Adjustment Following Spinal Cord Injury 425context of ethnicity, simple associations between ethnicity
and outcome are open to misinterpretation and speculation.
Disability-Related Characteristics
Level and completeness of the SCI do not reliably predict
subsequent adjustment, although some occasional differ-
ences may be observed. SCI alone does not adversely affect
emotional experiences, for example. People with SCI report
many intense emotional experiences regardless of the level of
autonomic feedback, and their ratings of positive and nega-
tive emotions are unequivocal to those provided by compari-
son groups (Chwalisz, Diener, & Gallagher, 1988). Changes
in the physical condition itself, however, can in”uence rou-
tine activities, available resources, and ongoing behavioral
patterns, thereby affecting adjustment.
For many years, clinical lore maintained that the passage
of time was associated with eventual acceptance of the injury
and lowered distress (see Frank, Elliott, Corcoran, &
Wonderlich, 1987). Such notions were typically used to de-
scribe initial reactions to the injury, but empirical scrutiny
has revealed inconsistent and uninformative relationships be-
tween indicators of time passage and adjustment. However,
more recent research suggests that persons who have lived
longer with SCI may have higher life satisfaction than those
who have been injured for shorter periods of time, once other
important variables such as education and employment are
taken into account (Dijkers, 1999). Qualitative research indi-
cates that regaining the ability to walk and having a focused
interest in cure research are particular concerns for persons in
the “rst year of injury that are not shared by persons who
have been injured for several years (Elliott & Shewchuk, in
press). Generally, individuals who have lived with SCI for
longer periods of time seem to be more interested in commu-
nity and health issues. Problems with bowel and bladder
management are shared by persons with both recent and
long-term SCI (Elliott & Shewchuk, in press; Rogers &
Kennedy, 2000). These differences may re”ect adaptation
that occurs as a person lives with SCI and resumes interest in
personal, social, and vocational roles and activities.
For years, people with SCI have reported that chronic, un-
resolved pain is especially distressing to them. Indeed, pain
may constitute one of the most dif“cult obstacles faced by
persons with SCI (Paralyzed Veterans of America, 1988).
Pain can often be observed soon after injury onset, and
reports of pain in the rehabilitation setting can be signi“-
cantly predictive of distress two years later (Craig et al.,
1994). Over time, pain is predictive of increases in depressive
behavior, indicating a causal relationship (Cairns, Adkins, &
Scott, 1996). Extreme pain is associated with increased rates
of rehospitalization, lower life satisfaction, poor physical and
mental health, and more problems with mobility and social
integration (Putzke, Richards, & Dowler, 2000b). It is under-
standable, then, that chronic, persistent pain can compromise
acceptance and adjustment (Summers, Rapoff, Varghese,
Porter, & Palmer, 1991).Predisability Behavioral PatternsPeople who engaged in health-compromising behaviors and
had problems in interpersonal adjustment prior to SCI often
have dif“culty coming to terms with disability. These factors
are often suspected variables in those who sustain SCI
through acts of violence. Although many of these persons are
victimized by acts of crime, others have been willing partici-
pants in a lifestyle characterized by violence or they have
lived in areas where violence was a commonplace event. Vi-
olent onset of SCI has been associated with a higher rate of
pressure sore occurrence in some studies (Waters & Adkins,
1997; Zafonte & Dijkers, 1999) but not in others (Putzke,
Richards, & DeVivo, 2001); persons who are injured by gun-
shot may be likely to develop chronic pain (Richards, Stover,
& Jaworski, 1990). These issues may stem from a con”uence
of societal and economic variables and may not be easily
attributed to any single speci“c demographic or disability-
related characteristic.
There is also some concern that people who incur SCI in
high-impact incidents occasionally sustain brain injuries (BI)
with subsequent neuropsychological consequences. In fact,
almost half of those who acquire SCI in this fashion may
experience loss of consciousness or posttraumatic amne-
sia (Dowler et al., 1997). Others may experience anoxia dur-
ing surgical procedures or during cardiopulmonary arrest
(Davidoff, Roth, & Richards, 1992). At times, a brain injury
will be obvious, either due to the nature of the wound, or as
evidenced by the immediate and pronounced sequelae (e.g.,
prolonged loss of consciousness, coma). However, in situa-
tions in which mild or moderate BI is suspected, diagnosis is
more dif“cult and research has not consistently demonstrated
how BI adversely affects adjustment, although there is some
evidence that some persons with BI do experience adjust-
ment dif“culties over time (Davidof f et al., 1992).
This literature has been plagued by inconsistent means of
diagnosing mild and moderate BI and the failure to account
for possible pre-SCI brain injuries that may have occurred.
Behaviors attributed to suspected mild BI may be related to
other long-standing behavioral patterns that predate the SCI.
Longitudinal research has not found meaningful differences
over time between persons with and without loss of con-
sciousness at injury onset, nor were differences found by