Volume 89, Issue 9 , Pages 1733-1740, September 2008
Changes and Determinants of Life Satisfaction After Spinal Cord Injury: A Cohort Study in The Netherlands
Article Outline
Abstract
van Koppenhagen CF, Post MW, van der Woude LH, de Witte LP, van Asbeck FW, de Groot S, van den Heuvel W, Lindeman E. Changes and determinants of life satisfaction after spinal cord injury: a cohort study in The Netherlands.
Objective
To determine the impact of spinal cord injury (SCI) on life satisfaction of persons with SCI 1 year after discharge of inpatient rehabilitation.
Design
A cohort study. Life satisfaction before SCI was retrospectively measured at the start of active rehabilitation. One year after discharge from inpatient rehabilitation, current life satisfaction was measured.
Setting
Eight rehabilitation centers in The Netherlands.
Participants
Persons (N=147) aged 18 to 65 and wheelchair-dependent at least for long distances.
Interventions
Not applicable.
Main Outcome Measure
The Life Satisfaction Questionnaire.
Results
Mean satisfaction with life ± SD as a whole was 5.3±0 before SCI and 4.3±1.3 one year after inpatient rehabilitation. Sexual life, self-care, and vocational situation showed the largest impact of SCI (P<.05), whereas the social relationships domains appeared to be the least affected. Decrease of life satisfaction after SCI was larger when using the retrospective ratings than when using general population scores. Significant determinants of life satisfaction after SCI were high lesion level (β=.31, P<.05), pain (β=.19, P<.05), and secondary impairments (β=.22, P<.05).
Conclusions
Life satisfaction decreased in persons with SCI. Level of lesion and suffering secondary impairments or pain were associated with low life satisfaction 1 year after discharge from inpatient rehabilitation.
Key Words: Cohort study, Follow-up studies, Quality of life, Rehabilitation, Spinal cord injuries
List of Abbreviations: AIS, American Spinal Injury Association Impairment Scale, ES, effect size, LiSat-9, Life Satisfaction Questionnaire, SCI, spinal cord injury, SWLS, Satisfaction With Life Scale
BECAUSE OF IMPROVEMENTS in medical care, the average life expectancy of persons with SCI has considerably increased in the last decades.1 Most persons with SCI may now expect to live for many years. Nevertheless, SCI is a major life event that leads to serious physical disability and secondary medical problems and seriously impacts life satisfaction of persons involved.2, 3
Life satisfaction is studied widely in the SCI population. However, there is a wide variation in the design of these studies regarding design, inclusion criteria, setting, and measures of life satisfaction. At least 3 different types of measures have been used: (1) single-item rating scales4, 5; (2) multiple-item rating scales focused on general life satisfaction, such as the SWLS,2, 6 the LiSat-9,7, 8 or the Life Satisfaction Index−A9, 10, 11; and (3) multiple-item rating scales including domain-specific life satisfaction, such as the LiSat-9.12, 13, 14, 15, 16 Most studies into life satisfaction of persons with SCI used a cross-sectional design and measured life satisfaction many years after SCI.2, 4, 5, 7, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18 Only 3 longitudinal studies were found. Stensman19 found in his 5-year follow-up study with small numbers almost unchanged life satisfaction for most of the persons with SCI. Another longitudinal study with measurements 1, 2, 4, and 5 years after discharge20 showed a slight progression of life satisfaction in the first 2 years and a stabilization in the following years. Krause8 studied long-term changes in life satisfaction and showed a small decline of life satisfaction. Several studies compared life satisfaction of persons with SCI to figures of healthy peers or the general population to quantify the impact of SCI on life satisfaction.3 However, the assumption underlying this comparison, that persons with SCI would have showed the same scores as the reference group if they would not have had the SCI, is challenged.21 Only 1 study22 compared life satisfaction before SCI with life satisfaction after SCI directly by asking persons with SCI to rate their life satisfaction before injury.
In SCI research, sex and race were largely unrelated to life satisfaction.3, 6, 23 The relationships between life satisfaction and age, marital status, time since injury, level of injury, impairment, and disability were inconsistent; some studies showed a significant relationship, whereas others failed to find an effect.3, 6, 23
The purpose of this study was to determine life satisfaction of persons with an SCI 1 year after discharge of inpatient rehabilitation, to compare life satisfaction before and after SCI, and to study the influence of personal and lesion characteristics and secondary conditions on life satisfaction and the change in life satisfaction after SCI.
Methods
Participants
This study is part of the Dutch research program “Physical Strain, Work Capacity, and Mechanisms of Restoration of Mobility in the Rehabilitation of Persons With a SCI.” Eight rehabilitation centers with a specialty in SCI rehabilitation participated in the study. Subjects were eligible to enter the project if they had an acute SCI; were between 18 and 65 years of age; were classified as grade A, B, C, or D on the AIS; and were expected to remain wheelchair dependent (at least for long distances). Exclusion criteria were as follows: SCI due to malignant tumor, progressive disease, known cardiovascular disease or psychiatric problems, and insufficient command of the Dutch language to understand the goal of the study and the testing methods. All subjects gave informed consent, and the Medical Ethics Committee of the SRL/iRv Hoensbroek approved all tests and protocols.
Procedure
Two measurements from the research program were relevant for this study. The first was performed at the start of active rehabilitation (the moment that a person could sit for 3–4h) and the second 1 year after discharge of inpatient rehabilitation. Both measurements comprised, among others, a medical anamnesis and physical examination by a rehabilitation physician, an oral interview by a trained research assistant, and a self-report questionnaire. At the first measurement, participants were asked to rate their life satisfaction before the SCI as part of the oral interview. At the second measurement 1 year after discharge, participants were asked to rate their current life satisfaction.
Instruments
Life satisfactionLife satisfaction was measured with the LiSat-9.24 The LiSat-9 consists of 9 questions about satisfaction with life as a whole and about satisfaction with 8 life domains: self-care ability, leisure time, vocational situation, financial situation, sexual life, partnership relations, family life, and contact with friends. Each question was scored on a 6-point scale: very unsatisfied, unsatisfied, rather unsatisfied, rather satisfied, satisfied, and very satisfied. The LiSat-9 is a valid measure of life satisfaction24 and has been used often in SCI research.12, 14, 15, 16
DemographicsDemographic characteristics 1 year after discharge were age, sex, educational level, marital status (married or living together, single, or living at parental home), and having children.
Lesion characteristicsThese were assessed according to the International Standards for Neurological and Functional Classification of Spinal Cord Injury.25 AIS grades A and B were considered motor complete, and grades C and D were considered motor incomplete. Neurologic lesion level was defined as the highest motor level. Neurologic levels below T1 were defined as paraplegia, and neurologic lesion levels at or above T1 were defined as tetraplegia.
Secondary conditionsThe secondary conditions were grouped into 2 categories: (1) 8 items about pain and other abnormal sensations such as itching and dull feelings that were scored as absent or present and (2) 8 items about other secondary conditions, including pressure ulcers, urinary tract infections, airway infections, neurogenic heterotopic ossification, and circulation disturbances. These items were also scored as absent or present.
Statistical Analyses
A nonresponse analysis was performed, comparing person and lesion characteristics of persons who completed both measurements with those of persons who did not complete the second measurement. Chi-square tests were used to test (in-) dependency between participant characteristics and dropouts.
A total LiSat-9 score was computed as the average of all item scores so that the total score also has a range from 1 up to 6. The Cronbach α of this score was good (0.8). Two methods to describe LiSat-9 results were used. First, mean item and total scores and mean change scores were described, and differences between mean scores of both measurements were tested for statistical significance by using paired t tests. ESs were used to interpret changes in mean life satisfaction scores and were computed as the difference between the first and last measurement, divided by the mean ± SD of both measurements. ESs were described as small (ES range, .20−.50), medium (ES range, .50−.80), or large (ES>.80).26 Pearson correlations were calculated to examine associations between LiSat-9 scores before and after SCI. The interpretation of correlation coefficients was weak (<.30), moderate (.30–.50), or strong (>.50).26 Second, LiSat-9 item scores were dichotomized as recommended by Fugl-Meyer Assessment24 into dissatisfied (scores 1–4) and satisfied (scores 5 or 6). Percentages of persons being satisfied and dissatisfied were reported, and the changes of satisfaction before and after SCI were analyzed by using the McNemar test. Persons with a substantial decrease of life satisfaction after SCI were compared with persons who did not perceive a substantial decrease of life satisfaction by using dichotomized scores. Substantial decrease was defined as a change from satisfied before SCI into dissatisfied after SCI in more than 2 life domains.
The impact of personal characteristics (sex, age, education), lesion characteristics (level, completeness, cause of lesion), pain, and other secondary impairments on life satisfaction was analyzed by using regression analyses. Linear regression analyses were performed with the LiSat-9 total score after SCI and with the change in LiSat-9 total score as dependent variables. A logistic regression analysis was performed with the dichotomous variable representing deterioration or no deterioration of life satisfaction as the dependent variable. All determinants were dichotomized. Based on score distributions, the score for pain and abnormal feelings was dichotomized into a group with 0 to 4 complaints and a group with 5 to 8 complaints. The score for other secondary impairments was dichotomized into a group with 0 complaints or 1 complaint and a group with 2 to 8 complaints. For all statistic procedures, the SPSSa statistical program was used. The level of significance was set at P less than .05. For multiple testing (Table 1, Table 2), we used an adapted P value of less than .005 (.05/10 tests).
Table 1. Life Satisfaction Scores Before and 1 Year After SCI
| LiSat-9 | n | Before SCI | After SCI | Difference Between Scores Before and After SCI | Correlations Between Scores Before and After SCI | ||
|---|---|---|---|---|---|---|---|
| Mean ± SD | Mean ± SD | Mean ± SD | t | ES | Pearson r | ||
| Life as a whole | 147 | 5.3±1.0 | 4.3±1.3 | 1.0±1.6 | 7.37† | 0.8 | .08 |
| Self-care ability | 147 | 5.7±0.9 | 4.2±1.6 | 1.5±1.9 | 9.40† | 1.2 | .08 |
| Leisure situation | 147 | 5.1±1.0 | 4.6±1.2 | 0.5±1.7 | 4.37† | 0.5 | .03 |
| Vocational situation | 99 | 5.1±1.1 | 4.1±1.4 | 1.1±1.2 | 6.60† | 0.9 | .12 |
| Financial situation | 147 | 4.8±1.2 | 4.4±1.4 | 0.4±1.6 | 3.48† | 0.3 | .27† |
| Sexual life | 144 | 4.9±1.1 | 3.3±1.7 | 1.6±1.9 | 10.06† | 1.1 | .19⁎ |
| Partner relationship | 109 | 5.5±0.9 | 5.1±1.2 | 0.4±1.2 | 3.11⁎ | 0.4 | .35† |
| Family life | 144 | 5.4±0.8 | 5.1±1.0 | 0.3±1.1 | 3.39† | 0.3 | .24† |
| Contact friends | 147 | 5.3±0.9 | 5.2±1.0 | 0.1±1.2 | 1.44 | 0.1 | .15 |
| LiSat-9 total | 147 | 5.2±0.7 | 4.5±0.8 | 0.8±1.0 | 9.35† | 1.0 | .16 |
⁎P<.05. |
†P<.01. |
Table 2. Percentage Satisfied and Dissatisfied and Change of Life Satisfaction Domains Before and After Onset of SCI
| Domains | Satisfied Before SCI, n (%) | Satisfied After SCI, n (%) | If Dissatisfied Before SCI: After SCI | If Satisfied Before SCI: After SCI | ||
|---|---|---|---|---|---|---|
| Dissatisfied, n (%) | Satisfied, n (%) | Dissatisfied, n (%) | Satisfied, n (%) | |||
| Life as a whole | 129 (88) | 83(57)⁎ | 6(4) | 12(8) | 58(40) | 71(48) |
| Self-care | 134(91) | 89(61)⁎ | 4(3) | 9(6) | 54(37) | 80(54) |
| Leisure | 125(85) | 96(65)⁎ | 7(5) | 15(10) | 44(30) | 81(55) |
| Vocational | 84(86) | 51(52)⁎ | 7(7) | 7(7) | 40(40) | 44(46) |
| Financial | 109(74) | 95(65) | 20(14) | 18(12) | 32(22) | 77(52) |
| Sex life | 102(73) | 47(34)⁎ | 32(23) | 6(4) | 61(44) | 41(29) |
| Partner relationship | 92(92) | 83(83) | 4(4) | 4(4) | 13(13) | 79(79) |
| Family life | 128(91) | 118(83) | 4(3) | 9(6) | 19(13) | 109(78) |
| Contact friends | 130(88) | 129(88) | 2(1) | 15(10) | 16(11) | 114(78) |
⁎McNemar test for measuring significance of change scores before and after SCI (P<.01). |
Results
Respondent Characteristics
Of the initial study group of 222 persons, 147 completed the measurements 1 year after discharge of inpatient rehabilitation. Dropout had different causes; 9 persons died, 12 persons were excluded from the study because they regained ability to walk for longer distances, and 19 refused to collaborate. Some other persons had moved, had developed a psychiatric condition after the first measurement, or could not be contacted at all.27 A comparison between participants and nonparticipants showed no differences regarding sex, age, and completeness of injury, but more nonparticipants (50%) than participants (30%) had tetraplegia (P<.05). Characteristics of the study group are displayed in table 3.
Table 3. Characteristics of Respondents (N=147)
| Characteristics | n | % |
|---|---|---|
| Sex | ||
| Men | 107 | 72.8 |
| Women | 40 | 27.2 |
| Age (y) | ||
| 18–25 | 22 | 15.1 |
| 25–35 | 37 | 25.3 |
| 35–45 | 24 | 16.4 |
| 45–55 | 27 | 18.5 |
| 55–65 | 36 | 24.7 |
| Cause of injury | ||
| Traumatic | 111 | 75.5 |
| Nontraumatic | 36 | 24.5 |
| Type of injury | ||
| Complete tetraplegia | 35 | 23.8 |
| Incomplete tetraplegia | 14 | 9.5 |
| Complete paraplegia | 70 | 47.6 |
| Incomplete paraplegia | 28 | 19.0 |
| Marital status | ||
| Living with a spouse | 82 | 55.8 |
| Living at parental home | 26 | 17.7 |
| Living alone | 39 | 26.6 |
| Children | ||
| Yes | 72 | 49.0 |
| No | 75 | 51.0 |
| Education | ||
| More than high school | 75 | 50.7 |
| Less than high school | 71 | 48.0 |
Nearly three quarters of the study group were men. The mean age ± SD 1 year after discharge was 41.6±14.5 years. The time since injury ranged from 16 months up to 45.2 months, with a mean of 25.3±6.1 months. The cause of injury was traumatic for 75%; traffic crash for 33%, injury as a result of falls for more than 15%, and sports-related injury for nearly 10%. Nontraumatic causes contributed for almost one fourth; most were myelum vessel problems.
Most persons suffered a complete paraplegia, followed by complete tetraplegia (together 71.4%). The majority of the participants lived together or were married, and more than half of the persons had 1 or more children. Half of the population had a degree in higher secondary education.
Life Satisfaction of Persons With SCI Before and After SCI
Table 1 shows LiSat-9 scores before and after SCI, change scores, and correlations between scores before and after SCI.
LiSat-9 scores were significantly lower after SCI compared with before SCI, except for the domain contact with friends. Large ESs were seen for deterioration of satisfaction with life as a whole, self-care ability, vocational situation, sexual life, and the LiSat-9 total score. Small ESs were seen for decrease of financial situation, family relations, and contacts with friends and acquaintances. Correlations between life satisfaction scores before and after SCI were weak and for the most part nonsignificant. Only for partner relations was a moderately strong correlation found.
Life satisfaction scores also showed a marked decrease after SCI if expressed as percentages of satisfied participants (see table 2).
The proportion of satisfied people decreased the most for satisfaction with life as a whole and for the domains self-care, vocational situation, and sexual life. The domains financial situation, partner relations, family life, and contact with friends and acquaintances appeared least significantly affected by SCI (see table 2). Most of the participants who were dissatisfied with life as a whole, self-care, leisure time, family life, and contacts with friends before SCI were satisfied with their functioning in these domains 1 year after SCI. A total of 49.2% participants perceived a change from satisfaction into dissatisfaction for more than 2 domains.
Determinants of Life Satisfaction and of Change in Life Satisfaction After SCI
Hierarchic regression analyses were performed to examine the independent influence of lesion characteristics and secondary impairments on life satisfaction and change in life satisfaction after SCI (table 4).
Table 4. Hierarchic Regression of Life Satisfaction With Personal Factors, Lesion Characteristics, and Secondary Conditions§ as Determinants
| Determinant | Life Satisfaction After SCI | Change in Life Satisfaction Before and After SCI | Deterioration of Life Satisfaction After SCI‡ | |||
|---|---|---|---|---|---|---|
| β | P | β | P | Odds Ratio | P | |
| Personal factors | ||||||
| Sex | −0.21 | .021⁎ | −0.12 | .203 | 0.41 | .070 |
| Age | 0.09 | .366 | 0.11 | .262 | 1.31 | .535 |
| Education level | 0.02 | .366 | −0.06 | .484 | 0.49 | .083 |
| R2 change | 3.0% | .350 | 2.0% | .556 | 3.0% | .350 |
| Lesion factors | ||||||
| Cause of injury | 0.07 | .677 | −0.04 | .721 | 1.23 | .702 |
| Completeness | 0.12 | .789 | 0.23 | .026⁎ | 1.97 | .188 |
| Lesion level | 0.31 | .001† | 0.28 | .002† | 4.02 | .003† |
| R2 change | 9.0% | .022⁎ | 10.0% | .027⁎ | 10.0% | .022⁎ |
| Consequences | ||||||
| Total pain | 0.19 | .032⁎ | 0.13 | .160 | 2.89 | .017⁎ |
| Total secondary impairments | 0.22 | .014⁎ | 0.22 | .015⁎ | 2.66 | .023⁎ |
| R2 change | 8.0% | .001† | 6.0% | .004† | 10.0% | .004† |
| Total explained variance | 19.0% | 17.0% | 23.0% | |||
⁎P<.05. |
†P<.01. |
‡Logistic hierarchic regression with Nagelkerke R2. |
§Dichotomization of determinants: sex: man=1, woman=0; age: young=1, old=0; education level: more than high school=1, less than high school=0; cause of injury: traumatic=1, nontraumatic=0; completeness: incomplete=1, complete=0; lesion level: low=1, high=0; total pain: low pain=1, much pain=0; total secondary impairments: few or none=1, many=0. |
Three regression analyses were performed with different dependent variables: first, the total LiSat-9 score after SCI; second, the change in LiSat-9 score between the measurements before and after SCI; and, finally, a dichotomous variable comparing the group of persons satisfied before SCI and dissatisfied after SCI with the other participants. Sex, age, and educational level showed little relationship with life satisfaction scores. Lesion level was a significant predictor in all 3 analyses, whereas completeness of lesion was only associated with the change in total LiSat-9 scores. Pain was associated with the total LiSat-9 score after SCI and the dichotomous change score, and having other secondary impairments was associated with decreased life satisfaction in all analyses. The amounts of explained variance were limited to 17% to 23%.
Discussion
The results of this study show a marked decrease in life satisfaction of persons with SCI at 1 year after discharge from inpatient rehabilitation compared with their life satisfaction before SCI, which was retrospectively reported early in inpatient rehabilitation. Decrease of life satisfaction was strongest for the domains sexual life, self-care, and vocational situation. Partner relations, family life, and contacts with friends and acquaintances appeared to be the least affected life domains. Age, sex, and education had little influence on life satisfaction after SCI and change of life satisfaction. High level of lesion, suffering from secondary impairments, and pain were associated with decrease of life satisfaction and with low life satisfaction 1 year after discharge.
Comparison of Life Satisfaction Before and After SCI
Only 1 earlier study22 compared life satisfaction after SCI with a retrospective rating of life satisfaction before SCI, both measured during initial inpatient rehabiliation. The levels of satisfaction with life as a whole before and after SCI (4.4 and 3 on a 0–5 scale) were similar to the scores of 5.3 and 4.3 on a 1 to 6 scale found in this study. Regarding other diagnostic groups, Fugl-Meyer and colleagues asked persons 3 years after multiple trauma28 and 4 to 6 years after stroke29 to rate their current life satisfaction and their life satisfaction before trauma with the LiSat-9. They also found a significant decrease of satisfaction with life as a whole and with most life domains and found the social relationships domains to be least affected. Of the stroke patients, 82% were satisfied with life as a whole before the event and 58% after the event. Of the trauma patients, 75% were satisfied with life as a whole before and 41% after the event.28, 29 The figures of this study (88% satisfied before, 57% satisfied after SCI) show a similar decrease and show percentages similar to the stroke group but somewhat higher percentages than in the trauma group. Remarkable in studying the domains of life satisfaction, most of the participants who were dissatisfied with life as a whole, self-care, leisure time, family life, and contacts with friends before SCI were satisfied with their functioning in these domains 1 year after SCI. Regression to the mean might be an explanation for persons with a low score being likely to score higher at the next measurement.
Satisfaction After SCI Compared With Population Figures
Satisfaction with life as a whole after SCI in the current study (4.3; 57% satisfied) was significantly but only moderately lower than in the general population (4.7; 66.8% satisfied) as described by Post et al.14 When comparing LiSat-9 life as whole scores, Swedish SCI and population studies showed a similar difference.12, 30 Dijkers3 reviewed comparative studies and found lower levels of life satisfaction in persons with SCI than in reference groups in 14 of 15 studies. Effect sizes ranged between 0.3 and 1.5, indicating that the difference in satisfaction with life as a whole in Dijkers's study was relatively small. However, the use of different life satisfaction measures hampers comparisons with these other studies.
Regarding separate life domains, sexual life showed the largest difference between SCI and population (0.8 points, ES=.48). Other differences were less pronounced. Three domains, financial situation, family life, and contacts with friends and acquaintances, were even rated higher by persons with SCI than by the reference group. Post14 found in comparison with the same control group lower ratings in the SCI-population for self-care, sexual life, leisure, and vocational situation and higher ratings for family life.
Retrospective Ratings
Interestingly, the retrospective ratings by persons with SCI of life satisfaction before SCI were much higher than ratings of current life satisfaction in the reference population.14 As a result, the decrease in life satisfaction after SCI was larger compared with the retrospective rating of the persons themselves as compared with population data.
One possible explanation for the extraordinary high ratings of life before SCI is memory bias, but the mean time between injury and the retrospective measurement was only 3 months. An alternative explanation for the high retrospective ratings is idealization of life before injury,22, 28 suggesting that these ratings are unrealistic and possibly even harmful for current life satisfaction.22 A better explanation for both the high ratings of life satisfaction before SCI and the relatively small differences between postinjury scores and population figures is provided by the response shift theory.31 This theory suggests a psychologic adaptation to life after SCI through changes in internal standards, values, and conceptualizations. Because of this adaptation, comparisons of life satisfaction ratings of persons with SCI to those of reference groups, as is usually recommended,3 might result in underestimations of the changes induced by the SCI. The comparison of current life satisfaction to a retrospective rating of life satisfaction before SCI, a so-called then test, might better reflect the impact of SCI on life satisfaction.32 In this study, life satisfaction before injury was included in the first measurement only and not in the measurement 1 year after discharge simultaneously with the rating of current life satisfaction. This limits the comparability of both measurements. On the other hand, such a later retrospective rating might more strongly suffer from memory bias. Further research is necessary to reveal the most useful approach.
Comparison With Other LiSat-9 Studies in SCI Populations
The results of this study were compared with those of other studies performed by using the LiSat-9 in persons with SCI and with a reference population.14 Mean scores were presented and, if necessary, obtained by personal communication with the authors. The mean score for satisfaction with life as a whole in this study (4.3) was in the range of the mean scores (4.2–4.6) reported in other SCI studies performed by using the LiSat-9 (fig 1).12, 14, 15, 16
Fig 1.
Comparison of LiSat-9 scores after SCI in different studies. Legend: 1, very unsatisfied; 2, unsatisfied; 3, rather unsatisfied; 4, rather satisfied; 5, satisfied; 6, very satisfied.
The overall pattern of higher- and lower-rated life domains was similar for all studies; satisfaction with sexual life was lowest, vocational situation also obtained relatively low scores, and social relationships (family, friends) were rated highest. Sexual dysfunction is common after SCI, either caused directly by sexual dysfunctions because of the disease or its treatment or indirectly by adjustment problems and reactions of others.33
Satisfaction scores for self-care ability, vocational situation, and financial situation in this study were more or less similar to those of 2 other Dutch studies14, 15 and a Swedish study.12 Because of the short time after injury in this study, lower satisfaction scores with vocational and financial situation might have been expected because vocational reintegration after SCI often takes several years.8, 34, 35, 36 An explanation might be the current social security system in The Netherlands, in which continuation of job and income are guaranteed during 2 years of sick leave and therefore still applying to many participants.
A U.K. study16 showed generally lower life satisfaction scores than the other studies. The reason for this is not clear. Semantic differences might be present, although an English version was provided by the author.24 Cultural differences might also be present but cannot be explored because LiSat-9 reference values for the British population are not available.
Determinants of Life Satisfaction
The relationships found between level of lesion and life satisfaction were in concordance with the study by Clayton and Chubon37 but were in contrast with results of other studies6, 9, 33, 35, 38, 39, 40 in which no relationships with level of lesion were found. Dijkers3 suggested in his meta analysis that the impairment itself (correlation, −.05) barely affected life satisfaction but that the impact of the impairment on activities (r=−.21) and participation (r range, −.17 to −.48) affected life satisfaction.
Pain was a determinant for life satisfaction in our study. Pain in the SCI population has been studied widely.41 In their 1- to 2-year postinjury follow-up study, Putzke et al6 found a decrease in life satisfaction of people who developed pain and an increase in life satisfaction in people who resolved their pain. Recent cross-sectional studies revealed a decreased life satisfaction in SCI population with pain.12, 42, 43, 44, 45
As expected, we found negative associations between secondary impairments and life satisfaction. These results are in accordance with the findings of Ville and Ravaud44 (urinary tract problems) and Post et al,40 who found a negative association between life satisfaction and the secondary complications pressure ulcers, spasticity, respiratory problems, and pain.
Study Limitations
The relatively high dropout of persons with tetraplegia might have resulted in an overestimation of life satisfaction after SCI. Another limitation is the lack of a prospective rating of life satisfaction before SCI, but, in most rehabilitation research, retrospective ratings will be unavoidable because SCI is a rare condition. For more common disabilities, the use of large longitudinal population cohort studies might provide useful comparisons of the impact of disability on life satisfaction.21, 46
Study Strengths
This is among the few studies in which life satisfaction was studied in persons with SCI in the first years of the injury and in which a retrospective rating of life satisfaction before injury enlarged insights into the impact of SCI on life satisfaction as perceived by the persons themselves. The large number of participants allowed for valid estimations of life satisfaction and for multivariate analyses. The use of the LiSat-9 provided descriptions of both satisfaction with life as a whole and satisfaction with important life domains and facilitated comparisons with 4 other studies of life satisfaction in SCI using the same instrument.
Clinical Implications
Life satisfaction 1 year after discharge was negatively influenced by pain and other secondary impairments, and these conditions should therefore be treated adequately in a multidisciplinary setting in outpatient rehabilitation. Sexual life must be questioned in follow-up situations for potential intervention because of the clearly low satisfaction with sexual life after SCI.33
The weak correlations between preinjury and postinjury life satisfaction suggest that life satisfaction is not a stable personal characteristic, so it might be positively influenced by psychologic interventions directed at strategies to cope with the SCI.13, 47, 48, 49
Conclusions
Measurement of life satisfaction 1 year after discharge might be too early to reflect a more or less stable situation.6 A long-term follow-up is necessary to identify determinants that influence life satisfaction.2, 14, 34, 50 The use of the LiSat-9 facilitated comparisons with other studies and is recommended for further study. The addition of the SWLS, which is used commonly in the United States, would further improve the comparability of study results.51 In the current study, person and lesion characteristics allowed only for a minor amount of explained variance of life satisfaction. We found a higher SD for all the LiSat-9 items after SCI compared with before SCI, showing the individual diversity in adaptation to life after SCI. Future studies need to focus on the influence of environmental factors like social support36, 52 and personal factors like coping style, self efficacy, and personality.13, 43, 45, 49, 53
Supplier
Acknowledgments
We thank the research assistants for collecting all the data and the following participating Dutch rehabilitation centers: Rehabilitation Centre De Hoogstraat (Utrecht), Rehabilitation Centre Amsterdam, Rehabilitation Centre Het Roessingh (Enschede), Rehabilitation Centre Hoensbroeck, Sint Maartenskliniek (Nijmegen), Rehabilitation Centre Beatrixoord (Haren), Rehabilitation Centre Heliomare (Wijk aan Zee), and Rijndam Rehabilitation Centre (Rotterdam).
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- a Version 15.0; SPSS, 233 S Wacker Dr, 11th Fl, Chicago, IL 60606.
Supported by the Health Research and Development Council of the Netherlands (grant no. 1435.0003).
No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated.
PII: S0003-9993(08)00344-4
doi:10.1016/j.apmr.2007.12.042
© 2008 American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.
Volume 89, Issue 9 , Pages 1733-1740, September 2008
