Family and Spinal Cord Injury
Wise Young, Ph.D., M.D.
W. M. Keck Center for Collaborative Neuroscience
Rutgers University, Piscataway, New Jersey
Effect of Spinal Cord Injury on Family Members
Studies of the effects of spinal cord injury on families usually focus on spouses and have paid little attention to other family members. Little has been published on the effects of spinal cord injury on children, siblings, parents, and other relatives. Family members suffer from stress, grief, and depression when a spinal cord injury occurs in the family.
Spouses. The burden of caregiving most frequently falls on the spouse. Caregiving spouses are often severely stressed, particularly due to health issues that arise after spinal cord injury. Chan (2000) studied this phenomenon in Hong Kong, finding that spouses of persons with spinal cord injury suffer emotional stress that is comparable to or greater than those of the injured partner. Spouses who are caregivers for people with spinal cord injury may be more depressed than their partners with disabilities. Caregivers have a higher incidence of physical stress, emotional stress, burnout, fatigue, anger, and resentment (Weitzenkamp, et al. 1997) than their partners or spouses who are not the caregivers. Chan, et al. (2000) report that the impact of spinal cord injury is more severe on marriages that began before than after the injury. An early study suggested that disabled people in pre-injury marriages receive more daily personal care assistance from their spouses than those in post-injury marriages (Crewe, et al, 1979).
Children. Given the disruptive and impoverishing effects of spinal cord injury on families, most people assume that spinal cord injury of a parent has deleterious effects on children. However, several studies suggests that spinal cord injury does not have as much deleterious long-term effect on the well-being of children. Killen (1990) assessed roles of children in families after spinal cord injury and found that spinal cord injury did not change the roles, i.e. mothers, fathers, husbands, and wives continued to play their traditional roles. Buck & Hohmann (1981) examined the effects of fathers with spinal cord injury and subsequent adjustment of 45 children compared to matched 36 children with able-bodied fathers. They found the children to be well-adjusted and emotionally stable with normal sex role identifies. Buck & Hohmann (1984) also analyzed the effects of financial insecurity and unemployment on child development, comparing children whose fathers were receiving ample income with those who were unemployed. They found no adverse relationship between child adjustment and financial resources of fatherÕs financial resources. Alexander, et al. (2002) described the impact of mothers with spinal cord injury on family and childrenÕs adjustments. They also found no adverse effects on the childrenÕs adjustment, gender role identity, self-esteem, or attitudes towards mother and father. There is a need for more studies on this subject, particularly with long-term follow-up of children whose parents have suffered spinal cord injury. While there is a dearth of information on the effects of parental spinal cord injury on children, much information is available concerning children who have parents with other disabilities. Through the Looking Glass (http://www.lookingglass.org/) is a wonderful web site in Berkeley California that has pioneered research, training, and services for families with disability. It is estimated that 2.6 to 4.7 million parents with disabilities are raising teenage children in the United States and nearly 10.9% of all American families with children include at least one parent who has a disability.
Parents. Almost everybody who is spinal injured has a parent. Over half of people in the United States are injured before age 26. When a person is young and not married, the burden of caregiving frequently is taken up by the parents. There is often nobody else. Yet, almost nothing is published in the medical literature concerning parents of people with spinal cord injury. I can say, however, from meeting many parents of injured people that the spinal cord injury of a child is as or more life-altering for them. One other factor may play a role as well. Many parents cannot adjust or forget. Years and even decades after the spinal cord injury, many parents are still grieving. It is not unusual to find tears in the eyes of a parent of a person with spinal cord injury when they talk about the accident and the events that follow. Feelings of helplessness and hopelessness, guilt, and depression often pervade their lives for a long time. There may also be differences between the responses of mother and fathers.
Siblings. Little is known about the effects of spinal cord injury on siblings, except for a few anecdotal stories (Shaddinger, 1995). The effects of injury of course depend on the age and closeness of the siblings. Very little has been published on the potential disruptive effects of spinal cord injury on the life, education, attitudes, and adjustment of siblings. Interestingly, there are several studies of the effect of spinal cord injury on identical twins. Tirch, et al. (1999) assessed depression in 11 monozygotic twins with one spinal-injured member and found no significant differences of depression, suggesting that depression may have a genetic basis and spinal cord injury does not inevitably lead to depression. An alternative interpretation is that depression in one member of the pair leads to depression in the other. Twin studies, however, have provided a variety of insights into spinal cord injury induced changes in body composition and metabolism (Spungen, et al., 2000; Bauman, et al. 1999). Likewise, Kahn, et al. (2001) examined platelet function in 12 pairs of monozygotic twins and showed significant differences in platelet function related to loss of high-affinity prostanoid receptors, perhaps explaining the greater incidence of coronary disease in people with spinal cord injury. Sibling studies have also been used to assess the insulin resistance and sympathetic functions in high spinal cord injury (Karlsson, 1999; Karlsson, et al., 1995).
Effect of Spinal Cord Injury on Marriages
Spinal cord injury significantly affects marriages. In general, people with spinal cord injury are less likely to be married and more likely to be divorced (DeVivo & Fine, 1985). Given the disruptive effects of spinal cord injury on the family, the burden of caregiving being carried by the spouse, and impairment of sexual function, most people assume that spinal cord injury causes divorces and strongly discourage post-injury marriages. However, the effects of spinal cord injury on marital rates and marital relationships are less deleterious than commonly assumed. While divorces are more common after spinal cord injury, divorce rates are highly variable. Finally, sexual function and children are not only possible but common after spinal cord injury.
Marriages. The marriage rate of people with spinal cord injury is lower than the general population but the factors that influence marriage rate may differ from what is commonly assumed. Disability appears to exert a greater effect on the marital status of females than males (Brown & Giesy, 1986). Although medical complications have an adverse impact on quality of life of adults with pediatric-onset spinal cord injury (Vogel, et al. 2002), the presence of pressure ulcers, severe urinary tract infections, and spasticity have little effect on marriage rate of adults with pediatric onset spinal cord injury. In contrast, the presence of head injury has much more adverse effects on marital status (Florian, et al. 1991).
Marital Relationships. Several studies have reported differences in the quality of marital relationships in pre- and post-injury marriages. Peters, et al. (1992) compared marital relationships between people with spinal cord injury and head injury, finding that the latter causes much greater adjustment difficulties for spouses than the former. Crewe & Krause (1988, 1992) report that individuals who marry after injury have measurably higher life satisfaction than those married before injury. Yim, et al. (1998) assessed the quality of marital life among Korean couples with spinal cord injury. Married couples with spinal cord injury were not more unstable, had similar dyadic adjustment and marital satisfaction, appear to be more cohesive than able-bodied couples, even though husbands with spinal cord injury tend to show less affection and the couples regarded loss of sexual function as a serious problem. Distressed couples with spinal cord injury tend to express more dissatisfaction with sexual relations and more negative communication during conflict resolution (Urey & Henggeler, 1987).
Divorces. Divorce rates are higher after spinal cord injury (DeVivo & Fine, 1985) but reported divorce rates are highly variable from 8-48%. One early study suggested that divorce rates of pre-injury marriages are comparable to divorce rates of the general population (El Ghatit & Hanson, 1976). DeVivo, et al. (1995) examined 622 married persons enrolled in the National Spinal Cord Injury Statistical Center data set since 1973, finding a total of 126 divorces compared to 74 expected divorces based on age-sex-specific divorce rates of the general population. Men had a 2.07 times higher rate of divorce than women with spinal cord injury. DeVivo, et al. (1991) and Kreuter (2000) both point out that divorce rates are high during an initial high-risk period but tend to stabilize. Lapham-Randlov (1994) suggests that while the experience of spinal cord injury is painful, it offers opportunities for personal growth and family coalescence.
Sexual satisfaction. Spinal cord injury obviously impairs sexual function. However, sexual satisfaction does not appear to be related to physical factors such as erectile function, genital sensation, or orgasmic capacity as much as perceived partner satisfaction and relationship quality (Phelps, et al., 2001). Fisher, et al. (2002) assessed sexual function in 40 people (32 men, 8 women) with spinal cord injury. By 6 months after discharge from hospital, most of the participants in the survey had made significant changes in sexual behavior and activity. Most of the respondents had realistic concerns coupled with more requests for sexual health intervention. However, many were engaging in sexual activity. In Iceland, 55.5% of spinal-injured people are married and 71% had an active sexual life after injury (Knutsdottir, 1993). As with able-bodied populations, sexual activity is reduced in elderly people with spinal cord injury (Larsen & Hejgaard, 1984). A survey of 79 men with spinal cord injury in Houston suggest that although sex life was ranked lowest in terms of satisfaction, it was also ranked fifth in terms of importance (White, et al., 1992). In women, sexual dysfunction is inversely related to the perceived importance of sex (Harrison, et al., 1995), i.e. greater sexual dysfunction is associated with less perceived importance of sex and vice versa. Thus, sex is important but is not necessary for sexual satisfaction or sexual activity, and is frequently not the most important factor in life satisfaction.
Menarche and Pregnancy. Most people assume that spinal cord injury impairs ability to have children. Spinal cord injury generally should not prevent fertility in young women (Ohry, et al. 1978) and many women have had normal children after spinal cord injury. Anderson, et al. (1997) examined menstruation after spinal cord injury in 37 people injured between age 10-16. Seven reported no interruption of menses while 8 had interrupted menses for 1-7 months and the rest had normal onset of menarche. Most women have sexual intercourse after spinal cord injury and most are capable of achieving orgasm and are normally fertile (Biering, et al., 2002). Autonomic dysreflexia does complicate pregnancy and delivery (Wanner, et al. 1987) but can be managed with appropriate drugs and delivery approaches. Cross, et al. (1992) described 22 women who had 33 pregnancies after spinal cord injury. The mothers waited on average 5 years to become pregnant and 43% had caesarians. All the newborns were healthy on delivery except for one premature baby and a double footing breach vaginal delivery. Baker, et al., (1992) likewise reviewed 11 spinal-injured women with 13 pregnancy, finding uniformly good infant outcome with no major obstetric complications.
Fertility in Men. While spinal cord injury does impair erectile and ejaculatory function, semen can be obtained from almost all men with spinal cord injury through the use of vibratory or electrical stimulation (Brackett, 1999; Sonksen & Ohl, 2002). Because the bladder sphincter may not be closed during ejaculation, the semen often goes into the bladder. Many techniques are available to manage erectile and ejaculatory dysfunction in men with spinal cord injury (Biering-Sorenson & Sonksen, 2001). Although ejaculates from men with spinal cord injury usually have normal sperm counts, sperm motility may be impaired. Myths abound concerning the roles of elevated scrotal temperature, ejaculation frequency, or bladder management methods as causes of this condition. Recent studies suggest that physiological factors due to the spinal cord injury influences semen quality of men with spinal cord injury (Brackett, et al. 1996; Monga, et al. 2001), due to imbalance of sympathetic and parasympathetic innervation of the prostate. This cause of reduced fertility can be effectively dealt with in several ways. With appropriate rehabilitation and treatments, most men with spinal cord injury can and do have children.
Factors Affecting Family Relationships
Family relationships strongly influence life satisfaction of people with spinal cord injury. Warren, et al. (1996) found that closeness to family, the level of family activities, and blaming oneself for the injury were the three most important variables determining life satisfaction in people with spinal cord injury. Many factors affect family relationships, including the presence of depression, suicidal ideation or attempts, and cultural factors. Some of these factors are ameliorated by development of independence, behavioral changes, and a sense of hope.
Depression. Depression is common in people with spinal cord injury although not as common as in multiple sclerosis (Shnek, et al., 1997). Krause, et al. (2000) suggests that 48% of patients with spinal cord injury in 1997 had clinical symptoms of depression at a year or more after injury. Kemp & Krause (1999) compared depression and life satisfaction amongst people with spinal cord injury, post-polio syndrome, and non-disabled population. The post-polio group tended to score better on both depression and life satisfaction; only 22% of the post-polio group had depressive symptoms compared to 41% of the spinal cord injury group and 15% of the non-disabled group. One study showed that 60% of Portuguese patients with spinal cord injury have depressive symptoms (de Carvalho, et al. 1998). Kennedy & Evans (2001) report high levels of emotional distress in 14% of patients at 6-24 weeks after injury, significantly higher in females. Kennedy & Rogers (2000) examined 104 patients (19 women, 85 men) for anxiety and depression, finding consistent patterns of depression that were highest during the acute phase and during the months leading up to discharge. Pain exacerbates depression (Cairns, et al., 1996; Nagumo, 2000; Ravenscroft, et al. 2000). Holicky & Charlifue (1999) report that married individuals have less depression, greater life satisfaction, superior psychological well-being, and better perceived quality of life. Depression may be seasonal (Joerres, et al., 1992). Coping effectiveness training can significantly reduce depression scores (King & Kennedy, 1999).
Suicide. In the U.S., suicide rates of Vietnam veterans with spinal cord injury are nearly 10 times the suicide rate in the general population (Rish, et al., 1997). In the civilian population, suicide accounts for 6.3% of deaths after spinal cord injury (DeVivo, et al., 1991) and ranges from 2-6 times more prevalent than the general population (Charlifue & Gerhart, 1991). In Denmark, suicide rate is 5 times higher than the general population and surprisingly not related to injury severity (Hartkopp, et al., 1998) . Kishi, et al. (2001a) reports that 7.3-11.3% of Japanese patients express suicidal ideation during hospital and rehabilitation phases, similar to other patients with acute life-threatening illnesses (Kishi, et al. 2001b). Some spinal cord injuries occur as a result of suicide attempts and nearly a third of such people in an British study appear to have schizophrenia (Kennedy, et al. 1999). Some people may respond with self-destructive behavior, including drug abuse (Krause, et al. 2001). While death due to infection in spinal cord injury has fallen substantially over the past 20 years, the suicide rate has increased over the same period (Soden, et al., 2000; Hartkopp, et al., 1998, 1997).
Blame. Several studies have identified a potential role of self-blame in depression and life satisfaction after spinal cord injury. A large majority of people either totally blame themselves or others for their injury (Brown, et al. 1999). Paradoxically, people who are blameless for the accident tend to be less successful coping (Stensman, 1994). Blaming oneself for the injury is associated with increased life satisfaction (Warren, et al., 1996). Reidy & Caplan (1994) examined the hypothesis that people who accept responsibility for their injury cope better with their spinal cord injury. Attribution of blame (either self or others) did not correlate with depression during the rehabilitation phase but people whose self-blame increased over time did exhibit greater depression. Over the long term, the relationship between self-blame and depression declines (Schulz & Decker, 1985). On the other hand, people who show anxiety and depression at a year after injury do not seem to get better with time (Craig, et al. 1994).
Cultural factors. Cultural differences may affect family life, social interactions, and perception of spinal cord injury (Saravanan, et al., 2001). Ide & Fugl-Meyer (2001) compared life satisfaction of people with spinal cord injury in Japan and Sweden. Even when corrected for injury level and severity, the data suggest that Swedish people are more satisfied than Japanese in terms of general health, economy, social activity, social services, family life, and sexual life. A recent comparison of spinal-injured individuals in Turkey and the United States, however, revealed limited differences in social participation once the data is corrected for age and injury differences (Dijkers, et al., 2002). Ville & Rayaud (2001) surveyed 1668 people with tetraplegia in France, finding that the age of impairment and having a job do not predict self-assessments of well-being although the presence of pain, subjective assessment of independence, and severity of disability strongly predict a sense of well-being; loss of independence only affected well-being in that it imposes limits on social activity. McColl, et al. (2002) compared American, British, and Canadians who are at least 20 years after spinal cord injury. They found that Americans had a better psychological profile with fewer health and disability-related problems, that British participants had less joint pain and less likelihood of perceiving that they are aging quickly, and that Canadians had more health and disability related complications. The reasons for these differences are not clear.
Independence. The independence of individuals with spinal cord injury may affect family relationships. Spinal-injured individuals who are more independent tend to perceive their family environment as more responsive and more open (McGowan & Roth, 1987). Even when corrected for injury severity and disability, the productivity of an individual after spinal cord injury is most influenced by the following variables in order: education, ability to drive a car, other transportation indices, and age (Noreau, et al., 1999). Boekamp, et al. (1996) reviewed the literature for potential causes of depression after spinal cord injury and found that social support and recent stressful events can be used to identify patients at a high risk of depression but that they are less likely to become depressed if they are independent. Adjustment to spinal cord injury and quality of life can be adversely affected by inadequate home facilities that make a person more dependent (Seki, et al., 2002). Expectations of independence decline steadily with increasing age (McColl, et al. 1999).
Adjustment. Spinal cord injury causes personality and behavioral changes as people adjust to life after injury. Buchanan & Elias (1999) assessed personality and behavior changes in people after spinal cord injury, comparing the perceptions of the changes by the person and the spouse. Both partners usually agree that spinal cord injury causes significant personality and behavior changes. It is important to emphasize that not all behavioral changes, however, are due to the spinal cord injury. Many people with spinal cord injury have had head injury. For example, in the above study from Buchanan & Elias, 5 of the 9 participants described post-traumatic amnesia lasting longer than 3 days, suggestive of traumatic brain injury. Perception of adjustment to spinal cord injury by persons and family members appear to be similar. Glass, et al. (1997) compared the views of adjustment by 250 persons with spinal cord injury and by their closest relatives. The injured personsÕ perceptions of adjustment appear to be at least as reliable as their closest relatives. Adjustment to spinal cord injury also changes with time after injury. Although most studies show increasing adjustment to spinal cord injury over time, this may not be true for the long term Krause (1997) examined 235 people with traumatic spinal cord injury who were more than 23 years after injury and found declines in perceived well-being.
Hope. Hope is a potentially important coping strategy for both the person and family with spinal cord injury. Davies (1993) interviewed people with spinal cord injury and found that goal-directed hope based on realistic perceptions of life, focusing on progress, positive interpretation of events, and goal setting are important in helping people and families cope with spinal cord injury. The process of hope can be a generalized and positive force to reduce depression, the sense of powerlessness, and grief (Lohn, 2001; Sullivan, 1990). Elliot, et al. (1991) assessed whether a sense of hope and a Òsense of pathwaysÓ (ability to find ways to meet goals) predicted psychosocial interactions, depression, and impairment. They found that a sense of ÒhopeÓ predicts psychosocial interactions while Òsense of pathwaysÓ negatively correlates with depression and impairment. Piazza, et al. (1991) report predictive relationships between hope, social support, and self-esteem in 77 patients, finding that the best predictors of hope in people with spinal cord injury are self-esteem, social support, and education.
¥ Alexander CJ, Hwang K and Sipski ML (2002). Mothers with spinal cord injuries: impact on marital, family, and children's adjustment. Arch Phys Med Rehabil 83:24-30. Summary: OBJECTIVE: To evaluate how mothers with spinal cord injury (SCI) adjust to parenting, their marriages, and their families, and how their children adjust to their mothers' disability. DESIGN: Randomized control study of mothers with SCI and their children, matched to able-bodied mothers and their children on key demographic variables. SETTING: Subjects were selected from 7 regional Spinal Cord Injury Model Systems from across the United States. PARTICIPANTS: A total of 310 volunteers (experimental: 88 mothers with SCI, 46 partners, 31 children; matched controls: 84 able-bodied mothers, 33 partners, 28 children). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Children's adjustment, gender role identity; self-esteem; children's attitude toward mother and father; dyadic and family adjustment; parenting stress; and satisfaction. RESULTS: No significant differences were found between mothers with SCI and able-bodied mothers. Moreover, there were no significant differences between children raised in families with mothers with SCI and children raised in families with able-bodied mothers. Also, no significant differences were found in dyadic or family functioning with mothers with SCI or able-bodied mothers. CONCLUSIONS: SCI in mothers does not appear to affect their children adversely in terms of individual adjustment, attitudes toward their parents, self-esteem, gender roles, and family functioning. Our results may challenge health care providers, social policy-makers, and the general public to end negative stereotyping of children, couples, and families with a disabled mother and wife. The Miami Project to Cure Paralysis, Department of Neurological Surgery, University of Miami School of Medicine, Miami, FL, USA. email@example.com
¥ Anderson CJ, Mulcahey MJ and Vogel LC (1997). Menstruation and pediatric spinal cord injury. J Spinal Cord Med 20:56-9. Summary: Menstrual characteristics were studied in young women who sustained spinal cord injuries (SCI) prior to puberty or in early adolescence. Subjects were 37 females who were injured prior to age 16 years and who were at least 10 years old at the time of interview; 22 were injured prior to menarche and 15 after menarche. Average age of menarche for females injured before puberty was 12.3 years which is similar to their mothers (mean 12.6 years) and to patients injured after menarche (mean 12.0 years). Of 15 females injured after menarche, seven reported no interruption in menses while eight had interruptions ranging from one to seven months. No significant menstrual problems were noted in either group. This information about menstruation should be included in sexuality teaching of parents and patients when an SCI occurs to a child or adolescent. Shriners Hospitals, Chicago Unit, IL 60707, USA.
¥ Baker ER, Cardenas DD and Benedetti TJ (1992). Risks associated with pregnancy in spinal cord-injured women. Obstet Gynecol 80:425-8. Summary: We reviewed the experience with pregnancy in spinal cord-injured women at the University of Washington over the past 10 years. During that time, 11 women with spinal cord injury had 13 pregnancies. Infant outcome was uniformly good. No major obstetric complication occurred. The mothers experienced medical problems including urinary tract infection in ten and pyelonephritis in three. Autonomic hyperreflexia occurred in three of five subjects with lesions at or above the sixth thoracic vertebra. Pregnancy in the spinal cord-injured patient involves medical risk for the mother, but with careful management, an excellent outcome for both mother and infant may be anticipated. Department of Obstetrics and Gynecology, University of Washington, Seattle.
¥ Bauman WA, Spungen AM, Wang J, Pierson RN, Jr. and Schwartz E (1999). Continuous loss of bone during chronic immobilization: a monozygotic twin study. Osteoporos Int 10:123-7. Summary: Acute immobilization is associated with rapid loss of bone. Prevailing opinion, based on population cross-sectional data, assumes that bone mass stabilizes thereafter. In order to address whole-body and regional skeletal mass in long-term immobilization, monozygotic twins were studied, one of each twin pair having chronic spinal cord injury (SCI) of a duration ranging from 3 to 26 years. The research design consisted of the co-twin control method using 8 pairs of identical male twins (mean +/- SD age, 40 +/- 10 years; range 25-58 years), one of each set with SCI. The twins were compared by paired t-tests for total and regional bone mineral content (BMC) and bone mineral density (BMD) measured by dual-energy X-ray absorptiometry. Linear regression analyses were performed to determine the associations of age or duration of injury with the differences between twin pairs for total and regional skeletal bone values. In the SCI twins, total-body BMC was significantly reduced (22% +/- 9%, p<0.001), with the predominant sites of reduction for BMC and BMD being the legs (42% +/- 14% 35% +/- 10%, p<0.0001), and pelvis (50% +/- 10% and 29% +/- 9%, p<0.0001). Duration of SCI, not age, was found to be linearly related to the degree of leg bone loss in SCI twins (BMC: r(2) = 0.60, p<0.05; BMD: r(2) = 0.70, p<0.01). Our findings suggest that pelvic and leg bone mass continues to decline throughout the chronic phase of immobilization in the individual with SCI, and this bone loss appears to be independent of age. Spinal Cord Damage Research Center, Departments of Medicine and Rehabilitation Medicine, Mount Sinai School of Medicine, New York, NY, USA.
¥ Biering-Sorensen F and Sonksen J (2001). Sexual function in spinal cord lesioned men. Spinal Cord 39:455-70. Summary: STUDY DESIGN: Review of literature. OBJECTIVE: To review the physical aspects related to penile erection, ejaculatory dysfunction, semen characteristics, and techniques for enhancement of fertility in spinal cord lesioned (SCL) men. SETTING: Worldwide: individuals with traumatic as well as non-traumatic SCL. RESULTS: Recommendations for management of erectile dysfunction in SCL men: If it is possible to obtain a satisfactory erection but of insufficient duration, then try to use a venous constrictor band to find out if this is sufficient to maintain the erection. Otherwise we recommend Sildenafil. If Sildenafil is not satisfactory then use intracavernous injection with prostaglandin E(1) (some SCL men may prefer cutaneous or intraurethral application). We discourage the implantation of penile prosthesis for the sole purpose of erection. Recommendations for management of ejaculatory dysfunction in SCL men: Penile vibratory stimulation (PVS) to induce ejaculation is recommended as first treatment choice. If PVS fails, SCL men should be referred for electroejaculation (EEJ). Semen characteristics: Impaired semen profiles with low motility rates are seen in the majority of SCL men. Recently reported data gives evidence of a decline in spermatogenesis and motility of ejaculated spermatozoa shortly after (few weeks) an acute SCL. It is suggested that some factors in the seminal plasma and/or disordered storage of spermatozoa in the seminal vesicles are mainly responsible for the impaired semen profiles in men with chronic SCL. Fertility: Home insemination with semen obtained by PVS and introduced intravaginally in order to achieve successful pregnancies may be an option for some SCL men and their partners. The majority of SCL men will further enhance their fertility potential when using either PVS or EEJ combined with assisted reproduction techniques such as intrauterine insemination or in vitro fertilization with or without intracytoplasmic sperm injection. Clinic for Para- and Tetraplegia, Department TH, The Neuroscience Centre, Rigshospitalet, Copenhagen University Hospital, Havnevej 25, DK-3100 Hornbaek, Copenhagen, Denmark.
¥ Boekamp JR, Overholser JC and Schubert DS (1996). Depression following a spinal cord injury. Int J Psychiatry Med 26:329-49. Summary: OBJECT: Depression is a common problem following a spinal cord injury (SCI) and can greatly interfere with the rehabilitation process because of reduced energy, negative expectations, and social withdrawal. Understanding various factors which influence a vulnerability to depression may improve the diagnosis and treatment of depressive disorders and can improve rehabilitation outcome. METHOD: A thorough literature search was conducted using Medline, PsychLit, Pyschinfo, and Social Science Citation Index to identify relevant articles published between 1967 and 1995. RESULTS: A diathesis-stress model is proposed to explain the increased risk of depressive symptoms after a SCI. Biological changes associated with SCI and pre-existing cognitive biases may influence the individual's vulnerability to stressful life events following the injury. The nature and frequency of stressful life events following the injury can tax the individual's coping resources. Furthermore, the perceived quality of social support and the severity of conflict within the family can influence the individual's adaptation. CONCLUSIONS: Social support and recent stressors should be assessed to identify patients at high risk for depression. Patients are less likely to become depressed if their independence is fostered and they are encouraged to develop new sources of self-esteem. Relatives can be counseled to help maintain supportive relationships within the family. Harvard Medical School.
¥ Brackett NL (1999). Semen retrieval by penile vibratory stimulation in men with spinal cord injury. Hum Reprod Update 5:216-22. Summary: Traumatic spinal cord injury resulting from car accidents, falls, violence or sport-related activities is a common occurrence throughout the world. Spinal cord injuries occur most often to young men in their parenting years. Among the medical challenges facing many of these men is the inability to ejaculate via sexual intercourse. To achieve biological fatherhood, their semen may be retrieved by methods of assisted ejaculation. This paper discusses the use of penile vibratory stimulation in men with spinal cord injury, and includes the topics: patient selection and management; proper placement and timing of stimulation; appropriate use of low-amplitude, high-amplitude or dual vibrators; and factors influencing ejaculatory success rate. Also summarized are recent data on semen quality in men with spinal cord injury. When performed properly, penile vibratory stimulation is a safe and easy method of obtaining semen from anejaculatory men with spinal cord injury. Semen quality is better when obtained by penile vibratory stimulation compared with electroejaculation, an alternative method of semen retrieval. For these reasons, and because of the low investment of time and money, it is recommended that penile vibratory stimulation be used as the first line of treatment for anejaculation in men with spinal cord injury. The Miami Project to Cure Paralysis, University of Miami School of Medicine, Florida, USA.
¥ Brackett NL, Nash MS and Lynne CM (1996). Male fertility following spinal cord injury: facts and fiction. Phys Ther 76:1221-31. Summary: Although most spinal cord injuries (SCIs) occur to males of parenting age, myths abound as to whether men can biologically father children after SCI. Following SCI, most men experience impairments in erectile and ejaculatory function. Semen can be obtained from almost all men with SCI through the use of vibratory or electrical stimulation. Their ejaculates often have normal sperm counts but more immotile sperm than found in men without SCI. This condition does not seem to be caused by lifestyle factors (such as elevated scrotal temperature, ejaculation frequency, and method of bladder management) but may be related to factors within the seminal plasma. Sperm from men with SCI may be used in assisted reproductive techniques to attempt biological fatherhood. Health care providers, including physical therapists, should encourage men with SCI seeking biological fatherhood to be evaluated at a center dedicated to assisting men with SCI in this specialty area. Male Fertility Research Program, Miami Project to Cure Paralysis, University of Miami School of Medicine, FL 33136, USA. firstname.lastname@example.org
¥ Brown JS and Giesy B (1986). Marital status of persons with spinal cord injury. Soc Sci Med 23:313-22. Summary: The proposition that persons are selected into and out of marriage on the basis of their health or disability status has often been advanced, but remains untested. This article presents a theoretical rationale for the proposition; provides an initial test of that proposition by comparing the marital status of a sample of persons with spinal cord injury with the marital status of the general public; and elaborates on the proposition by examining the extent to which other factors account for differences in marital status among members of this disabled group. The selected factors were sex, severity of disability (indicated by need for assistance, perceived health, and extent of paralysis), socio-economic status (indicated by adequacy of income and welfare status), current age, and age at onset of disability. A secondary analysis of existing survey data on 251 Oregon residents with spinal cord injury (182 males, 69 females) yielded the following results. The marital selection proposition was supported in that the marital status of this sample differed markedly from that of the general population. The disability exerted a greater effect on the marital status of females than of males. All the selected variables were significantly associated with marital status for one or for both sexes. Discriminant function analyses, employing these variables, identified correctly the marital status of 67.6% of the males, and 75.4% of the females. Profiles of married, formerly married, and single men and women with spinal cord injury are presented. Suggestions are offered for further testing of the marital selection proposition and for elaborating theory linking disability and health status to marital status.
¥ Brown K, Bell MH, Maynard C, Richardson W and Wagner GS (1999). Attribution of responsibility for injury and long-term outcome of patients with paralytic spinal cord trauma. Spinal Cord 37:653-7. Summary: Study Design: Survey. Objective: To assess the association between patients' perceptions of responsibility for the injury and long term outcomes. Setting: Duke University Medical Center Spinal Injury Service. Methods: One hundred and forty patients, who suffered spinal cord injuries between 1985 and 1990, were selected to participate in the study, and 26 (19%), including eight with quadriplegia, completed a telephone interview. The mean age at interview was 39+/-12 years and 12% were women. The mean time from injury to completion of the study was 8.7+/-1.5 years. Attribution of cause of injury, the Craig Handicap Assessment Reporting Technique, and the SF36 mental health depression/vitality surveyed instruments attribution of responsibility for the injury, functional capacity, mental health depression, and vitality. Results: The majority (18/26) of patients either totally blamed themselves or others for their injuries. Overall, there was no statistically significant association between attribution of injury and long-term outcomes. Outcomes were similar in patients who either totally blamed themselves or others for their predicament. Conclusion: In this study, long-term outcomes were not influenced by whether patients perceived themselves as being responsible for their injuries. Spine Injury Service, Duke University Medical Center, Durham, North Carolina 27710, USA.
¥ Buchanan KM and Elias LJ (1999). Personality & behaviour changes following spinal cord injury: self perceptions--partner's perceptions. Axone 21:36-9. Summary: There has been little specific investigation of personality and behaviour changes following spinal cord injury (SCI) and only limited consideration of the possible impact of concurrent traumatic brain injury (TBI). By mail-out questionnaire, we evaluated personality and behaviour changes in a married group (n = 9) with traumatic SCI, who knew their partners prior to injury, and who had not been identified as having concurrent TBI on referral to the Canadian Paraplegic Association. Both the person with SCI (and the partner) completed the revised Adjective Checklist and by their combined report, there were significant personality and behaviour changes. Unexpectedly, five individuals described post-traumatic amnesia (PTA) > or = 3 days. Subsequently, participants' reports were further divided into two groups--"longer PTA" and "shorter PTA". The "longer PTA" group self-reported less change and more positive change than did their partners. The "longer PTA" partners described changes that are consistent with the profile of TBI. The "shorter PTA" group described themselves more negatively than did their partners. Given the size of the groups (n = 5, n = 4), these findings are presented to illustrate trends and to stimulate further research. Division of Neurosurgery, Royal University Hospital/University of Saskatchewan.
¥ Buck FM and Hohmann GW (1981). Personality, behavior, values, and family relations of children of fathers with spinal cord injury. Arch Phys Med Rehabil 62:432-8. Summary: Many opinions have been expressed about the adverse effects on children of being raised by a parent who is physically disabled, but little research has been done. The present study examined the relationship between spinal cord injury (SCI) in fathers and the subsequent adjustment patterns of their children. Two groups of adult children were studied: 45 children reared from early age by fathers with SCI and a matched control group of 36 children with able-bodied fathers. The 2 groups were compared on psychologic tests assessing areas speculated in the literature to be influenced by parental disability. Although children of fathers with SCI differed from children with able-bodied fathers in some behaviors, values, and attitudes, the data failed to confirm any of the hypothesized relations between parental disability and child development. Children whose fathers had SCI were well-adjusted, emotionally stable persons who had attained normal sex role identities. Health patterns, body image, recreational interests, interpersonal relationships, and family relations were not found to be adversely associated with the disability status of the father. Limitations of the study and implications for rehabilitation, adoption, and court custody issues are discussed.
¥ Buck FM and Hohmann GW (1984). Child adjustment as related to financial security and employment status of fathers with spinal cord injuries. Arch Phys Med Rehabil 65:327-33. Summary: Many rehabilitation professionals have expressed concern about the effects that socioeconomic changes associated with disability in a parent have on children's adjustment. It has been speculated that financial insecurity and unemployment among fathers with disabilities adversely affect child development, because of the presumed consequence of reversal in parental roles. This study tested these notions by comparing children whose fathers with spinal cord injuries (SCI) were: (1) receiving ample, secure income vs low income that was not guaranteed, and (2) employed vs unemployed. All subjects were given seven tests measuring personality, values, and interests, which were completed in a standardized order and time period. On 16 demographic indices and more than 150 measures of children's personality, behavior, and attitudes, only 17 were related to the financial resources of fathers with SCI and 11 to their employment status. Contrary to opinions in previous reports, no adverse relationships were found between child adjustment and the financial security or employment status of fathers with SCI. Limitations and implications of the study are discussed.
¥ Cairns DM, Adkins RH and Scott MD (1996). Pain and depression in acute traumatic spinal cord injury: origins of chronic problematic pain? Arch Phys Med Rehabil 77:329-35. Summary: OBJECTIVE: To examine the relationship between pain and depression over time during acute phases of traumatic spinal cord injury (SCI). Theoretical models of the pain-depression relationship provided the framework: (1) pain causes depression; (2) depression causes pain; (3) pain and depression are independent sequelae to SCI. Understanding the pain-depression relationship provides treatment implications and hypotheses for origins of chronic pain in SCI. DESIGN: A repeated measures design assessing subjects at admission and discharge from rehabilitation. SETTING: Subjects were admitted to a large public hospital in Southern California which is a member of the Model Spinal Cord Injury System. Rehabilitation occurred on two 30-bed units. PARTICIPANTS: Complete admission and discharge data sets were collected from 68 acute traumatic SCI patients who served as subjects. One hundred twenty-one patients initially agreed to participate in a larger study of adjustments to SCI. Thirty-three did not have pain data at admission, 16 dropped out, and 4 had incomplete discharge data. Subjects volunteered and were paid a fee. INTERVENTION: A standard rehabilitation program for SCI. MEASURES: Pain assessment used a 101-point numerical rating scale. Depression assessment used the Center for Epidemiological Studies-Depression Scale(CESD). RESULTS: Pain and depression were independent at admission. At discharge, they were significantly related. Changes in pain affected depression more than changes in depression affected pain. CONCLUSIONS: Relationships between pain and depression develop over time. Reduced pain will have a greater effect on reducing depression than reduced depression will have on pain. Pain described as "burning" during the acute phase does not represent difficult to treat dysesthetic pain, as it may in chronic SCI pain. Clinical Psycology, Rancho Los Amigos Medical Center, Downey, CA, USA.
¥ Chan RC (2000). Stress and coping in spouses of persons with spinal cord injuries. Clin Rehabil 14:137-44. Summary: OBJECTIVE: To examine the sources of stress and the patterns of coping of spouses of persons with spinal cord injuries (SCI) among Hong Kong Chinese. DESIGN: A cross-sectional correlation design. A set of structured questionnaires and semi-structured interviews were administered. SUBJECTS: Forty spouses of persons with SCI were recruited and interviewed. OUTCOME MEASURES: These included coping strategies, depression, care-giving burden, life satisfaction and marital adjustment. RESULTS: The most stressful situations reported by the participants concerned health issues of their injured partners, the family and marital interactions, and the care-giving burden imposed on them. Cluster analysis indicated a potential at-risk group, characterized by high scores in external locus of control, inadequate coping modes and limited social support. They were noted to manifest high levels of depression, care-giving burden, low levels of life satisfaction and marital adjustment. CONCLUSION: The identification of the potential at-risk group indicates that spouses of persons with SCI suffer levels of stress comparable to those of their injured partners. Rehabilitation plans should include this potential at-risk group to help them release the stress and to prevent them from developing clinically significant mental disorders. Department of Psychology, The University of Hong Kong, China. email@example.com
¥ Chan RC, Lee PW and Lieh-Mak F (2000). Coping with spinal cord injury: personal and marital adjustment in the Hong Kong Chinese setting. Spinal Cord 38:687-96. Summary: STUDY DESIGN: A cross-sectional retrospective study was carried out with structured questionnaires and semi-structured interviews on 66 persons with spinal cord injury (SCI) and 40 spouses. OBJECTIVES: The study aimed to explore the psychosocial adjustment of Hong Kong Chinese couples at the post SCI stage. An important study interest was the impact of care-giving in spouses of persons with SCI. SETTING: Three major regional rehabilitation centres and one community resource centre in Hong Kong. METHODS: A set of psychometric measures tapping different aspects of psychological functioning was included. These were locus of control (Levenson's Internality, Powerful Others, and Chance Scale), perceived social support (Provision of Social Relationship), coping strategies (Ways of Coping Checklist), marital adjustment (Dyadic Adjustment Scale), caregiving burden (Caregiver Burden Inventory), depression (Beck Depression Inventory), life satisfaction (Satisfaction with Life Situation), and social role adjustment (Katz Adjustment Scale - Relative Form). RESULTS: Persons with SCI with pre-injury marriage were more depressed (P<0.05) as compared with those with post-injury marriage. However, the two groups did not differ in terms of satisfaction with life situation and social role dissatisfaction. The spouses in the preinjury marriage reported a significantly higher score in time-dependent burden than those in the post-injury marriage (P<0.05). Care-giving burden was associated with locus of control, social support, and modes of coping (P<0.05). CONCLUSION: The impact of SCI is a long-lasting effect not limited to the patients but also extending to their spouses. Findings from the adjustment outcomes and coping styles of persons with SCI and their spouses indicate that they are not passive victims. A similar injury may produce different outcomes in different individuals. Rehabilitation professionals should thus be alert to both the couple's differing needs and idiosyncrasies in their helping process. The Department of Psychology, The University of Hong Kong, Pokfulam, China.
¥ Charlifue SW and Gerhart KA (1991). Behavioral and demographic predictors of suicide after traumatic spinal cord injury. Arch Phys Med Rehabil 72:488-92. Summary: Among people with spinal cord injuries, death from suicide is two to six times more prevalent than in the general population. To determine if individual characteristics and behaviors present during rehabilitation can identify high-risk individuals, records of 5,200 spinal cord injured patients admitted to the Rocky Mountain Regional Spinal Injury System were reviewed. Of 489 deaths, 9% were due to suicide. They were compared with a control group of equal size, matched on age, gender, and injury level. The two groups differed significantly on postinjury despondency; expressions of shame, apathy, and hopelessness; and preinjury family disruption (p less than .01). They also differed on alcohol abuse, active involvement in the injury, preinjury depression or despondency, destructive behavior, and one aspect of etiology (p less than .05). Discriminant analysis yielded a predictive model that correctly classified 81% of the suicide group and 79% of the control group. Many of the demographic predictors identified in this study are similar to those reported in the scientific literature. However, when combined with specific behavioral characteristics manifested during rehabilitation, they comprise an array of variables that permits development of a clinical model for predicting suicide among persons with spinal cord injuries. Research Department of Craig Hospital, Englewood, CO 80110.
¥ Craig AR, Hancock KM and Dickson HG (1994). A longitudinal investigation into anxiety and depression in the first 2 years following a spinal cord injury. Paraplegia 32:675-9. Summary: This study is a 1 year extension of a controlled 1 year follow up study of spinal cord injured persons. The study assessed the extent of spinal cord injury (SCI) persons' depression and anxiety in comparison to an able bodied control group matched for age, sex, education and as far as possible, occupation. Psychological adjustment to SCI was assessed in terms of scores on the Trait Anxiety Inventory and the Beck Depression Inventory. Results obtained at the 2 year follow up were not significantly changed from those obtained over the first year. There was no significant improvement in anxiety and depression scores in the SCI group 2 years post injury. Examination of the SCI scores suggest that psychological morbidity was confined to a group of approximately 30% of persons, whilst the remaining persons were not severely anxious or depressed. Traditional stage models of adjustment to SCI which suggest that the passage of time is associated with better adjustment were not supported by the present data. School of Biological and Biomedical Sciences, University of Technology, Sydney, NSW Australia.
¥ Crewe NM, Athelstan GT and Krumberger J (1979). Spinal cord injury: a comparison of preinjury and postinjury marriages. Arch Phys Med Rehabil 60:252-6. Summary: A study of the preinjury and postinjury marriages of 55 spinal cord injured persons and their partners revealed several differences between the relationships. Although all patients had comparable levels of spinal cord injury, the disabled persons in preinjury marriages were judged to have less motivation for independence; a larger proportion of them received daily personal care assistance from their spouses. Furthermore, those in postinjury marriages were more likely to be employed and were judged to be better adjusted psychologically. Psychologists' assessment of marriages based on interviews with the spinal cord injured subjects and their spouses revealed that the postinjury marriages were happier than the preinjury marriages. Possible explanations for these findings are discussed, which include age and state of health, the impact of disability on the marital relationship and the personal assets of disabled persons who attract new partners.
¥ Crewe NM and Krause JS (1988). Marital relationships and spinal cord injury. Arch Phys Med Rehabil 69:435-8. Summary: A questionnaire study of 122 married individuals with spinal cord injury (SCI) revealed a number of differences between the marriages that took place after the onset of disability and those that had occurred earlier. The two groups were equivalent in terms of severity and duration of disability, but those married before SCI were older. ANCOVA was used in most analyses to control for age at the time of injury and at present. Those married after injury reported greater satisfaction with their sex lives, living arrangements, social lives, health, emotional adjustment, and control over their lives, and they indicated that loneliness was less of a problem. They were also far more likely to be working and to be socially active outside their homes. Department of PM&R, University of Minnesota, Minneapolis 55455.
¥ Cross LL, Meythaler JM, Tuel SM and Cross AL (1992). Pregnancy, labor and delivery post spinal cord injury. Paraplegia 30:890-902. Summary: There are approximately 3,000 women of childbearing age who become spinal cord injured each year in the United States. There are few reports in the literature that address pregnancy, labor and delivery in this patient population. We are reporting on 22 women post spinal cord injury who had 33 pregnancies. There were equal numbers of paraplegic and quadriplegic women. Three pregnancies aborted, one spontaneously. The babies were near normal or normal weight with one exception. The mothers waited 5 years on average to become pregnant. Cesarean section was performed on 43% of pregnancies. Abnormal presentations occurred in over 10% of pregnancies. Indications for cesarean section included 5 that were repeats; the remainder were necessary due to bleeding (1), breech presentation (1), transverse presentation (2), lack of progress (2), onset of labor 1 day post spinal fusion, and a mother's request to have tubal ligation. Epidural anesthesia was selected for 9 deliveries; 6 of these patients had controlled autonomic hyperreflexia. Five general and 4 local anesthetics were used, and 12 patients received no anesthesia. Diagnostic ultrasound and amniocentesis were used selectively. Complications included autonomic hyperreflexia (9), frequent urinary tract infections, infected pressure sores (3, 2 resulting in below-knee amputations), seizures during and after delivery, pneumonia, bladder stones (2), episiotomy dehiscence (1), and breakdown of spinal fusion. The newborns were healthy, although one double footing breech vaginal delivery had an APGAR of 1 at 1 min, 7 at 5 min and 9 at 10 min. One premature baby, who weighed only 1600 g, was a precipitate birth at home unattended. Implications for the care of pregnant SCI women are discussed. Department of Physical Medicine and Rehabilitation, University of Virginia, Charlottesville 22908.
¥ Davies H (1993). Hope as a coping strategy for the spinal cord injured individual. Axone 15:40-6. Summary: This case study described how one spinal cord injured individual used hope as a coping strategy. Using observations and unstructured interviews, the indicators of hope were explored, as well as how hope was sustained over time and during crises. Data were gathered while nursing the individual, and his family using the McGill Model of Nursing. Qualitative data analysis revealed four categories which reflected indicators of hope (focusing on progress, positive interpretation, selective attention, goal setting), and seven categories of how hope was sustained (family responsibility, meaning in life, significant others, uncertainty of physiological status, past experience, goal attainment). Analysis of data also revealed that hope was goal directed, and hope was based on the reality perceptions of the individual. Over time, all indicators of hope were gradually displayed more often, and there was a gradual increase in focus on the meaning in life, family responsibility and goal achievement to sustain hope. Implications for nursing and research are suggested.
¥ de Carvalho SA, Andrade MJ, Tavares MA and de Freitas JL (1998). Spinal cord injury and psychological response. Gen Hosp Psychiatry 20:353-9. Summary: Psychological adjustment and psychopathological morbidity issues during rehabilitation of patients with spinal cord injury, have been documented in international literature. However, most authors are faced with methodological difficulties, and results are contradictory. In this prospective study, the first to be made in the Portuguese population, a sample of 65 patients being treated in a rehabilitation unit during the years of 1993, 1994 and 1995, was obtained. The authors study the type of psychological response, when it does occur, which personality traits point to less suffering, which coping mechanisms are used by the better adjusted patients and the differences between the scores of paraplegic and quadriplegic patients. Two assessments were made. The following assessment instruments were used: an anamnestic data questionnaire, the SCL-90-R (Derogatis, 1983), the EPI (Eysenck & Eysenck, 1984), the Coping Styles Evaluation Scale (Figueira, 1990). The second assessments were carried out with the SCL-90-R only. The findings indicate that psychopathological scores consistent with depression occurred in 60% of patients if we consider any evaluation. Sleep disturbances, suicide ideation and guilt occurred in the same proportion. In 33% of them, we found persistent depressive scores in the two assessments. The authors find a highly significant positive correlation between psychopathology and neuroticism. On the contrary, the extroversion dimensions of EPI seem to be a good prognosis predictive factor as far as the occurrence of psychopathology is concerned. No differences in the psychopathological response were found concerning the paraplegic-quadriplegic situation. Hospital do Conde de Ferreira, Department of C/L Psychiatry, Oporto, Portugal. firstname.lastname@example.org
¥ DeVivo MJ, Black KJ, Richards JS and Stover SL (1991). Suicide following spinal cord injury. Paraplegia 29:620-7. Summary: A study of 9135 persons injured between 1973 and 1984 and treated at any of 13 model regional spinal cord injury (SCI) care systems was conducted. Follow-up ended December 31, 1985, by which time 50 persons had committed suicide (6.3% of deaths). Based on age-sex-race-specific rates for the general population, 10.2 suicides were expected to occur. Therefore, the standardized mortality ratio (SMR) for suicide was 4.9. The highest SMR occurred 1 to 5 years after injury. The SMR was also elevated for the first post-injury year, but was not significantly elevated after the fifth year. The SMR was significantly elevated for all neurological groups, but was highest for persons with complete paraplegia. The SMR was highest for persons aged 25 to 54 years, but was also elevated for persons aged less than 25 years. Suicide was the leading cause of death for persons with complete paraplegia and the second leading cause of death for persons with incomplete paraplegia. The most common means of committing suicide was by gunshot. These figures demonstrate the need for increased staff, patient and family awareness of this problem, and improved follow-up assessment and psychosocial support programmes. Department of Rehabilitation Medicine, University of Alabama, Birmingham 35294.
¥ DeVivo MJ and Fine PR (1985). Spinal cord injury: its short-term impact on marital status. Arch Phys Med Rehabil 66:501-4. Summary: We have had the impression that patients with spinal cord injury (SCI) experience fewer marriages and more divorces than their noninjured counterparts. To test this impression statistically, we examined the influence of SCI in association with other select variables on the marital status of 276 patients injured between 1973 and 1980 and treated at the University of Alabama in Birmingham Spinal Cord Injury Care System. The expected numbers of marriages and divorces in the study population were based on comparison with reported marriage and divorce rates for the general US population. Discriminant analysis was employed to identify variables associated significantly with a postinjury change in marital status. Substantially fewer marriages and more divorces occurred than were expected (p less than 0.05). No variables were associated significantly with marrying within three years of injury. However, divorcing patients were significantly more likely to be young black women who had been previously divorced, had no children, and had Barthel scores of less than 80. Using the most effective combination of these variables, 38.7% of the variance was explained, and the postinjury marital status of 81.5% of patients married at injury was predicted correctly. While other determinants of postinjury marital status undoubtedly exist, the likelihood of divorce can be assessed using a comparatively small set of predictor variables.
¥ DeVivo MJ, Hawkins LN, Richards JS and Go BK (1995). Outcomes of post-spinal cord injury marriages. Arch Phys Med Rehabil 76:130-8. Summary: The purpose of this study was to compare the divorce rate among persons who got married after spinal cord injury with that of the non-spinal cord-injured population of comparable age and gender and to identify factors associated with increased likelihood of divorce. The study included 622 persons enrolled in the National Spinal Cord Injury Statistical Center data set since 1973. These persons were followed between 1 and 15 years after their marriage (m