Age, resilience, social support, and health literacy as predictors of functional ability in people with spinal cord injury: a 6-month follow-up study
DOI:
https://doi.org/10.2340/jrm.v58.45268Keywords:
spinal cord injury, functional ability, resilience, social support, health literacy, rehabilitation nursingAbstract
Objective: To longitudinally examine age, resilience, social support, and health literacy as predictors of functional ability in people with spinal cord injury from rehabilitation initiation through to 6-month follow-up.
Design: Follow-up study.
Setting: The spinal surgery department of the Third Affiliated Hospital of Soochow University, China.
Subjects/Patients: This study included 367 inpatients with traumatic spinal cord injury at a single centre.
Methods: Functional ability (Modified Barthel Index, MBI), resilience (Connor–Davidson Resilience Scale), social support (Social Support Rating Scale), and health literacy (Brief Health Literacy Screening) were assessed at baseline, 3-month, and 6-month follow-up. Linear mixed-effects models analysed predictors of MBI change.
Results: MBI scores improved slightly from baseline to 6-month follow-up (43.50 [21.48] to 46.81 [22.10]), indicating a modest magnitude of change. Multivariate analysis identified younger age (β = –0.02; p = 0.028), higher resilience (β = 0.22; p < 0.001), and higher health literacy (β = 0.32; p = 0.001) as significant independent predictors of greater functional ability over time. Social support was significant only in univariate analysis (β = 0.44; p = 0.038).
Conclusions: Although the observed improvement in functional ability was modest, younger age, stronger psychological resilience, and higher health literacy were independent predictors of better functional ability in the first 6 months after discharge from spinal cord injury. Further research is warranted to determine the clinical significance of these changes. Rehabilitation strategies may consider integrating interventions targeting these modifiable psychosocial and cognitive resources.
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References
Eli I, Lerner DP, Ghogawala Z. Acute traumatic spinal cord injury. Neurol Clin 2021; 39: 471–488. DOI: https://doi.org/10.1016/j.ncl.2021.02.004
Adegeest CY, van Gent JAN, Stolwijk-Swüste JM, Post MWM, Vandertop WP, Öner FC, et al. Influence of severity and level of injury on the occurrence of complications during the subacute and chronic stage of traumatic spinal cord injury: a systematic review. J Neurosurg Spine 2022; 36: 632–652. DOI: https://doi.org/10.3171/2021.7.SPINE21537
van der Meer P, Post MW, van Leeuwen CM, van Kuppevelt HJ, Smit CA, van Asbeck FW. Impact of health problems secondary to SCI one and five years after first inpatient rehabilitation. Spinal Cord 2017; 55: 98–104. DOI: https://doi.org/10.1038/sc.2016.103
Adriaansen JJ, Ruijs LE, van Koppenhagen CF, van Asbeck FW, Snoek GJ, van Kuppevelt D, et al. Secondary health conditions and quality of life in persons living with spinal cord injury for at least ten years. J Rehabil Med 2016; 48: 853–860. DOI: https://doi.org/10.2340/16501977-2166
Bhattarai M, Shigemoto Y, Smedema SM. Role of self-efficacy on functional limitations among persons with spinal cord injury. Chronic Illn 2025; 21: 94–104. DOI: https://doi.org/10.1177/17423953231203731
Hastings BM, Ntsiea MV, Olorunju S. Factors that influence functional ability in individuals with spinal cord injury: a cross-sectional, observational study. S Afr J Physiother 2015; 71: 235. DOI: https://doi.org/10.4102/sajp.v71i1.235
Harvey LA, Glinsky JV, Chu J. Do any physiotherapy interventions increase spinal cord independence measure or functional independence measure scores in people with spinal cord injuries? A systematic review. Spinal Cord 2021; 59: 705–715. DOI: https://doi.org/10.1038/s41393-021-00638-0
Lee BA, Leiby BE, Marino RJ. Neurological and functional recovery after thoracic spinal cord injury. J Spinal Cord Med 2016; 39: 67–76. DOI: https://doi.org/10.1179/2045772314Y.0000000280
Hiremath SV, Marino RJ, Coffman DL, Karmarkar AM, Tucker CA. Assessing functional recovery for individuals with spinal cord injury post-discharge from inpatient rehabilitation. J Spinal Cord Med 2024; 47: 893–901. DOI: https://doi.org/10.1080/10790268.2023.2220983
Abdul-Sattar AB. Predictors of functional outcome in patients with traumatic spinal cord injury after inpatient rehabilitation: in Saudi Arabia. NeuroRehabilitation 2014; 35: 341–347. DOI: https://doi.org/10.3233/NRE-141111
Huang H, Chen M, Ding P, Xia X, Dai Q, Feng L, et al. Disability trajectories individuals with spinal cord injury in mainland China: do psychosocial resources and diseases factors predict trajectories? Spinal Cord 2025; 63: 1–8. DOI: https://doi.org/10.1038/s41393-024-01040-2
Milićević S, Bukumirić Z, Nikolić AK, Babović R, Janković S. Demographic characteristics and functional outcomes in patients with traumatic and nontraumatic spinal cord injuries. Vojnosanit Pregl 2012; 69: 1061–1066. DOI: https://doi.org/10.2298/VSP1212061M
Carrard V, Kunz S, Peter C. Mental health, quality of life, self-efficacy, and social support of individuals living with spinal cord injury in Switzerland compared to that of the general population. Spinal Cord 2021; 59: 398–409. DOI: https://doi.org/10.1038/s41393-020-00582-5
van Diemen T, Tran Y, Stolwijk-Swuste JM, Roels EH, van Nes IJW, Post MWM. Trajectories of self-efficacy, depressed mood, and anxiety from admission to spinal cord injury rehabilitation to 1 year after discharge. Arch Phys Med Rehabil 2021; 102: 1939–1946. DOI: https://doi.org/10.1016/j.apmr.2021.04.018
Tang X, Huang J, Wang W, Su X, Yu Z. Predictors of activation among persons with spinal cord injury during hospitalization: a cross-sectional study. Jpn J Nurs Sci 2023; 20: e12532. DOI: https://doi.org/10.1111/jjns.12532
de la Vega R, Molton IR, Miró J, Smith AE, Jensen MP. Changes in perceived social support predict changes in depressive symptoms in adults with physical disability. Disabil Health J 2019; 12: 214–219. DOI: https://doi.org/10.1016/j.dhjo.2018.09.005
Fekete C, Tough H, Arora M, Hasnan N, Joseph C, Popa D, et al. Are social relationships an underestimated resource for mental health in persons experiencing physical disability? Observational evidence from 22 countries. Int J Public Health 2021; 66: 619823. DOI: https://doi.org/10.3389/ijph.2021.619823
Berkman ND, Sheridan SL, Donahue KE, Halpern DJ, Crotty K. Low health literacy and health outcomes: an updated systematic review. Ann Intern Med 2011; 155: 97–107. DOI: https://doi.org/10.7326/0003-4819-155-2-201107190-00005
Munce SE, Webster F, Fehlings MG, Straus SE, Jang E, Jaglal SB. Perceived facilitators and barriers to self-management in individuals with traumatic spinal cord injury: a qualitative descriptive study. BMC Neurol 2014; 14: 48. DOI: https://doi.org/10.1186/1471-2377-14-48
Su X, Liu Q, Wang J, Song J, Tang X. Patient activation during the first 6 months after the start of spinal cord injury rehabilitation: a cohort study. Eur J Phys Rehabil Med 2025; 61: 250–262. DOI: https://doi.org/10.23736/S1973-9087.25.08758-1
Tang X, Liu Q, Su X, Yu Z. Effects of a self-efficacy-centered self-management program on neurogenic bladder after spinal cord injury: a randomized controlled trial. Jpn J Nurs Sci 2025; 22: e12642. DOI: https://doi.org/10.1111/jjns.12642
Yu X, Zhang J. Factor analysis and psychometric evaluation of the Connor-Davidson Resilience Scale (CD-RISC) with Chinese people. Social Behav Person 2007; 35: 19–30. DOI: https://doi.org/10.2224/sbp.2007.35.1.19
Xiao S. Theoretical basis and research application of social support rating scale. J Clin Psychiatry 1983; 4: 98–100 [in Chinese].
Chew LD, Griffin JM, Partin MR, Noorbaloochi S, Grill JP, Snyder A, et al. Validation of screening questions for limited health literacy in a large VA outpatient population. J Gen Intern Med 2008; 23: 561–566. DOI: https://doi.org/10.1007/s11606-008-0520-5
Singh G, Sawatzky B, Nimmon L, Mortenson WB. Perceived eHealth literacy and health literacy among people with spinal cord injury: a cross-sectional study. J Spinal Cord Med 2023; 46: 118–125. DOI: https://doi.org/10.1080/10790268.2021.1963140
Wallace LS, Rogers ES, Roskos SE, Holiday DB, Weiss BD. Brief report: screening items to identify patients with limited health literacy skills. J Gen Intern Med 2006; 21: 874–877. DOI: https://doi.org/10.1111/j.1525-1497.2006.00532.x
Wallston KA, Cawthon C, McNaughton CD, Rothman RL, Osborn CY, Kripalani S. Psychometric properties of the brief health literacy screen in clinical practice. J Gen Intern Med 2014; 29: 119–126. DOI: https://doi.org/10.1007/s11606-013-2568-0
Almanasreh E, Moles R, Chen TF. Evaluation of methods used for estimating content validity. Res Social Adm Pharm 2019; 15: 214–221. DOI: https://doi.org/10.1016/j.sapharm.2018.03.066
Bland JM, Altman DG. Cronbach’s alpha. BMJ 1997; 314: 572. DOI: https://doi.org/10.1136/bmj.314.7080.572
Leung SO, Chan CC, Shah S. Development of a Chinese version of the Modified Barthel Index: validity and reliability. Clin Rehabil 2007; 21: 912–922. DOI: https://doi.org/10.1177/0269215507077286
Hong W, Liu Z, Zhang X, Li M, Yu Z, Wang Y, et al. Distance-related functional reorganization predicts motor outcome in stroke patients. BMC Med 2024; 22: 247. DOI: https://doi.org/10.1186/s12916-024-03435-7
Li J, Liu G, Zheng Y, Hao C, Zhang Y, Wei B, et al. The epidemiological survey of acute traumatic spinal cord injury (ATSCI) of 2002 in Beijing municipality. Spinal Cord 2011; 49: 777–782. DOI: https://doi.org/10.1038/sc.2011.8
Chang F, Zhang Q, Xie H, Yang Y, Sun M, Wu A, et al. Effects of a rehabilitation program for individuals with chronic spinal cord injury in Shanghai, China. BMC Health Serv Res 2020; 20: 298. DOI: https://doi.org/10.1186/s12913-020-05181-x
Hartley P, Keating JL, Jeffs KJ, Raymond MJ, Smith TO. Exercise for acutely hospitalised older medical patients. Cochrane Database Syst Rev 2022; 11: Cd005955. DOI: https://doi.org/10.1002/14651858.CD005955.pub3
Huang Y, Shi JJ, Sun Y, Wu W, Wang XL. Study on the minimum clinically important difference of modified Barthel index in the evaluation of ischemic stroke. Chin J Health Statis 2022; 39: 215–217+221 [in Chinese].
van Diemen T, Scholten EW, van Nes IJ, Geertzen JH, Post MW. Self-management and self-efficacy in patients with acute spinal cord injuries: protocol for a longitudinal cohort study. JMIR Res Protoc 2018; 7: e68. DOI: https://doi.org/10.2196/resprot.8054
Silva FAR, Barbosa MA, Prudente COM, Morais LA, Moraes KL, Vila VSC, et al. Health literacy of people with spinal cord injury: a systematic review. Spinal Cord 2023; 61: 409–414. DOI: https://doi.org/10.1038/s41393-023-00903-4
Diviani N, Zanini C, Gemperli A, Rubinelli S. An exploration of information seeking behavior among persons living with spinal cord injury in Switzerland. Spinal Cord 2021; 59: 452–461. DOI: https://doi.org/10.1038/s41393-020-00583-4
Levasseur M, Carrier A. Do rehabilitation professionals need to consider their clients’ health literacy for effective practice? Clin Rehabil 2010; 24: 756–765. DOI: https://doi.org/10.1177/0269215509360752
Bhattarai M, Maneewat K, Sae-Sia W. Psychosocial factors affecting resilience in Nepalese individuals with earthquake-related spinal cord injury: a cross-sectional study. BMC Psychiatry 2018; 18: 60. DOI: https://doi.org/10.1186/s12888-018-1640-z
Nery-Hurwit M, Yun J, Ebbeck V. Examining the roles of self-compassion and resilience on health-related quality of life for individuals with Multiple Sclerosis. Disabil Health J 2018; 11: 256–261. DOI: https://doi.org/10.1016/j.dhjo.2017.10.010
Wilson JR, Davis AM, Kulkarni AV, Kiss A, Frankowski RF, Grossman RG, et al. Defining age-related differences in outcome after traumatic spinal cord injury: analysis of a combined, multicenter dataset. Spine J 2014; 14: 1192–1198. DOI: https://doi.org/10.1016/j.spinee.2013.08.005
Furlan JC, Fehlings MG. The impact of age on mortality, impairment, and disability among adults with acute traumatic spinal cord injury. J Neurotrauma 2009; 26: 1707–1717. DOI: https://doi.org/10.1089/neu.2009.0888
Sachdeva R, Gao F, Chan CCH, Krassioukov AV. Cognitive function after spinal cord injury: a systematic review. Neurology 2018; 91: 611–621. DOI: https://doi.org/10.1212/WNL.0000000000006244
Le Fort M, Lefèvre C, Kieny P, Perrouin-Verbe B, Ravaud JF. The functioning of social support in long-term prevention after spinal cord injury: a qualitative study. Ann Phys Rehabil Med 2021; 64: 101454. DOI: https://doi.org/10.1016/j.rehab.2020.10.007
Jenkins HT, Cosco TD. Spinal cord injury and aging: an exploration of the interrelatedness between key psychosocial factors contributing to the process of resilience. Health Psychol Behav Med 2021; 9: 315–321. DOI: https://doi.org/10.1080/21642850.2021.1911656
Müller R, Peter C, Cieza A, Geyh S. The role of social support and social skills in people with spinal cord injury: a systematic review of the literature. Spinal Cord 2012; 50: 94–106. DOI: https://doi.org/10.1038/sc.2011.116
Juguera Rodriguez L, Pardo Rios M, Leal Costa C, Castillo Hermoso M, Perez Alonso N, Diaz Agea JL. Relatives of people with spinal cord injury: a qualitative study of caregivers’ metamorphosis. Spinal Cord 2018; 56: 548–559. DOI: https://doi.org/10.1038/s41393-018-0092-0
Mayberry LS, Osborn CY. Family involvement is helpful and harmful to patients’ self-care and glycemic control. Patient Educ Couns 2014; 97: 418–425. DOI: https://doi.org/10.1016/j.pec.2014.09.011
Tramonti F, Gerini A, Stampacchia G. Relationship quality and perceived social support in persons with spinal cord injury. Spinal Cord 2015; 53: 120–124. DOI: https://doi.org/10.1038/sc.2014.229
Wang T, Tang J, Xie S, He X, Wang Y, Liu T, et al. Translation and validation of the Chinese version of the Spinal Cord Independence Measure (SCIM III) Self-Report. Spinal Cord 2021; 59: 1045–1052. DOI: https://doi.org/10.1038/s41393-020-00601-5
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