REHABILITATION AIMS TO improve participation and ultimately

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1 82 ORIGINAL ARTICLE Relationships Between Activities, Participation, Personal Factors, Mental Health, and Life Satisfaction in Persons With Spinal Cord Injury Christel M. van Leeuwen, MSc, Marcel W. Post, PhD, Paul Westers, PhD, Lucas H. van der Woude, PhD, Sonja de Groot, PhD, Tebbe Sluis, MD, Hans Slootman, MD, Eline Lindeman, PhD ABSTRACT. van Leeuwen CM, Post MW, Westers P, van der Woude LH, de Groot S, Sluis T, Slootman H, Lindeman E. Relationships between activities, participation, personal factors, mental health, and life satisfaction in persons with spinal cord injury. Arch Phys Med Rehabil 2012;93:82-9. From the Rudolf Magnus Institute of Neuroscience and Center of Excellence for Rehabilitation Medicine, University Medical Center Utrecht and Rehabilitiation Center De Hoogstraat, Utrecht (van Leeuwen, Post, Lindeman); Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht (Westers); Center for Human Movement Sciences, University Medical Center Groningen, University of Groningen, Groningen (van der Woude, de Groot), Reade Centre for Rehabilitation and Rheumatology, Amsterdam (de Groot); Rijndam Rehabilitation Center, Rotterdam (Sluis); and Heliomare, Wijk aan Zee (Slootman), The Netherlands; and Swiss Paraplegic Research, Nottwil, Switzerland (van Leeuwen, Post). Supported by the Dutch Health Research and Development Council, ZON-MW Rehabilitation program (grant nos , ). No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated. Reprint requests to Marcel W. Post, PhD, Rehabilitation Center De Hoogstraat, Rembrandtkade 10, 3583 TM, Utrecht, The Netherlands, m.post@ dehoogstraat.nl /12/ $36.00/0 doi: /j.apmr Objective: To clarify relationships between activities, participation, mental health, and life satisfaction in persons with spinal cord injury (SCI) and specify how personal factors (self-efficacy, neuroticism, appraisals) interact with these components. We hypothesized that (1) activities are related directly to participation, participation is related directly to mental health and life satisfaction, and mental health and life satisfaction are 2 interrelated outcome variables; and (2) appraisals are mediators between participation and mental health and life satisfaction, and self-efficacy and neuroticism are related directly to mental health and life satisfaction and indirectly through appraisals. Design: Follow-up measurement of a multicenter prospective cohort study 5 years after discharge from inpatient rehabilitation. Setting: Eight Dutch rehabilitation centers with specialized SCI units. Participants: Persons (N 143) aged 18 to 65 years at the onset of SCI. Interventions: Not applicable. Main Outcome Measures: Mental health was measured by using the Mental Health subscale of the 36-Item Short Form Health Survey and life satisfaction with the sum score of current life satisfaction and current life satisfaction compared with life satisfaction before SCI. Results: Structural equation modeling showed that activities and neuroticism were related to participation and explained 49% of the variance in participation. Self-efficacy, neuroticism, and 2 appraisals were related to mental health and explained 35% of the variance in mental health. Participation, 3 appraisals, and mental health were related to life satisfaction and together explained 50% of the total variance in life satisfaction. Conclusions: Mental health and life satisfaction can be seen as 2 separate but interrelated outcome variables. Self-efficacy and neuroticism are related directly to mental health and indirectly to life satisfaction through the mediating role of appraisals. Key Words: Quality of life; Rehabilitation; Spinal cord injuries; Structural models by the American Congress of Rehabilitation Medicine REHABILITATION AIMS TO improve participation and ultimately quality of life (QOL). 1 QOL has been studied extensively in persons with spinal cord injury (SCI). 2-4 Although QOL is a difficult construct to define, a distinction can be made between objective and subjective QOL. Within the latter concept, 2 components can be distinguished: (1) the cognitive component that refers to life satisfaction and (2) the emotional component that refers to a person s affect or mental health. 4 Studies of subjective QOL in persons with SCI showed that QOL recovered after being low immediately after the event. 5-7 In the long run, subjective QOL ratings often were higher than what was expected and were just slightly lower than those of the general population. 2,8 Factors consistently related to higher subjective QOL are higher education, 9-11 increased mobility, 9,10,12 better perceived physical health, 8,10-14 more social support, 9-13,15,16 and better psychological functioning, 7,11,16-20 such as higher levels of self-efficacy 7,16,19 and lower levels of neuroticism. 20 However, less attention has been given to theorybased and statistical modeling of relationships between subjective QOL and personal factors that could affect components of the International Classification of Functioning, Disability, and Health (ICF). 21 The ICF describes the influence of a health condition, such as SCI, on 3 main components of functioning, body functions and structure, activities, and participation, in relation to personal and environmental factors. 21 It is possible List of Abbreviations AIC Akaike s information criterion EPQ-RSS Eysenk Personality Questionnaire-Revised Short Scale ICF International Classification of Functioning, Disability, and Health ICQ Illness Cognition Questionnaire QOL quality of life SCI spinal cord injury SF Item Short Form Health Survey SIP-68 Sickness Impact Profile 68

2 FUNCTIONING, PERSONAL FACTORS, AND QUALITY OF LIFE, van Leeuwen 83 Fig 1. Simplified theoretical model of Rapkin and Schwartz. 26 to link the ICF to the concept of QOL. 4 Relationships between activities, participation, and subjective QOL have been analyzed, 11,22 but less is known about the way personal factors influence relationships between activities and participation on the one hand and mental health and life satisfaction on the other hand. 17,23-25 A theoretical model useful in this respect is that of Rapkin and Schwartz, 26 which describes how subjective QOL ratings change after a disease or treatment. Figure 1 shows the Rapkin 26 model in a simplified form without the supposed mechanisms. Appraisals are a key concept in this model that refer to the way an individual thinks about or appraises a situation. In the present study, appraisals are operationalized as illness cognitions about the SCI. Appraisals may affect subjective QOL ratings directly or indirectly by attenuating the functional impact of a disease (see fig 1). Moreover, antecedents may affect subjective QOL ratings directly or indirectly by influencing appraisals or the catalyst (SCI). 26 The present study was an exploratory study that combined elements of the ICF model with elements of the Rapkin 26 model. We built a structural equation model and blended 3 concepts of the ICF model, activities, participation, and personal factors, with 3 concepts of the Rapkin 26 model, appraisals, antecedents, and QOL. In our view, both appraisals and antecedents can be regarded as personal factors. However, like Rapkin, 26 appraisals and antecedents were analyzed as 2 separate constructs. In our model, self-efficacy and neuroticism were included as antecedents and QOL was split into mental health and life satisfaction. The aim of the study was two-fold. The first aim was to clarify relationships between activities, participation, mental health, and life satisfaction. Based on the ICF model and the work of Post et al, 11 it was hypothesized that activities are related directly to participation, participation is related directly to mental health and life satisfaction, and mental health and life satisfaction are 2 interrelated outcome variables. The second aim was to specify how antecedents (self-efficacy, neuroticism) and appraisals interact with activities, participation, mental health, and life satisfaction. Based on the model of Rapkin, 26 it was hypothesized that appraisals are mediators between participation and mental health and life satisfaction, and selfefficacy and neuroticism are both related directly to mental health and life satisfaction and indirectly through appraisals. METHODS Participants This study was a follow-up of the Dutch prospective multicenter cohort study Restoration of Mobility in the Rehabilitation of Persons With SCIs. 27 For this research program, 225 persons admitted for initial inpatient rehabilitation were selected consecutively from 8 rehabilitation centers with specialized SCI units in The Netherlands between August 2000 and July Subjects were included if they fulfilled the following criteria: (1) recently acquired SCI; (2) aged 18 to 65 years; (3) grade A, B, C, or D on the American Spinal Injury Association Impairment Scale; and (4) expected permanent wheelchair dependency. Participants were excluded if they had an SCI due to a malignant tumor, progressive disease, or psychiatric problems or insufficient command of the Dutch language to understand the goal of the study and test instructions. This follow-up measurement was approved by the Medical Ethics Committee of the University Medical Centre Utrecht. All persons gave written informed consent. Procedure Measurements took place 5 years after discharge from inpatient rehabilitation and included a medical examination, physical tests, oral interview with a trained research assistant, and self-report questionnaires. Self-report questionnaires included psychological measures, most of which were not included in earlier measurements. Instruments Functional status in the domain activities. This was measured by using the motor score of the FIM, consisting of 13 items about self care, mobility, transfers, and toileting. 28 Participation. Participation was measured by using the social health status dimension of the Sickness Impact Profile 68 (SIP-68). 29 The Mobility Range and the Social Behaviour scales together make up the social dimension, measuring the perceived impact of health problems on social functioning. 30,31 A high score reflects poor participation. The SIP-68 proved to be reliable and valid in patients with SCI. 30 Life satisfaction. This was measured by using 2 questions, 1 about satisfaction with life as a whole at the moment (range,

3 84 FUNCTIONING, PERSONAL FACTORS, AND QUALITY OF LIFE, van Leeuwen Table 1: Strategy for Analyses and Model Fit of the Different Models Steps What Was Analyzed? Description of Model Fit of Model 1A Relationships between activities, participation, Functional status participation Model fit is perfect because and life satisfaction were analyzed by comparing model 1A with model 1B Participation life satisfaction Functional status life satisfaction (based on the ICF-model and work of Post et al 11 ) of saturated model 1B Functional status participation AGFI 0.95 Participation life satisfaction AIC 11.8 (simplified model) 1C Mental health was added. Relationships between Functional status participation AGFI 0.92 activities, participation, mental health, and life Participation life satisfaction AIC satisfaction were analyzed by comparing model 1C with model 1D Participation mental health Mental health life satisfaction Life satisfaction mental health (based on work of Post 11 ) 1D Functional status participation AGFI 0.64 Mental health participation AIC 50.7 Participation life satisfaction (Based on the ICF 21 model) 1E Nonsignificant paths were deleted, leading to a final path model: figure 2 AGFI 0.96 AIC A Psychological factors were added to figure 2. Relationships between activities, participation, psychological factors, mental health, and life satisfaction were analyzed 2B Based on the ICF model, 21 all possible relationships between psychological factors on the 1 hand and activities, participation, mental health, and life satisfaction on the other hand were tested Nonsignificant paths were deleted, leading to a final path model: figure 3 AGFI 0.97 AIC 39.2 AGFI 0.97 AIC A 3B Appraisals were added to figure 3. Relationships between activities, participation, psychological factors, appraisals, mental health, and life satisfaction were analyzed Based on model of Rapkin and Schwartz, 26 appraisals were placed between participation and mental health and life satisfaction and were related to neuroticism and self-efficacy. All possible relationships were tested Nonsignificant paths were deleted, leading to a final path model: figure 4 AGFI 0.31 AIC AGFI 0.93 AIC 74.3 Abbreviation: AGFI, Adjusted Goodness of Fit Index. 1 very unsatisfying, 6 very satisfying) and 1 about comparison of QOL now with life before the SCI (range, 1 much worse, 7 much better). Supported by a strong 32 correlation (.53) between both questions, a total life satisfaction score was computed with a range of 2 to 13. This total score was normally distributed (skewness,.08), correlated strongly 32 (.70) with the global life satisfaction score of the Life Satisfaction Questionnaire 9 33 in this study, and was used in several earlier publications. 6,7,15,34 Mental health. This was assessed by using the Mental Health subscale of the 36-Item Short Form Health Survey (SF-36), consisting of 5 items (eg, How often during the last 4 weeks have you felt downhearted and low?). 35,36 The SF-36 has shown acceptable reliability and validity in persons with SCI. 36 Neuroticism. This personality trait reflects emotional stability and was assessed by using the Eysenk Personality Questionnaire-Revised Short Scale-Neuroticism (EPQ-RSS). 37 This scale consists of 12 dichotomous items (eg, Does your mood often go up and down?). The EPQ-RSS was shown to be reliable and valid in patients with cancer and healthy controls. 37 Cronbach of the neuroticism scale in our data was good (.82). Self-efficacy. This was measured by using Sherer s Selfefficacy Scale. 38,39 The scale consists of 16 items with 5-point Likert scales measuring expectancies about competencies that are not attributed to specific situations or behavior (eg, When I make plans, I am certain I can make them work). The selfefficacy questionnaire has good test-retest reliability and internal consistency. 39 Internal consistency in our data was good (Cronbach.87). Appraisals. Appraisals were assessed by using the Illness Cognition Questionnaire (ICQ). 40 Questions were modified slightly to refer to SCI instead of illness. 41 The ICQ consists of 18 statements with 4-point items in 3 subscales: helplessness (eg, Because of my condition, I miss the things I like to do most), acceptance (eg, I can handle the problems related to my condition), and disease benefits (eg, My condition has taught me to enjoy the moment more). 40 The ICQ proved to be reliable in persons with SCI. 41 In the present study, internal consistency of the subscales was good (Cronbach.84.88). Statistical Analyses Pearson correlations were computed to investigate correlations between activities, participation, life satisfaction and mental health, psychological variables, and appraisals. A cor-

4 FUNCTIONING, PERSONAL FACTORS, AND QUALITY OF LIFE, van Leeuwen 85 Table 2: Descriptive Characteristics at the Start of Active Rehabilitation of Participants and Nonparticipants 5 Years After Discharge Participants (N 143) Nonparticipants (N 82) Variables n % n % Sex (men) Marital status (together) Children (yes) Education.350 Low Middle High Unknown Type of injury.276 Incomplete paraplegia Complete paraplegia Incomplete tetraplegia Complete tetraplegia Cause of injury (traumatic) * Median IQR Median IQR Mental health (range, 0 100) Life satisfaction (range, 2 13) NOTE. Education and type of injury were categorical variables. One P value was calculated for the categorical variable Education and another P value was calculated for the categorical variable Type of injury. Abbreviations: IQR, interquartile range. *P.05. P relation was considered weak at less than 0.3, moderate between 0.3 and 0.5, and strong at greater than Structural equation modeling 42 using the statistical program LISREL 8.8 a was performed to examine the paths between different variables. Model fit was determined according to the adjusted goodness-of-fit index, which should be at least To determine the optimal path model, different path models were compared by using Akaike s information criterion (AIC). 42 The most parsimonious model (deleting paths that were not significant and did not contribute to model fit) with the lowest AIC was considered the best model. A series of 3 models of increasing complexity were analyzed (table 1). Significance was set at P.05. RESULTS Respondent Characteristics A total of 143 persons participated in follow-up measurements 5 years after discharge from inpatient rehabilitation. Reasons for dropping out between the first and last measurement of the research program were as follows: 30 persons died, 17 refused to collaborate, 5 moved, 10 could not be contacted, and 20 had other reasons to decline further participation. Mean SD age of participants was years. Comparison of participants and nonparticipants showed no significant differences between the 2 groups, except that participants had traumatic injuries more often (table 2). Descriptives and Correlations Median scores for activities, participation, life satisfaction and mental health, psychological variables, and appraisals are listed in table 3. Correlations between these variables are listed in table 4. Path Model of Relationships Between Activities, Participation, Life Satisfaction, and Mental Health Table 1 lists the different steps undertaken to build an optimal path model of relationships between activities, participation, life satisfaction, and mental health. First, relationships between activities, participation, and life satisfaction were analyzed. Model 1A was a saturated model and therefore model fit was perfect. However, the path between functional status (activities) and life satisfaction was not significant. Therefore, model 1B was preferred to model 1A. Second, mental health was added and relationships between activities, participation, life satisfaction, and mental health were examined by comparing model 1C with model 1D. Model 1C had a lower AIC and therefore was preferred to model 1D. Figure 2 shows the optimal path model in which relationships between activities, participation, life satisfaction, and mental health are specified. In this model, the path from life satisfaction to mental health was deleted because this path was not significant. Table 3: Descriptive Characteristics of Activities, Participation, QOL, Antecedents, and Appraisals Concept Indicator Range Median (IQR) Activities FIM ( ) Participation SIP (2 10) QOL Mental health SF (68 88) Life satisfaction 2 items (6 9) Antecedents Neuroticism EPQ-RSS (1 4) Self-efficacy SES (56 74) Appraisals Helplessness ICQ (10 16) Acceptance ICQ (15 21) Disease benefits ICQ (12 18) NOTE. N 143. Abbreviations: IQR, interquartile range; SES, Sherer s Self-efficacy Scale.

5 86 FUNCTIONING, PERSONAL FACTORS, AND QUALITY OF LIFE, van Leeuwen Table 4: Pearson Correlations Between Activities, Participation, QOL, Antecedents, and Appraisals Concept Indicator P MH LS N SE Help ACC DB Activities FIM.57*.07.22* * Participation SIP-68.41*.54*.30*.36*.56*.34*.28* QOL MH SF-36.58*.50*.52*.51*.56*.25* LS 2 items.36*.33*.59*.55*.36* Antec N EPQ-RSS.40*.42*.42*.05 SE SES.40*.39*.21* Appraisal Help ICQ.57*.08 ACC ICQ.26* DB ICQ NOTE. N 143. Correlation values are listed once in the upper half of the table. Empty plots in the lower half of the table reflect areas in which the correlation values repeated. Abbreviations: ACC, acceptance; Antec, antecedents; DB, disease benefits; Help, helplessness; IQR, interquartile range; LS, life satisfaction; MH, mental health; N, neuroticism; P, participation; SE, self-efficacy; SES, Sherer s Self-efficacy Scale. *P.05. Path Model of Relationships Between Antecedents, Appraisals, Activities, Participation, Life Satisfaction, and Mental Health Third, relationships between antecedents, activities, participation, life satisfaction, and mental health were analyzed (see table 1). Figure 3 shows the optimal path model. Selfefficacy was related to mental health and life satisfaction, and neuroticism was related to participation and mental health. Fourth, relationships between antecedents, appraisals, activities, participation, life satisfaction, and mental health were analyzed (see table 1). Figure 4 shows the optimal path model. In this model, activities were not related directly to antecedents, appraisals, or subjective QOL. Functional status (activities) and neuroticism were related to participation and together explained 49% of the total variance in participation. Selfefficacy and neuroticism explained a substantial amount of the variance in appraisals. Unlike the model in figure 2, participation was not related directly to mental health, but indirectly through the appraisal helplessness. Self-efficacy, neuroticism, and 2 appraisals (helplessness, acceptance) were related to mental health and together explained 35% of the total variance in mental health. Finally, participation, all 3 appraisals, and mental health were related to life satisfaction and together explained 50% of the total variance in life satisfaction. DISCUSSION The first hypothesis, that activities are related directly to participation, participation is related directly to mental health and life satisfaction, and mental health and life satisfaction are 2 interrelated outcome variables, was supported. A unidirectional relationship between mental health and life satisfaction was found. The second hypothesis, that appraisals are mediators between participation and mental health and life satisfaction and that self-efficacy and neuroticism are both related directly to mental health and life satisfaction and indirectly through appraisals, was partly supported. Helplessness was shown to be a mediator between participation and mental health and life satisfaction. However, acceptance and disease benefits were not related to participation and turned out to be mediators between antecedents and mental health and life satisfaction. In addition, the 2 antecedents neuroticism and self-efficacy were Activities Participation Quality of life Functional status Participation R²=.16 Life satisfaction R²= Mental Health R²=.08 Fig 2. Path model of relationships between activities, participation, mental health, and life satisfaction. All standardized path coefficients, similar to values in ordinary multiple regression analysis, were significant at P<.05 and can be interpreted in the usual way. R 2 adjusted R 2.

6 FUNCTIONING, PERSONAL FACTORS, AND QUALITY OF LIFE, van Leeuwen 87 Activities Functional status Participation Participation R²=.49 Quality of life Life satisfaction R²=.41 Fig 3. Path model of relationships between activities, participation, antecedents, mental health, and life satisfaction. All standardized path coefficients, similar to values in ordinary multiple regression analysis, were significant at P<.05 and can be interpreted in the usual way. R 2 adjusted R 2. Antecedents Neuroticism.34 Self-efficacy Mental health R²=.29 related directly to mental health and indirectly to life satisfaction by influencing all 3 appraisals. Relationships Between Activities, Participation, Life Satisfaction, and Mental Health The described relationship between activities and participation is in accordance with the ICF model, 21 and the mediating role of participation in the relationship between activities and life satisfaction is consistent with earlier research. 11,22 However, the position of mental health in the final path model contradicts the position of mental health as a body function (b152, emotional functions) in the ICF. 21 In our model, mental health is a separate outcome measure interrelated with the outcome measure life satisfaction. Although this finding is not consistent with the ICF, it is consistent with the conclusion that subjective QOL consists of a cognitive and an emotional component. 4 Finally, the model showed that life satisfaction is dependent on mental health, but mental health is not dependent Activities Participation Appraisals Quality of life -.23 Functional status -.43 Participation R²= Helplessness R²= Life satisfaction R²= Disease benefits R²= Mental health R²=.35 Antecedents Neuroticism.34 Self-efficacy.69 Acceptance R²= Fig 4. Path model of relationships between activities, participation, antecedents, appraisals, mental health, and life satisfaction. All standardized path coefficients, similar to values in ordinary multiple regression analysis, were significant at P<.05 and can be interpreted in the usual way. Correlations (range,.21.33) existed among the 3 appraisals, but were not shown for the clarity of the figure. R 2 adjusted R 2.

7 88 FUNCTIONING, PERSONAL FACTORS, AND QUALITY OF LIFE, van Leeuwen on life satisfaction. This implies that mental health might be seen as a determinant of life satisfaction, which also is assumed in some other studies. 11,17,18,24 Relationships Between Antecedents, Appraisals, Activities, Participation, Life Satisfaction, and Mental Health First, all 3 appraisals were mediating factors in the relationship between the 2 antecedents and subjective QOL. This mediating role of appraisals is in accordance with the model of Rapkin, 26 in which antecedents affect QOL ratings indirectly by influencing appraisals. This finding also is consistent with an earlier study of persons with SCI, which found that appraisals were associated more strongly with subjective QOL than certain psychological variables. 41 The reason that the appraisal helplessness was a mediator between participation and subjective QOL and the appraisals disease benefits and acceptance were not is unclear and warrants further research. Second, the finding that the 2 antecedents neuroticism and self-efficacy were related both directly and indirectly to subjective QOL also is in accordance with the model of Rapkin. 26 Neuroticism was related directly to lower mental health, which implies that persons who score high on neuroticism might have a higher risk for poor psychological adjustment. This negative relationship also was found in 2 earlier studies. 20,43 In contrast, high self-efficacy was related directly to higher mental health and might be seen as a resource for psychological adjustment, which also was described in earlier studies. 16,19,44 Interestingly, neuroticism was related most strongly to the appraisal helplessness, and self-efficacy was related most strongly to the appraisal acceptance. Furthermore, both helplessness and acceptance were related to mental health and life satisfaction. This might imply that both cognitive behavioral therapy, aimed at reducing neuroticism, 45,46 and self-management interventions, aimed at improving self-efficacy, 47 are different approaches that might positively influence mental health and life satisfaction of persons with SCI. Finally, the explained variance in life satisfaction was higher than the explained variance in mental health. An important difference was that participation explained part of the variance in life satisfaction, but not in mental health. The variance in mental health was explained by self-efficacy, neuroticism, helplessness, and acceptance, all personal factors. Other personal factors not assessed in the present study might explain additional variance in mental health. Perceived control, 13 coping, 25 and positive psychological variables, such as hope and optimism, 18 are examples of personal factors found to be related to mental health in earlier studies. Study Limitations A limitation to the present study was that only Dutch persons with SCI aged 18 to 65 years with expected permanent wheelchair dependency admitted to a rehabilitation center were included. This influenced the representativeness of the population and thereby the degree to which results of our study can be generalized to the entire population of persons with SCI. Second, persons who had a nontraumatic injury had a higher chance of dropping out of the study. Third, this study had a cross-sectional design and therefore no final conclusions can be drawn with respect to causality, although structural equation modeling allows testing of the direction of the 1-direction arrows shown in figures. Finally, the present study is exploratory in nature; therefore, testing of the final model should be repeated. Clinical Implications Monitoring neuroticism and self-efficacy in an early stage after SCI might help identify persons at risk for poor long-term adjustment. Turning helplessness cognitions into more beneficial cognitions might help persons better adjust to SCI. Although evidence is not consistent, cognitive behavioral therapy might be effective in this respect. 45,46 Furthermore, attention should be given to strengthening self-efficacy during rehabilitation because an earlier study reported that self-efficacy can be taught by focusing on 4 aspects: positive experiences, role models, giving feedback, and relaxation. 47 An additional advantage of strengthening self-efficacy is that acceptance cognitions might be enhanced, which are associated positively with higher mental health and life satisfaction. Future Research The structural equation modeling approach of this study can be used to examine complex relationships between the components of functioning described in the ICF and subjective QOL. Furthermore, this study was a first attempt to examine structural relationships between personal factors, functioning, and subjective QOL. Further research is needed to test whether the relationships found in the present study can be confirmed in studies with a longitudinal design and whether this model also is valid in other countries or cultures and diagnostic groups. CONCLUSIONS Mental health and life satisfaction can be seen as 2 separate but interrelated outcome variables. The personal factors selfefficacy, neuroticism, and appraisals have an important role to better understand the complex relationships between functioning and subjective QOL. Cognitive behavioral therapy, which aims to reduce helplessness cognitions, 45,46 and self-management interventions, which aim to strengthen self-efficacy, 47 are different approaches that might positively influence mental health and life satisfaction in persons with SCI. Acknowledgments: We thank the participating Dutch rehabilitation centers and research assistants in these centers who collected all data: Rehabilitation Center De Hoogstraat (Utrecht), Reade, Centre for Rehabilitation and Rheumatology (Amsterdam), Rehabilitation Center Het Roessingh (Enschede), Adelante (Hoensbroek), Rehabilitation Center Sint Maartenskliniek (Nijmegen), Center for Rehabilitation- Location Beatrixoord (Haren), Heliomare (Wijk aan Zee), and Rijndam Rehabilitation Center (Rotterdam). References 1. Wade DT. Describing rehabilitation interventions. Clin Rehab 2005;19: Dijkers MP. Quality of life of individuals with spinal cord injury: a review of conceptualization, measurement, and research findings. J Rehabil Res Dev 2005;42: Hammell KW. Exploring quality of life following high spinal cord injury: a review and critique. Spinal Cord 2004;42: Post M, Noreau L. Quality of life after spinal cord injury. J Neurol Phys Ther 2005;29: Lucke KT, Coccia H, Goode JS, Lucke JF. 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