Abstract
Background/Objective: Service dogs are trained to help individuals with disabilities maximize function and enhance social participation. This pilot study obtained an estimate of the proportion of veterans with spinal cord injuries (SCI) receiving care from a Veterans Affairs Medical Center who were interested in information about, or obtaining, a service dog.
Method: Fifty randomly selected veterans with SCI were interviewed by telephone.
Demographic and injury-related factors were examined for associations with interest in a service dog. Tasks the veterans would expect a service dog to do were identified.
Results: Nearly one-third reported no prior knowledge of service dogs. Thirty percent reported at least some interest in obtaining a service dog and 42 percent desired information concerning service dogs. The Satisfaction with Life Scale score, estimated change in the number of hours of unpaid assistance after obtaining a dog, and estimated change in the number of days per week the person would leave their home after obtaining a dog were the only variables that significantly predicted interest in service dogs. Less satisfied persons, persons who predicted they would need fewer hours of unpaid assistance, and those who predicted they would get away from their homes more frequently were more likely to be interested in information or in obtaining a service dog.
Conclusions: Among veterans with SCI there is a substantial interest in service dogs. Health care providers have a responsibility for educating individuals with SCI about the potential benefits and drawbacks of service dogs and for facilitating the process of obtaining information from service dog training organizations.

Key words: assistance animals, assistance dogs, service animals, service dogs, spinal cord injuries, veterans

Introduction
    The use of service dogs, one of several types of assistance dogs, is one approach to helping persons with mobility impairments achieve an optimal level of functional independence in activities of daily living and enhance their social participation. Through intense training, service dogs are able to perform a variety of tasks such as pulling wheelchairs, opening doors, retrieving items from store shelves, turning on light switches and electronics, retrieving the telephone, and picking up objects such as clothing and keys. In 2002, Public Law 107-135 (Title II, Section 201(c)(2)) was enacted, authorizing service dogs to be provided by the Department of Veterans Affairs to veterans with spinal cord injuries or dysfunction, other diseases causing physical immobility, or other types of disabilities susceptible to improvement or enhanced functioning in activities of daily living through employment of a service dog. Although there have been several published studies (Allen & Blascovich, 1996; Eddy, Hart, & Boltz, 1988; Fairman & Huebner, 2001; Lane, McNicholas, & Collis, 1998; Mader, Hart, & Bergin, 1989; Marks, 1993; Rintala, Sachs-Ericsson, & Hart, 2002; Roth, 1994; Valentine, Kiddoo, & LaFleur, 1993) and other studies are under way to assess the outcome of obtaining a service dog, to our knowledge, no information exists regarding the extent to which veterans with mobility impairments desire or consider themselves in need of a service dog. In view of the time and money invested in training service dogs, it seems important to determine the extent of desire and need for a service dog among veterans with mobility impairments.

    Most studies have found a positive relationship between obtaining a service dog and various outcome measures; however, there are some inconsistencies. Two studies of individuals who had obtained service dogs found respondents reporting that their service dog assisted them with health-related behaviors and that their general health improved as a result (Fairman et al., 2001; Lane et al., 1998), whereas another study found no differences in perceived health functioning when comparing individuals who had obtained a service dog to those still on the waiting list for one (Marks, 1993). Individuals partnered with service dogs have reported functional improvements in tasks of daily living. In Roth’s (1994) retrospective study, respondents reported their service dog assisted them with eating (22%), dressing (20%), retrieving the phone (20%), and grooming (17%). In a study by Fairman et al. (2001), individuals partnered with service dogs have reported, “it is easier to leave home” (77%), and “easier to use community resources” (73%).

    Many of the early scientific studies of the effects of service dogs focused on social aspects of living. Individuals partnered with service dogs were found to receive more social acknowledgement from strangers than individuals not partnered with service dogs. In a study of adults who used wheelchairs, bystanders were significantly more likely to smile and begin a conversation with persons accompanied by a service dog than with those not accompanied by one (Eddy et al., 1988). A similar study of children who used wheelchairs found that children with service dogs received more social acknowledgement than children who did not have service dogs (Mader et al., 1989). In a retrospective study of individuals who obtained a service dog, Valentine and colleagues (1993) found that participants reported feeling more independent (90%), having higher self-esteem (80%), being more content (80%), and being more assertive (80%) than they were prior to having a service dog. Rintala and associates (2002) found that self-esteem was significantly enhanced from pre-to post-placement of a service dog in a group of 16 adults with mobility impairments.
     Participants reported that the dogs had a positive effect on going out in public, feeling needed, feeling independent, and safety. Allen and Blascovich (1996) reported significant differences in a number of life areas between a group of persons who received a service dog and a wait-list control group. The group who received a service dog had significantly more self-esteem, more internal locus of control, better psychological well-being, and better community integration. They were more likely to attend school, work part time, or both, and they had significantly fewer hours of paid and unpaid personal assistance per week.

     The aims of this pilot study were to ascertain what proportion of veterans with spinal cord injuries (SCI) want or believe themselves in need of a service dog, the expectations veterans have regarding the potential effects of having a service dog, and what factors, if any, are related to interest in and a desire for a service dog. The local Institutional Review Board approved the study.

Methods
Participants
    In an earlier study, 348 of 509 veterans with SCI who had received care at a Veterans Affairs Medical Center during fiscal years 1999-2001 participated in a telephone survey regarding pain and other aspects of life (Rintala, Holmes, Fiess, Courtade, & Loubser, 2005). The remaining 161 former patients were unable to be contacted, did not wish to participate, or were unable to participate for various reasons. Of the 348 study participants in the earlier study, 327 (94%) agreed that they could be contacted regarding future research studies. Of these 327 veterans, 75 (23%) were randomly selected to be sent a letter recruiting them into the present study using the SPSS (SPSS Inc., 2005) “random sample of cases” function. Of the 75 veterans who were sent letters, 50 completed a telephone survey. Of the remaining 25 veterans who were sent letters, 24 could not be contacted and one was deceased. Fifty interviews was the target sample size given that this was an unfunded, individual student project, that required reasonably lengthy telephone interviews with each participant. A larger sample was not feasible given the available resources and time.

Procedure
    The recruitment letter, distributed with the IRB-approved questionnaire, explained the purpose of the study, the risks and benefits, and confidentiality issues. Each potential participant was given two weeks to think about the questions and study prior to receiving a telephone call from the investigators. If the person wished to participate, oral informed consent was obtained via telephone, and the interview was either conducted at that time or scheduled for a later time.

Measures
    Demographic and Injury-Related Information: Information was obtained regarding age, race and ethnicity, educational status, current occupational status, marital status, level of SCI (upper and lower body affected or only lower body affected), and time since SCI. Participants were asked if they had ever heard of an assistance or service dog. If they had not heard of a service dog, the interviewer referred to assistance dogs for persons with visual impairments (i.e., Seeing Eye dogs), of which most persons are aware, and then indicated that service dogs are trained to do tasks for persons who have mobility impairments. In some cases, the interviewer mentioned a few examples of tasks a service dog might do. All participants were asked if they had an interest in information about service dogs, and if they had an interest in obtaining a service dog. For each of these two questions, the response options were “no interest,” “some interest,” or “great interest.”
    Self-assessed Health Status was evaluated using one item from the Medical Outcome Study Health Status Survey SF-36 (Ware, Jr. & Sherbourne, 1992). The veterans were asked to indicate whether their health was excellent, very good, good, fair, or poor.
    Independence and Mobility: Selected questions from the Physical Independence and Mobility subscales of the Craig Handicap Assessment and Reporting Technique Short Form (CHART-SF) were used to evaluate the perceived levels of independence and mobility (Whiteneck, Charlifue, Gerhart, Overholser, & Richardson, 1992). Participants were asked how many hours in a typical 24-hour day they had (a) paid and (b) unpaid physical assistance with personal care activities such as eating, bathing, dressing, toileting, and mobility. They were then asked how many hours of paid and unpaid assistance in a typical 24-hour day they would expect to have if they had a service dog. They also reported on the number of days per week they were able to leave their homes and what they expected that number would be if they had a service dog.
    The Satisfaction with Life Scale (SWLS) was used to measure subjective quality of life (Pavot, Diener, Colvin, & Sandvik, 1991). The five-item scale asks the respondent to indicate the degree to which he or she agrees or disagrees with each statement on a seven-point scale ranging from strongly disagree to strongly agree. The five item scores are summed to obtain a total score which can range from 5 to 35. Higher scores reflect greater satisfaction with life.
    Tasks for Service Dogs: Participants were asked to indicate which of 36 tasks they would expect a service dog to do if they had one. The task list was derived from a longer list developed by a work group established by the Veterans Health Administration Prosthetic and Sensory Aids Service Strategic Health Care Group (VHA PSAS SHCG). The mission of the work group was to recommend a policy regarding prescription of service dogs for the aid of veterans with mobility deficits due to spinal cord dysfunction or other chronic diseases that impact physical functioning. In the present study, participants could also indicate any additional tasks they would expect a service dog to do that were not among the 36 tasks on the checklist.

Data Analysis
    The data were analyzed with SPSS Version 14.0 for Windows (2005) and StatXact Version 6.0 statistical software (Cytel Software Corp., 2003). Descriptive statistics were obtained for all study variables. These included means and standard deviations for normally distributed continuous variables (i.e., age and the SWLS score), medians and ranges for skewed continuous variables (i.e., time since SCI, hours of paid and unpaid assistance and outings per week), and percentages for categorical variables (gender, race and ethnicity, education, occupation, marital status, level of SCI, knowledge of, and interest in, service dogs, health status, and types of tasks a dog would be expected to do). One 70 year-old participant described his SCI as due to a birth defect, thus his time since SCI was 70 years and, therefore, an extreme outlier. The birth defect, however, had not caused him problems until about five years prior to participating in the survey, which explains how he was able to serve in the military in spite of the birth defect. The differences between current hours of paid and unpaid assistance and days out of the home, and the participant’s estimates of those hours and days if a service dog was available for use, were calculated. The sample in the current study and the previous sample of 348 from which it was selected were compared for age, time since SCI, gender, race and ethnicity, and educational level with t-tests and Pearson chi square analyses.

    Univariate analyses were conducted to identify relationships between interest in information about, and desire for, a service dog with other study variables, specifically: demographic and injury-related data, self-assessed health status, functional independence, mobility, and life satisfaction. Analyses of variance and non-parametric Kruskal-Wallace analyses were conducted for continuous variables as appropriate, depending on whether the distribution of the variable was relatively normal: age and SWLS score; or was skewed: time since SCI, hours per day of paid and unpaid assistance, days out of the home per week both currently and expected with a service dog, and the calculated expected change in hours of assistance and days out of the home. Pearson chi square analyses were performed for all categorical variables. To avoid small cell sizes, race and ethnicity was collapsed into two categories: non-Hispanic white and other; education was collapsed into three categories: high school or less, some college, and college degree; occupational status was collapsed into two categories: unemployed due to disability and other; marital status was collapsed into two categories: married and not married; and self-assessed health was collapsed into three categories: excellent/very good, good, and fair/poor. Because some cells still were quite small even after collapsing the data, StatXact was used to determine the exact probability rather than the asymptotic probability. Finally, to determine whether those who had previously heard of a service dog had different expectations about what tasks the dogs could do than those who had never heard of the dogs, the two groups were compared with regard to the proportion of participants who expected a service dog to perform each task.

Information for Participants
    The participants who expressed interest in information about service dogs were sent a packet with contact and application information for several organizations across the United States that train and provide assistance dogs.

Results
    Characteristics of the sample are displayed in the columns labeled “Overall” in Tables 1 through 3. Compared with the 348 veterans in the earlier study from which this sample was selected, the participants in this study were approximately two years older (56.7 ± 9.5 vs. 54.8 ± 11.6 years, t = 1.11, p = .270), had been injured about one year longer (18.6 vs. 17.5 years, t = 0.60, p= .547), were more likely to be female (4% vs. 1%, Chi square = 1.40, p = .121), were more likely to be non-Hispanic Caucasian (68% vs. 60%, Chi square = 0.78, p = .353), and were more likely to have an Associates degree or higher (32% vs. 20%, Chi square = 1.36, p = .217), but none of these differences was statistically significant. Over two-thirds (68%; Confidence Interval [CI] = 54% - 82%) of the sample had heard of assistance or service dogs. Of the 50 veterans, none currently had a formally trained service dog although one previously had a dog that he trained to assist him, and one currently had two dogs that were able to perform minimal tasks for him but were not formally trained as service dogs.

    Twenty-one of the 50 veterans (42%, CI = 30% - 54%) had some or great interest in information concerning service dogs and 15 veterans (30%, CI = 16% - 44%) expressed some or great interest in obtaining a service dog. Only 25 percent of those who had never heard of service dogs were interested in information about them, whereas 50 percent of those who had heard of service dogs were interested in information. In general, interest in information about service dogs reflected interest in actually obtaining one (Chi square = 47.69, p < .0001). None of the 29 (58%) persons who did not want information about service dogs was interested in obtaining a dog. Six (12%) persons indicated interest in information but not in obtaining a dog, and 15 (30%) persons were interested in both information and obtaining a dog. Everyone who had great interest in obtaining a dog (n = 7) expressed great interest in information as well.

    Displayed in Table 4 are the number of persons interested in information about service dogs as related to their interest in obtaining a dog, separately within the groups designating whether the veteran had previously heard of service dogs or not. One veteran said he wanted information to share with others but could not have a dog because his wife is allergic to dogs. Another veteran reported no interest in information about service dogs or obtaining one because he feared that his current level of functioning would deteriorate and he would lose his current abilities if he became dependent on the dog. One veteran was interested in information but was not allowed to have a dog in his apartment while another was not interested in information or a dog because he didn't have anyone who would help take care of the dog.

    Expectations varied with regard to the effect that having a service dog would have on the amount of paid and unpaid assistance needed. One veteran who currently received around-the-clock paid assistance expected the number of hours to decrease to zero if he got a dog and another thought the number of hours would decrease from 24 to 10 per day. Another veteran, however, expected paid assistance to increase from 8 to 10 hours daily, because he believed that he would need someone to assist with taking care of the dog in addition to assisting him, while another veteran thought it would change from zero hours of assistance daily to 1.5 hours for the same reason. Ninety percent of the participants believed that having a service dog would make no difference in the amount of paid assistance needed.

    With respect to unpaid hours of assistance, five veterans (10%) believed they would need one-half to 14 fewer hours of unpaid assistance daily if they had a service dog and four respondents (8%) said they would need one additional hour of unpaid assistance daily to provide care for the dog. Eighty percent believed that a service dog would not change the number of hours of unpaid assistance needed. Twenty percent (n=10) of the respondents thought they would get out of their home 1 to 5.5 more days per week with a service dog, while one respondent thought he would get out one-half day less per week with a dog. Seventy-six percent believed a service dog would not affect the number of days they got out of the home. However, of the 15 veterans who reported an interest in obtaining a service dog, eight expected an increase in the number of days they would leave their home in a week if they had a service dog.

    There was no significant difference in age with regard to interest in either information or obtaining a service dog (Table 1). Life satisfaction, however, was related to the degree of interest in information and obtaining a dog. On average, persons with great interest in information, obtaining a dog, or both, had lower scores on the SWLS (Table 1; higher scores = greater life satisfaction). In post-hoc pair-wise comparisons with Bonferroni adjustments for multiple comparisons, persons who had great interest in information had significantly lower scores on the SWLS than did those with some interest in information (p = .037). With regard to interest in obtaining a service dog, persons with great interest had significantly lower SWLS scores than persons who had no interest in obtaining a dog (p = .020).

    There was no relationship between interest in either information or obtaining a dog with current or estimated hours of paid assistance or change in those hours (Table 2). There was also no relation with current or estimated hours of unpaid assistance. However, the calculated estimated change in hours of unpaid assistance was significantly related to interest in information (K-W Chi square = 6.07, p = .048) and obtaining a dog (K-W Chi square = 7.68, p = .022). Persons with no interest in information or obtaining a dog believed that the hours of unpaid assistance would increase, whereas persons with some or great interest believed the hours of unpaid assistance would decrease if they obtained a service dog. Similarly for number of days out of the home per week, there was no significant relationship between interest in information or obtaining a dog with either current or estimated outings per week; however, calculated expected change in number of days out of the home per week was significantly related to interest in both information (K-W Chi square = 9.29, p = .010) and obtaining a dog (K-W Chi square = 11.40, p = .003). Persons who were interested in information, a dog, or both, believed they would get out of the home more days per week than they currently did if they had a service dog.

    Although the small number of women (n = 2) in the sample precluded statistical analysis of gender differences, it is notable that neither of the two females was interested in information or obtaining a service dog (Table 3). There was no significant association between interest in information or obtaining a service dog and race and ethnicity, education, occupational status, marital status, level of SCI, subjective health, and prior knowledge of service dogs.

    Displayed in Table 5 is the percentage of participants who expected that a service dog would do each of the 36 tasks on the checklist. The tasks most frequently selected were taking action in an emergency situation such as pushing an emergency call button, barking, or getting another person to help. Other frequently selected tasks were carrying items, retrieving items, and opening and closing doors. The least frequently selected tasks were helping to make and unmake beds and transferring credit cards or cash to a clerk. In addition to the tasks listed in Table 5, one veteran expected the dog to specifically provide assistance whenever his power chair became caught in a hole while outside in his yard. Two veterans expected the dog to provide companionship and be their friend in addition to other, more physical, tasks. Participants who had previously heard of service dogs were significantly more likely than those who had not heard of them to expect a service dog to open and close cabinets and drawers, transfer credit cards or cash to clerks, put items on a checkout counter, retrieve items, activate emergency devices, and bark in an emergency (Table 5). Participants who had not previously heard of service dogs were significantly more likely to endorse assistance with dressing.

Discussion
    Although a law has been passed authorizing the Department of Veterans Affairs to provide service dogs to veterans with mobility impairments, little is known about the number of veterans with SCI who are interested in service dogs. In the present study, 30% of veterans with SCI had at least some interest in obtaining a service dog. This was nearly twice the proportion of veterans interested in obtaining a service dog found in a previous study (Rintala, 2001). In that study, a telephone survey conducted with 590 community-dwelling individuals with SCI (80% non-veterans, 20% veterans), 17.3 percent of the respondents (non-veterans – 17.6%, veterans – 15.1%) wanted a service dog and only 0.4 percent had one. Despite more veterans reporting interest in service dogs in the current study than in the previous study, a large percentage of veterans in the current study (32%, CI = 18% - 46%) reported they had no prior knowledge about service dogs. Since veterans who had never heard of service dogs were less likely to be interested in information or obtaining a dog, there is a need to educate veterans with mobility impairments about service dogs and their potential benefits. As more veterans are informed about service dogs and their potential effects on daily life, perhaps there will be more veterans interested in obtaining a dog, which, in turn, may help them become even more independent and active with increased satisfaction with life.

    It is surprising that in spite of many veterans’ interest in service dogs, none of the 50 participants had a formally trained service dog and only one had owned a service dog in the past. It would have been interesting to ask those who had great interest in obtaining a dog why they had not yet gotten one. There are a number of possible reasons, some of which were mentioned by respondents, such as a family member having an allergy to dogs, living in an apartment where dogs are prohibited, and having no one to help take care of the dog. Other reasons might include not knowing where or how to apply for a dog, not knowing what the requirements are to receive a service dog, fearing that it might be too expensive to obtain and maintain one, and having heard that there are long waiting lists. One of the reasons some persons may express no interest in service dogs is that they or their family members do not like dogs in general, or at least do not like having a dog inside their homes.

    A strong association was found between the veterans’ subjective satisfaction with life and their interest or lack of interest in service dogs. Veterans who were less satisfied were more likely than those who were more satisfied to be interested in information about service dogs and in obtaining one. We are aware of no other studies that reported a significant association between life satisfaction and interest in service dogs. As noted in the introduction, in previous studies, participants have reported that their service dogs have had a positive effect on their health and health-promoting behaviors, self-esteem, performing activities of daily living, going out in public, interactions with other persons in public, feeling needed, feeling independent, and their safety. In retrospect, it would have been interesting to ask the participants to complete the SWLS a second time, adopting the perspective of how they believed they would answer if they already owned a service dog.

    Strong associations were also found between interest in service dogs with the expected change in number of hours of unpaid assistance and expected change in number of days the person would get away from home per week. It is reasonable that persons who are less satisfied with their lives who perhaps believe they will be more satisfied if they had a service dog would be the most interested in obtaining a service dog. It is also reasonable that persons who expect a decrease in the amount of unpaid assistance they need or an increase in the number of times they leave their homes per week would have an interest in service dogs. It is somewhat surprising, however. that neither age nor any of the categorical variables (Tables 1 and 3) were related to interest in service dogs. In particular, one might have expected that persons with upper body impairments would be more likely to be interested in obtaining a dog than persons with only lower body impairments.

    The tasks the participants most frequently indicated they would expect a service dog to perform are realistic. For example, the most commonly endorsed tasks in the present study involved summoning help in an emergency. In the study by Rintala et al. (2002), six months after receiving a dog, participants rated the frequency with which the dog helped them with safety issues as a 4.0 on a scale of 1 (no help) to 5 (a great deal of help).

    This pilot study has several limitations. The number of persons interviewed (n = 50) is relatively small, thus estimates of the proportions of people with (a) prior knowledge, (b) interest in information about service dogs, and (c) interest in obtaining a service dog, are not very precise, thus yielding relatively wide confidence intervals. Similarly, because of the small sample size, the statistically significant findings regarding life satisfaction, change in unpaid assistance, and change in days out of the house may not generalize to other veterans with SCI. With regard to the estimated change variables, it is important to note that the participants were not asked to estimate the change directly, but were asked to estimate the values if they had a dog. The differences between the current and estimated values were calculated later. Nevertheless, these values were based on self-reported estimates, which may not accurately reflect what actual changes would occur if service dogs were placed with the participants.

    The extent to which the fact that one-third of the randomly selected sample of 75 former survey participants could not be contacted has an impact on the findings is unknown. The sample may not accurately represent the population of veterans with SCI, although it was similar to the larger sample from which it was selected with respect to available demographic information. Furthermore, the results may not generalize to the SCI population as a whole since all of the participants were veterans who had received health care at a Veterans Affairs facility within a three-year period. As noted above, other interesting questions might have been included in the study. Because it was based on the task list developed by the VHA PSAS SHCG work group, the checklist of 36 tasks the dogs might be expected to do was limited to physical activities and did not include other aspects such as improved social and psychological well-being which have been shown to be major areas affected by service dogs.

Conclusion
Training of service dogs is expensive and time consuming. Extensive training of the person-dog team is necessary and there are often long waiting lists. Most of the available evidence, however, suggests that the time and money spent on training the dog and the teams are worthwhile. Veterans with lower satisfaction with life were found to be more interested in information about, and possibly obtaining, a service dog. One can hypothesize that persons interested in obtaining a service dog expect that they will get more satisfaction from life as a result. This association between satisfaction with life and interest in service dogs needs to be cross-validated with a larger study. If the finding is supported, then satisfaction with life may be important to include in studies assessing the actual effectiveness of service dogs on the lives of the recipients to determine whether receiving a dog does, in fact, promote greater life satisfaction.

    Remarkably, nearly one-third of the veterans reported having no prior knowledge of service dogs or of the benefits a dog could provide. Half of the persons who had heard of service dogs were interested in information about them whereas only one-fourth of those who had not heard about them wanted information. The Department of Veterans Affairs, being committed to helping veterans with disabilities become as independent and active as possible, should strive to provide education about service dogs and the benefits they can provide to veterans with impaired mobility. Discussions of possible drawbacks and limitations, such as costs, necessary care, and unwelcome attention in public, should also be included so that expectations about obtaining a service dog are realistic. One method of achieving this would be to educate the clinical teams that treat these veterans about the benefits and drawbacks of service dogs and the process of obtaining one. These team members could then educate their patients about service dogs and facilitate the process of obtaining a service dog for those veterans who are interested. The teams might also consider using and further developing an instrument to aid in identifying candidates, and matching individuals with disabilities with appropriate service dogs such as the Service Animal Adaptive Intervention Assessment (SAAIA) developed by Zapf and Rough (2002). Financial support of the dog training organizations is the most limiting factor in terms of the number of trained service dogs available. The VA could help support these organizations financially or establish training centers of its own to increase the availability of trained dogs in order to accomplish what Public Law 107-135 intended.

References
Allen, K. & Blascovich, J. (1996). The value of service dogs for people with severe ambulatory disabilities. A randomized controlled trial. JAMA, 275, 1001-1006.

Cytel Software Corp. (2003). StatXact 6.0 [Computer software]. Cambridge, MA: Cytel Software Corp.

Eddy, J., Hart, L. A., & Boltz, R. P. (1988). The effects of service dogs on social acknowledgments of people in wheelchairs. The Journal of Psychology, 122, 39-45.

Fairman, S. & Huebner, R. (2001). Service dogs: A compensatory resource to improve function. Occupational Therapy in Health Care, 13, 41-52.

Lane, DR, McNicholas, J., & Collis, GM (1998). Dogs for the disabled: Benefits to recipients and welfare of the dog. Applied Animal Behaviour Science, 59, 49-60.

Mader, B., Hart, L. A., & Bergin, B. (1989). Social acknowledgements for children with disabilities: Effects of service dogs. Child Development, 60, 1529-1534.

Marks, L. (1993). The effect of service dogs on the self-concept of the physically disabled. Unpublished Master’s Thesis, Florida International University, Miami, FL.

Pavot, W., Diener, E., Colvin, C. R., & Sandvik, E. (1991). Further validation of the Satisfaction with Life Scale: Evidence for the cross-method convergence of well-being measures. Journal of Personality Assessment, 57, 149-161.

Rintala, D. H. (2001). Service dogs: Effects on the community integration of persons with spinal cord injury. In D. H. Rintala & K. A. Hart (Eds.), Final Report: NIDRR Research and Training Center in Community Integration for Individuals with Spinal Cord Injury. (pp. 86-95). Houston, TX: Baylor College of Medicine and The Institute for Rehabilitation and Research.

Rintala, D. H., Holmes, S. A., Fiess, R. N., Courtade, D., & Loubser, P. G. (2005). Prevalence and characteristics of chronic pain in veterans with spinal cord injury. Journal of Rehabilitation Research and Development, 42, 573-584.

Rintala, D. H., Sachs-Ericsson, N., & Hart, K. A. (2002). The effect of service dogs on the lives of persons with mobility impairments: A pre-post study design. SCI Psychosocial Process, 15, 65, 70-82.

Roth, S. (1994). The effects of service dogs on the occupational performance and life satisfaction of individuals with spinal cord injuries. Unpublished Master’s Thesis, Rush University, Department of Occupational Therapy, Chicago, IL.

SPSS Inc. (2005). SPSS 14.0 [Computer software]. Chicago, IL: SPSS, Inc.

Valentine, D. P., Kiddoo, M., & LaFleur, B. (1993). Psychosocial implications of service dog ownership for people who have mobility or hearing impairments. Social Work in Health Care, 19, 109-125.

Ware, J. E., Jr. & Sherbourne, C. D. (1992). The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Medical Care, 30, 473-483.

Whiteneck, G. G., Charlifue, S. W., Gerhart, K. A., Overholser, J. D., & Richardson, G. N. (1992). Quantifying handicap: A new measure of long-term rehabilitation outcomes. Archives of Physical Medicine and Rehabilitation, 73, 519-526.

Zapf, S. A. & Rough, R. B. (2002). The development of an instrument to match individuals with disabilities and service animals. Disability and Rehabilitation, 24, 47-58.

Tiffanie A. Brashear, PA, is in the Physician Assistant Program at Baylor College of Medicine, Houston, TX
Diana H. Rintala, PhD,Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, Baylor College of Medicine, Department of Physical Medicine and Rehabilitation, Houston, TX

INDEX

Abstract
    Social workers and psychologists can play an important role within the wider interdisciplinary team by ensuring contemporary research findings are translated into daily practice. Despite shifts in knowledge found in contemporary literature, new understandings are not always translated into daily practice. Health care professionals tend to anticipate more negative consequences of psychosocial adjustment to SCI than is necessarily experienced by individuals themselves. This has implications for effective clinical interventions. This practice issues paper aims to present current research finding which debunk seemingly persistent myths surrounding adjustment to SCI, and to consider strategies for bridging the research/practice divide.

Introduction
    The impact of the psychological and emotional issues confronted by people who sustain spinal cord injuries (SCI) cannot be underestimated. Health care professionals, however, tend to anticipate more negative consequences than are actually reported by individuals with SCI. In practice, practitioners respond to people in ways that perpetuate these misconceptions (Bodemhamer, Achterberg Lawlis, Kevorkian, Belanus, & Cofer, 1983; Cushman & Dijkers, 1990; Gerhart, Koziol McLain, Lowenstein, & Whiteneck, 1994). The authors were recently confronted by the content of a discipline-specific practice forum for critical care nurses. The forum, on the subject of adjustment to SCI, focused on the inevitable negative consequences of traumatic SCI, based primarily on outdated stage theories. The education content failed to incorporate contemporary understandings of adjustment to SCI and, as a consequence, perpetuated outdated beliefs and practice interventions for frontline professionals.

    In practice settings, these beliefs often persist despite new understandings drawn from current SCI research. Most SCI units reflect a staffing mix of interdisciplinary health care professionals who range in experience from recent graduates to those who have many years experience. Where professionals are primarily influenced by discipline-specific training and maintain different perspectives and understandings of adjustment issues, myths can be perpetuated. Despite the best intentions, day-to-day ward-based demands often override opportunities for the dissemination of recent research findings to the wider team. The perpetuation of established myths that are not challenged leads to miscommunication within interdisciplinary teams and ultimately diminished outcomes for individuals with SCI.

    Social workers and psychologists play an important role within the interdisciplinary team in critical care, rehabilitation and community settings. Knowledge of psychosocial adjustment and skilled clinical interventions can assist the team to navigate the shifting sands of knowledge expansion. This journey can be uncomfortable and sometimes confronting, especially for professionals who have extensive experience and practice knowledge. The challenge for social workers and psychologists is how to best facilitate the incorporation of contemporary research findings into practice frameworks. This article on practice issues presents findings from contemporary research which debunks seemingly persistent myths surrounding adjustment to SCI and considers strategies to bridge the research practice divide within the interdisciplinary team.

Myth 1 Depression
Depression is an essential stage of successful adjustment and it is inevitable that persons with SCI will become depressed.
    Depression is the most commonly explored psychological response to SCI, particularly in the early literature where it was assumed that all individuals with SCI would inevitably experience a depressive stage and adjustment difficulties (Bracken & Shephard, 1980; Stewart, 1977-78; Wittkower, Gingras, Merler, Wigdor, & Lepine, 1954). Methods used to assess depression in many of the early studies relied on subjective clinical impressions of staff or the person’s self-report of mood. The validity of these methods has more recently been called into question and replaced by more reliable and valid methodologies. (Bodemhamer et al., 1983; Cushman & Dijkers, 1990; Krishman, Glass, Jackson, & Bingley, 1988). Traditional stage theories contended that depression was an essential factor in a linear staged process of adjustment and that failure to experience depression was predictive of pathological adjustment (Elliott & Frank, 1996; Trieschmann, 1988). Since the 1980s research clearly demonstrates that, while the rate of clinical depression in the early stages following SCI is higher than in the general population, it is not a universal or inevitable consequence (Frank, Elliott, Corcoran, & Wonderlich, 1987; Howell, Fullerton, Harvey, & Klien, 1981; Judd, Burrows, & Brown, 1986; Judd, Stone, Webber, Brown, & Burrows, 1989; MacDonald, Nielson, & Cameron, 1987; North, 1999).

    Contemporary research indicates that stage theories contribute little to understanding the dynamic and interacting nature of the psychosocial and environmental factors that mediate adjustment (Dorsett & Geraghty, 2004). When applied to practice, faulty theoretical assumptions that premise therapeutic interventions can only undermine the effectiveness of those interventions. Despite the discounting of stage theories in contemporary literature, these theories continue to strongly influence contemporary rehabilitation practices with negative consequences for people with SCI (Trieschmann, 1988).

    In contrast to earlier beliefs, research indicates that depression may in fact contribute to problematic adjustment outcomes rather than positive adjustment processes. Depression has been linked to decreased functional outcomes and higher levels of mortality and morbidity as well as lowered adjustment scores, decreased levels of social activity and employment, reduced mobility, longer rehabilitation periods, and increased costs to health systems (Fuhrer, Garber, Rintala, Clearman, & Hart, 1993; Fuhrer, Rintala, Hart, Clearman, & Young, 1993; Krause, Sternberg, Lottes, & Maides, 1997; Malec & Neimeyer, 1983; Tate, Forchheimer, Maynard, & Dijkers, 1994; Umlauf, 1992; Umlauf & Frank, 1987). Thus, depression does not play a functional role in the adjustment process but rather contributes to diminished quality of life and health-related problems and is, in fact, counterproductive (Judd, Paulus, Wells, & Rapaport, 1996).

    Theoretical approaches found in the field of positive psychology, in contrast, focus on strengths and the redefinition of personal meaning instead of pathological affective responses. This focus provides new insights into coping processes with practical applications for therapeutic interventions. The presence of hope, optimism, problem solving and goal setting skills are in fact more predictive of quantifiable positive adjustment outcomes for people with SCI (Elliott, Kurylo, & Rivera, 2000, 2002; Elliott & Sherwin, 1997; Elliott, Witty, Herrick, & Hoffman, 1991; Fine, 1991; Kennedy & Rogers, 2000; Snyder & Rand, 2003; Snyder, Sympson, Michael, & Cheavens, 2001; Taylor, Kemeny, Bower, Gruenwald, & Reed, 2000). Qualitative research findings highlight that these approaches are more consistent with perspectives held by people with SCI (Dorsett, 2004a). Thus, clinical interventions that focus on coping strengths rather than pathology, are more therapeutic and contribute to enhanced psychosocial and health outcomes.

Myth 2 Quality of Life
SCI is so devastating that negative consequences for the person with SCI are inevitable. Living with SCI means a poor quality of life.
    The myth of poor quality of life is sustained by a common belief held by health care professionals that life with SCI would not be worth living. A study of emergency workers, for example, reports that only eighteen percent could imagine that they would be glad to be alive following a severe SCI. This is in contrast to ninety-two percent of people with SCI who reported they were glad to be alive even after sustaining SCI (Gerhart et al, 1994). This bias pervades western society and these assumptions inevitably influence the approach professionals have towards people with SCI. (Dijkers, 1996; Gerhart, 1997; Gerhart et al., 1994; Hammell, 2004; Zandrow, 2001).

    It is generally accepted that people with SCI are not a homogeneous group. No individual is exactly like another and each person responds to SCI in way that is unique (Gallagher & MacLachlan, 1999). There has been much controversy surrounding the definition of quality of life and how to measure it. The definition of measurement has moved from a set of predetermined health-related indicators to a measurement of perceived well being (Dijkers, 1997; Hammell, 2004). Each individual has diverse social and environmental contexts which in turn impacts on their perceived quality of life. Consequently people respond in individualized ways to SCI. A person’s perception of quality of life is, therefore, subject to a complex and dynamic interchange of factors such as the disability itself; interpersonal and intrapersonal characteristics such as social context, pre-morbid personality, health status and functional ability; the environment which includes social supports and cultural background; available resources such as finances, access, transport and vocational options; and socio-political aspects (Dorsett, 2001; Garske & Turpin, 1998; Harvey, 1996; Livneh, 2001; Oliver & Sapey, 1999; Trieschmann, 1988).

    Severe sudden-onset disabilities such as SCI do not necessarily impact negatively on subjective well being or quality of life in the longer term (Boswell, Dawson, & Heininger, 1998; Dijkers, 1997). A ten-year longitudinal study found that most people with SCI reported a high level of life satisfaction that remained relatively stable for a decade (Dorsett, 2004b; Dorsett & Geraghty, 2004). The disability itself was not perceived by people with SCI as a major constraint to life participation and satisfaction in this study. The highest levels of satisfaction were found within the domains of family relationships, general health, perceived control over life, and social support. Life opportunities, access to recreational pursuits, and emotional adjustment were identified as minor issues (Dorsett, 2004b).

    It is important that health professionals are aware of the impact their own beliefs have on clinical interventions and attitudes towards people with SCI. It is, therefore, crucial that we are familiar with contemporary research outcomes in order to provide accurate information and effective clinical services (Hammell, 2004). The implications of this research for clinical practice shifts the focus from those domains that professionals consider most important to those that the people with SCI tell us are of more relevance to their life satisfaction and capacity to re-engage in social roles. The challenge is to incorporate clinical interventions which focus on the maintenance of formal and informal social support networks, the removal of barriers, and capacity building in the areas of hope, goal setting and problem solving.

Myth 3 Unrealistic Hope
Unrealistic hope must be dispelled to assist the person to come to terms with the disability. “I will walk again!” is but a statement indicative of the non-acceptance of disability or of poor adjustment.
    According to traditional stage theories, this oft heard statement must be interpreted as pathological adjustment to disability. The question of unrealistic hope has been hotly contested and opinion is polarised (Elliott et al., 1991). Early interventions derived from stage theories focused on addressing false hope, based on the premise that acceptance of one’s fate would allow for a positive adjustment (Kerr & Thompson, 1972; Mueller & Thompson, 1950; Wortman & Silver, 1991). The above statement, I will walk again, creates particular alarm for physical therapists and nurses who become concerned that a state of denial will impact on the progression through the rehabilitation process. Hope is often confused with denial. An injured person’s hope to walk again and the preparation for a life with a disability are not, however, mutually exclusive. Drawing from the field of palliative care, where the importance of hope is openly acknowledged, powerful examples, such as acknowledging when one is dying yet hoping to stay alive, can be found (Back, Arnold, & Quill, 2003). Positive illusions, denial, false hope or optimism may act as a buffer that allows people to maintain purpose. Only at the extreme end of reality distortion is false hope found to be counterproductive (Elliott & Richards, 1999; Elliott et al., 1991). It is important that professionals are able to understand the importance of the role of hope in their interactions with clients.

    It has been said that confronting patients with reality (as in truth telling) destroys hope but this need not be so. Even people who understand that their spinal lesion is complete and are aware that there is no chance of recovery, are able to maintain a seemingly contradictory hope (Dorsett, 2005). In fact it has been established that hope leads to better adjustment (Elliott & Kurylo, 2000; Elliott & Sherwin, 1997). Generally, people who have greater hope are less distressed and less angry and have fewer handicaps in the first year following SCI (Elliott & Richards, 1999).

    When a person with SCI feels emotionally abandoned or believes that their perspective is being dismissed, hope can be destroyed. Supporting and encouraging hope is the role of every rehabilitation professional and begins with interconnected, respectful relationships that are characterised by empathy and understanding (Carpenter, 1994; Snyder, Lehman, Kluck & Monsson, 2006).

Myth 4 Divorce
Divorce is a likely consequence for people who have sustained SCI.
    It is a common belief of many rehabilitation professionals that SCI results in marital stress increasing the risk of divorce. Research findings, however, indicate that while divorce rates are elevated in the first three years following SCI, beyond that period, divorce rates are similar to, or even less than, those of the general population (DeVivo & Fine, 1985; DeVivo & Richards, 1996). These findings suggest that there is an initial period of stress and adjustment in many relationships following SCI. Beyond the first three years, however, it would seem that the relationships of people with SCI differ little from those in the general population, and it is speculated that marriages that are intact after first three years may even be strengthened (Crewe, Athelstan, & Krumberger, 1979; Crewe & Krause, 1990, 1992; De Vivo & Fine, 1985; De Vivo, Hawkins, Richards, & Go, 1995; El Ghatit & Hanson, 1976). Marriages, however, entered into post-injury have significantly lower divorce rates than reported in the general population (De Vivo et al., 1995).

    Divorce rates must be interpreted with caution, never in isolation, when drawing conclusions about adjustment. Divorce rates say little about the quality of relationships prior to sustaining SCI or the quality of relationships that do not result in termination. Likewise, marital satisfaction cannot necessarily be assumed if partnerships have not been terminated. The literature does suggest that it is the attitude of the person with SCI that influences the ability to enter into or maintain relationships (Berkowitz, Harvey, Greene, & Wilson, 1992).

    The research findings tells us that the first three years are the most challenging in marital adjustment following SCI. Attitudes of professionals caring for people with SCI must reflect this knowledge. Services need to be responsive during this period as divorce is not an inevitable consequence of SCI.

Myth 5 Unemployment
A person with an SCI is unlikely to gain meaningful employment.
    There is a perception that serious physical disability precludes a person from re-engaging in meaningful employment. For those that do return to work, professional opinion varies as to the length of the recovery period prior to re-entering the workforce.
    Employment rates, while less than pre-injury rates, are reported by some researchers to be as high fifty percent in some populations (Dorsett, 2001; Krause, 1992). Though poor employment outcomes are commonly reported, Krause (1992) suggests that reporting employment figures at a static point in time may misrepresent employment rates and perpetuate the recurring theme of low employment rates following SCI. It has, however, been found that approximately thirty percent of people with SCI are working at any given period (Engel, Murphy, Athanasou, & Hickey, 1998). Though opinions vary concerning return to work, some consistent generalizations emerge from the literature such as the influences of degree of disability, age, and education level. Other variables identified as influencing return to work include being able to independently access transport (particularly the ability to drive oneself and access to a modified vehicle), marital status, dependent children, motivation, pre-injury employment status and social support (DeVivo & Richards, 1992; DeVivo, Richards, Stover, & Go, 1991; DeVivo, Rutt, Stover, & Fine, 1987; Hess, Ripley, McKinley, & Tewksbury, 2000; Krause et al., 1999; McShane & Karp, 1993).

    The overall picture may be more encouraging than has been suggested. There is evidence that employment opportunities for people with disabilities including SCI have changed over the last two decades in some communities creating a more optimistic outlook for people with SCI. In 1982 it was reported in Queensland, Australia, that less than one fifth of people with SCI were employed in a 1975-80 sample whereas the findings of a later Queensland study report indicate an improving trend (Dorsett, 2001; Richards, 1982). It is probable that these changes are attributable to greater inclusiveness, more opportunity, improved transport and technology, and greater employment incentives.

    Qualitative reports indicate that not all people have the same access to vocational opportunities and that the meaning of work can be of significant individual importance (Fronek, 2005). Most research has focused on the characteristics of those who are employed and failed to address the barriers confronted by those who are marginalised, or the perceptions of those individuals who are unemployed and their unique social or vocational situation (Crisp, 1990; Inge, Wehman, & Targett, 1996). Rehabilitation interventions should work towards providing opportunities, eliminating barriers and incorporating flexible work arrangements as opposed to focusing on the effects of the disability itself. Other factors that relate to discriminatory practices require intervention at a policy or societal level. Policy development, education, transport and other environmental barriers, however, can be addressed and will directly impact on the individual. Positive expectations regarding resumption of work after SCI are an important indicator of successful reintegration into the workforce (Schonherr, Groothoff, Mulder, Schoppen, & Eisma, 2004).

Discussion
    Myths persist far too often in practice settings despite expanding knowledge. Little is written on how to debunk persistent myths that may exist in the interdisciplinary team. In the authors’ clinical experience, modification of practice attitudes can be influenced at two levels; on a case-by-case basis, and through team capacity building. The challenge is for social workers and psychologists to ensure that new knowledge is reflected at both the micro and macro levels. Entrenched views will influence the way rehabilitation is delivered, ultimately impacting on client outcomes. Therefore, it is important that interdisciplinary practices are based on the best evidence available and by collaborative exchanges.

    There are a number of strategies that can be used to facilitate change on a micro level. An important first step is the reflective self-evaluation of personally-held belief systems and how these beliefs stack up against the evidence. A number of issues arise in rehabilitation settings that provide opportunities for sharing contemporary knowledge, offering supportive collaboration and modelling behaviours. As an example, Myth 3, Unrealistic Hope, can create a great deal of anxiety for team members, and it is important to manage these situations by providing information appropriate to clients’ perspectives while acknowledging and responding to the anxiety of the team member. Environments that support and encourage collaborative discussions are important for the dissemination of new learning and are most valued by professionals (Bokhour, 2006; Howarth, Holland, & Grant, 2006).

    On macro level, education strategies and team building are important factors in addressing outdated professional knowledge. Systems generally exist to address educational need in forums such as professional development, supervision, seminars, and conferences. There is an obligation to provide contemporary, evidence-based, needs-related, and client-focused education. Critical thinking and questioning are core components of professional development.

    Traditional approaches have focused on discipline-specific practices while increasingly quality rehabilitation services are moving towards collaborative interdisciplinary exchanges. The myths discussed above perpetuate the old ways of doing things. They provide potent examples of spoken and unspoken influences that profoundly impact on rehabilitation practices and client outcomes. At a leadership level, it is increasingly important to nurture cultures of collaborative practice that promote professional growth.

Conclusion
    Adjustment to SCI is a complex and individual process incorporating the interplay of a multitude of factors. The research tells us that the views of professionals working with people with SCI can vastly differ from the views of people living with SCI. As professionals, our obligation is to respect the unique body of knowledge that the client brings to the rehabilitation process. People with SCI deal with the immediate impact of trauma in the short term and the effects of living with disability in the long term. Effective clinical interventions need to be focused where there is most benefit. Therefore, it is important that as rehabilitation professionals, we respond in ways that positively influence the individual’s coping abilities and assist the person to overcome the life crisis being confronted. By debunking myths based on tradition and adopting a leadership role within the interdisciplinary team, social workers and psychologists are in a unique position to influence the way rehabilitation professionals deliver services. Translating new understandings based on contemporary research into practice is the first step towards truly holistic rehabilitation. Perhaps we need to re-evaluate our positions within the interdisciplinary team and facilitate, in new ways, the negotiation of the shifting sands between knowledge and practice.

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Pat Dorsett, MD, is a professor at the School of Human Services, Griffith University, Queensland, Australia.
Patricia Fronek, BSW, is with the Queensland Spinal Cord Injuries Services, Queensland, Australia.

INDEX

Abstract
     This case study explored the challenge of using verbal feedback with an individual following simultaneous with spinal cord injury and traumatic brain injury (SCI/TBI) with visual impairment. A man in his late 20’s received a severe open head injury and T5 ASIA B ischemic spinal cord injury secondary to a motorcycle accident in which he was not wearing a protective helmet. Neuropsychological testing revealed moderate-to-severe deficits in the area of delayed memory, with particular problems in acquisition and maintenance of new information. The individual demonstrated difficulty in making functional rehabilitation progress related to visual and memory decrements. At the conclusion of inpatient rehabilitation, he demonstrated the capacity to make functional rehabilitation gains through the use of consistent verbal cues and reinforcement.

Keywords: brain injury, rehabilitation, spinal cord injury, visual impairment

Introduction
     Spinal cord injury is a destructive event that often results in significant physical and emotional changes and life-long adjustment. Although the etiology of SCI is varied, the primary causes include motor-vehicle accidents, falls, sports-related injuries, and violence (e.g., Elovic & Kirschblum, 1999). Given that these events are also the major causes of traumatic brain injury (TBI), it should not be a surprise that a growing body of research has begun to examine the complex association between TBI and SCI. Although estimates vary, it is thought that between 20% and 50% of patients with cervical SCI have experienced some degree of TBI (Cook, 2003). Although the literature pertaining to the management of either TBI or SCI is quite large, empirical investigations examining dual-diagnosis SCI/TBI are relatively lacking.

     There are 10,000 hospital admissions for SCI in the United States each year. In contrast, there are more than 250,000 TBI-related hospital admissions (Elovic & Kirschblum, 1999). The majority of SCIs occur in young people, with approximately 55% of traumatic SCIs sustained by individuals between the ages of 16 and 30. Similarly, the highest incidence rate reported for people with TBI occurs in those between the ages of 15 and 24 (Elovic et al.). TBI is considered primary when the individual’s brain injury is more severe in actual physical damage and resulting brain-behavior impairment, where SCI is the primary focus due to pervasive paralysis and physical impairment. It is far more common for patients with SCI to have concomitant TBI, with the incidence rate ranging from 24% to 50%, than for those with primary identified TBI to also have SCI, with estimates for this problem ranging from 1.2% to 6% (Elovic et al.).

     Arzaga, Shaw, and Vasile (2003) have highlighted the complexity of dual-diagnosis SCI/TBI, noting that many brain injuries tend to be undetected, or, if detected, their importance minimized, particularly during the emergent and acute phases of rehabilitation. According to the researchers, treatment providers may begin to notice that the SCI individual has a brain injury when they begin to demonstrate problems with resistance or cannot carry out functional activities appropriate to their level of SCI. In general, the researcher’s findings show that cognitive deficits can greatly complicate the ability of a person with SCI to learn compensatory strategies for dealing with the physical limitations imposed by their SCI.

     In terms of etiology, dual-diagnosis TBI and cervical SCI are primarily due to high-velocity mechanisms of injury, with the severity of TBI or initial Glasgow Coma Scale (GCS) scores offering less utility as predictor variables. Additionally, individuals undergoing blunt trauma in high-velocity mechanism incidents appear to be at particular risk for extradural supportive soft tissue cerebrospinal injuries (Albrecht, Malik, Kingsley, & Hart, 2003). The range of causes of SCI/TBI has not been fully examined; more research is needed in this area.

     Neurocognitive differences have been found between persons with SCI and non-SCI individuals. Specifically, Tran, Boord, Middleton, and Craig (2004) found that individuals with SCI, compared to able-bodied controls, demonstrated consistently reduced brain wave activity as measured by peak amplitude and magnitude, with these differences found to be larger in the parietal and occipital regions of the brain. According to the researchers, individuals sustaining SCI had consistently lower frequencies than controls without SCI. A notable additional finding was that a subgroup of SCI participants with tetraplegia displayed significantly reduced brain activity compared to the paraplegic subgroup and able-bodied controls.

     Co-occurring TBI has been found to impair the functional outcome of persons with SCI. Macciocchi, Bowman, Coker, Apple, & Persons (2004) found that SCI patients with dual-diagnosis TBI demonstrated significantly lower Cognitive FIM scores at admission and discharge from rehabilitation compared to persons with SCI alone. The researchers also found that individuals with dual-diagnosis SCI/TBI achieved a significantly lower Motor FIM change than persons with SCI. In contrast, GCS scores or the presence of intracranial lesions were not successful predictors of functional outcome in the dual-diagnosis group. These results underscore the notion that while brain injury appears to limit the functional gains made by SCI patients, a non-linear relationship appears to exist between brain injury severity and functional change.

     These findings have important implications for rehabilitation, as there may be significant disruption of traditional rehabilitation treatment, goals, and outcome when TBI and SCI occur together (Riker & Regan, 1999). Due to the psychological and neuropsychological features of concomitant SCI/TBI, interdisciplinary rehabilitation teams are required to adjust rehabilitation approaches and modify treatment expectations for the SCI/TBI individual. This case study explored the unique challenge of using verbal feedback with an individual following dual-diagnosis SCI/TBI and visual impairment.

Case Background
     A male in his late 20’s received a SCI/TBI secondary to a motorcycle accident in which he was not wearing a helmet. He sustained a T5 ASIA B ischemic spinal cord injury and severe open head injury. Length of coma was approximately 12 weeks. His medical records revealed that he experienced legal blindness in both eyes as a result of ischemic optic neuropathy caused by significant blood loss associated with his accident.

     This individual presented to an urban Veterans Affairs Medical Center SCI inpatient unit for rehabilitation in preparation for an intensive blind rehabilitation program. Psychology received a formal consult to evaluate his cognitive status in preparation for this program. Specifically, he was transferred to this program for an upgrade of his activities of daily living (ADL’s), bed-to-wheelchair transfers, and bowel and bladder management.

     The man presented with a complex symptom constellation. From a cognitive standpoint, he showed persistent delayed memory loss with subsequent problems in rehabilitative skill acquisition. Central to these problems was the significant difficulty he experienced remembering details. Although he had a limited daily schedule, he would easily forget his appointments if a nursing aide did not remind him of them. When residing in an assisted living environment, he was noted to forget appointments quite frequently.

     His pronounced memory problems greatly impacted his progress in physical rehabilitation activities, as he would consistently forget what he had accomplished the previous day and what he was scheduled to do during the present day, as well as failing to recall his future therapeutic goals. He also reported increased forgetting for detail. In general, his functional rehabilitation difficulties appeared to be related to his difficulty in acquiring and retaining new information. Psychology was consulted to help develop a plan to improve this individual’s participation in rehabilitation activities.

Method
Study Design
     This case study was AB in nature, with A = the baseline period prior to verbal feedback and B = verbal feedback. Verbal feedback was defined as detailed professional information given to the patient related to his rehabilitation progress. Verbal feedback was also provided through the use of a Voice Cueâ„¢ device (see below). Dependent variables included functional rehabilitation gains as measured in a variety of areas, psychological health, and cognitive performance.

Neuropsychological Evaluation
     Neuropsychological testing was conducted over the course of two, two-hour testing sessions, with the evaluation taking place approximately four weeks into the individual’s ten-week inpatient stay. A brief cognitive screen administered during the first testing session revealed severe impairments in the area of immediate memory for words presented in auditory fashion, although the individual performed within normal limits on the rest of the cognitive domains assessed during the first testing period. The individual’s performance during the second testing session revealed average to above-average verbal intelligence. Abstraction capabilities appeared average. Similarly, he was able to complete arithmetic problems with accuracy. Working memory appeared to be above-average. Consistent with findings obtained during the first test period, he displayed moderate deficits in the area of delayed memory for auditory information. A notable finding on testing was that the patient appeared to experience significant problems recalling information after periods of distraction. Given the results of testing, combined with his presentation, the individual received a diagnosis of post-concussion syndrome. These results were consistent with findings from a previous neuropsychological evaluation the individual underwent approximately two years prior.

Individual and Team Recommendations
     Based on the results of neuropsychological evaluation, the following recommendations were offered. It is important to note that these recommendations pertained not only to the individual, but also to the interdisciplinary SCI treatment team.
     1. Given that the individual appears to be able to learn information effectively (although he cannot retain this information well), he should be encouraged to develop creative strategies for information retention, including using his mini tape recorder to replay important information.

     2. Although the individual is of above-average intelligence, he appears to retain information presented in a simple manner much better than detailed data. When interacting with him, rehabilitation staff should attempt to present information to him in as straightforward a manner as possible.

     3. The individual will continue to benefit from information presented in different sensory modalities. If possible, important information regarding his goals should be presented in both tactile and verbal forms.

     4. A structured daily schedule with clear goals and expectancies may benefit the individual greatly in his rehabilitation efforts. This schedule should be communicated by nursing staff to the patient at the start of each day so he is able to plan his activities accordingly.

     5. In an effort to improve the individual’s ability to cope with his loss of vision, he is encouraged to seek assistance from the Vision Clinic, affiliated with VA Boston Healthcare System.

     6. The individual is also encouraged to continue to meet with an occupational therapist to assist him in bed-to-wheelchair transfers and other independence-promoting exercises.

     All SCI interdisciplinary team members worked intensively with the individual beginning with his admission to the inpatient unit. Members of the treatment team included physicians, social workers, occupational therapists, physical therapists, and psychologists. A speech and language pathologist was also an important member of the treatment team since this professional worked with the patient to increase his facility with the Voice Cueâ„¢ device.

Cognitive Rehabilitation
     Psychology met with this individual over the course of 12 individual psychotherapy sessions, conducted over the span of approximately 1.5 months. Psychotherapy incorporated divergent techniques, mainly derived from the cognitive rehabilitation literature. In an attempt to improve the individual’s sustained attention and concentration, visual imagery was used. In addition to the cognitive rehabilitation aspect of psychotherapy, other areas of treatment focus included increasing the individual’s willingness to advocate for his current and future medical and emotional needs, and to process his feelings regarding his childhood and current estrangement from his family.

     In addition to working individually with the person, psychology consulted with the SCI inpatient interdisciplinary team, asking staff to provide the man with clear and constant expectations regarding his progress in all rehabilitation modalities. This communication was particularly necessary in the area of physical, occupational, and kineseotherapy, given that the individual experienced the majority of his problems in these areas. Psychology also worked with him to develop techniques for coping with his poor memory, including brainstorming ways to retain more information over a longer period of time.

     These techniques included using a Voice Cueâ„¢ device that was clipped to the patient’s shirt and used to record verbal instructions, programmed to replay these instructions at preset times throughout the day. These instructions ranged from “brush your teeth” and “take your medication” to reminders of how much weight the patient lifted or how many exercises he did during a certain day. As detailed in the results section, this device was found to significantly improve the patient’s functional rehabilitation gains.

     Along with the use of the Voice Cueâ„¢ device, information was also presented in a straightforward manner and in both tactile and verbal modalities, which appeared to benefit the individual. Examples of tactile presentation included the therapist guiding the patient’s hands around the various Voice Cueâ„¢ buttons in addition to the work of physical and occupational therapy staff in helping the patient maneuver his body to successful transfer positions. Additionally, a structured daily schedule with goals and expectancies was used, with this information posted on the individual’s walls and communicated to him throughout the day. All of these techniques appeared to be helpful in improving his participation in rehabilitation activities.

Results
     At the conclusion of an eight-week rehabilitation period, the individual was able to demonstrate capacity to make functional rehabilitation gains via consistent verbal cues. Functional gains were demonstrated across a variety of treatment domains, including physical and occupational therapy, speech and language, and mental health. In the area of physical and occupational therapy the patient demonstrated significantly faster times in conducting bed-to-wheelchair and wheelchair-to-bed transfers. He was also observed to perform this activity in a more focused manner. In the area of speech and language, at the conclusion of rehabilitation the patient demonstrated significant greater facility in using his Voice Cueâ„¢ device. With the aid of this device, he was also able to complete his activities of daily living with greater proficiency.

     The patient demonstrated notable progress in the areas of emotional and cognitive functioning. Notably, his Global Assessment of Functioning (GAF), a brief general measure of psychological well-being, improved from an admission rating of 60 to 75 at the time of discharge. Additionally, his Cognitive FIM score increased significantly throughout the course of treatment.

     At the conclusion of cognitive rehabilitation the individual actively endorsed pursuing the following goals: 1) listening to books on tape, 2) participating in increased arts and crafts activities, 3) working with clay (sculpting) and doing oil painting, 4) using a computer to do book reports, and 5) participating in increased occupational therapy, physical therapy, and kinesoeotherapy.

     Despite the patient’s improvement across a variety of areas, he experienced significantly greater problems achieving functional gains in rehabilitation when compared with other SCI inpatients who had not sustained a traumatic brain injury. He also experienced significantly greater difficulty achieving functional gains in comparison to dual-diagnosis SCI/TBI patients without visual impairment.

Discussion
     The use of verbal feedback with a person with SCI/TBI and visual impairment proved to be quite challenging, but through interdisciplinary team communication and efficient staff interventions, the individual was able to demonstrate notable functional gains, ultimately improving his functional independence and personally-defined quality of life.

     The difficulty that the individual experienced in achieving functional gains in the current study are consistent with aforementioned findings by Macciocchi et al. (2004) who found that persons with dual-diagnosis SCI/TBI achieved smaller functional gains during rehabilitation when compared to peers with SCI. Corroborating findings from Macciocchi et al., it appeared that while the individual in the present study was limited by both his brain injury severity and visual impairment, the relationship between the impact of these constructs did not form a direct linear relationship with the person’s functional limitations.

     In terms of visual rehabilitation services, the VA Boston VIST team may have been of service to this patient, although it is important to note that traditional education materials and groups in SCI or TBI programs will need to adapt their training procedure and materials to individuals with dual diagnosis. This can be done by targeting residual strengths in the emotion, physical, and cognitive areas. Similarly, environmental modification, a clear and consistent daily schedule of therapy, limiting distractions and competing stimuli, and prioritizing activities and providing rest breaks may also be of benefit.

     Future research may focus on the importance of patients’ attributional style and self-definition of their SCI. Findings from Crewe (1996) suggest that individuals who demonstrate better adjustment to SCI are those that redefine their values and increase their awareness and appreciation across a variety of life activities and abilities. Additionally, Hammell (2004) suggests that quality of life among community-dwelling individuals with high spinal cord injury can be improved through a reorientation of life values and goals. Future studies in this area may also focus on using assessment measures for vision rehabilitation (Babcock-Parziale & Williams, 2006).

     In summary, effective intervention with this patient did not solely include cognitive rehabilitation, but targeted emotional intervention as well. Although more progress is left to be made, this unique treatment mixture proved to be effective in successfully treating the challenging combination of the patient’s SCI, TBI, and visual impairment.

References
Albrecht, R. M., Malik, S., Kingsley, D. D., & Hart, B. (2003). Severity of cervical spine ligamentous injury correlates with mechanism of injury, not with severity of blunt head trauma. American Surgery, 69(3), 261-265.

Arzaga, D., Shaw, V., and Vasile, A. T. (2003). Dual diagnosis: the person with a spinal Cord injury and a concomitant brain injury. SCI Nursing, 20, 86-92.

Babcock-Parziale, J. L. & Williams, M. D. (2006). Historical perspective on the development of outcomes measures for low-vision and blind rehabilitation in the Department of Veterans Affairs. Journal of Rehabilitation, Research and Development, 43(6), 793-808.

Cook, N. (2003). Respiratory care in spinal cord injury with associated traumatic brain injury: bridging the gap in critical care nursing interventions. Intensive Critical Care Nursing, 19(3), 143-153.

Crewe, N.M. (1996). Gains and losses during due to spinal cord injury: views across 20 years. Topics in Spinal Cord Injury Rehabilitation, 2, 42-54.

Elovic, E., & Kirschblum, S. (1999). Epidemiology of Spinal Cord Injury and Traumatic Brain Injury: The Scope of the Problem. Topics in Spinal Cord Injury Rehabilitation: Dual Diagnosis: SCI-TBI, 5(2), 1-20.

Hammell, K.W. (2004). Quality of life among people with high spinal cord injury living in the community. Spinal Cord, 42, 607-620.

Macciocchi, S.N., Bowman, B., Coker J, Apple, D., Leslie D. (2004). Effect of co-morbid traumatic brain injury on functional outcome of persons with spinal cord injuries. American Journal of Physical Medicine Rehabilitation, 83(1), 22-26.

Ricker, J.R., & Regan, T.M. (1999). Neuropsychological and Psychological Factors in Acute Rehabilitation of Individuals with Both Spinal Cord Injury and Traumatic Brain Injury. Topics in Spinal Cord Injury Rehabilitation: Dual Diagnosis: SCI-TBI, 5(2), 76-82.

Tran, Y., Boord, P., Middleton, J., & Craig, A. (2004). Levels of brain activity (8-13Hz) in persons with spinal cord injury. Spinal Cord, 42, 73-79.

John W. DenBoer, MA, is Clinical Fellow in Psychology, Harvard University School of Medicine, Teaching Fellow in Psychiatry, Boston University School of Medicine, and Psychology Intern at the Spinal Cord Injury and Neuropsychology Services, VA Boston Healthcare System
Sigmund Hough, PhD, ABPP, is Assistant Professor, Harvard University Medical School; Adjunct Assistant Professor, Boston University School of Medicine, and Clinical Neuropsychologist at the Spinal Cord Injury Service, VA Boston Healthcare System.

INDEX

Greetings!
The Annual Conference approaches and I encourage members to register before July 1 for the best registration rate. The Program Committee has organized an excellent venue of speakers and will be providing additional information regarding the Gaylord Palms Resort & Convention Center, area amenities, activities, and events. We are also fortunate to have the band, The Incredible Shrinking Heads (featuring many of our members) performing on Tuesday night. We anticipate an excellent conference experience.
I want to take this opportunity to address one of the ways we are networking to enhance the conference. Paralyzed Veterans of America has reached out to our association, APS & AASCIN expressing their commitment to our core mission of providing education on SCI care. For the 2007 conference, PVA has agreed to sponsor a plenary speaker and reception to facilitate member access to VA administrators and they are also funding an honoraria, thereby stretching our resources and allowing us to invite excellent speakers. PVA is also providing members who are employees of the VA 30 registration scholarships per association. Information about accessing the scholarships will be posted in Dr. Margaret Hammond’s June/July newsletter. Most happily, we have been assured that PVA wants to continue to be a source of assistance moving forward.

    Our dialogue with PVA is part of a broader strategic plan to enlarge our circle of support. PVA provided funding for a Tri-Association Strategic Planning meeting, April 27-29. Four members of each Board participated in addition to United Spinal President & CEO Paul Tobin; United Spinal Associate Executive Director Vivian Beyda; PVA Director of Research and Development Thomas Stripling; and PVA Deputy Executive Director Maurice Jordan. AASCIPSW representatives were Helen Bosshart, Patti Rogers, Lester Butt and I. The major points of agreement among the three Associations include commitments to:

1) Moving toward greater interdependence, collaboration, and communication between associations;

2) Maintaining dynamic conversations to respond to vital issues and trends, such as decreasing membership;

3) Collaborating on fund raising;

4) Expanding partnerships with other associations;

5) Acknowledging that United Spinal and PVA will be our principal partners;

6) Maintaining separate Boards of Directors at each association to ensure decision making rights for each Association;

7) Expanding and improving the conference and The Journal of Spinal Cord Medicine, which is core to the Tri-Association mission.

    The Tri-Association Strategic Planning group will meet immediately following the annual conference for expanded dialogue on our goals. We anticipate seeking funding for future planning meetings as well.

    In March, the AASCIPSW Board of Directors held discussion about our association’s strategic planning. We affirmed our principal mission of providing our members with access to the most comprehensive education and networking opportunities within SCI psychosocial rehabilitation care. The core of the plan includes:

1) Education: Strengthening and integrating the annual conference with APS and AASCIN, exploring development of an SCI 101 course, online CEU’s;

2) Web development as a portal to introduce mental health professionals to our Associations and member-only access to vital information/networking;

3) Collaboration with our partners that may include, among other possibilities, preparing White Papers on policy issues, preparing consume tip sheets, or providing articles for association publications.

4) Financial viability: We are exploring collaborative fund raising with APS & AASCIN and looking into revenue generating projects. A major part of this plan is the creation of a finance committee and a Board of Directors position of Treasurer.

    I trust that it is apparent that AASCIPSW is positioning itself for growth. Growing pains are inevitable, yet I am greatly encouraged by the number of individuals who renewed membership, our members’ interest in participating on our committees and the Board, and the steadfast commitment of our sister Associations and partners, most notably, United Spinal and PVA.

    You are aware that funding changes at United Spinal have necessitated the elimination of grants for conference attendance from 2009 forward. United Spinal, however, remains resolute in working with the three Associations to create the best conference. They are reaching out to occupational, physical and respiratory therapists, as well as consumers to enhance our rehab team model and they are committed to ensuring that the conference remains affordable. They will also maintain our Association’s infrastructure to allow our ongoing growth and activities in pursuit of our mission. By cultivating partnerships, we stand the best opportunity for growth and meeting our goal of providing access to an outstanding conference.

    Before closing, I want to take a moment to introduce new leadership:

Board of Directors-Sara Klaas, MSW; Sigmund Hough, PhD, ABPP; Alan Goldberg, PhD, ABPP.

Clinical Practice Committee-Shirley Jackson, MSW; and Cathy Williams-Sledge, PsyD.

Membership Committee-Carey Pawlowski, PhD, Bill Finger, PhD.

Research Committee-Glenn Curtiss, PhD, Michelle Meade, PhD.

Program Committee-Robin Kohn, MSW, LSCW; Stan Ducharme, PhD.

Electronic Communication Committee-Karen Boswell, PhD, Emily Scott, LCSW; Elizabeth Letsch, PhD.

We welcome their creativity, ideas, and energy!

    At the close of the annual meeting, we will bid farewell to several Board members: Helen Bosshart, Chuck Merbitz, Pam Fitzpatrick and Scott Richards. Each has served our Association well and will be greatly missed. We know that Helen, Chuck, Pam, and Scott, with their deep appreciation for our mission and work, will remain available to help as needed. Words are inadequate to express our thanks for your hard work and you’re your numerous, valuable contributions!

    Have a wonderful summer. Please do not hesitate to contact me if you have any question or comments. I look forward to seeing you in Orlando in August!
    Best Regards,

Terrie Price, PhD, ABPP
President

INDEX

Bush Vetoes Stem Cell Bill Again
    For the second time in two years, the U.S. Senate passed S5, the Stem Cell Research Enhancement Act, which would lift the ban on federally funded stem cell research. President Bush vetoed the bill in 2006 after it had passed both Houses of Congress by wide margins and, despite the Senate passing it again this spring, the President vetoed it for a second time on June 20, infuriating scientists and disability groups. Senator Hillary Clinton and others immediately accused the President of placing his moral beliefs ahead of science and the needs of millions with disabilities who may benefit from the research.

     Although the President maintained his position of not sacrificing human embryos for research cures, he did sign a second executive order to continue “ethically responsible” research in other federally funded research with stem cells such as embryonic fluid and mice stem cells. However, the American Fertility Association which represents the 40,000 individuals who have created the more than 400,000 frozen human embryos, has issued a statement urging Congress to override the President’s veto stating, “Our members have suffered greatly-psychologically, emotionally, physically, socially and financially-to produce the embryos. In large measure, and for a variety of reasons, the hundreds of thousands of embryos banked in liquid nitrogen will not be used for family building purposes. For many couples who wrestle with the embryo disposition dilemma, donating them to research is a life-affirming choice that allows for closure.” Indeed, in a study just released by Duke University Medical Center and John Hopkins University found that 60% of the 1,000 fertility donors surveyed indicated they would likely donate surplus embryos for stem cell research as opposed to seeing them discarded.

     Last year, the National Spinal Cord Injury Association joined members of the Coalition for the Advancement of Medical Research as co-signers of a letter supporting passage of H. R. 810. The bill would have amended the Public Health Service Act to require the Secretary of Health and Human Services to conduct and support research that utilizes human embryonic stem cells. Provisions would include that: the embryos have been donated from in vitro fertilization clinics; were created for the purposes of fertility treatment; were in excess of the needs of individuals seeking such treatment and would never be implanted to a woman and therefore discarded; and, were donated by such individuals with written informed consent and without any financial inducements.

     Since President Bush’s original Executive Order restricting funding to 62 lines of stem cells, these have steadily declined and there are reportedly only 10 lines that can continue to be used. For more information, contact the National Spinal Cord Injury Association’s website at www.spinalcord.org.

Robotic Leg Program at Sister Kenny Institute
     Therapists at Sister Kenny Rehabilitation Institute at Abbott Northwestern Hospital in Minneapolis have been using locomotion therapy to help patients relearn how to walk after strokes and partial spinal cord injuries. The Lokomat System combines robotic legs, a treadmill, and a high-powered computer with synchronized drives to actively move patients’ legs on a treadmill similar to an otherwise normal gait. Locomotion therapy is not new but became well-known several years ago when Christopher Reeves appeared to be making progress by gaining back leg strength and mobility under the direction of Dr. John McDonald.

    Dr. McDonald has since patented his locomotion therapy walking system. In the past, locomotion therapy was initiated by physical therapists who manually moved patients’ legs by hand. The new computerized process instead involves inserting patients’ legs into robotic legs attached to the synchronized gears and treadmill. The machine’s computer provides biofeedback regarding leg force and hip and knee joint movements. According to researcher Tim Bowman, the therapy allows patients to reduce stiffness, improve force and regain a range of motion that can help them relearn to walk.

Panel Faults Outdated US Policies for Problems for Many Persons with Disabilities
    Alan Jette, director of Boston University’s Health and Disability Research’s Institute of Medicine panel blamed outdated US policies for keeping many Americans with disabilities from getting the help they need. Jette wrote, “Society must do more now before a crisis is upon us… far too little progress has been made in the last two decades to prepare for the aging of the baby boom generation and to remedy obstacles that limit what too many people with physical and cognitive impairments can achieve.”

    The report explored a wide range of issues including building and community accessibility, policy gaps and limitations in health insurance coverage and payment obstacles for equipment such as wheelchairs and scooters. The group further cited that younger and middle-aged people face increasing risk for disability due to sedentary lifestyles leading to obesity and Type II diabetes.

    The 14 member panel also drew attention to the thousands of US soldiers with disabilities returning home from Iraq and Afghanistan, saying that their plight and the inadequacy of currently available services would bring even greater national attention to Americans with disabilities. Archaic Medicare and Medicaid policies requiring persons with physical disabilities to be prisoners in their own home before qualifying for certain services need to be immediately addressed. The panel also urged Congress to eliminate the two-year waiting period for Medicare eligibility for people receiving Social Security Disability Insurance, since the majority of them need coverage urgently.

    The Institute of Medicine provides advice on health issues to US policymakers, and had previously produced reports regarding disability issues in 1991 and 1997.

INDEX

    Mr. Chavez* fell down a flight of stairs in his home last year. The accident left him quadriplegic. He spent the next several months in rehabilitation centers and nursing homes before coming to the Spinal Cord Injury unit at the Edward Hines Veterans Affairs Medical Center for further acute rehabilitation. Mr. Chavez is 70 years old, a veteran, and a retired high school guidance counselor. His wife is an 85-year-old retired biologist. It is a second marriage for both and they have had a loving relationship for over 30 years. They each have adult children from previous marriages who live in other parts of the country. Until the accident, they were enjoying their retirement, spending their savings on travel.

    The Hines SCI staff believes it unlikely that Mr. Chavez will ever walk again. Mrs. Chavez is having great difficulty accepting her husband’s condition and believes that if he keeps getting physical rehabilitation, he will improve. Mr. Chavez worked hard in rehab but made few gains. After several months of rehab at Hines, staff prepared Mr. and Mrs. Chavez for his discharge home. In a discharge planning meeting, they were told quite frankly that he sustained an injury that, short of a miracle, would not allow him to walk again. Staff also discussed the level of care Mr. Chavez would need to remain healthy at home.

    After discharge, Mr. Chavez became part of the Hines SCI Home Care Program where he could be followed by an interdisciplinary team. In preparation for discharge, the Chavez home was evaluated by the SCI Home Care program. Recommendations for making the home wheelchair accessible were made and needed equipment was ordered and delivered.

    Tellingly, Mrs. Chavez missed appointments with the Hines physical therapists for training on a manual lift, yet she often cornered the physician and social worker wanting to discuss future physical rehabilitation as the key to her husband’s full recovery. Meanwhile, Mr. Chavez regularly saw the psychologist on the rehab unit and was coming to terms with his disability. Generally, he had a positive attitude and was grateful for the years he had before the accident. At times, however, he expressed frustration with his wife’s difficulty in accepting his condition.

    Once discharged home, Mr. Chavez would need two hours of care in the morning to get him out of bed, groomed, and dressed and another two hours of assistance in the evening to prepare him for bed. As the social work intern assigned to Mr. Chavez, I provided his wife with a list of caregiver agencies as well as Americans with Disabilities Act specifications for ramp construction. I spent time with Mrs. Chavez at the hospital and on the phone listening to her concerns and providing resources. She was very anxious about her husband’s return home because she would not be able to provide much of his care due to her arthritis. By the time Mr. Chavez was ready for discharge, she had put in place a good caregiving system.

    Mr. Chavez’s transition home was not smooth. He was coming to Hines twice a week for physical rehabilitation and when I asked him how it was at home he said, “Psychologically it is better, but operationally it is worse.” He described feeling trapped in their living room because the split-level, ranch style home had steps leading into all adjoining rooms; there were a few bowel accidents in the night; there were problems operating the lift; Mrs. Chavez’s anxiety level had skyrocketed. She was not sleeping and had become depressed. It was suggested that they increase the caregiver’s hours from four to eight hours per day in order to alleviate some of her stress. Mrs. Chavez asked for a list of nursing homes in the area, which I provided for her. Within two weeks of returning home, Mr. Chavez was once again in a nursing home.

    A month after entering the nursing home, Mr. Chavez was admitted to the Hines SCI unit, this time for a medical procedure. We asked him if he would be interested in being added to the waiting list for the Hines Spinal Cord Residential Care Facility, which houses approximately 30 veterans with spinal cord injuries. Mr. Chavez liked the idea and so did Mrs. Chavez. I escorted Mrs. Chavez on a tour of the facility and she was very happy with what she saw. Mr. Chavez would have twenty-four hour care, access to the physical rehab unit, socialization with his peers, and would be able to move about the vast Hines campus. Mrs. Chavez says she misses living with her husband and becomes lonely at times but said she was totally overwhelmed with his care. Mr. Chavez is now living in a nursing home waiting for admission to the Residential Care Facility.

Clinical Impressions:
    In an instant, Mr. Chavez was rendered quadriplegic. This is how it happens for most: a fall, a diving accident, an automobile accident, or a gun-shot wound-an accident that forever alters an individual’s life and a family’s life. No one can ever be prepared for something like this and social workers and psychologists have a very important role to play in adjusting to the injury. They provide therapeutic counseling, psycho-educational training, case management, community resource information, and assistance in navigating Social Security and other health benefits.

    Spinal cord injury social workers and psychologists help individuals and their families adjust to a devastating physical and emotional experience. If we cannot emotionally connect with the person, or if we feel judgmental about their shortcomings and weaknesses, we will not be able to provide the best care. Having empathy for Mr. and Mrs. Chavez made working with them easier.

    There were times, however, when my patience wore thin and I would discuss my frustrations with a colleague and get some clinical advice. As we go about what is, at times, the emotionally difficult task of helping others, the value of consultation and support from our mentors and our peers cannot be overstated.

* The names and some details of the case have been changed.

Robin Dannevik is a recent graduate of Loyola University’s school of social work. Her master’s degree field placement was at Hines V.A. Hospital where she was a social work intern for eight months on the spinal cord injury unit.

INDEX

     Individuals who incur a spinal cord injury (SCI) face immediate, profound, and often permanent life changes. The enormity of the SCI, however, often dominates the clinical picture, and when concomitant impairments such as traumatic brain injury (TBI) occur they are often overlooked. This can create less than optimal outcomes for individuals as they move through the continuum of care. Pioneering research of these issues suggested that 25% to 57% of persons with acute SCI might have a concomitant traumatic brain injury (Roth et al., 1989; Scheuman & Morris, 1982), and some cognitive impairment may be present in 67% of individuals in SCI rehabilitation (Wilmot, Cope, Hall, & Acker, 1985). Most studies indicate that cognitive impairment affects between 40% and 50% of persons with SCI (Davidoff, Roth & Richards, 1992). Consequently, individuals who sustain co-morbid TBI or have pre-morbid cognitive deficits can have poorer outcomes, especially during inpatient rehabilitation.

    Co-morbid traumatic brain injury is often not identified, or is misinterpreted as a behavioral or psychological effect of the SCI. According to Davidoff and colleagues (1992), the sequelae of even mild cognitive impairment include “…difficulties with attention, concentration, memory, problem solving, abstract reasoning, new learning, and high-level cognitive skills” (p. 275). Macciocchi, Bowman, Coker, Apple and Leslie (2004) suggest the presence of any brain injury may be sufficient to delay or offset skill acquisition in rehabilitation. Their data indicate that during acute rehabilitation, dual diagnosis of TBI and SCI may be associated with fewer functional gains in comparison to patients with SCI, but the association between TBI and overall response to SCI rehabilitation may be more complex than clinically assumed.

    One of the most challenging aspects to the issues of concomitant SCI and TBI is the accurate identification and assessment of cognitive deficit. Unfortunately, due to the severity of problems associated with primary SCI, mild or moderate head injuries may be overlooked during initial assessment (Narayan, Gokaslan, Bontke & Berrol, 1990; Ricker & Regan, 1999). A thorough assessment of cognitive deficits requires an examination of any pre-injury cognitive deficits and acquired cognitive deficits due to trauma. Pre-injury sources of cognitive impairment can include past TBI, alcohol and substance use, poor pre-injury academic, intellectual or occupational functioning, age-related cognitive decline, and other medical conditions and psychiatric disorders. Pre-injury cognitive deficits can contribute to poorer rehabilitation outcomes, even without the presence of an acute TBI at the time of injury. For example, the general cognitive deficits associated with chronic alcohol consumption can include decreased motor coordination, difficulty with abstract thought, deficits in attention and concentration, and loss of visual and verbal memory (Ryan & Butters, 1986). Chronic alcoholism also negatively affects higher-order cognitive processes, such as planning, organizing, and behavior regulation (Arria & Van Thiel, 1992), all of which can affect the inpatient rehabilitation process.

    Pre-injury sources of cognitive impairment can also be a factor in the development of secondary complications. A history of alcohol abuse also contributes to secondary medical complications at a predictable rate. For example, Elliott, Kurylo, Chen, and Hicken (2002) found rates of diagnosed pressure sores among persons in acute SCI rehabilitation were 2.5 times higher over the first three years of SCI among those with severe alcohol abuse histories prior to SCI onset when compared to their peers without alcohol use problems.

    A thorough assessment of the individual with a traumatic SCI must examine both pre-morbid and acutely sustained TBI. The assessment of acute TBI is challenging and often not done due to the more obvious presentation of the SCI. The following methods of assessment should be included to help identify the presence of traumatic brain injury:

Documented Loss of Consciousness
    Loss of Consciousness (LOC) may occur at the time of a spinal cord injury. Loss of Consciousness is routinely documented by emergency personnel at the scene of an accident; additionally, this documentation is usually found in the admitting History and Physical from the emergency room physician. Clinicians cannot take the lack of this documentation at face value, however, since victims or witnesses may not report LOC at the time of the accident. The clinician is therefore advised to include a specific question about LOC in rehabilitation assessment protocols.

Glasgow Coma Scale
    The Glasgow Coma Scale (GCS) was designed in to objectively measure the degree of unconsciousness following a TBI. It is the most widely used severity scale in United States emergency rooms and hospitals (Sorenson & Kraus, 1991). The GCS was developed in 1974 to standardize the clinical assessment of unconsciousness by examination of three primary areas: motor response, verbal response and eye opening (Sternbach, 2000). In its current use, the GCS allows clinicians to determine severity, predict outcome and direct clinical management. A GCS score of 13 to 15 is considered a mild head injury, 9-12 is considered moderate and 8 or less is considered to be severe (Teasdale, Pettigrew, Wilson, Murray, & Jennett, 1998).

Post-traumatic Amnesia
    Posttraumatic amnesia (PTA) is a severity measure for traumatic brain injury. PTA has been described as the transient stage of confusion and disorientation characterized by intellectual and behavioral disturbances (Ahmed, Bierley, Shekh, & Date, 2000). Posttraumatic amnesia is considered to begin at the moment of injury and last until the time when a patient can provide a clear and consistent account of present events. It also provides some predictive utility in that longer duration of PTA is associated with increased cognitive, neurological and functional outcome deficits.

    One of the most widely used measures of PTA is the Galveston Orientation and Amnesia Test (GOAT). The GOAT was developed by Levin (1979) to provide clinicians with a brief, quantitative measure of disorientation and amnesia in a closed head injury. The GOAT is easily used with patients in the acute hospital setting and has been determined to be very beneficial for making a diagnosis of PTA in the SCI population (Davidoff et al., 1988) The GOAT allows clinicians to identify the patient’s current orientation as well as estimate the period of PTA. Additionally, the GOAT may be used as a repeated measure in order to evaluate a patient’s progress from PTA onset to PTA resolution.

Medical Assessments
    Medical assessments, such as routine skull films, computed tomography (CT) scans and magnetic resonance imaging (MRI) are frequently used to identify TBI. Skull films are also utilized in the emergency room to detect the existence of TBI. These diagnostic tools will also provide valuable clinical information about the likelihood and severity of cognitive impairment associated with SCI. The clinician must be aware, however, that a negative result in these types of measures does not mean that a traumatic brain injury has not occurred. For example, the changes from a mild traumatic brain injury resulting in a LOC may not be detected in an MRI yet still result in cognitive deficits.

    The general literature concerning SCI and concomitant TBI has been plagued by inconsistent means for diagnosing mild to moderate brain injury. There has also been a general failure to account for possible brain injuries or cognitive deficits that occurred prior to SCI onset, and behaviors attributed to suspected mild TBI may instead be related to other long-standing behavioral patterns that predate the SCI. Longitudinal research has yet to find meaningful empirical differences over time between persons with and without LOC at injury onset, or by level of injury or completeness of lesion (Richards, Brown, Hagglund, Bua, & Reeder, 1988). Consequently, the empirical scrutiny of concomitant TBI and SCI should be a recognized priority in rehabilitation psychology. Further, education of rehabilitation professionals on the issues related to identification and assessment of possible co-morbid TBI is critical for all clinicians working with traumatic SCI in order to enhance rehabilitation outcome.

References
Ahmed, S., Bierley, R., Sheikh, J. I., & Date, E. S. (2000). Post traumatic amnesia after closed head injury: A review of the literature and some suggestions for future research. Brain Injury, 14, 765-780.

Arria, A., & Van Thiel, D. (1992). The epidemiology of alcohol-related chronic diseases. Alcohol Health and Research World, 16, 209-216.

Davidoff, G., Thomas, P., Johnson, M., Brent, S., Dyker, M, & Doljanac, R. (1988). Closed head injury in acute traumatic spinal cord injury: Incidence and risk factors. Archives of Physical Medicine and Rehabilitation, 69, 869-872.

Davidoff, G. N., Roth, E. J., & Richards, J. S. (1992). Cognitive deficits in spinal cord injury: Epidemiology and outcome. Archives of Physical Medicine and Rehabilitation, 73, 275-284.

Elliott, T. R., Kurylo, M., Chen, Y., & Hicken, B. (2002). Alcohol abuse history and adjustment following spinal cord injury. Rehabilitation Psychology, 47, 278-290.

Levin, H. S., O’Donnell, V. M., & Grossman, R. G. (1979). The Galveston Orientation and Amnesia Test. A practical scale to assess cognition after head injury. The Journal of Nervous and Mental Disease, 167, 675-684.

Macciocchi, S., Bowman, B., Coker, J., Apple, D., & Leslie, D. (2004). Effects of co-morbid traumatic brain injury on functional outcome of persons with spinal cord injuries. American Journal of Physical Medicine and Rehabilitation, 83, 22-26.

Narayan, R. K., Gokaslan, Z. L., Bontke, C. F., & Berrol, S. (1990). Neuropsychologic sequelae of head injury. In M. Rosenthal, E. R. Griffith, M. R. Bond, & J. D. Miller (Eds.), Rehabilitation of the adult and child with traumatic brain injury (2nd ed., pp. 94-106). Philadelphia: F. A. Davis.

Richards, J. S., Brown, L., Hagglund, K., Bua, G. & Reeder, K. (1988). Spinal cord injury and concomitant traumatic brain injury: Results of a longitudinal investigation. American Journal of Physical Medicine and Rehabilitation, 67, 211-216.

Ricker, J. H., & Regan,T. (1999). Neuropsychological and psychological factors in acute rehabilitation of individuals with both spinal cord injury and traumatic brain injury. Topics in Spinal Cord Injury Rehabilitation, 5, 76-82.

Roth, E., Davidoff, G., Thomas, P. Doljanac, R., Dijkers, M., Berent, S., et al. (1989). A controlled study of neuropsychological deficits in acute spinal cord injury patients. Paraplegia, 27, 480-489.

Ryan, C., & Butters, N. (1986). The neuropsychology of alcoholism. In D. Wedding, A. Horton, & J. Webster (Eds.), The neuropsychology handbook: Behavioral and clinical perspectives (pp. 376-409). New York: Springer.

Schueneman, A. L., & Morris, J. (1982). Neuropsychological deficits associated with spinal cord injury. Science Digest, 64, 35-36.

Sorenson, S. B., & Kraus, J. F. (1991). Occurrence, severity, and outcomes of brain injury. Journal of Head Trauma Rehabilitation, 6, 1-10.

Sternbach, G. L. (2000). The Glasgow Coma Scale. The Journal of Emergency Medicine, 19, 67-71.

Teasdale, G. M., Pettigrew, L. E., Wilson, J. T., Murray, G., & Jennett, B. (1998). Analyzing outcome of treatment of severe head injury: A review and update on advancing the use of the Glasgow Coma Scale. Journal of Neurotrauma, 15, 587-597.

Wilmot, C., Cope, D., Hall, K., & Acker, M. (1985). Occult head injury: Its incidence in spinal cord injury. Archives of Physical Medicine and Rehabilitation, 66, 227-329.

Ann Marie Warren, PhD, is a licensed psychologist with the Spinal Cord Injury Team at Baylor Institute for Rehabilitation in Dallas, Texas where she also serves as the Administrative Coordinator of Rehabilitation Research.
Timothy R. Elliott, PhD, is a professor at Texas A&M University in the Department of Educational Psychology and is the current Editor of Rehabilitation Psychology.

Sam Gontkovsky, PsyD, editor of the Commentary section of SCI Psychosocial Process, is an associate professor in the Department of Psychology, Jackson State University. He is also a scientist at the Center for Neuroscience and Neurological Recovery, Methodist Rehabilitation Center, also in Jackson. Comments or suggestions are welcome and Dr. Gontkovsky may be reached at sgontkovsky@hotmail.com.

INDEX

Laura Cushman could be one of AASCIPSW’s best kept secrets. Commonly described as quiet, shy, and introverted, Cushman is all about stealth. Soft-spoken is probably a better descriptor than quiet. And shy or introverted? Suspend judgment. Cushman attended her first AASCIPSW conference in 1990, and responded to the realization that she didn’t know anyone by volunteering to serve on the Membership Committee the following year. She then became involved with the prototype for the Clinical Practice Committee and also created the Professional Issues Committee. She participated in writing our first Standards of Care, and, ever the introvert, was elected to the Board of Directors. She has served two consecutive terms twice, so she has been on the Board for 12 of her 17 years as a member of the association.

    Consequently, Cushman is well-known among the other association workhorses, who also seem to be the people having the most fun around here. Helen Bosshart has worked with her extensively over the years, most recently on the Program Committee which Cushman now chairs. “Laura is always on top of the best restaurants and cultural happenings no matter where you travel with her,” Bosshart said. “She often suggests some unusual, off the wall place, but it’s usually a memorable dining experience! Once, I believe in New York, we had the pleasure of dinner at a restaurant where all the waiters and waitresses were dressed in drag!”

    Any good traveler knows that if you want to compare cities, it helps to have a benchmark. “Who else, besides me of course, would go to the Liberace Museum on an annual pilgrimage each year during AASCIPSW convention?” asked Alan Goldberg. “To say that Laura is a bit quirky is a bit of an understatement,” he added, without a trace of irony. Goldberg knows from quirky. “Who else sends Halloween cards rather than Christmas cards? Who else goes to Toronto’s Shoe Museum? Who else is a master at old movies and often has the posters from them as well?” Who else frames everything in the form of a question? Wait, that was Goldberg, who nevertheless managed to make his point affectionately. “Laura is a lot of fun, enjoys fine food and the company of friends. No wonder we get along so well.”
All of this makes sense, knowing that Cushman pragmatically chose not to become a frustrated artist. “I’ve always been drawn to the arts, but I had no talent,” she said. “By the time I got to college I knew I couldn’t sing, act, dance or paint. I decided to cultivate the appreciation, and pursue it as an avocation.” Whatever Cushman lacked in artistic ability she was graced with intellectually, and she was as deliberate in selecting a future in psychology as she was in excluding a career in the arts. “I found some old social psychology research in my high school library,” she recalled. “I liked science and English, and thought nothing could be more interesting than applying the scientific method to the study of human behavior.” Her personal clarity on this proved invaluable, as the diversity of her interests could have been the source of some confusion. “At some point I completed the Strong-Campbell Interest Inventory, and my interests were most closely related to those of male Catholic priests.”

    Before anyone pitches their remaining supply of vocational interest inventories, it seems only fair to acknowledge that Cushman’s spirituality has also been a central and sometimes challenging part of her life. At about the time she discovered social psychology she also discovered feminism, which was at odds with the church she was raised in. “I began attending a different church when I was in high school, and ended up at a small evangelical college.” Seduced by the high academic standards of a school where two-thirds of the graduates pursued a post-graduate education, she was blind-sided by the extent to which her background and beliefs alienated her there. Her first year was pretty miserable, but she found a mentor and role model as a sophomore. “The most influential person I met there was the director of the theater program,” she said. “He was talented, compassionate and strongly spiritual, and showed me how to survive within a rigid and confining system.”

    A useful skill to be sure, but Cushman was relieved to face new challenges in personal development when she chose to pursue her graduate work at Wayne State University. “Detroit was like a bombed out city then, because residents had abruptly taken flight for the suburbs,” she said. “There were huge socioeconomic barriers, with invisible fences and glass walls.” Graduate student housing was subsidized, but the living conditions were rough. Cushman made the best of it, and particularly took to the history and culture of the city. “I learned to love jazz in Detroit. It wasn’t even permitted on my undergraduate campus because of the historical association with prohibition.”

    Cushman also immediately realized that Wayne State offered excellent opportunities in Clinical Neuropsychology, and immersed herself in the training. She completed two internships, and vaguely expected to work in one of the brain injury rehabilitation facilities that were proliferating madly at the time. “I had never considered pursuing an academic position,” she said. “I applied for a position in the psychiatry department at the University of Rochester with the intention of using it as a practice interview.” A position for a Rehabilitation Psychologist that had not yet been formally advertised had opened there at the same time, and proved to be an excellent fit. Cushman worked for the University of Rochester Medical Center for more than 20 years. “We had a 20-bed inpatient rehabilitation unit within a large acute care hospital. More than half the patients were there for spinal cord injury rehabilitation.”

    Within a few years she found her way to AASCIPSW, and the longevity of her relationship with the association has been mutually invaluable. When Cushman lost her husband to polycythemia vera about six years ago, her involvement in the association provided a sense continuity and comfort. “He was admitted to the ICU immediately, and died four days later,” she said. “I was on the Board of Directors at the time, and it was a tremendous source of stability and support through a very rocky year.” Cushman believes that her demeanor once caused other Board members to question her leadership abilities, but either her doubts, or theirs, vanished as she continued to serve the association during that difficult time.

    ”Cushman is quiet and unassuming, but she can run a great meeting,” observed Helen Bosshart, after the recent Program Committee meeting in Orlando. “This is no small task with a group of opinionated social workers and psychologists!”

    Cushman currently divides her time among several clinical and research endeavors in Rochester. She is close to her mother who lives nearby, and is a devoted dog mom. “Something many folks may not know is how much Laura loves animals,” said Marcia Scherer, who has worked with Cushman both within and beyond AASCIPSW. “Before she got her current dog, she would take in animals recovering from medical problems, or as a foster parent for those between owners.”

    Dogs have the sense not to get hung up on the semantics of quiet, shy, or introverted, and make the best of people as we are. Fortunately with Cushman, AASCIPSW has shown the same wisdom.

HOME

    I recently retired from my job with the State of Louisiana. At about the same time, I also fell and wound up with both a tibia plateau and a femur fracture and have been basically home-bound. The highlight of my morning has been the newspaper and the Ellen Degeneres Show (a fine American, a.k.a. good New Orleanian), and the highlight of my afternoon the mail (mostly junk—but, hey, we take what we can get). I’ve also spent a lot of time trying to avoid the morass of talk shows that flood the tube all day long. Once in a while, however, one of those infernal talk shows or something on the back pages of the paper catches my attention—and lately, it seems that many of those have to do with topics that pit a person’s civil rights against quality of life.

    Sometime back, we all heard about the family who decided to remove the uterus and breast buds of their daughter with a developmental disability, so that she will stay small, allowing them to more easily care for her. I have to admit that when I first heard about this I was quite upset. But after our wonderful associate editor-Lance Harris, PhD- forced/urged me to take another look at the situation, I found that the solution is not as cut and dried as I originally thought. In the beginning, I have to admit that I was viewing things from the point of view of a person with a disability. After hearing what Lance had to say, I began to think about it from the parents’ perspective. As he pointed out, these parents did not just arbitrarily make this decision to make their lives easier. These are parents who love their daughter and they are, indeed, looking out for her future. They realized that as their daughter grew and matured, it would be much more difficult to care for her at home—especially as they, themselves, aged. They also did not make this decision alone nor, I’m sure, did they make it overnight. They consulted many people prior to making their decision, including ethicists. Finally, the decision was made to perform the surgery.

    The agony that these parents must have endured disconcertingly reminded me of other decisions that are just as difficult for parents-including prospective parents-if you consider the advances in reproductive medicine and prenatal testing we have access to today.

    I was born in the early 50’s. My mom’s obstetrician was probably not long out of medical school, and back in those days they didn’t have residency programs. They hung out their shingles and were ready for practice-literally. I was the first baby with spina bifida that Mom’s doctor had delivered, and the corrective surgery to close the lesion had only been done for a couple of years. My parents were advised to go home and leave me at the hospital to “let nature take its course.” But they made the difficult decision to go ahead with the surgery—and the rest, I’m happy to say, is history.

    These days, spina bifida is very treatable. There have even been some cases of prenatal surgery with a large research study now on-going in three hospitals across the country to study the efficacy of such surgery. Many people have asked me how I feel about prenatal surgery for spina bifida. Would I have the surgery if I were pregnant with a child with spina bifida? How would I counsel a couple who was expecting a baby that had spina bifida? (Strangely enough, I was asked this same question when Roe v. Wade was passed. Funny how history repeats itself).

    Mercifully, I’ve never had to decide what to do in either of these situations, but I did have to work with parents who knew they were going to have a child with Down Syndrome and who were trying to decide whether or not to abort the pregnancy. Lucky for me, this came easily since my mom’s youngest sister had Down Syndrome and I was able to tell these parents from a niece’s perspective what it was like to have an aunt with Down Syndrome who was adored by our entire family. Fortunately, Gloria did not require constant supervision or care until the last few years before she died, when she developed Alzheimer’s Disease. After my grandparents died, she lived in a group home and later in a supervised apartment. This, sadly, will never be the case for the family who made the tough, and at first glance, repulsive decision, to have radical surgery performed on their little girl. She will require around the clock care for the rest of her life And those parents want to be the ones to administer her care.

    By the time I finished pondering this situation, I had not only gained a whole new perspective, but a great deal of respect for these parents who I do not even know. Their child should not have to live her years as just another body occupying a bed in some nursing home after her parents become unable to care for her seriously increased needs due to her size, her puberty, and her greatly increased propensity for combative behaviors. With the surgery, she should be able to live out the rest of her days in the loving arms of her family. I just wish all parents were bold enough to make decisions such as these before it is too late. After all, as I have often told parents, “just because God has given you this wonderful child, he has not granted you immortality.”

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