Satisfaction with social roles and activities across mobility status among persons with spinal cord injury

Study design:cross-sectional study Objective: to examine the differences in satisfaction with social roles and activities among ambulatory individuals, manual wheelchair users, and power wheelchair users with spinal cord injuries (SCIs). Setting:community setting Methods:Participants completed surveys of their demographics and clinical data as well as the Spinal Cord Injury – Quality of Life Satisfaction with Social Roles and Activities-Short Form. Participants’ mobility status was categorized into 1) ambulatory individuals, 2) independent manual wheelchair users, and 3) power wheelchair/scooter users. One-way ANOVA and ANCOVA were used, respectively, to examine unadjusted and adjusted differences in satisfaction with social roles and activities across mobility status. Adjustment covariates included age, sex, time since SCI, and SCI injury level. Results:A total of 129 participants (mean age = 47.4 ± 13.6 years, 73 % male) were included in the analyses. Unadjusted (F = 3.8, p = 0.03) and adjusted models (F = 3.4, p = 0.04) evidenced signi�cant differences in satisfaction with social roles and activities according to mobility status . Pairwise Bonferroni Post-Hoc analysis indicated that manual wheelchair users were more satis�ed with their social roles and activities when compared to ambulatory individuals (mean difference = 2.8, p < 0.05). Conclusions: Due to the current challenges associated with walking recovery after SCIs, clinicians may want to discuss the use of wheelchairs with individuals with limited walking ability when the goal is to improve participation and quality of life. Emphasizing alternative means of mobility may enhance satisfaction with social roles and activities.


Introduction
Spinal cord injuries (SCIs) commonly lead to long-terms disability that affects different domains of a person's life.In the United States, about 17,810 new cases of SCIs are diagnosed each year resulting in approximately 300,000 individuals living with the condition [1].Those individuals are generally active adults with an average age of 43 years [1].Depending on the type of injury (complete or incomplete), SCIs usually result in partial or complete loss of motor and/or sensory functions below the level of injury [2].
Moreover, depending on the level of injury (cervical, thoracic, or lumbar), SCIs may lead to different levels of mobility [2].Mobility impairments which are an underlying consequences of SCIs may be categorized into ambulation and non-ambulation.In general but not exclusively, ambulatory individuals usually present with motor and sensory incomplete lower injury, while non-ambulatory individuals commonly present with motor and sensory complete higher injury [3][4][5].With the recent advances in the care of people with SCIs and the emerging development of neuromodulation techniques, overlaps exist and some individuals with higher and complete injury (i.e., an individual with a motor and sensory complete thoracic 4 injury) may regain walking functions [6,7].
Depending on the degree of mobility impairments, individuals living with SCIs may rely on assistive devices such as crutches, walkers, or wheelchairs to improve their mobility independence and their ability to perform daily living activities.The performance of such activities is essential as it is an important factor that affects individuals with SCIs' participation in the communities and consequently their quality of life [8].After SCIs, it is well-known that indicators of well-being including participation and quality of life are affected and the reintegration of individuals with SCIs into their communities becomes a priority for clinicians working with this population.
Participation in social roles and activities is an essential long-term rehabilitation programs' goal for individuals with SCIs.Participation has been recognized as an essential aspect of human life which re ects the interaction between functional consequences of disability or injury, individual characteristics, and environmental factors [9].Moreover, satisfaction with participation and life after SCIs is an important predictor of survival among individuals with SCIs [10].Because of the heterogeneity of SCIs, rehabilitation programs designed to enhance participation should be tailored to individuals' needs and level of mobility.
Therefore, the comparison of health indicators across levels of mobility in SCIs is insightful as it helps guide rehabilitation programs to achieve their purpose.Consistent with this rationale, a recent study indicated that manual wheelchair users with SCIs and multiple sclerosis reported higher participation enfranchisement when compared to power wheelchair users [11].However, the difference in participation between ambulatory individuals and wheelchair users has not been examined.Establishing such comparison will be insightful for rehabilitation professionals as ambulation is a common and highly desired rehabilitation goal of individuals with SCIs [12].Therefore, we aimed to examine the differences in satisfaction with social roles and activities based on individuals with SCIs' mobility status.We hypothesized that wheelchair users will have a higher satisfaction with social roles and activities compared to ambulatory individuals.The hypothesis was based on the rationale that ambulatory individuals with SCIs may be limited to satisfactorily perform desired activities that require moderate to long distance traveling or long standing period which would be feasible for those who use a wheelchair.

Procedures
This is a secondary data analysis of a cross-sectional study that used a combination of baseline surveys, Ecological Momentary Assessment (EMA) of subjective symptoms and functioning, objective measure of physical activity, and End of Day diaries [13].Data from EMA, physical activity, and End of Day diaries are not the focus of this study and therefore were not described.The baseline surveys were used in the description of the procedures of this study.Data were collected at 3

Participants
Participation in the current study required meeting the following inclusion criteria: 1) 18 years old or older, 2) self-reported SCI, con rmed in medical record review, 3) ≥ 1 year after SCI, 4) have the ability to read at 6th grade level, and 5) able to converse uently in English.Potential participants were excluded from participating if they were inpatients at the time of data collection.
Participants were recruited through outpatient clinics, placement of yers in medical centers, community locations, electronic medical records, and existing participants/patient registries.Eligibility screening was conducted either in person or via the telephone.Eligible volunteers were then scheduled for an in-person visit in which they underwent informed consent procedures.After obtaining written informed consent to participate in the study, participants completed a survey battery.The surveys of interests to this study are described below.

Study measures
Participants completed a survey of their demographic data (e.g.age, sex, race, education, marital status).Participants also completed a self-reported clinical data that included (e.g.injury level, time since injury, SCI etiology, means of mobility).The information on means of mobility used by the participants most part of the time included assistive device used to walk such as cane or walker, use manual wheelchair, and use of power wheelchair or scooter.The information on means of mobility was used to categorize participants in the following mobility status: 1) ambulatory (with or without assistive device), 2) manual wheelchair users, and 3) power wheelchair/scooter users.
Spinal Cord Injury-Quality of Life V1.0 (SCI-QOL) Satisfaction with Social Roles and Activity Short Form was used to examine Satisfaction with Social Roles and Activity [14].The 10-item outcome examines satisfaction with performing one's usual social roles and activities and responsibilities, including work, family, friends and leisure in the past 7 days.Response options are scored on a Likert-scale from 1 to 5 that include Not at all, A little bit, Somewhat, Quite a bit, and Very much.Total raw scores are converted into a T-score varying from 28.3 to 60.5 (mean score of American adult general population = 50 and standard deviation of 10) [14].Higher T-scores indicate more satisfaction with social roles and activities.The SCI-QOL Satisfaction with Social Roles and Activity Short Form is reliable (test-retest Intraclass Coe cient Correlation = 0.77) and strongly correlated with the full bank (r = 0.96) [14].

Statistical analysis
Before data analysis, Kolmogorov-Smirnov test and observation of histograms indicated a normal distribution of the variables included in this study.Descriptive statistics (mean ± SD or median and range for continuous variables or frequency and percentage for categorical variables) were therefore calculated to determine participants' total and group demographics.Demographic differences between mobility status (ambulatory, manual wheelchair users, and power wheelchair/scooter users) were analyzed using one-way ANOVA or Kruskal-Wallis test for continuous variables and Chi-square for categorical variables.One-way ANOVA was also used to examine the differences in satisfaction with social roles and activities across mobility status.A General Linear Model one-way ANCOVA was then used to examine differences in satisfaction with social roles and activities across mobility status adjusting for age, sex, time since SCI, and SCI injury level.A Bonferroni Post-Hoc analysis was conducted to determine speci c group differences.Before ANCOVA model building, we ensure the assumptions of ANCOVA were met.For effect size (ES), the partial eta squared statistic was reported, with 0.01, 0.06, and 0.14 representing small, medium, and large ES, respectively [15].Signi cance was set at p < 0.05 and all statistical analyses were performed using SPSS for Windows version 28.0 (SPSS Inc., Chicago, IL).

Results
Data from a total of 131 individuals with SCI who completed the baseline assessments of the study were available.One participant did not provide complete response on the SCI-QOL Satisfaction with Social Roles and Activity and another participant did not provide all demographics information; thus, data analyses were completed on 129 participants.Sample descriptive characteristics are provided in Table 1.
Consistent with the general epidemiology of SCI [1], the sample was mostly male (approximately 73%), white (75%), and the mean age was 47.4 ± 13.6 years.Most participants sustained a cervical injury (38%) and had an incomplete injury (approximately 61%).The majority of the participants were wheelchair users (46%), followed by power wheelchair or scooter users (30%), and ambulatory individuals (24%).Across the mobility status, manual wheelchair users had a higher time since injury when compared to ambulatory individuals.Also, signi cant differences were found across mobility status for level of injury and completeness of injury (See Table 1).

Level of mobility and SCI-QOL Satisfaction with Social Roles and Activity
The ndings of this section are summarized in Table 2. One-way ANOVA indicated signi cant differences in satisfaction with social roles and activities across mobility status (F = 3.8, p = 0.03).The ES of the model was moderate (partial eta squared = 0.06).An adjusted Bonferroni pairwise comparisons presented in Table 3 revealed that manual wheelchair users were more satis ed with their social roles and activities when compared to ambulatory participants with SCI (mean difference = 2.8, 95% CI, 0.3 to 5.3, p = 0.02).No other signi cant differences were found.After adjusting for covariates including age, sex, time since SCI, and SCI injury level, the signi cant differences in satisfaction with social roles and activities across mobility status was maintained (F = 3.4, p = 0.04) (See Table 2).The ES of the model was also moderate (partial eta squared = 0.05).After adjusted Bonferroni pairwise comparisons (See Table 3), the difference between manual wheelchair users and ambulatory PwSCI on satisfaction with social roles and activities was also maintained (mean difference = 2.8, 95% CI, 0.2 to 5.5, p = 0.03).No other signi cant differences were found.

Discussion
This study examined the differences in satisfaction with social roles and activities across mobility status in people with SCIs.Satisfaction with social roles and activities is an important factor associated with QOL and a general rehabilitation goal [8].Our ndings indicate that satisfaction with social roles and activities in SCIs varies according to mobility status.Speci cally, we found that above and beyond the effects of age, sex, chronicity of injury, and level of injury, manual wheelchair users reported higher satisfaction with social roles and activities when compared to ambulatory individuals.Due to the stigma associated with wheelchair use [16,17] and the fact that walking recovery is one of the main goals of individuals with SCIs [12], clinicians should seriously consider preparing marginal ambulators for occasionally use of a wheelchair when one of the rehabilitations goals is to enhance the participation of this population.
Barriers and facilitators to participation in SCIs have been well-documented [17][18][19][20][21].However, the comparisons of factors associated with participation between ambulatory and wheelchair users with SCIs have not been explored [18,19].The higher satisfaction with social roles and activities reported by manual wheelchair users compared to ambulatory individuals may be explained by the ability of manual wheelchair users to complete several activities when compared to their ambulatory peers.Evidence suggests that manual wheelchair users with SCIs who have a higher mobility level are more likely to report higher participation [22,23].In fact, mobility training including wheelchair skills training is a rehabilitation priority for clinicians working with wheelchair users [24].Most barriers to participation among wheelchair users are related to physical accessibility and built environment [17,20].On the other hand, a recent study has indicated that individuals with incomplete SCIs who were independent ambulators reported several physical function and social barriers that affect their participation in the society [25].Moreover, evidence suggests that ambulatory individuals experience more fatigue and daily pain compared to wheelchair users which may signi cantly affect their satisfaction with social roles and activities [26].Therefore, ambulatory individuals with or without mobility aids may be limited to complete activities that require moderate to long walking distances or long standing period.Those limitations may signi cantly affect satisfaction with participation of ambulatory individuals when compared to manual wheelchair users.
It is worthwhile to mention that many individuals with SCIs who primarily ambulate also use a wheelchair and vice-versa.Also, many ambulatory individuals with SCIs at 1 year postinjury transition from ambulation to wheelchair use at 5 and 10 years postinjury [27].This may also justify the ndings reported in our study as ambulatory individuals SCIs who are aging may need a wheelchair to maintain their involvement in valued activities.However, the transition from ambulation to wheelchair use may be complex and has been found to be associated with higher levels of depression among individuals with SCIs [27].As many marginal ambulators continue to transition to wheelchair use [27], clinicians such as physical and occupational therapists should be aware of mixed positive and negative effects and consider these aspects in their decision-making (i.e., training of wheelchair skills among ambulatory individuals).This may be essential to partly avoid the negative consequences associated with the transitions from ambulation to wheelchair use [27].Furthermore, clinicians such as psychologists should be involved early on in the rehabilitation process of individuals with SCIs to prepare ambulatory individuals to transitioning to wheelchair use, if clinically necessary.This may ultimately lead to an increased satisfaction in social roles and activities as reported in our study.
Our ndings may not re ect the desired outcome principally for individuals with SCIs as our results indicate that wheelchair users are more satis ed with their social roles and activities compared to ambulatory individuals.This is because many individuals with chronic SCIs often express a desire to regain walking abilities [12] and wheelchair use has been associated with social judgments such as stigma and negative emotions such as lack of sense of purpose [16,17,28].Despite the high desire to walk expressed by individuals with SCIs, studies have indicated that -unfortunately-independent or community ambulation after SCIs may not be attainable for everyone [5,[29][30][31].This is because despite the recent growing promising results to regain walking functions using neuromodulation and taskoriented therapy [6, 7], walking is strongly dependent of factors such as subject's age and details of the injury (i.e., motor and sensory areas preserved) [32,33].In addition, most interventions designed to recover walking abilities after SCIs have not produced a walking recovery outcome such as walking speed that exceeds the Minimal Clinical Important Difference (MCID) or a walking speed needed to ambulate independently in the community [34].Therefore, ambulatory individuals may experience frustration to participate satisfactorily in social roles and activities especially when compared to wheelchair users who may be quicker to perform the same tasks [35].

Limitations
There are several limitations to this study.First, the nature of this study (secondary data analysis) limited the outcomes that could be included in the analyses.The differences of levels of functional independence and quality of life across mobility status would have also been interesting to examine.In line with this previous limitation, we were not able to account for the type of injury according to the American Spinal Injury Association Impairment Scale or analyze those individuals who alternate means of mobility because the data were not available.We suggest that future studies include in the comparisons, the category of ambulatory individuals who also use a wheelchair.Furthermore, we were not able to analyze separately ambulatory individuals who use walking aids and those who do not due to the small sample of ambulatory individuals.Future studies with bigger samples should account for the walking aids of ambulatory individuals.Lastly, we were not able to indicate whether the mean difference in satisfaction with social roles and activity between manual wheelchair users and ambulatory individuals (mean difference = 2.8) is clinically meaningful as the MCID of the SCI-QOL Satisfaction with Social Roles and Activity has not yet been established.

Conclusion
Among participants with SCIs, manual wheelchair users reported a higher satisfaction with social roles and activities compared to ambulatory individuals.Considering the challenges associated with ambulation and walking recovery after SCIs, clinicians may want to emphasize the alternate use of a wheelchair among marginal ambulators when the goal is to enhance satisfaction with social roles and activities and therefore, participation and quality of life in this population.Clinicians should understand the implications of the differences in satisfaction with social roles and activities across mobility status and account for these differences in their decision-making.
collaborating sites (the University of Michigan in Ann Arbor, the Wayne State University/Rehabilitation Institute of Michigan in Detroit, and the

Table 1
Sample descriptive statistics (n = 129) SCI-QOL SSRA: Spinal Cord Injury-Quality of Life Satisfaction with Social Roles and Activity; WC: wheelchair; * Statistically signi cant difference between ambulatory and manual WC users after Kruskal-Wallis test.# Statistically signi cant difference across mobility status after Chi-square; a Data was available for n = 119.(Insert Table 1 here)

Table 2
Differences in Satisfaction with Social Roles and Activity across levels of mobility (ambulatory, manual wheelchair, and power wheelchair) in a sample of people with SCI (n = 129).

Table 3
Results of pairwise post-hoc analyses of the differences in Satisfaction with Social Roles and Activity across levels of mobility (ambulatory, manual wheelchair, and power wheelchair) (n = 129)