Generating Rasch-based activity of daily living measures from the Spinal Cord Injury Longitudinal Aging Study.

STUDY DESIGN: Retrospective Longitudinal Study. OBJECTIVES: (1) To determine whether the Spinal Cord Injury Activities of Daily Living (SCI_ADL) measure shows adequate item-level and precision psychometrics; (2) to investigate whether the SCI_ADL measure effectively detects ADL changes across time; (3) to describe self-care task(s) participants can and cannot do across time. SETTING: Two Midwestern hospitals and 1 Southeastern specialty hospital in 1993. METHODS: All participants were adults with traumatic SCI of at least 1-year duration at enrollment. We used 20-year (1993-2013) retrospective longitudinal data and categorized participants into three injury levels: C1-C4 (cervical; n=50), C5-C8 (n=126) and T1-S5 (thoracic, lumbar and sacral; n=168). We first examined psychometrics of the SCI_ADL with factor and Rasch analyses; then we investigated longitudinal change of SCI_ADL scores at three time points over 20 years (1993, 2003 and 2013) using generalized linear mixed modeling and post hoc analyses. RESULTS: The SCI_ADL measure demonstrated unidimensionality, person strata of 2.9, high Cronbach's α (0.93) and fair person reliability (0.76). T1-S5 had the highest measures, following C5-C8 and C1-C4 at three time points (P<0.05). The C1-C4 and T1-S5 groups showed significant decreases from 2003 to 2013; however, none of the three groups showed significant differences from 1993 to 2003 (P<0.05). CONCLUSIONS: The SCI_ADL measure could detect longitudinal ADL changes of the population with SCI across time. The C1-C4 group decreased the most in ADLs, indicating higher need of long-term services and rehabilitation.

Rasch measurement properties of the Pain Medication Questionnaire in persons with spinal cord injury.

STUDY DESIGN: Secondary analysis of cross-sectional population-based self-report data. OBJECTIVE: To determine how well the Pain Medication Questionnaire (PMQ) measures risk of pain medication misuse and its precision in separating individuals with spinal cord injury (SCI) into meaningful classification categories. SETTING: Academic medical center in Southeastern United States. METHODS: Data were collected from a population-based registry of SCI (n=971). Eligible participants included adults with traumatic SCI with residual effects who were at least 1 year post injury and 18 years of age and who had PMQ data in which they reported active use of pain medication at the time of the study (n=745). RESULTS: Most items (23/26) of the PMQ contributed to a single unidimensional construct. Rasch analysis results revealed that the rating scale, majority of persons (>93%), and majority of items (20/23) fit the Rasch measurement model. The PMQ demonstrated adequate reliability (person reliability =0.67) and separated persons into two strata-those likely to misuse pain medication and those with low liklihood of misusing pain medication. CONCLUSIONS: Findings offer a deeper understanding of the measurement properties of the PMQ as a precursor for widespread population-based studies to elucidate the incidence of pain medication misuse in persons with SCI. Results also have important research and clinical implications for commonly used PMQ total score cut-offs, which may misclassify an individual's risk of pain medication misuse.

The natural course of spinal cord injury: changes over 40 years among those with exceptional survival.

OBJECTIVES: To identify 40-year longitudinal changes in health, activity, employment, life satisfaction and self-rated adjustment after spinal cord injury. STUDY DESIGN: Longitudinal, mailed self-report. METHODS: Participants were identified from outpatient records of a Midwestern USA university hospital in 1973. Follow-ups were conducted in 1984 and approximate 10-year intervals thereafter. A total of 49 participants completed each of the five assessments. Data were reviewed and analyzed by research team members and a research associate with experience in biostatistics at a medical university in Southeastern USA. Life Situation Questionnaire included the following: (1) demographic and injury characteristics, (2) educational status and employment, (3) community participation, (4) life satisfaction, (5) adjustment, and (6) recent medical history. RESULTS: Proportion of individuals with 10+ non-routine physician visits increased from consistently <10% to >40% during the 40 years. Proportion who spent a week or more in hospital increased from a low of 10% at 20-year follow-up to 43% at 40-year follow-up. Percentage employed and average hours employed initially improved over time but decreased substantially during the last two times of measurement. Satisfaction with health, sex life and social life declined over time, whereas satisfaction with employment improved initially and was maintained over time. Self-rated current adjustment remained stable, whereas predicted future adjustment declined steadily over 40 years. CONCLUSIONS: Age-related declines were apparent for need of physician visits and hospitalizations, with notable declines in satisfaction with sex life, social life and health. However, not all indices declined over time. Participants appeared to maintain stability when rating their own adjustment.

Effects of aerobic exercise training on fitness and walking-related outcomes in ambulatory individuals with chronic incomplete spinal cord injury.

STUDY DESIGN: Single group, pretest-post-test study. OBJECTIVES: To determine the effects of a non-task-specific, voluntary, progressive aerobic exercise training (AET) intervention on fitness and walking-related outcomes in ambulatory adults with chronic motor-incomplete SCI. SETTING: Rehabilitation research center. METHODS: Ten ambulatory individuals (50% female; 57.94±9.33 years old; 11.11±9.66 years postinjury) completed voluntary, progressive moderate-to-vigorous intensity AET on a recumbent stepper 3 days per week for 6 weeks. The primary outcome measures were aerobic capacity (VO2peak (volume of oxygen that the body can use during physical exertion)) and self-selected overground walking speed (OGWS). Secondary outcome measures included walking economy, 6-minute walk test (6MWT), daily step counts, Walking Index for Spinal Cord Injury (WISCI-II), Dynamic Gait Index (DGI) and Berg Balance Scale (BBS). RESULTS: Nine participants completed all testing and training. Significant improvements in aerobic capacity (P=0.011), OGWS (P=0.023), the percentage of VO2peak used while walking at self-selected speed (P=0.03) and daily step counts (P=0.025) resulted following training. CONCLUSIONS: The results indicate that total-body, voluntary, progressive AET is safe, feasible, and effective for improving aerobic capacity, walking speed, and select walking-related outcomes in an exclusively ambulatory SCI sample. This study suggests the potential for non-task-specific aerobic exercise to improve walking following incomplete SCI and builds a foundation for further investigation aimed at the development of exercise based rehabilitation strategies to target functionally limiting impairments in ambulatory individuals with chronic SCI.

A mechanistic approach to understanding range shifts in a changing world: What makes a pioneer?

A species' range can be thought of as a manifestation of the ecological niche in space. Within a niche, evolution has resulted in traits that maximize fitness. Across millennia, natural oscillations in temperature have caused shifts in the geographic location of appropriate habitat and with corresponding changes in species' ranges. Contemporary climate change and human disturbance may lead to rapid range expansion or contractions with largely unknown consequences. Birds provide an excellent case study of this phenomenon with some taxa expanding range and others contracting even to the point of extinction. What leads some populations to expand while others contract? Are there physiological and behavioral attributes of "pioneers" at the forefront of a range shift/expansion? The concept of allostasis provides a framework with which to begin to evaluate when a species will be able to successfully expand into new habitat. This tool allows the integration of normal energetic demands (e.g. wear and tear of daily and seasonal routines) with novel challenges posed by unfamiliar and human altered environments. Allostasis is particularly attractive because it allows assessment of how individual phenotypes may respond differentially to changing environments. Here, we use allostasis to evaluate what characteristics of individuals and their environment permit successful range expansion. Understanding variation in the regulatory mechanisms that influence response to a novel environment will be fundamental for understanding the phenotypes of pioneers.

Pain medication misuse among participants with spinal cord injury.

STUDY DESIGN: Self-reported survey. OBJECTIVE: Our purpose was to identify the predictors of pain medication misuse (PMM) among participants with spinal cord injury (SCI). SETTING: A medical university in the southeastern United States. METHODS: A total of 919 adults with impairment from traumatic SCI of at least 1-year duration, who reported at least one painful condition and were taking prescription medication to treat pain, were included in this study. PMM was measured by the Pain Medication Questionnaire (PMQ). RESULTS: The average PMQ score was 19.7, with 25.8% of participants scoring at or above the cutoff of 25, which is indicative of PMM. A three-stage logistic regression analysis was conducted by sequentially adding three sets of predictors to the equation: (1) demographic and injury characteristics; (2) pain characteristics and (3) frequency of pain medication use. Age and education level were protective of PMM, whereas pain intensity, pain interference and pain medication use were risk factors. Number of painful days was not significant in the final model. CONCLUSION: PMM must be of concern after SCI, given its high prevalence among those with at least one painful condition and its relationship with pain indicators.

Diabetes increases financial burden of individuals with traumatic spinal cord injury (TSCI).

STUDY DESIGN: Secondary analysis of existing data. OBJECTIVE: To estimate the association of diabetes with family income in a pooled 15-year cohort of individuals with TSCI. SETTING: A large specialty hospital in the southeastern United States. METHODS: A total number of 1408 individuals identified with TSCI were surveyed regarding family income as well as clinical and demographic factors. Due to income being reported in censored intervals rather than individual dollar values, interval regression was used to estimate models of the association of family income with diabetes. RESULTS: Approximately 12% of individuals with TSCI reported being diagnosed with diabetes. The most frequent family income interval in our sample was <$10,000, lower than the poverty threshold. The family income interval with the highest rate of diabetes was $15,000-$20,000. In an unadjusted model, diabetes was associated with a significant reduction of $8749 and in a fully adjusted model, diabetes was significantly associated with a reduction of $8560 in family income. Being a minority was also significantly associated with a reduction whereas educational attainment was associated with increased family income. TSCI severity was not significantly related to family income. CONCLUSION: Diabetes imposes an additional financial burden on individuals with TSCI an already vulnerable population with high health care costs. The burden is more pronounced in minorities with TSCI. Providers should be aware of the higher prevalence of diabetes among patients with TSCI and pursue a policy of testing early and vigilant management. Further studies are needed regarding special interventions for managing diabetes in the TSCI population.

Prevalence of cigarette smoking and attempts to quit in a population-based cohort with spinal cord injury.

OBJECTIVE: The purposes of this study were to assess (i) prevalence of smoking in a population-based cohort of persons with spinal cord injury (SCI), (ii) history of quit attempts and (iii) the relationship between access to health care, socioeconomic status (SES), smoking status and history of quit attempts. STUDY DESIGN: Cross-sectional study. SETTING: Population-based SCI cohort. METHODS: A total of 833 adults with SCI of at least 1-year duration were identified through a population-based surveillance system. Current smoking status, attempts to quit smoking in the past year and seeking professional help to quit smoking were assessed. RESULTS: Over one-third (35.3%) of the sample were current smokers, of whom 75.4% had ever tried to quit, and of these, only 27.9% had ever sought professional help. Those with lower SES were more likely to be current smokers, as were those with less access to health care. Access to care was positively related to likelihood of having sought professional help. CONCLUSIONS: We found rates of smoking among persons with SCI to be well above national prevalence rates. We also found poorer access to care related to a greater likelihood of being a current smoker, had no association with trying to quit smoking, but decreased likelihood of using cessation support among those who did attempt to quit.

Pain and fatigue as mediators of the relationship between mobility aid usage and depressive symptomatology in ambulatory individuals with SCI.

STUDY DESIGN: Cross-sectional cohort study. OBJECTIVES: To investigate a mediational model where pain (intensity and interference) and fatigue mediate the relationship between the use of mobility aids and moderate-to-severe depressive symptomatology among ambulatory participants with spinal cord injury (SCI). SETTING: A medical university in the southeastern United States. METHODS: Ambulatory adults (N=652) with chronic SCI responded to a mail-in survey. The Patient Health Questionnaire-9 was used to assess moderate-to-severe depressive symptomatology. The Brief Pain Inventory was used to assess pain intensity and interference, and the Modified Fatigue Impact Scale-5-item version was used to assess fatigue. Participants self-reported use of mobility aids. RESULTS: On examining mobility aids used for ambulation, 65% were found to have used at least one aid. Severe pain intensity was reported by 11%, and 14% reported severe pain interference. Disabling fatigue was reported by 10% of the participants. Twenty-one percent (n=138) reported moderate-to-severe levels of depressive symptoms. On examining the relationships between mobility aids and depressive symptomatology, using people as a mobility aid was associated with increased odds of depressive symptomatology (2.6) and always using a wheelchair was associated with lower odds (0.3). However, these relationships were no longer significant after controlling for the mediating variables pain intensity, pain interference and fatigue. CONCLUSIONS: Pain and fatigue mediate the relationship between usage of certain mobility aids and depressive symptomatology. The use of people to assist in ambulation is associated with greater odds of moderate-to-severe depressive symptomatology, while always using a wheelchair is associated with lower odds.

Race-ethnicity and poverty after spinal cord injury.

STUDY DESIGN: Secondary analysis of existing data. OBJECTIVE: Our objective was to examine the relationship between race-ethnicity and poverty status after spinal cord injury (SCI). SETTING: A large specialty hospital in the southeastern United States. METHODS: Participants were 2043 adults with traumatic SCI in the US. Poverty status was measured using criteria from the US Census Bureau. RESULTS: Whereas only 14% of non-Hispanic White participants were below the poverty level, 41.3% of non-Hispanic Blacks were in poverty. Logistic regression with three different models identified several significant predictors of poverty, including marital status, years of education, level of education, age and employment status. Non-Hispanic Blacks had 2.75 greater odds of living in poverty after controlling for other factors, including education and employment. CONCLUSION: We may need to consider quality of education and employment to better understand the elevated risk of poverty among non-Hispanic Blacks in the US.

Risk factors for mortality after spinal cord injury in the USA.

STUDY DESIGN: Cohort study. OBJECTIVES: First, to examine three sets of risk and protective factors for mortality after spinal cord injury (SCI), with an emphasis on health and secondary conditions. Second, to extend earlier work with several methodologic enhancements and addition of new predictors. SETTING: Twenty hospitals designated as SCI Model Systems (SCIMSs) of care in the United States. METHODS: Altogether, 8183 adults with traumatic SCI who received at least one follow-up evaluation between November 1995 and October 2006 from one of the SCIMSs were included in the study. There were 76,262 person-years and 1381 deaths at the end of June 2011. Mortality status determined by National Death Index and Social Security Death Index searches. Three successive sets of risk factors were evaluated with a logistic regression model on person-year observations to estimate the chance of dying in any given year. RESULTS: Several biographic and injury, socio-environmental and health factors were significantly related to the odds of mortality. A history of pneumonia or kidney calculus was associated with greater odds of mortality, whereas deep vein thrombosis was not. Poor general health, decline in health over the past year, hospitalization and a grade 3 or 4 pressure ulcer were also related to mortality. Consistent with a mediating effect, odds ratios declined with the addition of each successive set of factors. CONCLUSION: The relationship of biographic and injury characteristics with mortality after SCI is mediated by socio-environmental and health factors. Assessment of these variables enhances our ability to identify individuals at risk for excess mortality.

Gainful employment and risk of mortality after spinal cord injury: effects beyond that of demographic, injury and socioeconomic factors.

OBJECTIVE: To evaluate the association of three levels of gainful employment with the risk of mortality after traumatic spinal cord injury (SCI) while controlling for known predictors of mortality status (including education and income). STUDY DESIGN: Prospective cohort study. SETTING: A total of 20 federally funded SCI Model Systems of care in the United States. METHODS: Participants included 7955 adults with traumatic SCI. Preliminary assessments were conducted between 1995 and 2006. Mortality status was determined by the Social Security Death Index (1308 deaths). A two-stage logistic regression model was used to estimate the chance of dying in any given year. Life expectancy was calculated under different economic assumptions. RESULTS: Compared with those who were working 30+ h per week, the odds of mortality was 1.37 for those who worked 1-29 h and 1.67 for those who were unemployed. The addition of gainful employment only modestly reduced the effects of household income and education, both of which remained significant. For instance, the odds of mortality for household income (referent $75 000+) decreased from 1.50 to 1.38 for $25 000-$75 000 and from 2.10 to 1.82 for < $25 000. Life expectancy varied widely depending on socioeconomic characteristics more than doubling under certain assumptions. CONCLUSION: Substantial variation in mortality is attributable to employment, above and beyond the effects of previously established demographic, injury and socioeconomic predictors. Although some excess mortality may be the inevitable consequence of SCI, risk is substantially increased with poor socioeconomic characteristics.

Socioeconomic and behavioral risk factors for mortality: do risk factors observed after spinal cord injury parallel those from the general USA population?

OBJECTIVE: To evaluate the association of demographic, behavioral and socioeconomic factors with all-cause mortality while controlling for health status among a cohort of participants with severe disability related to spinal cord injury (SCI). STUDY DESIGN: Prospective cohort study. SETTING: Data were analyzed at a major medical university in the Southeast United States of America. METHODS: Participants included 1361 adults with traumatic SCI of at least 1-year duration who were recruited through a large specialty hospital in the Southeast United States of America. Three Cox proportional hazard models were generated relating the predictors to all-cause mortality. RESULTS: Age, disability, smoking and income were significant in the final model. Both current (hazard ratio (HR)=2.03, 95% confidence interval (CI)=1.46-2.82) and former smokers (HR=1.58, CI=1.16-2.16) were at elevated hazard of mortality, as were those with incomes below $10,000 (HR=2.29, CI=1.53-3.44) and between $10,000 and $35,000 (HR=1.47, CI=1.03-2.10). CONCLUSIONS: Even after controlling for health and severity of disability, the coefficients for smoking and income were significant, exceeding that reported previously within the general population. The importance of these factors may be magnified after severe disability, even though life expectancy is already greatly diminished in this population.

Stability of predictors of mortality after spinal cord injury.

STUDY DESIGN: Cohort study. OBJECTIVES: To identify the stability of socio-environmental, behavioral and health predictors of mortality over an 8-year time frame. SETTING: Data were analyzed at a large medical university in the Southeast United States of America (USA). METHODS: Adults with residual impairment from a spinal cord injury (SCI) who were at least 1-year post-injury at assessment were recruited through a large specialty hospital in the Southeast USA. A total of 1209 participants were included in the final analysis. A piecewise exponential model with two equal time intervals (8 years total) was used to assess the stability of the hazard and the predictors over time. RESULTS: The hazard did significantly change over time, where the hazard in the first time interval was significantly lower than the second. There were no interactions between the socio-environmental, behavior or health factors and time, although there was a significant interaction between age at injury (a demographic variable) and time. CONCLUSION: These results suggest there is stability in the association between the predictors and mortality, even over an 8-year time period. Results reinforce the use of historic variables for prediction of mortality in persons with SCI.

Natural course of life changes after spinal cord injury: a 35-year longitudinal study.

OBJECTIVES: To identify the natural course of changes in participation, employment, health and subjective quality of life over a 35-year interval among participants with spinal cord injury (SCI). METHODS: Participants were enrolled in 1973 from a specialty hospital in the Midwestern United States and assessed again approximately 35 years later. The inclusion criteria were the following: having traumatic SCI; being 18 years of age or older; and a minimum of 2 years having elapsed post injury. There were 64 participants who responded on both occasions. Average age at follow-up was 61.5 years, with 41.1 years having passed since SCI onset. The Life Situation Questionnaire was used to measure outcomes. RESULTS: Attrition analyses indicated that those who participated at follow-up were younger and had better overall outcomes at baseline (1973) when compared with those who dropped out of the study. Longitudinal analyses indicated a mixed pattern of favorable and unfavorable changes over the 35 years. The overall social participation decreased over time, although the sitting tolerance and hours spent in gainful employment increased. Non-routine physician visits increased. Satisfaction with employment improved over time, whereas satisfaction with social life, sex life and health declined. Self-reported adjustment improved, but the prediction of future adjustment in 5 years declined. CONCLUSION: Our study suggests that the natural course of SCI is marked by a survivor effect, whereby those with better outcomes are more likely to survive to follow-up, and a mixed pattern of favorable and unfavorable changes. Rehabilitation professionals should work to promote favorable outcomes in areas of strength, as well as minimize the likelihood of adverse outcomes.

A longitudinal study of depression in survivors of spinal cord injury.

STUDY DESIGN: Cohort study. OBJECTIVES: The objective of this study is to assess depression over a 5-year period in persons with spinal cord injury (SCI) and to assess risk factors for depression over time. SETTING: Rehabilitation hospitals in the Southeast and Midwest. METHODS: Participants included 801 adults with residual effects from a traumatic SCI averaging over 15 years post injury. Participants responded to two questionnaires, one in 2002 (Time1) and another in 2008 (Time 2). Probable major depression (PMD) was measured by the Older Adult Health and Mood Questionnaire. RESULTS: In all, 22.1% of participants had PMD at Time 1 and 20.2% at Time 2. There was a non-significant trend for change in PMD status (P=0.058). Of those who had PMD at Time 1, 55.7% had PMD at Time 2. Between the two time points, the most change occurred in the group with clinically significant symptomatology. Demographic factors (race-gender, age, time since injury) and health behaviors (pain medication use, hours out of bed, days out of the house, exercise) were significantly associated with PMD over time. Socioeconomic factors (income, education) were significantly related to depression but were not significant after controlling for behavioral factors. CONCLUSION: Depression is fairly consistent over time in persons with SCI, with the majority of change coming from those in the clinically significant symptomatology group. Examining depression at multiple time points, our results underscore the importance of health behaviors in relation to PMD, even after controlling for demographic, injury and environmental factors.

Secondary health conditions in individuals aging with SCI: terminology, concepts and analytic approaches.

STUDY DESIGN: Literature review. OBJECTIVES: Utilizing individuals with spinal cord injury (SCI) as a representative population for physical disability, this paper: (1) reviews the history of the concept of secondary conditions as it applies to the health of individuals aging with long-term disabilities; (2) proposes a definition of secondary health conditions (SHCs) and a conceptual model for understanding the factors that are related to SHCs as individuals age with a disability; and (3) discusses the implications of the model for the assessment of SHCs and for developing interventions that minimize their frequency, severity and negative effects on the quality of life of individuals aging with SCI and other disabilities. METHODS: Key findings from research articles, reviews and book chapters addressing the concept of SHCs in individuals with SCI and other disabilities were summarized to inform the development of a conceptual approach for measuring SCI-related SHCs. CONCLUSIONS: Terms used to describe health conditions secondary to SCI and other physical disabilities are used inconsistently throughout the literature. This inconsistency represents a barrier to improvement, measurement and for the development of effective interventions to reduce or prevent these health conditions and mitigate their effects on participation and quality of life. A working definition of the term SHCs is proposed for use in research with individuals aging with SCI, with the goal of facilitating stronger evidence and increased knowledge upon which policy and practice can improve the health and well-being of individuals aging with a disability.

Association of spasticity and life satisfaction after spinal cord injury.

STUDY DESIGN: Cross-sectional survey; secondary analysis of existing data by linear regression analysis between spasticity and quality of life. OBJECTIVE: To identify the relationship between spasticity and life satisfaction as measured by three multi-item factor scales and a rating of overall quality of life among participants with spinal cord injury (SCI). SETTING: Large specialty hospital in the Southeastern United States. METHODS: Participants included 1549 adults with traumatic spinal cord injuries, at least 18 years of age and a minimum of 1-year post-injury at survey. Outcome measures included: (1) home life satisfaction, (2) global satisfaction, (3) vocational satisfaction, (4) overall quality of life and (5) three subscales from the Patient Reported Impact of Spasticity Measure. RESULTS: Three aspects of spasticity (daily activities, positive impact and spasticity at its worst) all were negatively correlated with home life satisfaction, global satisfaction and overall quality of life. Only the daily activities scale and the spasticity at its worst rating had a significant negative correlation with vocational satisfaction. CONCLUSION: Spasticity is negatively associated with quality of life after SCI. These negative outcomes need to be considered in an individual's rehabilitation and treatment methods.

Barriers and facilitators to employment after spinal cord injury: underlying dimensions and their relationship to labor force participation.

STUDY DESIGN: Cross-sectional survey. OBJECTIVE: To identify barriers and facilitators to employment after spinal cord injury (SCI) and their relationship with labor force participation. METHODS: Participants were initially identified through specialty hospitals in the Midwest and Southeastern United States of America. 781 adults with traumatic SCI, at least 1 year post-injury, and between the ages of 18-64, participated. A 30-item instrument on barriers and facilitators to employment was administered. Analyses included exploratory factor analysis (EFA), confirmatory factor analysis (CFA) and comparisons of scores as a function of employment status. RESULTS: EFA indicated six primary themes (root mean square error of approximation (RMSEA)=0.040), including: (a) resources, (b) health status, (c) disability considerations, (d) lack of importance, (e) disincentives and (f) motivation. CFA indicated an acceptable fit (RMSEA=0.078). Univariate analyses indicated each item and factor was significantly different as a function of labor force participation. After controlling for biographical and injury factors, multinomial logistic regression indicated three factors significantly differentiated those never employed, those currently unemployed but had worked since injury and those currently employed. Those employed reported higher scores for resources and motivation and lower scores for lack of importance. CONCLUSIONS: Barriers and facilitators were consistently related to labor force participation, with facilitators more highly related to labor force participation than barriers. Although loss of financial and medical benefits (disincentives) as well as health status have been reported as barriers to employment, they were not as highly correlated with labor force participation as were other factors.

Psychological factors affecting alcohol use after spinal cord injury.

STUDY DESIGN: Cross-sectional. OBJECTIVE: The purpose of this study is to assess risk factors, including personality and socioeconomic indicators, with alcohol use among persons with spinal cord injury (SCI). SETTING: A large rehabilitation hospital in the Southeastern United States. METHODS: A total of 1549 participants responded to a survey on outcomes after SCI. We used polychotomous logistic regression to assess the relationships of personality and socioeconomic factors with alcohol use. RESULTS: In this study population, 19.3% were heavy drinkers, 29.4% moderate and 51.7% abstinent. Annual household income and education were both associated with heavy alcohol use, with persons with higher income or education more likely to be heavy drinkers. Impulsive sensation seeking, neuroticism-anxiety and aggression-hostility were associated with increased odds of heavy drinking. CONCLUSION: This study adds to the body of evidence indicating a substantial portion of individuals with SCI are heavy drinkers, and that personality and socioeconomic status are associated with heavy drinking.