The incidence for spinal cord injury is in the range of 11.5 per million to 58 per million subjects Worldwide, whereas, in India this range is from 15-20 million every year. Community participation and rehabilitation of spinal cord injury is a long process that need considerable healthcare resources and put a significant financial burden on the affected subjects and their families. Community and social participation of subjects with spinal cord injury indicate the adequate rehabilitation. Community participation is a multifaceted phenomenon that is interchangeably used with community reintegration, social participation, and participation in the literature.¹

Participation is considered as a process of being a part of mainstream in the community and family life, being contributing and active member of society and their own social groups, and participation in normal responsibilities and roles. The process of community re-integration is seen in three main stages that are named as stability, re‑emergence into society, and withdrawal.²

Appropriate assistance, access to specialized equipment, and social support are considered to facilitate the community participation in subjects with spinal cord injury. There is further need for community‑based rehabilitation as it improves the results in subjects having disabilities. Many subjects with spinal cord injury in India have different educational, employment, social, medical, and physical deficiencies as majority of them lives in rural areas that have majority of existing services limited to the cities.³

Various studies from the previous literature have assessed different determinants of community reintegration in subjects with spinal cord injury. These factors are mobility capacity, socioeconomic status, mobility aids accessibility, exercise, and environmental barriers. However, existing literature data is scarce and limited linked to community participation, disability level, and functional dependence in subjects with spinal cord injury. Understanding of the major factors of community reintegration is vital to enable policymakers and clinical practitioners to take actions in facilitation of reintegration in subjects with spinal cord injury to the community.⁴ Hence, the present study was aimed to assess the factors affecting the community and social participation of subjects with spinal cord injury in India.

The present cross-sectional analytical study was aimed to assess the factors affecting the community and social participation of subjects with spinal cord injury in India. The study was done at Department of Orthopaedics, Government Medical College, Jammu, Jammu & Kashmir. Verbal and written informed consent were taken from all the subjects before study participation. The study assessed 55 Indian subjects with spinal cord injury that participated in the community settings. All the subjects were assessed using WHO Disability Assessment Schedule 2.0 (WHODAS), Craig Handicap Assessment and Reporting Technique (CHART), and Spinal Cord Independence Measure Version III self reporting (SCIM III SR) for assessment of the clinical outcomes. The inclusion criteria for the study were subjects aged >18 years, had spinal cord injury >6 months ago, and underwent rehabilitation therapy within the defined study period. The exclusion criteria for the study were subjects with acute infection or acute illness and were hospitalized within the past three months for any reason. After final inclusion, the data from the study subjects were gathered using the preformed structured proforma. The questionnaire comprised of five parts including the demographic data, details of the spinal cord injury, measurement of the functional independence, measure of functional disability, and objective measure of study participation. Community reintegration was assessed using the CHART-SF (Craig Handicap Assessment and Reporting) technique.5 It certain the degree by which participants can fulfil the roles as they would have done without disability. The questionnaire had 32 questions from 6 domains as economic self sufficiency, social integration, occupation, mobility, cognitive independence, and physical independence. Functional independence in study subjects was assessed using SCIM-III which has 19 questions covering the three domains as mobility, respiratory and sphincter management, and self-care.6 Along with these, WHODAS 2.0 was used for assessment of disability severity in subjects with spinal cord injury comprising of 36 questions covering the 6 domains as participation, life activities, getting along, self-care, mobility, and cognition.7 Statistical analysis for gathered data was done using chi-square test, Fisher’s exact test, Mann Whitney U test, and SPSS (Statistical Package for the Social Sciences) software version 24.0 (IBM Corp., Armonk. NY, USA) using ANOVA, chi-square test, and student's t-test. The significance level was considered at a p-value of <0.05.

The present cross-sectional analytical study was aimed to assess the factors affecting the community and social participation of subjects with spinal cord injury in India. The study assessed 55 Indian subjects with spinal cord injury that participated in the community settings. There were 95% (n=52) males and 5% (n=3) females in the study with 95% (n=52) subjects in age range of 18-60 and 5% (n=3) from >60 years. There were 24% (n=13) subjects residing in urban areas and 76% (n=42) in the rural areas. There were 60% (n=33) married and 40% (n=22) single subjects in the study. The etiology of injury was traumatic and non-traumatic in 91% (n=50) and 9% (n=5) study subjects with paraplegic and quadriplegic presentation in 11% (n=6) and 89% (n=49) study subjects. Injury level was T11-S4, T5-T10, T1-T4, and C5-C8 in 60% (n=33), 22% (n=12), 7% (n=4), and 11% (n=6) subjects respectively. Injury type was complete and incomplete in 48% (n=27) and 52% (n=28) study subjects. The use of mobility aid was none, assistive device, wheelchair, and both in 6% (n=3), 30% (n=17), 18% (n=10), and 46% (n=25) study subjects respectively (Table 1).

It was seen that for the clinical characteristics in the study subjects, median and range for CHART_SI was 8 and 2-98, CHART_ Prod was 12 and 2-34, CHART_ Mob was 4 and 2-6, CHART_ Cog was 14 and 3-28, CHART_ TA was 97 and 95-97, CHART_ Mob was 20 and 0-38, CHART_ RC was 26 and 3-38, CHART_ SC was 18 and 0-21, and WHODAS was 32 and 0-112 respectively (Table 2). A moderate positive correlation was seen in SCIM self‑care and CHART physical independence with p<0.05. A weak negative correlation was seen in WHODAS and CHART mobility with r= -0.394 and SCIM mobility sub score with r= -0.319 and moderate correlation in self-care as r= -0339, and respiratory and sphincter management with r= -0.464. no significant correlation was seen in CHART social interaction and CHART occupation to SCIM sub scores and WHODAS.

The study results showed that for correlation in WHODAS, SCIM, and CHART in the study subjects, a non-significant correlation was seen in CHART- SI to SCIM- Mob, SCIM- RS, SCIM- SC, and WHODAS with values of -0.019, -0.102, -0.001, and -0.019. CHART- Prod also showed with values of -0.032, -0.013, 0.0002, and -0.032. Similar non-significant association was seen in CHART- Cog to CHART- SI to SCIM- Mob, SCIM- RS, SCIM- SC, and WHODAS. However, a significant association was seen in CHART- Mob to CHART- SI to SCIM- Mob, SCIM- RS, SCIM- SC, and WHODAS with respective r- values of -0.319, -0.464, -0.439, and -0.319 respectively. Also, a significant association was seen in CHART- TA and SCIM- SC with r- value of -0.444 (Table 3).

Concerning the findings from the multiple linear regression, CHART_ Prod showed a significant association with gender with p=value of 0.004. Similar significant association was seen in CHART- Mob to SCIM- RS and SCIM- SC with p=0.001. CHART- Cog showed significant association with SCIM- SC and SCIM-Mob with p=0.001. Also, a significant association was seen in CHART- TA to WHODAS and SCIM- SC with p=0.004 (Table 4).

Table 1: Demographic characteristics in the study subjects

Table 2: Clinical characteristics in the study subjects

Table 3: Correlation in WHODAS, SCIM, and CHART in the study subjects

Table 4: Findings from multiple linear regression

The present study assessed 55 Indian subjects with spinal cord injury that participated in the community settings. There were 95% (n=52) males and 5% (n=3) females in the study with 95% (n=52) subjects in age range of 18-60 and 5% (n=3) from >60 years. There were 24% (n=13) subjects residing in urban areas and 76% (n=42) in the rural areas. There were 60% (n=33) married and 40% (n=22) single subjects in the study. The etiology of injury was traumatic and non-traumatic in 91% (n=50) and 9% (n=5) study subjects with paraplegic and quadriplegic presentation in 11% (n=6) and 89% (n=49) study subjects. Injury level was T11-S4, T5-T10, T1-T4, and C5-C8 in 60% (n=33), 22% (n=12), 7% (n=4), and 11% (n=6) subjects respectively. Injury type was complete and incomplete in 48% (n=27) and 52% (n=28) study subjects. The use of mobility aid was none, assistive device, wheelchair, and both in 6% (n=3), 30% (n=17), 18% (n=10), and 46% (n=25) study subjects respectively. These data were comparable to the previous studies of Whiteneck G et al8 in 2004 and Callaway L et al9 in 2017 where authors assessed subjects with data comparable to the present study in their studies.

The study results showed that for the clinical characteristics in the study subjects, median and range for CHART_SI was 8 and 2-98, CHART_ Prod was 12 and 2-34, CHART_ Mob was 4 and 2-6, CHART_ Cog was 14 and 3-28, CHART_ TA was 97 and 95-97, CHART_ Mob was 20 and 0-38, CHART_ RC was 26 and 3-38, CHART_ SC was 18 and 0-21, and WHODAS was 32 and 0-112 respectively (Table 2). A moderate positive correlation was seen in SCIM self care and CHART physical independence with p<0.05. A weak negative correlation was seen in WHODAS and CHART mobility with r= -0.394 and SCIM mobility sub score with r= -0.319 and moderate correlation in self-care as r= -0339, and respiratory and sphincter management with r= -0.464. no significant correlation was seen in CHART social interaction and CHART occupation to SCIM sub scores and WHODAS. These findings were in agreement with the results of Atobatele KO et al10 in 2018 and Charlifue S et al11 in 2004 where clinical characteristics in subjects with spinal cord injury reported by the authors were comparable to the results of the present study.

It was seen that for correlation in WHODAS, SCIM, and CHART in the study subjects, a non-significant correlation was seen in CHART- SI to SCIM- Mob, SCIM- RS, SCIM- SC, and WHODAS with values of -0.019, -0.102, -0.001, and -0.019. CHART- Prod also showed with values of -0.032, -0.013, 0.0002, and -0.032. Similar non-significant association was seen in CHART- Cog to CHART- SI to SCIM- Mob, SCIM- RS, SCIM- SC, and WHODAS. However, a significant association was seen in CHART- Mob to CHART- SI to SCIM- Mob, SCIM- RS, SCIM- SC, and WHODAS with respective r- values of -0.319, -0.464, -0.439, and -0.319 respectively. Also, a significant association was seen in CHART- TA and SCIM- SC with r- value of -0.444. These results were consistent with the findings of Sekaran P et al12 in 2010 and Silver J et al13 in 2012 where correlation in WHODAS, SCIM, and CHART results comparable to the present study were also reported by the authors in their studies.

On assessing the findings from the multiple linear regression, CHART_ Prod showed a significant association with gender with p=value of 0.004. Similar significant association was seen in CHART- Mob to SCIM- RS and SCIM- SC with p=0.001. CHART- Cog showed significant association with SCIM- SC and SCIM-Mob with p=0.001. Also, a significant association was seen in CHART- TA to WHODAS and SCIM- SC with p=0.004. These results were in correlation with the findings of Kader M et al14 in 2018 and Barclay et al15 in 2019 where results reported by authors in subjects with spinal cord injury were comparable to the results of the present study.

The present study, within its limitations, concludes that mobility and self-care in subjects with spinal cord injury helps in determination of their ability for successful reintegration of them into the community which warrants a need for comprehensive program for rehabilitation of the community.

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