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Physical therapy after spinal cord injury: A systematic review of treatments

focused on participation

Article  in  The journal of spinal cord medicine · January 2014

DOI: 10.1179/2045772314Y.0000000194 · Source: PubMed

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Review
Physical therapy after spinal cord injury: A
systematic review of treatments focused
on participation
Natàlia Gómara-Toldrà 1, Martha Sliwinski 2, Marcel P. Dijkers3
1
Faculty of Psychology and Educational and Sports Sciences, Ramon Llull University, Barcelona, Spain, 2Department
of Rehabilitation and Regenerative Medicine, Columbia University Program in Physical Therapy, New York, NY,
USA, 3Department of Rehabilitation Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA

Context: Over the last four decades, the focus of spinal cord injury (SCI) rehabilitation has shifted from medical
management to issues that affect quality of life and community participation. Physical therapists (PTs) need to
design and implement interventions that result in maximal participation to provide an individual with SCI an
effective rehabilitation program.
Objective: The aim of this review is to assess the extent, content, and outcomes of physical therapy (PT)
interventions focused on improving the participation of individuals with SCI.
Methods: A search was conducted in Medline, Embase, CENTRAL, CINAHL, PEDro, and PsycINFO. We
included studies, of all designs, focused on improving the participation of individuals with SCI using PT
interventions.The primary author and a reviewer independently selected articles for inclusion, assessed
articles quality, and extracted the data.
Results: Five studies met the inclusion criteria. The interventions applied were 9- and 12-month body weight-
supported treadmill training in two studies, a supervised 9-month exercise program, a 12-week home
exercise program, and a 10-week multidisciplinary cognitive behavioral program for coping with chronic
neuropathic pain. Four of five PT interventions positively impacted the individual’s perceived participation
and satisfaction with participation.
Conclusion: The body of research by PTs on interventions to improve participation is limited. PTs must document
the effects of interventions with a valid outcome tool to enable more research that examines participation.
Expanding participation research will allow PTs to meet the needs of individuals with SCI and identify what
interventions best facilitate integration into the community.
Keywords: Physical therapy modalities, Rehabilitation, Review, Social participation, Spinal cord injuries

Introduction including spinal cord injury (SCI).2,3 As the social aspect

The International Classification of Functioning, of functioning, participation is achieved through a
Disability, and Health (ICF)1 defines participation as person’s roles in family, community, and the larger
an individual’s involvement in life situations, and society and, as such, is a highly valued rehabilitation
describes this concept in relation to the concepts health outcome for people with disabilities, including those
conditions, body functions and structures (impairments), with SCI, their care partners, and society at large.4
activities, and contextual factors. The ICF is a compre- According to Dijkers,5 participation can be considered
hensive and widely accepted framework to classify and as a key component of or as a contributor to quality of
describe aspects of functioning, disability, and health in life (QOL), depending on how the QOL construct is con-
people with a broad spectrum of diseases and conditions, ceptualized. In individuals with SCI, participation is
more strongly associated with subjective QOL than are
Correspondence to: Natàlia Gómara-Toldrà, Clinical Physical Therapy, bodily impairments and activity limitations.6,7
Faculty of Psychology and Educational and Sports Sciences (FPCEE), Physical therapy (PT) interventions potentially have
Ramon Llull University, Barcelona, Spain.
Email: [email protected] targets across all three functioning domains of the

© The Academy of Spinal Cord Injury Professionals, Inc. 2014

DOI 10.1179/2045772314Y.0000000194 The Journal of Spinal Cord Medicine 2014 VOL. 37 NO. 4 371
Gómara-Toldrà et al. Physical therapy after spinal cord injury

ICF: body functions/structures, activities, and partici- used were: spinal cord injury and physical therapy and
pation. Modifying specific body impairments such as ( participation or social adaptation/integration/roles
strength, cardiovascular fitness, joint mobility, muscle or independent living or leisure activities or recreation
extensibility, bone loss, pain, and spasticity may or sports or work or return to work or vocational or
improve the ability to perform activities without assist- employment, supported or family relations or parent-
ance from a caregiver, or to perform tasks using com- ing). The search strategy was adjusted for each data-
pensatory methods with or without equipment. By base. We utilized MeSH terms, MeSH subhierarchy
reducing activity limitations, PT interventions may terms, thesaurus synonyms, and thesaurus words
address the ultimate aim of rehabilitation, namely when the database offered this option. Details of the
increased participation and thereby improved overall search strategies are provided in the Appendix 1. In
QOL.8 addition, the reference lists of papers identified and of
People with SCI nowadays are living longer and related systematic reviews14–16 were searched for
achieving greater functional independence as a result further references.
of improved medical, rehabilitative, technological,
and pharmacological management of SCI.9 The Data collection
research demonstrates that the focus of the rehabilita- The primary author and another reviewer independently
tion for these individuals has shifted from medical screened all 879 unduplicated titles and abstracts
management of the acute condition, to the issues of retrieved to identify potentially eligible studies,
QOL, and community participation, particularly looking for the term or concept “physical therapy inter-
gainful work, community life, interpersonal relation- vention”, “spinal cord injury”, and “participation”. The
ships, and leisure activities, as these are strongly full text of 42 articles was obtained and evaluated by the
related to the subjective QOL.10–12 Designing, imple- primary author and a second independent reviewer,
menting, and evaluating interventions that result in using the same criteria, now applied to the full text.
enhanced participation outcomes is a requirement for Information relevant to the topic (design, methodologi-
the PT profession and for individual PTs who aim to cal quality indicators, study purpose, PT treatment,
provide individuals with an SCI a successful rehabilita- participants, participation outcome measure(s), findings)
tion program.13 was extracted independently by the latter pair and then
At a time when PT clinical practice is increasingly compared to correct any discrepancies.
based on available evidence, it is necessary to assess Quality assessment
the outcomes of clinical interventions systematically The methodological quality of the studies that were
through review processes. The purpose of this systema- found was rated using the Physiotherapy Evidence
tic review is to identify PT treatments with a focus on Database (PEDro) scale.17 This scale consists of 11
participation. The specific aims are to (1) assess if PTs items of which the first is not included in calculating
design and implement interventions targeted on par- the PEDro score. Scores ranges from 0 to 10 with
ticipation outcomes in individuals with SCI; (2) higher scores indicating a better methodological
explore what kind of PT interventions are focused on quality of the study. The following cut points were
participation outcomes; and (3) identify which suggested by PEDro to categorize studies by quality:
aspects of participation PTs are pursuing in individ- excellent (9–10), good (6–8), fair (4–5), and poor (≤3).
uals with SCI. No prior systematic review of this
topic was identified. Inclusion and exclusion criteria
We included studies if participation, as conceptualized
Methods in the ICF, was incorporated as an outcome measure
Search strategy to evaluate PT interventions, of individuals with trau-
A literature search was conducted by the primary matic or non-traumatic SCI, that targeted participation
author in June 2013. Databases included were directly. We included as well studies where a measure of
Medline (1964 to June 2013), Embase (1980 to June the participation was used as an outcome measure to
2013), Cochrane Central Register of Controlled Trials evaluate the PT interventions with a different primary
(CENTRAL) (The Cochrane Library, 2012, Issue 2), focus. We considered the PT interventions to be treat-
CINAHL (1982 to June 2013), PEDro (1929 to June ments carried out by the PTs where the type of pro-
2013), and PsycINFO (1806 to June 2013). The cedural intervention was one that is included in the
search was not restricted by language, research design, Guide to PT Practice of the American Physical
or characteristics of patients or treatments. Keywords Therapy Association.18 Papers were rejected for several

372 The Journal of Spinal Cord Medicine 2014 VOL. 37 NO. 4

 Gómara-Toldrà et al. Physical therapy after spinal cord injury

reasons: disorders other than SCI, interventions deliv- Short-Form 36-Item Health Survey (SF-36),23 and the
ered by other disciplines, non-intervention studies, Subjective Quality of Life Scale (SQOL).23
articles that applied models such as the ICF to cases Meta-analysis was not applicable because of the con-
or treatment procedures, and articles that only described siderable heterogeneity (clinical and otherwise) of the
the validation of outcome measures. studies. The overall results of the five studies point to
a relationship between PT interventions and improve-
Study outcomes ment in participation. BWSTT and the exercise pro-
Both single-item participation outcome measures (e.g. grams impacted the individuals’ perceived
yes/no employed, hours of socializing per week) and participation and QOL positively with statistically sig-
indices combining multiple items into a single score nificant results (Table 1).
Three of the five studies finding a statistically signifi-
(e.g. CHART)19 were considered. Because some QOL
instruments quantify satisfaction with aspects of partici- cant increase in participation strongly suggested that this
pation, or score participation components as part of came about through a decrease in pain.22–24 Two studies
included global health measures,20,21 which had pain as
health-related QOL, studies using measures of QOL
were also reviewed for relevant outcomes, and reported a component of the scale.
where they included (satisfaction with) aspects of
participation.
Discussion
The first aim of this study was to assess if PTs design and
implement interventions targeted on participation out-
Results comes in individuals with SCI. We found five articles
Five studies met the inclusion criteria (Table 1). The that met the inclusion criteria, indicating a lack of docu-
interventions used in two were 4.5 and 12 months of mented research on PT interventions for improving par-
body weight-supported treadmill training ticipation. The PT interventions administered to
(BWSTT).20,21 Two investigations evaluated a super- improve participation were (aim 2) ambulation training
vised 9-month exercise program,22 and a 12-week with BWSTT, supervised exercise, and home exercise. In
home exercise program, respectively.23 The fifth addition, a goal of one study was to achieve improve-
intervention was a 10-week multidisciplinary cognitive ments in participation using an interdisciplinary cogni-
behavioral program.24 tive behavioral approach conducted by a psychologist
Study characteristics and findings are summarized in and a physiotherapist.24 Participation gains identified
Table 1. A total of 191 participants were included in the (aim 3) included access to public facilities, ability to
five studies. Their mean age was 43.8 years, and the work, leisure time activities (including exercise, sports,
majority were males (70.6%) living in the community. hobbies), family life (including housekeeping), and
Three studies were randomized controlled trials social functioning.
(RCTs)22–24 with the control groups of between 13 and It is somewhat surprising that only five studies were
40 participants. The intervention groups ranged from found, and it may seem that PTs are not focusing on
21 to 40 participants. Two of these RCTs used a wait improving participation. However, ∼200 of the rejected
list control design.22,24 The third RCT compared two papers included aspects of participation, but they did
different training methods for a home exercise interven- not meet the inclusion criteria for this review (e.g.
tion.22 The other two studies used longitudinal prospec- studies discussing the creation or validation of partici-
tive designs (Table 1).20,21 The methodological quality pation-related outcome measures, disorders other than
scores on the PEDro scale ranged from 1 to 7, with a SCI, non-intervention studies, and disability models
median of 4,6. applied to cases). This would suggest that participation
Four different self-report measures of participation is not a concept that is alien to the PTs; however, pub-
were used: the Utrecht Activities List (UAL),24 the lished research, specifically the research designed to
Social Interaction Inventory (SII),23 Lawton’s assess the PT interventions’ effect on the participation,
Instrumental Activities of Daily Living (IADL),21 and is limited.
the Canadian Occupational Performance Measure There may be several reasons for the shortage of
(COPM).20 Five different QOL scales measuring research in this area. According to Geyh et al.,25 the
aspects of participation were used: the Schedule for concentration on the biomedical problems in the SCI
the Evaluation of Individual Quality of Life rehabilitation, to the exclusion of the psychosocial
(SEIQoL),20 the Life Satisfaction Questionnaire issues, distorts the perspectives and even interferes
(LiSat-9),24 the Perceived QOL scale (PQOL),22 the with patient care.25,26 The ICF model is based on the

The Journal of Spinal Cord Medicine 2014 VOL. 37 NO. 4 373

374

Gómara-Toldrà et al.
The Journal of Spinal Cord Medicine

Table 1 Summary of PT intervention studies focusing on participation

Primary PEDro
author Design score Purpose: PT treatment and subjects Participation outcome measures Findings

Physical therapy after spinal cord injury

20
Effing Controlled single- 2 Purpose: investigate the effects of treadmill SEIQoL COPM: perceived performance in Positive changes were reported in the
(2006) case design training (TT) on functional health status and the areas of self-care, productivity, and majority of the most important problematic
QOL in subjects with a chronic incomplete leisure Semi-structured interview of activities in daily life (COPM scores:
SCI. First phase: 6 weeks of motor-driven subjects and their partners about access to public facilities, concentration
treadmill with static body weight support changes in daily life during and after TT improvement during work, leisure
(BWS) Second phase: 12 weeks of motor- activities). Reported changes in QOL are
driven treadmill with dynamic BWS Subjects: relatively small and different in nature for
N=3 the three subjects
Heutink24 Multicenter RCT 6 Purpose: evaluate the effects of a Primary outcome: GPGQ-pain-related UAL: significant differences between the two
2014

(2012) multidisciplinary cognitive behavioral disability Secondary outcomes: UAL: groups were found after intervention
treatment program on pain intensity and participation in activities; and LiSat-9 life (P = 0.034) and at follow-up (P = 0.008)
pain-related disability, and secondarily on satisfaction LiSat-9 scores remained stable over time
mood, participation in activities, and life
VOL.

satisfaction. Multidisciplinary cognitive

37

behavioral therapy program with

educational, cognitive, and behavioral
strategies targeted at coping with chronic
NO.

neuropathic pain. Program: 10 weekly

4

sessions, 3 hours per session Subjects:

N=3
Hicks22 RCT 5 Purpose: examine the effects of exercise 11-item PQOL: Participation-relevant items: The exercise group reported a better QOL
(2003) training on strength and the QOL how often get outside the house (e.g. than did the control group (P < 0.05)
dimensions of psychological well-being, driving, using public transportation, going
pain, perceived health status, and overall life into town), work situation, recreation, or
satisfaction Program: 9 months, two leisure SF-36 Pain
sessions a week, 90–120 minutes a session
Subjects: N = 21
Hicks21 Longitudinal, 3 Purpose: determine the effects of long-term IADL Following BWSTT, no significant changes
(2005) prospective, BWSTT on functional walking ability and were found in perceived ability to perform
within-subject perceived QOL in persons with chronic IADLs. During the follow-up period
design incomplete SCI Program: 12 months, 3 exercise adherence (BWSTT alone or
sessions a week, 144 sessions Subjects: combined with fitness training) had
N = 14 significant positive correlations with
change in perceived ability to perform
IADLs (r = 0.75 and r = 0.70, BWSTT alone
or combined with fitness training,
respectively).
Mulroy23 RCT 7 Purpose: determine the effect of an exercise Secondary outcomes: SII, SF-36 role Community activity, as measured with the SII,
(2011) program (shoulder strengthening and physical (RP) and bodily pain, and the increased more for the exercise/movement
stretching exercises) and instruction in SQOL optimization group (P ≤ 0.03). Overall
performance of upper-extremity tasks SQOL scores increased following the
(transfers, raises, and wheelchair intervention (P = 0.04). The largest
propulsion) on shoulder pain in people with improvements were seen in the SF-36
paraplegia 12 weeks shoulder home subscales of RP (physical limitation in
exercise program Subjects: N = 40 fulfilling life roles) (P ≤ 0.05)
 Gómara-Toldrà et al. Physical therapy after spinal cord injury

“biopsychosocial” paradigm to provide a comprehen- taxonomy of activities and participation (the d-codes)
sive view of the different dimensions of health from a both make it difficult to argue one way or another, if
biological, psychological, and social perspective.27 one uses ICF as one’s guidebook.38 But even if PTs
While the ICF as an integrative paradigm is still not only work on impairments and activity limitations
fully assimilated into clinical practice,2,28 many efforts after SCI, it would be helpful to include measures of
are underway to incorporate the ICF framework in participation in their data collection so that the connec-
the thinking and operations of disciplines such as tion between basic functioning and activities, on the one
PT.4,29–32 hand, and participation on the other can be assessed.4,35
A second possible explanation for the paucity of Only in that way can they determine whether the
investigations in this field is the lack of a universally changes in body functions and activity limitations
accepted participation measure used by PTs in their treatments achieve are sufficiently large and well-
their treatment documentation. In the inpatient rehabili- targeted to actually bring about significant improve-
tation setting, the Functional Independence ments in participation—the area that really counts for
15,33
Measure and the Spinal Cord Independence patients.
Measure34 may be implemented from admission to dis- A last reason for the scarcity of investigations could
charge, but these do not include the items of be the fact that, in the USA, the decreased length of
participation. The consistent use of measures of stay (LOS) for individuals with SCI in inpatient rehabi-
participation such as the CHART or the Impact on litation is not sufficient for participation-oriented treat-
Participation and Autonomy,15,35 would help PTs to ment and evaluation of any resulting participation
describe participation needs and further explore the effi- changes. Many patients may be medically restricted
cacy of interventions aiming to enhance participation. from practicing skills, such as wheelchair mobility,
The taxonomy of the SCI PT interventions developed that would provide for participation opportunities,39,40
in 2009 as a part of the SCIRehab Project36 may although in many cases it is followed by extensive outpa-
provide a starting point for the PTs to evaluate which tient rehabilitation.41 The median length of acute reha-
of the 19 treatment activities identified most effectively bilitation hospitalization in the USA from 2005 to
improves the participation. 2010 was 37 days.42 Individuals with SCI may perforce
Silver et al. 37 have identified barriers to community be discharged without the knowledge and the functional
reintegration encountered by individuals with SCI skills necessary for community level participation.
during the first year after discharge from inpatient reha- However, a study by Whiteneck et al. 42 examining inpa-
bilitation. The major categories of self-reported barriers tient and outpatient hours of rehabilitation services
were mobility issues (e.g. problems with transfers, received during the first year after SCI revealed that a
balance), spasticity, lack of support transitioning to significant proportion of PT services were received
another living situation (e.g. acquiring the personal after discharge from the inpatient setting. In fact, the
care assistance needed), poor skills needed for wheel- estimated total number of hours of post-discharge PT
chair maintenance, and access to wheelchair accessible was greater than the number of hours of inpatient
transportation. Many of the barriers are issues that therapy. In this situation, there certainly is sufficient
PTs address in their interventions and are included in opportunity for PTs to teach skills relevant to commu-
the taxonomy. Measuring participation outcomes nity functioning; in fact, all five of the studies included
would provide PTs with a clearer understanding of in this review involved community-resident persons
which interventions effectively improve participation with SCI. In Western Europe and the rest of the
by helping persons with SCI overcome barriers that world, inpatient LOS tends to be much longer than in
are acknowledged by this population. the USA, and is followed by often extensive outpatient
Another possible explanation for the paucity of treatment. Generally, the outpatient setting presents
research is that PTs (similar to other rehabilitation more challenges for research by PTs. The comprehensive
specialists) typically do not work on improving “partici- interdisciplinary approach to patient care may be less
pation” directly; instead, they influence participation consistently applied in the outpatient setting, and there
indirectly by improving aspects of body structure, are usually fewer resources to support research.
body function, or activities that, in turn, have effects However, given the fact that outpatients are already
on “participation”. The lack of both a clear definition living in the community, one might ask: what a better
of “Participation” and “Participation restrictions” in place than outpatient to address participation issues.
the ICF and a lack of differentiation in the ICF’s Future studies should examine the impact of post-

The Journal of Spinal Cord Medicine 2014 VOL. 37 NO. 4 375

Gómara-Toldrà et al. Physical therapy after spinal cord injury

discharge care on participation outcomes in greater been associated with lower QOL in individuals with
detail.42 SCI.36,49–51 Both are impairments in the ICF model
Recently, community participation issues have been and may impact mobility activities negatively, which
highlighted as a research priority for people with would decrease participation. Moreover, perceived par-
SCI.43,44 PTs need to consider contextual factors ticipation restrictions are determinants of life satisfac-
( personal and environmental features) and their tion in people with SCI.52,12 Research is needed to
impact on all three functioning categories of the ICF address the complexities of the secondary conditions
model (impairments, activities, and participation).33 of people living with SCI, what interventions are used
The relationship between the three domains of the to prevent them, and their relationship to the partici-
ICF is clear: impairments impact activities and activities pation restrictions.
have an impact on participation. Integrating validated The main limitation of our systematic review is the
participation measures will provide a means to research low number of studies avaliable for analysis, making
how effective various PT interventions are in targeting drawing conclusions on the (relative) effectiveness of
participation. various PT interventions difficult. Another limitation
Personal factors that influence participation, such as to be considered is posed by the quality of the studies
motivation, may be enhanced by including mentors included. Two of the five are not RCTs, limiting the
during individual and group PT sessions to facilitate strength of the conclusions that can be drawn as to treat-
the process of community participation.45,46 ment effectiveness.
Cognitive and behavioral strategies used by PTs also
plays a key role in physical activity in this population,
Conclusions
along with enhancing motivation.47 A study by Sand
We did find five studies on PT interventions with a focus
et al. 46 found that having clear information during
on participation allowing a preliminary conclusion sup-
the hospital stay about the injury, patient participation
porting exercise and gait training both have a positive
in planning the rehabilitation program, and emotional
effect on participation after SCI. The specific aspects
support were important factors influencing the rehabi-
of participation that were impacted included work,
litation process. Strategies such as accepting assistance
social, family, and leisure participation.
and finding a role model (another person with SCI
However, the fact that PT research does not include
who already was physically active) had a positive
measures of participation does not mean that PTs are
effect on participation in physical activities following
not addressing participation in their interventions. We
rehabilitation.46,47 Educational sessions can be used
can only identify the effectiveness of these interventions
to enhance coping strategies and problem solving
by conducting more research. Including valid partici-
skills for the patient and the family.46
48 pation outcome measures will provide a better under-
Papadimitriou describes how the interactions
standing of how community participation may be
between the patient and the PT are crucial for people
increased and lead to identifying effective interventions
with SCI to transition to a new framework or perspec-
for this population. As participation represents a key
tive, named “newly abled”. Acquiring this new percep-
outcome of rehabilitation, further research by PTs is
tion of one’s self is a collaborative process between the
required to provide evidence for interventions measured
patient and the PT and reinforces patients’ involvement
with valid participation outcome tools that enhance par-
in their rehabilitation.
ticipation in individuals with a SCI.
Finally, the participation gains identified in this
review related to work, access to public facilities,
leisure time activities, and social functioning may also Acknowledgments
reduce the incidence of secondary medical problems. We would like to acknowledge the contribution of
According to Hammell,43 individuals with SCI identify Vanessa Lazar, a student in the Columbia
pain-related disability, depression, fatigue, pressure University Doctorate of Physical Therapy Program
sores, spasticity, and the management of bladder and (New York), and Dr. Mercè Sitjà-Rabert, Professor
bowel as research priorities. In this review, three of the at Ramon Llull University (Barcelona, Spain)
five studies measured pain-related disability as an Physical Therapy program, for their assistance as
outcome.22–24 High levels of pain and spasticity have independent reviewers.

376 The Journal of Spinal Cord Medicine 2014 VOL. 37 NO. 4

 Gómara-Toldrà et al. Physical therapy after spinal cord injury

Appendix 1 Search strategies for various databases

Databases Search strategy

MEDLINE (PubMed) Spinal cord injuries [MeSH] or spinal cord inj* [tw] or tetrap* [tw] or quadrip*[tw] or quadriplegia [MeSH] or
parapl*[tw] or paraplegia [MeSH]
Physical therap* [tw] or physiotherap*[tw] or physical therapy modalities [MeSH] or physical therapy
specialty [MeSH]
Social participation [MeSH] or social support [MeSH] or consumer participation [MeSH] or patient
participation [MeSH] or interpersonal relations [MeSH] or independent living [MeSH] or leisure activities
[MeSH] or job satisfaction [MeSH] or sports [MeSH]
Employment [MeSH] or employment supported [MeSH] or work [MeSH] or return to work [MeSH]
Parenting [MeSH] or family relations [MeSH] or family health [MeSH] or family [MeSH]
1 and 2 and (3 or 4 or 5)
EMBASE (Ovid) Spinal cord injuries.mp. or spinal cord injury/ or spinal cord inj*.mp or paraplegia/ or parapl*.mp or
quadriplegia
Physical therapy modalities.mp or physiotherapy/ or physical therap*.mp or physiotherapy practice/ or
physiotherapist/
Consumer participation.mp or social support.mp or independent living.mp or social adaptation.mp or social
interaction.mp or social functioning.mp or International Classification of Functioning, Disability, and
Health.mp
Work/ or work.mp or vocational rehabilitation/ or return to work.mp or employment/ or employment.mp or
employment supported.mp
Parenting/ or parenting.mp or family relations.mp or family.mp or family health.mp
1 and 2 and (3 or 4 or 5)
PEDro (website) Abstract & Title: spinal cord injury and (participation or return to work or family)
CENTRAL (CLib) Spinal cord injury [MeSH] or spinal cord inj* [tw] or parapl* [tw] or paraplegia [MeSH] or tetrap* [tw] or
quadrip* [tw] or quadriplegia [MeSH]
Physical therapy modalities [MeSH] or physical therap* [tw] or physiotherap* [tw] or physical therapy
specialty [MeSH]
Social participation [MeSH] or social support [MeSH] or independent living [MeSH] or interpersonal
relations [MeSH] or patient participation [MeSH] or consumer participation [MeSH] or leisure activities
[MeSH] or sports [MeSH] or job satisfaction [MeSH]
Employment [MeSH] or employment supported [MeSH] or work [MeSH] or return to work [MeSH]
Parenting [MeSH] or family relations [MeSH] or family health [MeSH] or family [MeSH]
1 and 2 and (3 or 4 or 5)
CINAHL (Ovid) Spinal cord injuries.mp or spinal cord inj*[tw] or parapl* [tw] or quadrip* [tw] or tetrap*[tw]
Physical therapy.mp or physical therapy practice.mp or physical therapy practice, evidence-based.mp or
physical therapy assessment.mp, physical therapy.mp or home physical therapy.mp or physical
therap*[tw]
Community role.mp or interpersonal relations.mp or consumer participation.mp or leisure activities.mp or
social support.mp or sports.mp or community living.mp or International Classification of Functioning,
Disability, and Health.mp
Work.mp or job Re-entry.mp or employment.mp or employment, supported.mp or employment of disabled
or return to work [tw]
Family.mp or family relations.mp or parenting.mp or parents, disabled.mp
1 and 2 and (3 or 4 or 5)
PsycINFO (Ovid) Spinal cord injuries.mp or exp Spinal cord injuries/ or spinal cord inj*.mp or paraplegia.mp or exp
paraplegia/ or quadriplegia.mp or exp quadriplegia/ or tetraplegia.mp
Physical therapy.mp or exp physical therapy/ or physical therap*.mp or physiotherapy.mp or physical
therapy modalities.mp or exp physical therapy methods/
Participation/ or exp interpersonal relations/ or exp group participation or exp relationship satisfaction/ or
exp community involvement/ or exp interpersonal interaction/ or exp social adjustment/ or exp social
support/ or exp self care skills/ or exp leisure time/ or exp recreation/ or exp sports/ or “sports
(attitudes toward)”
Return to work.mp or work.mp or employment.mp or “work (attitudes toward)”/ or “Quality of Work life”/ or
Reemployment/Employment status/ or Vocational rehabilitation or Supported employment/ or
employment supported.mp
Parenting.mp or parenting skills.mp or parenting style.mp or family relations.mp or family.mp
1 and 2 and (3 or 4 or 5)

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