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 findings indicate that satisfaction with social roles and activities in SCIs varies according to mobility status. Specifically, 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 [17–21]. 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 significantly 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 significantly 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 findings 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 findings may not reflect the desired outcome principally for individuals with SCIs as our results indicate that wheelchair users are more satisfied 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, 29–31]. This is because despite the recent growing promising results to regain walking functions using neuromodulation and task-oriented 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.