The International Journal of Psychosocial Rehabilitation

 Quality of Life Correlates Among Individuals with a
Spinal Cord Injury:  Does Race Matter?
 
Reece Olley Rahman, Ph.D.
Assistant Professor
Department of Psychology
Division of Natural Sciences
University of Pittsburgh at Johnstown; Johnstown, PA; USA
 
 Martin Forchheimer, MPP
Senior Research Associate
Department of Physical Medicine and Rehabilitation
University of Michigan Health System
University of Michigan; Ann Arbor, MI; USA
 
Denise G. Tate, Ph.D., ABPP
Professor and Director of Research
Department of Physical Medicine and Rehabilitation
University of Michigan Health System
University of Michigan; Ann Arbor, MI; USA
 
  Citation:
Rahman R.O., Forchheimer M., & Tate, D.G. (2004). Quality of Life Correlates Among Individuals with a Spinal
Cord Injury:  Does Race Matter?   International Journal of Psychosocial Rehabilitation. 9(1), 153-165.
Contact Author:
Reece Olley Rahman, Ph.D. , Assistant Professor , Department of Psychology,  Division of Natural Sciences , University of Pittsburgh at Johnstown
111 Krebs Hall, Johnstown, PA  15904
E-mail:   rorahman@pitt.edu
Web:     www.pitt.edu/~rorahman

Keywords:  Quality of Life, Spinal Cord Injury, Race, Ethnicity
Abstract
The purpose of the present study was to investigate Quality of Life (QOL), and factors associated with QOL, in individuals with Spinal Cord Injury (SCI) in relation to race.  The primary goal of this study was to examine the relationship between certain Physical / Injury-Related factors, Psychosocial factors, and Demographic factors with QOL in hopes of gaining understanding into which of these factors are most related to increased QOL.  The secondary goal was to explore any potential differences in the associations between the aforementioned factors and QOL as related to race.  For Caucasians, many of the factors examined within the aforementioned domains were found to be associated with the various instruments utilized in an effort to assess QOL.  However, for African Americans, only one items (having a spouse or partner) had any such association.   

Introduction
The concept of health, like many modern day perceptions, has demonstrated its dynamic nature in that it is no longer limited in scope to the absence of disease or pathology, be it physical or psychological; but rather has come to appreciate the merits of wellness and excellence within these realms.  Though this broadened conceptualization was formally adopted by the World Health Organization in 1948 25, only recently has this precept begun to pervade the present day culture of the western world’s health care systems.  As a resultant, of this change in perspective, recent years have seen an emerging effort to evaluate health from a more multidimensional, global perspective. 

In light of efforts to appraise health across numerous domains (e.g. physical, psychological, social), there has been mounting attention placed on assessing subjective quality of life (QOL).  QOL is a broadly-defined umbrella term that encompasses numerous themes, concepts, and factors such as self-perceptions of general physical health, similar perceptions of psychological health and emotional well-being, meaningful and worthwhile interpersonal relationships, active and satisfying sexual relationships, as well as spirituality to name a few.29,33  As many of these QOL-related factors have entered into the conceptualization and definition of health, they have similarly become components of interest in the assessment and determination of success in the field of medical rehabilitation.22  This is particularly so in relation to individuals with a spinal cord injury (SCI).  Although the field of study addressing QOL is still in its infancy, there is an emerging literature exploring differences in QOL between minority and non-minority individuals with SCI, the primary interest of the present study.

There have been numerous and significant differences consistently documented between minority and non-minority individuals with SCI within the literature.  For example, minorities have been observed to report lower levels of satisfaction on measures of career opportunities and finances.13  Minorities are less likely to be gainfully employed post-injury, controlling for differences in education, age, and medical characteristics,3,7,14,16,17,19-21 and they have been found to report elevated levels of post-injury depression, compared to their Caucasian counterparts.12,18

While prior studies have indicated that some of these factors are associated with QOL, these relationships have not been observed consistently.   These factors may be cursorily divided into three general categories:  Physical / Injury factors, Psychosocial factors, and Demographic factors. In terms of Physical / Injury Related Factors, differences in neurological level of injury have fairly consistently failed to yield any variations in QOL.10,26,34  Time since injury has, however, produced mixed results, with some researchers suggesting that increased time since injury is associated with increased QOL30,34 and others suggesting that no such relationship exists.26  One study noted that QOL changes during the first two years post-injury but is stable thereafter.6

In terms of psychosocial factors, being employed, level of education, social integration and activity, as well as extent of community access have all been found to be associated with increased QOL.8,30  

Demographic factors include variables such as marital status, age, and race.  Findings regarding marital status have demonstrated that married individuals with SCI report greater QOL than those who are single.11,27  Increased age has been associated with lower QOL.26  In regards to race, however, the findings are inconsistent.  Various studies suggest that any racial differences in QOL that may be observed are no longer discernible after controlling for various demographic variables (e.g. education, age, income), 4,8,9,28  while others suggest that race is indeed a noteworthy correlate of QOL in its own right.15,30

Hypotheses
The purpose of the present study is to investigate potential differences in factors associated with QOL, in individuals with SCI according to race.  The underlying thesis is that differences in QOL should not be associated with race; factors that have been shown to be associated with QOL should do so similarly across races.  Informed by the existing research discussed above the study’s specific hypotheses are:

1) There are no significant differences (p < .05) in QOL between Caucasian and African American individuals with SCI.

2) There are no significant differences (p < .05) in QOL between individuals with paraplegia and those with tetraplegia amongst either Caucasians or African Americans.

3)  Increased number of hours spent working or volunteering is associated with increased QOL in both Caucasians and African Americans, and should be significant at a level of p < .05 for both groups. 

4) Greater time spent in recreational or self-improvement activities is associated with increased QOL in both Caucasians and African Americans, and should be significant at a level of p < .05 for both groups. 

5) Having a spouse, or being involved in a romantic relationship, is associated with increased QOL in both Caucasians and African Americans, and should be significant at a level of p < .05 for both groups.

6) Increased age is associated with decreased QOL in both Caucasians and African Americans, and should be significant at a level of p < .05 for both groups.

Methods
This study utilizes data gathered via a collaborative, longitudinal project amongst five of the national Model Spinal Cord Injury Care Systems (MSCICS) entitled Lifetime Outcomes and Needs: Refining the Understand of Aging with Spinal Cord Injury (Longitudinal Study).  It has been funded by the National Institute on Disability Rehabilitation Research since 1990.  The data used for this study were collected during the period from 1995-2000.  

Participants
Participants were selected from the data base according to the following criteria.  All members of this study’s sample frame had experienced a new, traumatic spinal cord injury, were first interviewed for the longitudinal study during the period between 1990 and 1995.  They were all participants in the MSCICS and had been injured between ten and 25 years when interviewed. All subjects were at least 18 years of age and people were excluded if their neurological status upon discharge from initial rehabilitation was unknown or classified as minimal deficit. The racial composition of the data used for analyses was limited to Caucasian and African American as the numbers of participants in other racial/ethnic categories were too limited to be included in the analyses in terms of making any statistically valid comparisons.  Furthermore, the inclusion of diminutive numbers of other racial and ethnic minority individuals, in order to create a “minority” group for comparison, would yield questionable results in terms of generalizability regarding any of the groups included under said “minority” designation.  To this end the sample utilized for analyses did not included individuals of Hispanic ethnicity, be they Caucasian or African American.

In addition, those individuals meeting the International Standards for Neurological Classification of Spinal Cord Injury2 Impairment Grade D were excluded, limiting the sample to individuals classified as either with paraplegia or tetraplegia.  Though conceptually and scientifically, the inclusion of Grade D individuals was desirable, the sheer lack of sufficient individuals meeting this designation (Caucasian N = 37; African American N = 11) served as a prohibitive factor to inclusion in these analyses.  Finally, only those individuals for whom complete data was available on the three primary outcome measures of interest, as described below, were included in this dataset. 

Measures

Physical / Injury-Related.  Data regarding subjects’ neurological impairments was obtained from the Longitudinal Study’s database. 

Psychosocial.  Participants were also asked to provide estimations regarding the numbers of hours spent per week in selected activities including working at a job, volunteering, recreation and self-improvement.  These questions are components of the Craig Handicap Assessment and Reporting Technique.35

Demographics.  In addition to age and race, participants were asked additional questions regarding whether they were married or in a romantic relationship.

QOL Outcomes.  QOL was estimated using the Life Satisfaction Index – Z (LSI-Z),24 an instrument composed of 13 Likert scale items aimed at assessing an individual’s overall satisfaction with life.  Higher scores on this index are representative of greater satisfaction with life. In addition, participants were administered the Perceived Stress Scale (PSS),5 composed of ten Likert scale items, which is a measure of the degree to which situations in an individual’s life are appraised as stressful.  Lower scores on this measure are indicative of lower levels of perceived stress.  Finally, participants were posed one face-valid item concerning their estimation of their current QOL.  Responses were based upon a four point Likert scale consisting of the following responses:  0 = poor, 1 = fair, 2 = good, 3 = excellent. 

Statistical Analyses
Initially, sample demographics were appraised by race.  Each of the specific hypotheses was then examined by means of two-tailed independent samples t-tests to investigate between-group differences, as well as bivariate correlations to investigate relationship between factors.  For the testing of all hypotheses, the criteria used for statistical significance was an alpha level of p < .05.

Results
Sample Characteristics
Data from 416 subjects were analyzed.  Approximately 80% of the sample was male with a similar percentage of Caucasian participants.  There was a near equal split in neurological level of injury in the sample between Para ABC (53.4%) and Tetra ABC (46.6%).  The participants’ average age was approximately 42 years, ranging from 20 to 78.  The average numbers of years post injury for this sample was approximately fifteen years, with a range of ten to 25 years.  Additional details regarding sample characteristics may be found in Table 1.

Table 1:  Sample Demographics. 

 

 

 

 

Caucasian

(N= 379)

African American

(N = 88)

Total
Sample
(N = 416)

Neurological Status (%)

Para ABC

52.7

56.4

53.4

 

Tetra ABC

47.3

43.6

46.6

Gender (%)

Male

80.2

85.9

81.3

 

Female

19.8

14.1

18.8

Years Post Injury

Mean

14.67

15.51

14.83

 

Standard Deviation

4.29

5.07

4.45

Age

Mean

41.16

43.31

41.56

 

Standard Deviation

10.60

10.30

10.56

Hypotheses Examined
Hypothesis #1:  There are no significant differences (p < .05) in QOL between Caucasian and African American individuals with SCI.  This hypothesis was confirmed. Independent sample t-tests yielded no significant differences between the two groups on the LSI-Z, PSS, or the single QOL item.  See Table 2 for results.

Table 2:  Differences in QOL between Caucasians and African Americans

N

Mean

SD

t

p - value

LSI-Z

Caucasian

338

11.28

4.49

1.318

.188

 

African American

78

10.53

4.72

PSS

Caucasian

338

12.08

7.33

.470

.639

 

African American

78

11.65

6.72

QOL item

Caucasian

338

2.11

.75

1.55

.123

 

African American

78

1.96

.78


Hypothesis #2:  There are no significant differences (p < .05) in QOL between individuals with paraplegia and those with tetraplegia amongst either Caucasians or African Americans.  Mixed results were obtained for this hypothesis.  Among Caucasians, independent sample t-tests indicated that those with paraplegia had significantly higher levels of life satisfaction and lower levels of stress than did those with tetraplegia.  The two groups did not differ in terms of their responses to the single item QOL. In contrast, for the African American group, no differences were observed between individuals with paraplegia and those with tetraplegia in terms of any of these three indices of QOL.  Results are available in Table 3.

Table 3:  Differences in QOL between Para ABC and Tetra ABC by Race 

Caucasian

N

Mean

SD

t

p - value

LSI-Z

Para

178

11.88

4.19

2.65

.009

 

Tetra

160

10.60

4.72

PSS

Para

178

11.28

6.96

-2.14

.033

 

Tetra

160

12.98

7.63

QOL item

Para

178

2.09

.72

-.504

.615

 

Tetra

160

2.13

.79

African American

N

Mean

SD

t

p - value

LSI-Z

Para

44

11.07

4.84

1.16

.250

 

Tetra

34

9.82

4.52

PSS

Para

44

11.86

7.60

.312

.756

 

Tetra

34

11.38

5.48

QOL item

Para

44

1.95

.81

-.088

.930

 

Tetra

34

1.97

.78

 
Hypothesis #3:  Increased number of hours spent working or volunteering is associated with increased QOL in both Caucasians and African Americans, and should be significant at a level of p < .05 for both groups.  This hypothesis was only partially confirmed.  For Caucasians, increased hours per week spent working and / or volunteering was associated with lower PSS scores, increased LSI-Z scores, and increased QOL item ratings.  However, none of the aforementioned relationships were found to be of significance amongst the African American group.  These results are shown in Table 4.  It is, however, of import to note that Caucasians (M = 16.75, SD = 21.10) spent significantly more hours per week working and/or volunteering than did African Americans (M = 6.32, SD = 14.32) (p < .0001). 

Table 4:  Correlations for work/volunteer hours and QOL measures, differential examination based upon race.
Caucasian PSS LSI-Z QOL Item
Hours spent working and / or volunteering per week Pearson Correlation -.117 .330 .246
p - value . 039 .000 .000
N* 313 313 313
African American PSS LSI-Z QOL Item
Hours spent working and / or volunteering per week Pearson Correlation -.054 .078 .114
p - value .647 .509 .332
N** 74 74 74
*  25 Caucasians were missing data regarding number of hours working/volunteering per week
** 4 African Americans were missing data regarding number of hours working/volunteering per week


Hypothesis #4: Greater time spent in recreational or self-improvement activities is associated with increased QOL in both Caucasians and African Americans, and should be significant at a level of p < .05 for both groups.  Mixed results were obtained for this hypothesis.  Increased hours spent in recreational activities was associated with higher QOL item ratings and greater hours spent in self improvement related activities was associated with lower levels of perceived stress for Caucasians.  For African Americans, increased time spent in recreational activities was associated with lower levels of perceived stress, though no correlations were observed between time spent in self-improvement and any of the outcome measures.  As with vocational activity, discussed above, the distribution of hours of self-improvement activity was highly abnormal among African Americans, See Table 5 for more details.  Caucasians (M = 10.72, SD = 11.64) reported spending significantly more time in self improvement activities per week than did African Americans (M = 5.54, SD = 8.47) (p < .0001).  Though a similar trend was observed with Caucasians (M = 7.21, SD = 8.24) spending more hours per week involved in recreational activities than African Americans (M = 5.28, SD = 5.85), it was not statistically significant (p < .06).

 Table 5:  Correlations for involvement in recreational and self improvement activities and QOL measures, differential examination based upon race.

Caucasian

PSS

LSI-Z

QOL Item

Recreation hours per week

Pearson Correlation

-.084

.082

.156

p - value

.134

.145

.005

N*

321

321

321

Self Improvement hours per week

Pearson Correlation

-.124

-.032

-.064

p – value

.027

.575

.253

N*

317

317

317

African American

PSS

LSI-Z

QOL Item

Recreation hours per week

Pearson Correlation

-.236

.185

-.019

p – value

.042

.111

.870

N**

75

75

75

Self Improvement hours per week

Pearson Correlation

-.059

-.146

.084

p – value

.619

.215

.477

N**

74

74

74
* 17 Caucasians were missing recreation data; 21 were missing self improvement data
** 3 African Americans were missing recreation data; 4 were missing self improvement data


Hypothesis #5:  Having a spouse, or being involved in a romantic relationship, is associated with increased QOL in both Caucasians and African Americans, and should be significant at a level of p < .05 for both groups.  This hypothesis was partially confirmed.  Amongst Caucasians, having a spouse or romantic partner was associated with increased LSI-Z and QOL item scores, but yielded no relationship to PSS scores.  For African Americans, however, having a spouse or romantic partner was associated with lower PSS scores, increased QOL item scores, and increased LSI-Z scores.  Furthermore, the percentage of Caucasians (54.1%) reporting having a spouse/partner was similar to that reported by African Americans (55.4%).  These results are provided in Table 6.

Table 6:  Correlations for having a marital or romantic relationship and QOL, differential examination based upon race.

Caucasian

PSS

LSI-Z

QOL Item

Have a spouse or romantic partner

Pearson Correlation

-.093

.274

.168

p - value

.110

.000

.004

N*

296

296

296

African American

PSS

LSI-Z

QOL Item

Have a spouse or romantic partner

Pearson Correlation

-.380

.263

.268

p – value

.002

.034

.031

N**

65

65

65
*  42 Caucasians were missing data regarding having a spouse or romantic partner
** 13 African Americans were missing data regarding having spouse or romantic partner.


Hypothesis #6: Increased age is associated with decreased QOL in both Caucasians and African Americans, and should be significant at a level of p < .05 for both groups.  The posited relationship was observed among Caucasians, with increased age associated with lower QOL item scores, though no relationship was observed between age and any of the outcome measures among African Americans.  These results are available in Table 7.  There were no significant differences (p < .106) in terms of age observed between Caucasians (M = 41.16, SD = 10.60) and African Americans (M = 43.31, SD = 10.30).

Table 7:  Correlations for age and QOL, differential examination based upon race.

Caucasian

PSS

LSI-Z

QOL Item

Age

Pearson Correlation

-.076

-.095

-.157

p - value

.163

.081

.004

N

338

338

338

African American

PSS

LSI-Z

QOL Item

Age

 Pearson Correlation

-.121

-.015

-.174

p – value

.293

.897

.127

N

78

78

78

 



















Discussion
As the concept of QOL is in its relative infancy within mainstream healthcare, its definition remains dynamic and amorphous.  The purpose of the present study was to investigate QOL, and factors associated with QOL, in individuals with SCI in relation to race.  The primary goal of this study was to examine the relationship between certain Physical / Injury-Related factors, Psychosocial factors, and Demographic factors with QOL in hopes of gaining understanding into which of these factors are most related to increased QOL.  The secondary goal was to explore any potential differences in the associations between the aforementioned factors and QOL as related to race.

It was posited that there would be no differences in QOL outcomes as a function of level of neurological level of impairment.  While no association was observed among African American’s, within the Caucasian sub-sample those with paraplegia reported lower levels of perceived stress and higher levels of life satisfaction than did those with tetraplegia.  Conversely, no differences in QOL were observed between African Americans with paraplegia and those with tetraplegia.

Five items were evaluated as psychosocial variables within this study:  time spent working or volunteering, time spent in recreational activities, time spent in self-improvement activities, and having a spouse or romantic partner.  Greater number of hours spent working or volunteering was associated with lower perceived stress, increased life satisfaction, and greater QOL specific item scores for Caucasians.  However, there was no such relationship observed for African Americans.  Increased time spent in recreational activities was associated with high QOL item scores for Caucasians, but not for African Americans.  Increased time spent in self-improvement activities was associated with decreased stress for Caucasians, but not for African Americans.  For Caucasians, having a spouse or romantic partner was associated with increased life satisfaction.  For African Americans, a relationship was observed between having a spouse or partner and decreased perceived stress in addition to increased life satisfaction.  An association between increased QOL item scores and having a spouse or partner was observed in both groups.  In general, as was hypothesized, all of the psychosocial outcomes were associated with the studies indicators of QOL amongst the Caucasian participants.  This posited relationship was not, however, observed among the African American participants, barring the observed relationship regarding having a spouse or partner. 
Lastly, as race was a focus of the analyses, the remaining demographic variable that was subject to investigation consisted solely of participants’ age.  Caucasians exhibited a relationship between increased age and lower QOL item scores.  There were no observed relationships between the QOL measures and age for African Americans.

For Caucasians, many of the aforementioned factors were associated with the various instruments aimed at assessing QOL.  However, for African Americans, only one items (having a spouse or partner) had any such association.  The specific etiology of these observed differences in QOL between Caucasians and African Americans with SCI remains unclear.  There are, however, numerous factors that necessitate further evaluation in terms of their potential contributory effects concerning these differences.  The primary factor involves the innumerable sociocultural and ethnic differences between non-minorities (Caucasians) and minorities.  The need for systematic consideration of ethnic diversity and multicultural issues have been noted in terms of general rehabilitation31,32 and, vocational rehabilitation,23 as well as within the intricate relationship existing within behavioral health and biopsychosocial mechanisms.1  This same consideration must be examined in the assessment of QOL.  One hypothesis to assist in explaining the observed differences is that the concept of QOL is differentially defined by the two groups.  Thus, the instruments utilized in the present study may not be effectively identifying and assessing the issues related to QOL for African Americans.  If unable to identify the factors associated with improving a particular groups’ QOL, it is difficult to appropriately allocate resources so they will have the greatest impact.  Similarly, such imprecise assessment may further translate into limited resources being diverted into treatments or interventions that may be of little consequence for a particular group. 

To this end, the continued study of QOL amongst ethnically diverse populations is a requisite to the development and implementation of successful treatments and interventions within the field of rehabilitation, and the general realm of health care. 

Limitations
This study has some important limitations that should be noted.  The data utilized for these analyses were archival in nature.  Thus, there was no ability to purposively select the instruments aimed at assessing QOL, and there were limitations on the variables available for analyses in terms of their association with QOL.  Furthermore, there were large discrepancies in the sample sizes used form comparison between Caucasians and African Americans.  Moderate sized relationships which might be classified as statistically significant among Caucasians could be deemed insignificant among African Americans for this reason alone. Also, distributional anomalies, which were most severe in the African American sub-samples made drawing definitive conclusions tenuous.  Future studies would benefit from incorporating additional and broader measures of QOL.  It would be of further benefit to include additional variables within each of the three factors discussed (physical / injury-related, psychosocial, and demographic).  Oversampling of African Americans would be of benefit to allow for greater equity in sample size between the two groups, which would of course assist in the statistical analyses.  Finally, use of statistical techniques appropriate for abnormal distributions, particularly censored ones, would be beneficial in future work.

 

References

1.  Anderson NB. Behavioral and sociocultural perspectives in ethnicity and health. Health Psychology 1995;14.

2.  ASIA. International Standards for Neurological Classification of Spinal Cord Injury, revised 2002 ed. Chicago, IL: American Spinal Injury Association, 2002.

3.  Castle R. An investigation into the employment and occupation of patients with a spinal cord injury. Paraplegia 1994;32:182-7.

4.  Clayton KS, Chubon RA. Factors associated with the quality of life in long-term spinal cord injured persons. Archives of Physical Medicine and Rehabilitation 1994;75:633-8.

5.  Cohen S, Kamarack T, Mermelstein R. A global measure of perceived stress. Journal of Health and Social Behavior 1983;24:386-96.

6.  Crewe NM, Krause JS. An eleven-year follow-up of adjustment to spinal cord injury. Rehabilitation Psychology 1990;35:205-10.

7.  Devivo MJ, Fine PR. Employment status of spinal cord injured patients 3 years after injury. Archives of Physical Medicine and Rehabilitation 1982;63:200-3.

8.  Dijkers M. Correlates of life satisfaction among persons with spinal cord injury. Archives of Physical Medicine and Rehabilitation 1999;80:867-76.

9.  Dowler RN, Richards JS, Putzke JD, Gordon W, Tate D. The impact of demographic and medical factors on satisfaction with life post-spinal cord injury. Archives of Physical Medicine and Rehabilitation 2000;24:87-91.

10.  Hall K, Knudsen S, Wright J, Charlife S, Graves D, Werner P. Follow-up study of individuals with high tetraplegia (C1-C4) 14 to 24 years postinjury. Archives of Physical Medicine and Rehabilitation 1999;80:1507-13.

11.  Holicky R, Charlife S. Aging with spinal cord injury: the impact of spousal support. Disability and Rehabilitation 1999;21:250-7.

12.  Kemp B, Krause JS, Adkins RH. Depression among African-Americans, Latinos, and Caucasians with spinal cord injury:  An exploratory study. Rehabilitation Psychology 1999;44:235-47.

13.  Krause JS. Dimensions of Subjective Well-Being After Spinal Cord Injury:  An empirical analysis by gender and race/ethnicity. Archives of Physical Medicine and Rehabilitation 1998;79:900-9.

14.  Krause JS. Employment after spinal cord injury. Archives of Physical Medicine and Rehabilitation 1992;73:163-9.

15.  Krause JS. Subjective well-being after spinal cord injury: Relationship to gender, race-ethnicity, and chronologic age. Rehabilitation Psychology 1998;43:282-96.

16.  Krause JS, Anson CA. Adjustment after spinal cord injury:  Relationship to gender and race. Rehabilitation Psychology 1997;42:31-46.

17.  Krause JS, Anson CA. Employment after spinal cord injury: Relation to selected participant characteristics. Archives of Physical Medicine and Rehabilitation 1996;77:737-43.

18.  Krause JS, Kemp B, Coker J. Depression after spinal cord injury:  Relation to gender, ethnicity, aging, and socioeconomic indicators. Archives of Physical Medicine and Rehabilitation 2000;81:1099-1109.

19.  Krause JS, Kewman D, DeVivo MJ Employment after spinal cord injury:  An analysis of cases from the Model Spinal Cord Injury Systems. Archives of Physical Medicine and Rehabilitation 1999;80:1492-500.

20.  Krause JS, Kewman DG, DeVivo MJ. Employment after spinal cord injury:  An analysis of cases from the Model Spinal Cord Injury Systems. Archives of Physical Medicine and Rehabilitation 1999;80:1492-500.

21.  Krause JS, Sternberg M, Maides J, Lottes S. Employment after spinal cord injury:  Differences related to geographic region, gender, and race. Archives of Physical Medicine and Rehabilitation 1998;79:615-24.

22.  Laing IS, Chase T. A practical guide to health promotion after spinal cord injuryed. Gaitherburg (MD): Aspen Publishers, 1995.

23.  Leal A, Leung P, Martin WE. Multicultural aspects of rehabilitation counseling. Journal of Applied Rehbilitation Counseling 1988;19.

24.  Neugarten BL, Havighurst RJ, Tobin SS. Life Satisfaction Index Z [LSIZ]. In Fisher J ed. Measures for clinical practice: A sourcebook. New York: Free Pr., 1987:209-10.

25.  Organization WH. WHO definition of Health [Website], 2003. Accessed October 24, 2003, http://www.who.int/about/definition/en/.

26.  Post MWM, Van Dijk AJ, Van Asbeck FWA, Schrijvers AJP. Life satisfaction of persons with spinal cord injury compared to a population group. Scandinavian Journal of Rehabilitation Medicine 1998;30:23-30.

27.  Putzke JD, Elliott TR, Richards JS. Marital status and adjustment 1 year post-spinal-cord-injury. Journal of Clinical Psychology in Medical Settings 2001;8:101-7.

28.  Putzke JD, Richards JS, Hicken BL, DeVivo MJ. Predictors of life satisfaction: A spinal cord injury cohort study. Archives of Physical Medicine and Rehabilitation 2002;83:555-61.

29.  Renwick R, Brown I. Quality of Life in Health Promotion and Rehabilitation. In Brown I ed. The Center for Health Promotion's Conceptual Approach to Quality of Life:  Being, becoming, and belonging. Thousand Oaks (CA): Sage Publications, 1996:75-86.

30.  Richards JS, Bombardier CH, Tate D, Djikers M, Gordon W, Shewchuck R, DeVivo MJ. Access to the environment and life satisfaction after spinal cord injury. Archives of Physical Medicine and Rehabilitation 1999;80:1501-6.

31.  Rosenthal M, Dijkers M, Harrison-Felix C, Nabors N, Witol AD, Young ME, Englander JS. Impact of minority status on functional outcome and community integration following traumatic brain injury. Journal of Head Trauma Rehabilitation 1996;11:40-57.

32.  Saravanan B, Manigandan C, Macaden A. Re-examining the psychology of spinal cord injury:  A meaning centered approach from a cultural perspective. Spinal Cord 2001;39:323-6.

33.  Schumaker S, Anderson R, Czajikowski S. Psychological tests and scalesed. New York (NY): Raven, 1990.

34.  Westgren N, Levi R. Quality of life an traumatic spinal cord injury. Archives of Physical Medicine and Rehabilitation 1998;79:1433-9.

35.  Whiteneck G., Charlifue S, Gerhart K Overholser J, Richardson G. Quantifying handicap: A new measure of long-term rehabilitation outcomes.  Arch Phys Med Rehabil. 1994;73:103-111.


Copyright © 2004 Hampstead Psychological Associates, Ltd - A Subsidiary of Southern Development Group, SA.
All Rights Reserved.   A Private Non-Profit Agency for the good of all, published in the UK & Honduras