Rehabilitation Psychology 2013, Vol. 58, No.

2, 158 165

In the public domain DOI: 10.1037/a0032047

Pain, Depression, and Health Care Utilization Over Time After Spinal Cord Injury
Philip M. Ullrich, Randi K. Lincoln, and M. Jan Tackett
VA Puget Sound Healthcare System, Seattle, WA and University of Washington

Scott Miskevics
Edward Hines Jr. Veterans Affairs Hospital, Hines, Illinois

Bridget M. Smith and Frances M. Weaver

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Edward Hines Jr. Veterans Affairs Hospital, Hines, Illinois and Loyola University Chicago
Objective: The aim of this research was to examine comorbid pain and depression after spinal cord injury (SCI) in terms of: frequency, longitudinal course, and associations with medical conditions and use of SCI specialty care. Method: Three consecutive standardized annual psychological evaluations were reviewed for 286 persons with SCI receiving care at an SCI specialty care center. Chart abstraction included medical and demographic information, a depression scale, and a pain scale. Administrative databases were used to collect SCI specialty care utilization data. Participants were categorized as having elevated pain, elevated depression, both elevated pain and depression, or neither elevated, using cut-off scores on the pain and depression scales. ANOVA and repeated measures ANOVA were used to compare study groups. Results: Approximately 20% of the sample showed both elevated pain and depression at Year 1. Persons with elevated pain and depression showed higher scores on those measures than did persons with either pain or depression alone. Pain scores tended to be stable over time. Depression scores tended to improve over 3 years, but persons with elevated pain and depression showed less improvement on depression scores than did persons with depression alone. Persons with pain and depression tended to utilize more SCI specialty care. Conclusions: Pain and depression are often comorbid after SCI. This comorbidity is associated with higher pain and depression severity, more persistent pain and depression over time, and more use of SCI specialty care. Comorbid pain and depression should be anticipated among persons with SCI and addressed in care plans. Keywords: spinal cord injury, pain, depression, health care

Impact and Implications Statement

Pain and depression often occur after SCI but very little research has examined the co-occurrence of these problems or how co-occurrence is associated with severity and course. This study made the novel observation that co-occurring pain and depression after spinal cord injury (SCI) is common and may be associated with more severe conditions, poorer recovery over time, and increased utilization of SCI specialty care. Clinical practice often addresses pain and depression as separate, independent disorders when in fact these conditions typically occur together with important negative ramifications for patients. Comorbid pain

and depression should be expected among persons with SCI and treatment plans should be prepared to address the additional challenges represented by comorbidity.

Introduction
Pain and depression are commonly linked among persons with medical problems (Bair, Robinson, Katon, & Kroenke, 2003; Banks & Kerns, 1996). This is of particular concern because pain and depression levels tend to be more severe when co-occurring (Campbell, Clauw, & Keefe, 2003), and the presence of one

Philip M. Ullrich, Randi K. Lincoln, and M. Jan Tackett, Department of Veterans Affairs, Spinal Cord Injury and Disorders Services, VA Puget Sound Healthcare System, Seattle, Washington, and Department of Rehabilitation Medicine, University of Washington; Scott Miskevics, Department of Veterans Affairs, Spinal Cord Injury Quality Enhancement Research Initiative and Center for Management of Complex Chronic Care, Edward Hines Jr. Department of Veterans Affairs Hospital, Hines, Illinois; Bridget M. Smith and Frances M. Weaver, Department of Veterans Affairs, Spinal Cord Injury Quality Enhancement Research Initiative and Center for Management of Complex Chronic Care, Edward Hines Jr. Department of Veterans Affairs Hospital, and 158

Stritch School of Medicine, Program in Health Services Research, Loyola University Chicago. This research was supported by a grant from the Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service, Spinal Cord Injury Quality Enhancement Initiative (SCI QUERI). This article presents the views of the authors; it does not necessarily represent the views or policies of the Department of Veterans Affairs or the Health Services Research and Development Service. Correspondence concerning this article should be addressed to Phil M. Ullrich, PhD, 128 NAT, 1660 S Columbian Way, Seattle, WA, 98108. E-mail: philip.ullrich@va.gov

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condition may adversely affect the detection and treatment of the other (Banks & Kerns, 1996). This research should be noted by individuals with spinal cord injury (SCI) and their care providers because of the high rates of pain and depression after SCI. Elevated depressive symptoms are found among 20% to 30% of persons with SCI (Bombardier, Richards, Krause, Tulsky, & Tate, 2004; Craig, Tran, & Middleton, 2009; Elliott & Frank, 1996). A number of studies have found that depression scores tend to be stable over time among persons with SCI (Craig, Hancock, & Dickinson, 1994a; Hancock, Craig, Dickson, Chang, & Martin, 1993). In fact, Hoffman and colleagues found that over the course of 5 years depressive symptoms were about as likely to worsen as improve after SCI (Hoffman, Bombardier, Graves, Kalpakjian, & Krause, 2011). Pain after SCI is similar to depression in frequency and recalcitrance. Severe pain is experienced by about one third of persons with SCI (Finnerup, Johannesen, Sindrup, Bach, & Jensen, 2001; Jensen, Hoffman, & Cardenas, 2005). Pain conditions following SCI tend to persist (Cruz-Almeida, Martinez-Arizala, & Widerstrom-Noga, 2005; Siddall, McClelland, Rutkowski, & Cousins, 2003) or worsen (Jensen et al., 2005; Rintala, Hart, & Priebe, 2004) over time. Some researchers have examined associations between pain and depression after SCI. A recent review of research found that pain after SCI is often associated with greater levels of depression (Craig et al., 2009). Pain levels at the time of discharge from inpatient rehabilitation were predictive of depressed mood up to 2 years later (Craig, Hancock, & Dickinson, 1994b). Increasing pain levels over the course of 5 years was a risk factor for the development of depression in that same time period among persons with SCI (Hoffman et al., 2011). Only one study to our knowledge has directly examined the frequency of comorbid pain and depression after SCI. Cairns, Adkins, and Scott (1996) found that during inpatient rehabilitation, between 22% and 35% of persons with SCI were identified as having both elevated depression and pain, making the co-occurrence of these conditions more common than either alone. These studies collectively suggest that pain and depression commonly co-occur after SCI, but it is unknown whether or not comorbid pain and depression is associated with higher severity ratings or poorer courses of recovery over time, as is the case in other populations. The objectives of this study were to examine among persons with SCI (a) rates of comorbid pain and depression; (b) associations between comorbid pain and depression and the severity and longitudinal course of those conditions; and (c) associations between comorbid pain and depression, medical conditions, and SCI specialty care utilization. It was hypothesized that persons with comorbid pain and depression would evidence higher scores on those indices than persons with either pain or depression alone. Persons with elevated pain and depression were also hypothesized to show poorer courses of improvement from pain and depression over time as compared with persons with either condition alone. Finally, because pain and depression often co-occur among persons with medical illnesses (Bair et al., 2003), it was hypothesized that persons with pain and depression would show increased prevalence of medical conditions and increased use of SCI specialty care as compared with persons without pain or depression.

Participants and Data Collection

Participants were veterans with an SCI or disorder (SCI/D) who received a standardized annual evaluation at one Veterans Affairs (VA) SCI specialty care center during the first year of the study, calendar year 2005. Four-hundred and forty-eight Veterans with SCI/D received an annual evaluation during this time period. Medical records were reviewed to abstract data for the next two subsequent annual evaluations. Medical comorbidity and SCI specialty care utilization data was gathered by accessing VA administrative databases, where information on medical diagnostic codes, outpatient and inpatient visits is stored. Of the 448 veterans who had annual evaluations in the first year, 63.8% had complete data sets for the next 2 years of annual evaluations. Thus, the final sample analyzed for this study was the 286 veterans who entered the sampling frame in 2005 and had annual evaluations for all three study years. All study procedures were approved and overseen by the authors Human Subjects Research Institutional Review Boards.

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Measures
Measures abstracted from the medical records were routine assessments conducted as part of the annual evaluation. Depression. The Center for Epidemiological Studies Depression Scale (CES-D; Radloff, 1977) is a 20-item questionnaire assessing current symptoms of depression. Respondents indicate on a 0 to 3 scale how often they have experienced a variety of symptoms during the past week. The scale has a good record of reliability and validity in studies involving persons with SCI (Kalpakjian, Bombardier, Schomer, Brown, & Johnson, 2009). Scores of 16 or higher are considered indicative of high risk for clinical depression (Weissman, Sholomskas, Pottenger, Prusoff, & Locke, 1977). Pain intensity. Participants were asked to rate their average pain intensity during the past week on a 0 10 Numerical Rating Scale (NRS), with 0 no pain to 10 pain as bad as could be. Numerical pain ratings scales have been shown to have good testretest reliability and adequate validity in terms of associations with other pain measures and treatments (Jensen, Turner, Romano, & Fisher, 1999). Participants used the NRS to rate overall pain intensity. Scores of 4 or higher on the NRS are considered to indicate clinically significant pain (Forchheimer, Richards, Chiodo, Bryce, & Dyson-Hudson, 2011). The NRS has a record of strong psychometric performance among persons with SCI (Hanley, Masedo, Jensen, Cardenas, & Turner, 2006). Medical comorbidities. Medical comorbidities were identified using algorithms based on ICD-9 codes in VA administrative databases. Medical comorbidities identified included diabetes, heart disease, hypertension, COPD, flu, pneumonia, UTI, and pressure ulcers. The total number of medical comorbidities during the study time period was summed to be used in analyses, yielding a score of 0 8 for each patient. SCI specialty care utilization. Administrative databases were utilized to measure SCI specialty care utilization at the site of the study over the study time period, calendar years 20052007. Utilization variables included number of SCI unit inpatient admis-

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sions, total number of SCI unit inpatient days, number of SCI service outpatient visits, and number of outpatient visits with an SCI psychologist.

Statistical Analyses
Participants were categorized as having elevated pain levels at Year 1 if their NRS pain scores were 4 or higher. Participants were also categorized as having elevated depression scores if their CESD scores were 16 or higher. This created four categories of patients based on pain and depression scores at Year 1: PainDepression, Depression, Pain, or Neither condition. ANOVAs were used to examine whether persons with PainDepression would evidence higher pain and depression scores. ANCOVA was used to include age, medical comorbidities, and level of injury as covariates in comparisons of pain and depression groups on SCI specialty care utilization and comorbidities. Scheff tests were used for post hoc comparisons of groups when ANOVA or ANCOVA was statistically significant. Repeated measures ANOVA was used to test for changes over time and for group by time interactions, that is, to test whether those with PainDepression would show poorer courses of pain and depression over the 3 years of the study as compared with persons with either condition alone.

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plegia (motor level T2S4/S5) was the most common type of SCI/D (49%) followed by low tetraplegia (38%; C5T1) and high tetraplegia (13%; C1C4). About half (46%) of the participants had complete injuries. Demographic characteristics were not significantly associated with pain, depression, or health care utilization. Medical comorbidities were correlated with SCI specialty outpatient visits, number of inpatient SCI unit admissions, and total number of SCI unit inpatient days (all p values .05), with greater numbers of comorbidities being associated with more utilization. Age was significantly associated with total number of SCI unit inpatient days (p .05). Low motor levels were associated with fewer SCI unit inpatient admissions (p .05). Mean values of key study variables, and correlations between study variables are shown on Table 1. On average, participants experienced 2.5 medical comorbidities during the 3-year study time period. Participants were hospitalized on the SCI unit about once a year, on average, and spent an average of nearly 40 days in the hospital over the course of the 3-year study time period. SCI specialty outpatient visits occurred about four times a year, on average, and a psychologist was seen about once a year, on average.

Results
Participants excluded due to incomplete data were compared with those with complete data on key study variables. T tests were used for continuous data (age, level of injury, time since SCI, pain, depression, comorbidities, and SCI specialty care utilization) and chi-square tests for categorical variables (gender, marital status, education, employment status, and completeness of SCI). Participants with complete data were younger (t 3.46, p .05) than those with incomplete data (mean age 52.7 vs. 57.1, respectively). No other significant differences were apparent.

Pain and Depression Over Time

Table 2 displays rates of pain and depression at Year 1. Most (59%) participants had either elevated pain, depression, or both at Year 1. Figure 1 shows depression scores over 3 years according to pain and depression conditions at Year 1. Persons with PainDepression at Year 1 had higher depression scores than did other groups, including those with Depression alone, and those with Depression alone had higher depression scores than did the two groups without depression [F(3, 282) 230.11, p .001]. Repeated measures ANOVA showed significant effects for time [F(1, 282) 24.09, p .001] and a time by group interaction [F(3, 282) 14.21, p .001] indicating that the course of depression over time varied between the four groups. Figure 1 suggests that the interaction effect is due to declining depression scores among those with Depression alone and those with PainDepression. Repeating this ANOVA only among the participants with PainDepression, and Depression alone revealed that the interactive effect remained statistically significant [F(3, 74) 9.20, p .05], indicating that

Descriptive Characteristics of Sample

The study sample resembled the general population of veterans with SCI/D on demographic and medical characteristics. On average, participants were 53 years of age and had been living with SCI/D for 17 years. The sample tended to be White (92%) and male (97%). About half (46%) were married or living with a partner, and about half were employed or in school (53%). Para-

Table 1 Descriptive Statistics and Correlations for Key Study Variables (N 286)
Pearson Correlations Variable 1. 2. 3. 4. 5. 6. 7. Depression Year 1(CESD) Pain Year 1 (NRS) Comorbidities Inpatient admissions Inpatient days SCI outpatient visits Psychologist visits M 11.1 3.8 2.5 3.4 39.3 12.8 2.9 SD 10.0 2.9 1.6 2.7 68.9 17.6 8.5 1 2 .37

3 .13 .17

4 .15 .19 .42

5 .12 .06 .35 .48

6 .30 .17 .13 .09 .17

7 .27 .08 .06 .06 .18 .40

Note. CESD Center for Epidemiological Studies Depression Scale; NRS Numeric Rating Scale; SCI spinal cord injury. p .05. p .01. p .001.

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Table 2 Rates of Elevated Pain and Depression (N 286)

Depression Pain Low, 03: High, 410: Low ( 16) 118 (41) 92 (32) High (16 ) 22 (8) 54 (19)

Note. Numbers and percent (%) within each cell at year 1.

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depression scores declined less over time among those with PainDepression in comparison to those with Depression alone. Figure 2 shows pain scores over 3 years according to pain and depression conditions at Year 1. Persons with PainDepression at Year 1 had higher pain scores than did other groups, including those with Pain alone, and those with Pain alone had higher pain scores than did the two groups without pain [F(1, 282) 7.18, p .01]. Repeated measures ANOVA showed a statistically time by group interaction [F(3, 282) 14.53, p .001] indicating that the course of pain over time varied among the four groups. Figure 2 suggests that the interaction effect could be due to increasing pain scores among those with Depression alone.

Figure 2. Pain Scores Over Three Years. Note: Plotted lines represent absolute mean scores on pain NRS collected annually over the course of three years. NRS, numeric rating scale.

associated with total number of SCI unit inpatient days [F(1, 282) 1.61, p .15]. There was a trend toward significant differences between pain and depression groups on number of comorbidities [F(1, 282) 2.16, p .10].

Discussion SCI Specialty Care Utilization and Comorbid Illness

SCI specialty care utilization is displayed according to pain and depression status on Figure 3. Persons with PainDepression evidenced the highest utilization on most indices. Age, medical comorbidities, and level of injury were entered into the following equations as control variables. Pain and depression status was associated with number of SCI unit inpatient admissions over 3 years [F(1, 282) 5.98, p .01], specifically, persons with PainDepression and Pain alone experienced more inpatient admissions than those with Depression alone or Neither condition. Pain and depression status was also associated with number of SCI outpatient visits [F(1, 282) 7.20, p .001]; persons with PainDepression and Depression alone experienced more SCI outpatient visits than those with Pain alone or Neither condition. Finally, pain and depression status was associated with number of psychologist visits [F(1, 282) 6.31, p .001]; persons with PainDepression and Depression alone experienced more psychologist visits than those with Pain alone or Neither condition. Pain and depression status was not significantly Pain and depression are two of the most vexing complications to follow SCI and yet rates of co-occurrence and the impact of co-occurrence have not been well understood. Findings from this study suggested that the co-occurrence of these conditions is common among persons who have lived with SCI for many years. Moreover, comorbid pain and depression was associated with higher severity of conditions, more persistent conditions over time, and more utilization of SCI specialty care services. Over half of participants reported elevated pain levels at Year 1 of the study, and over one quarter reported elevated levels of depression. These rates are consistent with past reports but it should be noted that this sample was 17 years post-SCI/D, on average, whereas many past studies of pain and depression after SCI have focused on persons with newer injuries. The fact that high rates of elevated pain and depression occur so many years after SCI/D is concerning because it suggests longstanding, treatment-resistant problems. In this study, 19% of participants had comorbid PainDepression, whereas Depression alone was experience by only 8%. The rate of 19% with comorbid PainDepression is close to the rates of 22%35% reported by Cairns et al. (1996). This finding is surprising because the Cairns study (1996) involved measurements at the start and finish of rehabilitation, when higher rates of pain and depression might be expected. Taken together, these findings suggest that comorbid PainDepression is common after SCI, perhaps more common than depression alone, even many years after initial injuries are healed. Persons with comorbid PainDepression evidenced higher depression scores than those with Depression alone, and higher pain scores than those with Pain alone, matching findings from the general medical population. Additionally, the presence of comorbid PainDepression was associated with consistently high scores over 3 years on the depression measure. In fact, persons with Depression alone at Year 1 had scores below the cutpoint on the CESD by Year 3 of the study, suggesting successful courses of treatment or natural recovery. By contrast, persons with comorbid

Figure 1. Depression Scores Over Three Years. Note: CESD, Center for Epidemiological Studies Depression scale. Plotted lines represent absolute mean scores on CESD collected annually over the course of three years.

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Figure 3. SCI Specialty Care Utilization by Pain-Depression Groups Note: Values represent absolute means.

PainDepression had average scores above the CESD cutpoint at the final measurement of the study. These results suggest that pain and depression may have amplifying effects on each other, and may have adverse effects on the natural recovery and treatment of depression.

Measurement of pain over the course of 3 years in this sample revealed that pain levels tended to be stable across most participants. The stability of pain problems after SCI is well known (Siddall et al., 2003; Cruz-Almeida et al., 2005). More intriguing was the finding from this study that pain scores appeared to increase over time among persons who had Depression alone at Year 1. This suggests that depression could possibly be implicated as a contributing factor to the development of pain concerns through a number of mechanisms. What mechanisms might account for the associations between pain and depression found in this study? Cognitive factors are thought to be influential in the origins and maintenance of pain among persons with disabilities (Jensen, Moore, Bockow, Ehde, & Engel, 2011) and cognitive errors are especially prevalent among persons with pain and depression (Lefebvre, 1981; Smith, OKeeffe, & Christensen, 1994). For example, persons with pain and depression show cognitive distortions such as enhanced memory for negative self-referent pain and illness information in comparison to persons with pain who are not depressed (Pincus, Pearce, McClelland, & Isenberg, 1995). Depression and pain may heighten the perceived threat of functional activities, resulting in cessation or avoidance of activities (Vlaeyen & Morley, 2004). Put in operant behavioral terms, depression and pain may therefore reduce positive reinforcements (Romano & Turner, 1985) and create problems due to uncompleted tasks or unfulfilled role obligations. Similarly, cognitive errors such as catastrophizing may heighten fear of pain and underestimate pain coping resources, thereby impacting activity levels and functioning (Pincus & Morley, 2001; Sullivan et al., 2001). Banks and Kerns (1996) have also proposed a diathesis-stress model in which pain acts as a stressor on maladaptive cognitive processing diatheses. Biological explanations for associations between pain and depression emphasize the importance of the neurotransmitters serotonin and norepinephrine. Symptoms of depression have been associated with dysfunction in serotonergic and norepinergic pathways ascending from the brainstem to innervate areas of the brain (see Bair et al., 2003; Stahl & Briley, 2004 for reviews). These same areas of the brainstem are also the source of descending pathways responsible for inhibiting sensory input such as pain. A disruption in the functioning of these systems can, therefore, result in both depression and painful symptoms (Bair et al., 2003; Stahl & Briley, 2004). Participants with PainDepression had the highest levels of SCI specialty care utilization over the 3 years of this study on most indices, suggesting that the co-occurrence of these conditions is broadly related to increased SCI specialty care utilization. Determinants of SCI specialty care utilization are likely numerous and interrelated, as evidenced by research demonstrating associations between health care utilization and age, ethnicity, geographical proximity to health care, medical comorbidities, and level of injury (Guilcher et al., 2010; Krause & Saunders, 2009; LaVela, Smith, Weaver, & Miskevics, 2004). It is notable that findings from the present study remained in models controlling for the effects of age, medical comorbidities, and level of injury on SCI specialty care utilization. Participants with PainDepression and Depression alone were similar on SCI Service outpatient visits and outpatient psychologist visits, and both those groups had higher SCI specialty care utilization on those indices than did those with Pain alone or Neither condition. This suggests that depression was more closely

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associated with utilization of outpatient visits than pain. This finding could be attributed to factors that influence depression and outpatient visits simultaneously, such as mounting medical problems that were not measured by this studys index of medical comorbidities. Alternatively, it may be that features of depression can lead to poor self-care or nonadherence with medical regimens (DiMatteo, Lepper, & Croghan, 2000) resulting in worsening illness and increased utilization. It is curious that pain was not associated with more visits to SCI psychologists. Psychological assessment and treatment is recognized as a component to interdisciplinary treatment for pain in major reviews of treatments for pain after SCI (e.g., Siddall et al., 2006; Bryce & Ragnarsson, 2001; Finnerup, Johannesen, Sindrup, Bach, & Jensen, 2002). Given the favorable view of the role of psychologists in treating pain it would be expected that patients presenting with pain would be referred to them, resulting in increased visits. On the other hand, it is well known that evidence-based psychological treatments can be difficult to implement in real world settings (Addis, 2002; Stirman, Crits-Christoph, & DeRubeis, 2004). In the general population of patients that are referred for psychological treatment, less than half enter treatment (Blumenthal & Endicott, 1996/1997). Failure to enter psychological treatment for pain could be explained by patient-level and system-level factors. For example, patients may be generally disinterested in psychological treatments (Elliott & Shewchuck, 2002; Elliott & Kennedy, 2004; Wells, Robins, Bushnell, Jarosz, & OakleyBrowne, 1994) and more specifically may have poor opinions of psychological treatments for pain (Warms, Turner, Marshall, & Cardenas, 2002; Widerstrom-Noga & Turk, 2003). Underutilization of psychological treatments for pain could also be attributable to system-level problems such as lack of screening for conditions or lack of referral to providers. Paradoxically, problems with screening and referral are most common among the patients with medical issues that may require those services the most (Desai, Rosenheck, & Craig, 2006). Pain appeared to be more closely associated with inpatient SCI specialty care utilization than was depression, as suggested by findings that participants with PainDepression and those with Pain alone had more inpatient visits and trended toward longer overall inpatient length of stay over 3 years than did patients with Depression alone or Neither condition. These findings were not accounted for by number of comorbid illnesses. One explanation for these results is that painful comorbid illnesses not measured in this study contributed to increased inpatient care needs of participants. Persons with SCI are vulnerable to various painful issues such as arthritis, musculoskeletal problems, and spasms that could lead to additional inpatient stays.

covered have been small in magnitude (Martz, Livneh, Priebe, Wuermser, & Ottomanelli, 2005; Ullrich, Jensen, Loeser, Cardenas, & Weaver, 2008). It is unknown whether participants in this study were receiving care outside of the VA that could have effects on pain, depression, and other key study variables.

Conclusions
Pain and depression are often comorbid after SCI. When pain and depression do co-occur after SCI, severity levels are higher, the conditions may be more likely to persist over time, and more medical comorbidities may be present. Comorbid pain and depression should be anticipated among persons with SCI and addressed in care plans. For example, treatment-matching paradigms have been proposed to manage complicated syndromes involving pain and depression, with a key guideline being the assessment of cognitive and behavioral factors that could represent foci for treatment (cf., Jensen, 2011; Turk, 2005; Vlaeyen & Morley, 2005). Evidence-based psychological interventions such as cognitive behavioral and interpersonal psychotherapy may be modified to address comorbid issues including pain and depression (Ehde & Jensen, 2004; Poleshuck et al., 2010). Stepped care models for comorbid pain and depression have been developed and are showing promising results in empirical trials (Kroenke et al., 2009).

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References
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Limitations
A number of study limitations should be highlighted. This study was conducted at one SCI center within the VA; it is unknown whether these results generalize to other VA SCI centers, or to populations outside the VA. Veterans with SCI/D, including this sample, tend to be older in age and farther out in years from their injuries as compared with nonveteran populations with SCI/D. However, direct comparisons of veterans to nonveterans with SCI have found few statistically significant differences and those dis-

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Received August 1, 2011 Revision received May 22, 2012 Accepted January 23, 2013