure, and an SCI community needs measure containing information on 13 SCI-related needs.

RESULTS

A total of 1,549 persons with SCI (traumatic lesion, n = 1,137; nontraumatic lesion, n = 412) across Canada completed the survey. Most critical needs for community integration were expressed by a substantial proportion of survey participants, but significantly more expressed and met needs were reported by persons with a traumatic than a nontraumatic lesion. Personal and environmental characteristics influenced the probability of expressing and meeting needs (eg, severity of injury and household income). Help and support to meet expressed needs were received from government agencies, community organizations, and friends or family.

CONCLUSION

Better assessment of expressed and met or unmet needs for services remains a challenge but will serve as a tool to optimize service delivery in the community. Environmental barriers to services, particularly the process of getting needs met and associated costs, remain an issue that requires a reconsideration of some aspects of access to services.

Self-rated health among persons with spinal cord injury: what is the role of physical ability?

OBJECTIVES

Self-rated health (SRH) is a powerful concept that has greatly advanced our understanding of health and health outcomes. The SRH measure has become increasingly common in health research. Yet, puzzles remain about what shapes SRH ratings. The absence of knowledge is particularly acute in the context of disability. The aim of this study was to examine the relationship between SRH and self-rated physical ability in a sample of individuals with spinal cord injury (SCI).

METHODS

Data from 140 eligible participants drawn from a study of life in the community after SCI were analyzed. The study, cross-sectional in design, was conducted in a large urban city in the mid-western United States. Basic statistics such as ANOVA and chi-square tests were performed as appropriate, and a multiple linear regression analysis modeled the relationship between SRH and physical ability adjusting for potential confounding variables.

RESULTS

Self-rated physical ability was significantly associated with SRH after controlling for relevant covariates (P < 0.001). An analysis of the interaction between physical ability and level of injury revealed that the relationship was significant for persons with paraplegia but not for persons with tetraplegia.

CONCLUSIONS

This study provides evidence that self-rated physical ability is an important factor associated with SRH for persons with SCI, but that the strength of the relationship depends on level of injury (paraplegia vs. tetraplegia). The challenge for future research is to replicate the study using a more comprehensive measure of physical ability and to ask how beliefs in one's ability to do those activities that are most meaningful and desired shape SRH. Only in this way will our understanding of the physical ability-SRH relationship be clarified.