- Email: [email protected]
Perception of Employment by the Veterans Participating in the National Veterans Wheelchair Games: A Survey Study
PM R XXX (2017) 1-6
www.pmrjournal.org
Original Research
Perception of Employment by the Veterans Participating in the National Veterans Wheelchair Games: A Survey Study William Kim, MD, Leah Lee, Daniel Lans, MS, David Tostenrude, MPA, Kenneth Lee, MD
Abstract Background: Employment in those with disability is an important rehabilitation goal, along with achieving some measure of functional independence and is at the same time one of the most difficult goals to achieve. The number of people with disabilities participating in adaptive sports has been increasing steadily over the years. A few studies have looked at the relationship between physical fitness and employment status in those with disability, but there have been no studies that focused on the results of organized adaptive sports events affecting employment outcome. Objective: To determine whether participation in the National Veterans Wheelchair Games (NVWG) has a positive impact on employment in those with disability. Study Design: Prospective, cross-sectional survey. Setting: 2015 NVWG in Dallas, Texas (nonclinic setting). Participants: A total of 338 survey participants; 36 surveys were excluded due to incompletion. Methods: Veterans who participated at the 2015 NVWG were given the opportunity to complete a 2-page survey. Survey participants received $5.00 gift card as compensation. Main Outcome Measurements: Percentage of those who perceived NVWG made a difference in attaining employment, risk ratio analyses. Results: A total of 50% of the participants stated that the NVWG made a difference in attaining employment. Those currently working were 1.5 times more likely to say that the NVWG had a positive effect on employment than those not currently working (P < .01). Those who felt that the NVWG had a positive effect on employment attended 3-4 more wheelchair games on average than those reporting that the NVWG did not have an impact on employment (P < .001). Positive responses were obtained from the Likert scale distribution. Conclusions: Our study suggests that participating in the NVWG provides psychosocial support to the veterans and may have a positive influence in employment outcomes. Level of Evidence: To be determined.
Introduction Adaptive Sports: Physical, and Psychological Impact The number of people with disabilities participating in adaptive sports has been increasing steadily over the years with the development of improved equipment and increased opportunities for participation. It is estimated that in the United States, 2-3 million individuals with physical and mental disabilities compete in organized competitions each year [1]. The National Veterans Wheelchair Games (NVWG) is the largest annually
occurring multievent wheelchair sports and rehabilitation program sponsored jointly by the Department of Veterans Affairs and Paralyzed Veterans of America [2]. It is open to U.S. military veterans who use wheelchairs for sports competition as the result of their disability (amputations, spinal cord injury [SCI], and other neurologic conditions). Ever since its opening in 1981, there have been on average about 500 athletes who participate in this event, which hosts 19 adaptive sports [2]. The NVWG is one of the many adaptive sports programs hosted across the nation for those with disability with the goal of promoting improved health and fitness both physically and mentally via competition and
1934-1482/$ - see front matter ª 2017 by the American Academy of Physical Medicine and Rehabilitation https://doi.org/10.1016/j.pmrj.2017.09.002
2
Impact of Participation in the NVWG on Employment
teamwork. The literature has shown that participants involved in adaptive sports programs achieved significant gains in their rehabilitation outcome, level of independence, quality of life, and community integration. Wetterhahn et al [3] linked the benefits of exercise in amputees by comparing outcome measures in appearance assessment and fitness evaluation between active and minimally active groups. A study by Sporner et al [4] at NVWG and Winter Sports Clinic demonstrated that adaptive sports events helped to increase participants’ knowledge of sports equipment, learning sports, mobility skills, and acceptance of disability. It is well established in the literature on SCI that participating in adaptive sports or even engaging in an exercise program is associated with better quality of life and improved psychological profiles (reduction in pain, stress, anxiety, and depression) [5-9]. In addition, a study by Hanson et al [10] demonstrated better community integration in athletes with SCI after analyzing the Craig Handicap Assessment and Reporting Technique scores in people with SCI. Employment in Those With Disability Employment is an important rehabilitation goal along with achieving functional independence. There are many studies that investigate employment and return to work rates, barriers to employment, and other vocational aspects. The 2015 National Employment and Disability Survey by Kessler Foundation showed that the rate of employment among people with disabilities was 42.6% and that 68.4% of people with disabilities were striving for work [11]. Employment rate after SCI was 24.8%, and the time to obtain a first full-time job after SCI was about 6.3 years from Krause’s studies [12,13]. In those with traumatic brain injury (TBI) with impaired cognitive functioning, employment rate was 55% at 3 years after trauma, and psychiatric symptoms were the most challenging barrier to employment [14]. A few studies have looked at the relationship between physical fitness and employment status. Active involvement in fitness and sports by those with SCI increased their likelihood of employment in some studies [15-17], but no significant correlation also has been reported in other studies [18]. To our knowledge, there have been no studies that focused on the results of organized adaptive sports programs (such as NVWG) in terms of employment outcome. The objective of this study was to determine whether participation in the NVWG positively influence employment outcome in people with disabilities. Methods The study was approved by the Institutional Review Board of the research committee within Veterans Affairs Medical Center. A research grant was approved by the Paralyzed Veterans of America.
Participants All those with qualifying disability who registered to participate in the 2015 NVWG were eligible for the study; veterans of all ages, genders, and medical diagnoses (stroke, TBI, SCI, multiple sclerosis, amputation) were enrolled. For those who were not able to fill out the survey because of physical impairment (eg tetraplegia), their caretakers helped to fill out the survey with verbal answers provided by the veterans. After completion of the survey, they were given a $5.00 gift card as compensation for their time. Survey Questionnaire An 8-question survey was created by the investigators of the study (Appendix 1). The first page of the questionnaire focused on demographics. The following demographic data were obtained (Questions 1-2): age, gender, level of education, medical diagnosis for their injury, year of injury leading to disability, and years of participation in the NVWG. They were asked whether their medical diagnosis was service connected, but because of differing understanding (or lack of) the meaning, the answer to this question was later discarded after completion of the project. They also were asked when they were employed (Questions 3-5): employment status before their injury, employment status after their injury but before participating in the NVWG, and current employment status. The second page of the survey contained questions about whether participating in NVWG made a difference Table 1 Demographics of survey participants (n ¼ 302) Description Gender Male Female Age, y, mean; SD 25-54 55-64 64þ Education (graduation level) High school College Postcollege Other Diagnosis Traumatic brain injury Stroke Multiple sclerosis Amputations Spinal cord injury Paraplegic Tetraplegic Years since injury, mean; SD Times attending the NVWG, mean; SD Values are n (%) unless otherwise noted. NVWG ¼ National Veterans Wheelchair Games.
Numerical Values 274 (91) 28 (9) 54.8; 12.12 138 (46) 92 (30) 72 (24) 93 160 43 6
(31) (53) (14) (2)
20 (7) 9 (3) 25 (8) 49 (16) 227 (75) 146 66 20.6; 14.8 6.7; 6.8
W. Kim et al. / PM R XXX (2017) 1-6 Table 2 Employment status of survey participants (n ¼ 302). Status Working PI Yes No Working PN Yes No Working C Yes No Volunteer PI Yes No Volunteer PN Yes No Volunteer C Yes No
n (%) 214 (71) 88 (29) 84 (28) 218 (72) 47 (16) 255 (84) 18 (6) 284 (94) 45 (15) 257 (85) 59 (20) 243 (80)
PI ¼ prior to injury; PN ¼ after injury but prior to participating in the NVWG; NVWG ¼ National Veterans Wheelchair Games; C ¼ current status.
in terms of attaining employment (Questions 6-7). If they answered “yes” to Question 6, then they were asked the follow-up question with how it helped them attain employment (Question 7). Question 7 had 10 choices (“networking opportunities,” “motivation,” “improved my mood and morale,” “sense of accomplishment from the games,” “increased awareness of my own functional capabilities,” “broadened knowledge of my condition,” “challenge myself to go beyond my limitations,” “increased confidence in myself,” “rekindled the fighting spirit,” and “others”) in a Likert scale format with a score of “5” being most helpful and score of “0” being not helpful at all.
3
Question 8 contained 2 parts: first, it asked whether the participants currently were receiving any financial compensation/aid. If they answered “yes,” then they were asked whether this compensation influenced them to be less motivated to seek employment. Data Analysis Descriptive analyses were generated based on the responses to the survey. Continuous variables were expressed as means, standard deviations, and ranges. Categorical variables were expressed by their frequencies and percent makeup of the sample. To assess whether a positive effect on employment exists due to participation in the NVWG, several patient characteristics were compared against the patient’s response to the relevant question in the survey. A discriminant analysis was used to analyze differences in characteristics among patients who had differing opinions on whether the NVWG influenced employment. MannWhitney U tests for nonparametric data and c2 tests for categorical data were used to assess the differences between groups. Relative ratios were derived from the c2 to describe the relationship between patient characteristics and the outcome. P values of less than .05 were viewed as significant. Statistical Analysis System (SAS) 0.4 (SAS Institute Inc, Cary, NC) was used to complete all analyses. Results The basic demographics and injury diagnoses are outlined in Table 1. Of the 643 veterans who registered at the site for the 2015 NVWG, 338 participated in the survey. Of the 338 survey results, 36 were disregarded because of survey incompletion. Of 302 participants,
Figure 1. Likert scale distribution on how veterans perceived NVWG helped to attain employment. 0: Did not help at all; 5: Most helpful.
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Impact of Participation in the NVWG on Employment
274 (91%) were male and 28 (9%) were female. The mean age of the survey participants was 54.8 years (standard deviation or SD ¼ 12.12). About two-thirds (67%) had college education. For diagnosis, about three-quarters of the participants had SCI (75%); 146 (64%) of them were paraplegic, whereas 66 (29%) of them were tetraplegic. Other diagnoses included amputation (16%), multiple sclerosis (8%), TBI (7%), and stroke (3%). The average number of years since injury was 20.6 years (SD ¼ 14.8), and the average number of times attending the NVWG was 6.7 (SD ¼ 6.7). In Table 2, the participants’ employment status in the past and present are outlined. “PI” stands for status before injury, “PN” stands for status after injury but before participating in the NVWG, and “C” stands for current status. Thirty-two percent reported that they currently were working and/or volunteering at the time of the survey, and 16% reported that they currently were working. The total number of participants who stated that the NVWG made a difference in terms of attaining employment was 150 (50%). Figure 1 represents the frequency of Likert scale responses when asked how different factors helped to attain employment. Most of the veterans answered with “5” (most helpful) in all categories. Table 3 presents data on whether participants were receiving any financial compensation/aid at the time of the survey and whether this had an influence in their motivation to seek employment. Of the 302 participants, 267 (88%) stated that they received financial compensation. Of those 267, 39 (15%) admitted that their motivation to seek employment was lessened by their current financial compensation. Table 4 shows the results for positive NVWG effect on employment by diagnosis. Veterans with SCI were 8% more likely to say that the NVWG had a positive effect on employment than veterans with other diagnosis, but this was not statistically significant (P > .2). Similarly, veterans with TBI were 6% more likely to say that the NVWG had a positive effect on employment than veterans with other diagnosis, but this was also not statistically significant (P > .5). Table 5 shows the results for positive NVWG effect on employment by employment status. A total of 70% of veterans who currently were working stated that the NVWG positively influenced their employment status, whereas 46% of veterans not currently working stated that the NVWG positively influenced their employment Table 3 Participants receiving financial compensation n (%) Financial compensation (n ¼ 302) Yes No Compensation and motivation (n ¼ 267) Yes No
267 (88) 35 (12) 39 (15) 228 (85)
Table 4 RRs for positive NVWG effect on employment by diagnosis Diagnosis
A
Amputation MS SCI Stroke TBI
23 9 117 4 11
B (47%) (36%) (52%) (44%) (55%)
127 141 33 146 139
(50%) (51%) (44%) (50%) (49%)
RR
95% CI
0.92 0.63 1.18 0.89 1.12
0.67-1.27 0.35-1.12 0.89-1.57 0.54-2.36 0.74-1.70
A indicates the number of participants in that diagnosis who stated that the Games had a positive impact on employment (with percentage); B indicates the number of participants in the other diagnoses who stated that the Games had a positive impact on employment (with percentage). RR ¼ relative ratio; NVWG ¼ National Veterans Wheelchair Games; CI ¼ confidence interval; MS ¼ multiple sclerosis; SCI ¼ spinal cord injury; TBI ¼ traumatic brain injury.
status. Those who currently were working were almost 1.5 times more likely to say that the NVWG have a positive influence on employment (RR 1.52, P < .01). Similarly, 76% of veterans who currently were volunteering stated that the NVWG positively influenced their employment status, whereas 43% of veterans not currently volunteering stated that the NVWG positively influenced their employment status. Those who currently were volunteering were about 1.7 times more likely to say that the NVWG have a positive influence on employment (RR 1.77, P < .001). Table 6 shows the results for positive NVWG effect on employment by financial compensation. Those who were receiving financial aid were about 1.4 times more likely to say that the NVWG had a positive influence on employment, but this was not a statistically significant finding (RR 1.38, P > .1). Table 7 lists some of the subject characteristics as well as the difference between those that stated that NVWG had a positive impact and those who did not believe in a positive impact. Veterans who felt that the NVWG had a positive effect on employment had attended about 3-4 more NVWG on average than those who felt that the NVWG did not have an impact on Table 5 RRs for positive NVWG effect on employment by employment status Status
A
Work PI Work PN Work C* Volunteer PI Volunteer PN* Volunteer C*
110 49 33 13 33 45
B (51%) (58%) (70%) (72%) (73%) (76%)
40 101 117 137 117 105
(45%) (46%) (46%) (48%) (45%) (43%)
RR
95% CI
1.13 1.27 1.52 1.50 1.63 1.77
0.87-1.48 1.01-1.60 1.21-1.92 1.10-2.05 1.31-2.03 1.45-2.17
A indicates the number of participants in that working status who stated that games had a positive impact on employment (with percentage); B indicates the number of participants in the other working groups who stated that games had a positive impact on employment (with percentage). RR ¼ relative ratio; NVWG ¼ National Veterans Wheelchair Games; CI ¼ confidence interval; PI ¼ prior to injury; PN ¼ after injury but prior to participating in the NVWG; C ¼ current status. * P < .01.
W. Kim et al. / PM R XXX (2017) 1-6 Table 6 RR for positive NVWG effect on employment by financial compensation
Financial compensation
A
B
RR
95% CI
137 (51%)
13 (37%)
1.38
0.46-1.13
A indicates the number of participants receiving financial compensation (with percentage); B indicates the number of participants not receiving financial compensation (with percentage). RR ¼ relative ratio; NVWG ¼ National Veterans Wheelchair Games; CI ¼ confidence interval.
employment (P < .001). In addition, veterans who felt that NVWG had a positive effect on employment were on average suffered from injury about 4 years more than those who felt that the NVWG did not have an impact on employment (P ¼ .02). No statistical significance was noted in the age of the veterans and their thoughts on the NVWG and employment. Discussion To our knowledge, this is the first study to explore veterans’ perceptions of employment opportunities through participating in the NVWG. Nearly one half of those who participated in the study claimed that participating in NVWG helped them attain employment. This figure was greater than what the authors expected. When asked how (by grading each factor from a scale of 0-5), bulk of the answers were favorable, suggesting that all different factors took part in attaining employment with participation in the NVWG. It is worth noting that veterans believed NVWG took a more significant role in their character development (sense of accomplishment, awareness of their limitations, boosting confidence, and motivation) than opportunities to form connections with different veterans and participants. In this study, the percentage of those working was 16%, which was low compared with that of the 2015 National Employment and Disability Survey report and other published studies in the SCI literature [11-13]. Many studies mention that employment and return-towork rates have been varied throughout different studies because of the heterogeneity of study design and patient demographics [14,18]. In our study, a quarter of the participants were older than the age of 65 years. Likely, they were retired at the time of the survey and hence explains the low working rate. One of the key findings from the study was that longterm involvement with the NVWG had a more favorable
5
response to perceived employment outcome. Veterans who felt that the NVWG had a positive effect on employment had attended about 3-4 more NVWG on average. A possible explanation is that through years of participation in the NVWG, where veterans are challenged in a competitive environment and engage in a collaborative teamwork, they become more aware of their own functional limitations and learn to cope with their limitations via improving their skills of using adaptive equipment and sharing the moments of hardships with each other. Studies have shown that those who share similar characteristics are more comfortable with each other, and this intended environment of camaraderie among veterans is one of the major goals of NVWG [4]. As they gradually build confidence in the event participation and in themselves, they develop a different outlook in life and envision new goals such as looking for employment. There were some findings in the study that were different from the authors’ expectations. For example, type of injury did not play a role in whether the veterans believe the NVWG have a positive effect on their employment. The authors expected that different functional limitations in those with different diagnosis (functional limitations seen in SCI and amputations versus the cognitive limitations seen in TBI and/or stroke) will lead to different perspectives about obtaining employment. However, this was not apparent in our study. In addition, financial aid did not have a significant correlation with regard to participants’ impression about employment outcome, suggesting that their current earnings did not influence their answer to the survey question. There were a few limitations in the study. The authors did not consider retirement as mentioned previously. In the survey questionnaire, the participants were asked if they were retired at the time of the survey. However, many of the participants skipped this section of the survey, and because of incompletion, this was not reflected in our data analysis. If this was taken into consideration, there likely would have been a greater percentage of those who were currently working at the time of NVWG. In addition, the Likert scale responses were limited in explaining how the NVWG helped the veterans attain employment. This may have been more informative if open-ended questions were implemented or questions were focused more towards how the NVWG assisted the veterans to overcome physical obstacles or accessibility issues in public areas.
Table 7 Comparisons between subjects who felt NVWG had a positive or no impact
Age, y No. NVWG Years since injury
All Subjects
A: Positive Impact
B: No Impact
Delta
P Value
54.8 (12.1) 6.7 (6.81) 20.6 (14.8)
54.9 (11.4) 8.5 (7.4) 22.7 (14.5)
54.6 (12.8) 4.9 (5.62) 18.6 (14.9)
0.3 3.6 4.1
.84 <.0001 .02
Data presented as mean (SD). Delta indicates difference in means (A-B). NVWG ¼ National Veterans Wheelchair Games.
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Impact of Participation in the NVWG on Employment
Conclusion Overall, veterans in the study reported a positive influence in their employment pursuit by participating in an adaptive sports program like the NVWG. The study also identified some of the key psychosocial elements (self-esteem, morale, networking/bonding) that were deemed invaluable by the participants for their motivation to seek employment. There are many studies that explain how the complex medical, functional, and psychosocial consequences of musculoskeletal and neurological injury bring multiple barriers to employment. However, the authors of this study believe in the therapeutic value of these adaptive sporting programs, and through our study, hope to provide an optimistic prospect to this special patient population. Acknowledgments The authors thank Dr Ru-Jeng Teng for secondary review. Supplementary Data Supplementary data associated with this article canbe found in the online version at https://doi.org/ 10.1016/j.pmrj.2017.09.002. References 1. Curtis KA, Dillon DA. Survey of wheelchair athletic injuries: Common patterns and prevention. Spinal Cord 1985;23:170-175. 2. National Veterans Wheelchair Games [Internet]. Department of Veterans Affairs; 2015. Available at http://wheelchairgames. org/35th-annual-national-veterans-wheelchair-games. Accessed June 24, 2015. 3. Wetterhahn KA, Hanson C, Levy CE. Effect of participation in physical activity on body image of amputees. Am J Phys Med Rehabil 2002;81:194-201.
4. Sporner ML, Fitzgerald SG, Dicianno BE, et al. Psychosocial impact of participation in the National Veterans Wheelchair Games and Winter Sports Clinic. Disabil Rehabil 2009;31:410-418. 5. Gioia MC, Cerasa A, Di Lucente L, Brunelli S, Castellano V, Traballesi M. Psychological impact of sports activity in spinal cord injury patients. Scand J Med Sci Sports 2006;16:412-416. 6. Hicks AL, Martin KA, Ditor DS, et al. Long-term exercise training in persons with spinal cord injury: Effects on strength, arm ergometry performance and psychological well-being. Spinal Cord 2003;41: 34-43. 7. Kennedy P, Taylor N, Hindson L. A pilot investigation of a psychosocial activity course for people with spinal cord injuries. Psychol Health Med 2006;11:91-99. 8. Tasiemski T, Kennedy P, Gardner BP, Taylor N. The association of sports and physical recreation with life satisfaction in a community sample of people with spinal cord injuries. NeuroRehabilitation 2005;20:253-265. 9. Zabriskie RB, Lundberg NR, Groff DG. Quality of life and identity: The benefits of a community-based therapeutic recreation and adaptive sports program. Ther Recreation J 2005;39:176. 10. Hanson CS, Nabavi D, Yuen HK. The effect of sports on level of community integration as reported by persons with spinal cord injury. Am J Occup Ther 2001;55:332-338. 11. 2015 National employment and disability survey [Internet]. Kessler Foundation; 2015. Available at https://kesslerfoundation.org/ kfsurvey15. Accessed December 10, 2015. 12. Krause JS, Kewman D, Michael J, et al. Employment after spinal cord injury: An analysis of cases from the Model Spinal Cord Injury Systems. Arch Phys Med Rehabil 1999;80:1492-1500. 13. Krause JS. Years to employment after spinal cord injury. Arch Phys Med Rehabil 2003;84:1282-1289. 14. Grauwmeijer E, Heijenbrok-Kal MH, Haitsma IK, Ribbers GM. A prospective study on employment outcome 3 years after moderate to severe traumatic brain injury. Arch Phys Med Rehabil 2012;93: 993-999. 15. Curtis KA, McClanahan S, Hall KM, Dillon D, Brown KF. Health, vocational, and functional status in spinal cord injured athletes and nonathletes. Arch Phys Med Rehabil 1986;67:862-865. 16. Foreman PE, Cull J, Kirkby RJ. Sports participation in individuals with spinal cord injury: Demographic and psychological correlates. Int J Rehabil Res 1997;20:159-168. 17. Noreau L, Shephard RJ. Return to work after spinal cord injury: The potential contribution of physical fitness. Spinal Cord 1992;30: 563-567. 18. Tasiemski T, Bergstro ¨m E, Savic G, Gardner BP. Sports, recreation and employment following spinal cord injuryda pilot study. Spinal Cord 2000;38:173-184.
Disclosure W.K. Department of Physical Medicine and Rehabilitation, Medical College of Wisconsin, 9200 W. Wisconsin Avenue, Milwaukee, WI 53226; and Division of Spinal Cord Injury, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI. Address correspondence to: W.K.; e-mail: [email protected] Disclosure: nothing to disclose L.L. Case Western Reserve University, Cleveland, OH; and Division of Spinal Cord Injury, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI Disclosure: nothing to disclose D.L. Department of Research and Development, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI Disclosure: nothing to disclose
D.T. Department of Veterans Affairs Central Office, Washington, DC Disclosure: nothing to disclose K.L. Medical College of Wisconsin, Milwaukee; and Division of Spinal Cord Injury, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI Disclosures related to this publication: grant, Paralyzed Veterans of AmericaeWisconsin Chapter (money to institution) This work was presented at the 2016 American Academy of Physical Medicine and Rehabilitation Annual Assembly as a poster presentation. This study received research grant from Paralyzed Veterans of America e Wisconsin Chapter (grant ID: WPVA RG#100). Submitted for publication February 1, 2017; accepted September 2, 2017.
www.pmrjournal.org
Original Research
Perception of Employment by the Veterans Participating in the National Veterans Wheelchair Games: A Survey Study William Kim, MD, Leah Lee, Daniel Lans, MS, David Tostenrude, MPA, Kenneth Lee, MD
Abstract Background: Employment in those with disability is an important rehabilitation goal, along with achieving some measure of functional independence and is at the same time one of the most difficult goals to achieve. The number of people with disabilities participating in adaptive sports has been increasing steadily over the years. A few studies have looked at the relationship between physical fitness and employment status in those with disability, but there have been no studies that focused on the results of organized adaptive sports events affecting employment outcome. Objective: To determine whether participation in the National Veterans Wheelchair Games (NVWG) has a positive impact on employment in those with disability. Study Design: Prospective, cross-sectional survey. Setting: 2015 NVWG in Dallas, Texas (nonclinic setting). Participants: A total of 338 survey participants; 36 surveys were excluded due to incompletion. Methods: Veterans who participated at the 2015 NVWG were given the opportunity to complete a 2-page survey. Survey participants received $5.00 gift card as compensation. Main Outcome Measurements: Percentage of those who perceived NVWG made a difference in attaining employment, risk ratio analyses. Results: A total of 50% of the participants stated that the NVWG made a difference in attaining employment. Those currently working were 1.5 times more likely to say that the NVWG had a positive effect on employment than those not currently working (P < .01). Those who felt that the NVWG had a positive effect on employment attended 3-4 more wheelchair games on average than those reporting that the NVWG did not have an impact on employment (P < .001). Positive responses were obtained from the Likert scale distribution. Conclusions: Our study suggests that participating in the NVWG provides psychosocial support to the veterans and may have a positive influence in employment outcomes. Level of Evidence: To be determined.
Introduction Adaptive Sports: Physical, and Psychological Impact The number of people with disabilities participating in adaptive sports has been increasing steadily over the years with the development of improved equipment and increased opportunities for participation. It is estimated that in the United States, 2-3 million individuals with physical and mental disabilities compete in organized competitions each year [1]. The National Veterans Wheelchair Games (NVWG) is the largest annually
occurring multievent wheelchair sports and rehabilitation program sponsored jointly by the Department of Veterans Affairs and Paralyzed Veterans of America [2]. It is open to U.S. military veterans who use wheelchairs for sports competition as the result of their disability (amputations, spinal cord injury [SCI], and other neurologic conditions). Ever since its opening in 1981, there have been on average about 500 athletes who participate in this event, which hosts 19 adaptive sports [2]. The NVWG is one of the many adaptive sports programs hosted across the nation for those with disability with the goal of promoting improved health and fitness both physically and mentally via competition and
1934-1482/$ - see front matter ª 2017 by the American Academy of Physical Medicine and Rehabilitation https://doi.org/10.1016/j.pmrj.2017.09.002
2
Impact of Participation in the NVWG on Employment
teamwork. The literature has shown that participants involved in adaptive sports programs achieved significant gains in their rehabilitation outcome, level of independence, quality of life, and community integration. Wetterhahn et al [3] linked the benefits of exercise in amputees by comparing outcome measures in appearance assessment and fitness evaluation between active and minimally active groups. A study by Sporner et al [4] at NVWG and Winter Sports Clinic demonstrated that adaptive sports events helped to increase participants’ knowledge of sports equipment, learning sports, mobility skills, and acceptance of disability. It is well established in the literature on SCI that participating in adaptive sports or even engaging in an exercise program is associated with better quality of life and improved psychological profiles (reduction in pain, stress, anxiety, and depression) [5-9]. In addition, a study by Hanson et al [10] demonstrated better community integration in athletes with SCI after analyzing the Craig Handicap Assessment and Reporting Technique scores in people with SCI. Employment in Those With Disability Employment is an important rehabilitation goal along with achieving functional independence. There are many studies that investigate employment and return to work rates, barriers to employment, and other vocational aspects. The 2015 National Employment and Disability Survey by Kessler Foundation showed that the rate of employment among people with disabilities was 42.6% and that 68.4% of people with disabilities were striving for work [11]. Employment rate after SCI was 24.8%, and the time to obtain a first full-time job after SCI was about 6.3 years from Krause’s studies [12,13]. In those with traumatic brain injury (TBI) with impaired cognitive functioning, employment rate was 55% at 3 years after trauma, and psychiatric symptoms were the most challenging barrier to employment [14]. A few studies have looked at the relationship between physical fitness and employment status. Active involvement in fitness and sports by those with SCI increased their likelihood of employment in some studies [15-17], but no significant correlation also has been reported in other studies [18]. To our knowledge, there have been no studies that focused on the results of organized adaptive sports programs (such as NVWG) in terms of employment outcome. The objective of this study was to determine whether participation in the NVWG positively influence employment outcome in people with disabilities. Methods The study was approved by the Institutional Review Board of the research committee within Veterans Affairs Medical Center. A research grant was approved by the Paralyzed Veterans of America.
Participants All those with qualifying disability who registered to participate in the 2015 NVWG were eligible for the study; veterans of all ages, genders, and medical diagnoses (stroke, TBI, SCI, multiple sclerosis, amputation) were enrolled. For those who were not able to fill out the survey because of physical impairment (eg tetraplegia), their caretakers helped to fill out the survey with verbal answers provided by the veterans. After completion of the survey, they were given a $5.00 gift card as compensation for their time. Survey Questionnaire An 8-question survey was created by the investigators of the study (Appendix 1). The first page of the questionnaire focused on demographics. The following demographic data were obtained (Questions 1-2): age, gender, level of education, medical diagnosis for their injury, year of injury leading to disability, and years of participation in the NVWG. They were asked whether their medical diagnosis was service connected, but because of differing understanding (or lack of) the meaning, the answer to this question was later discarded after completion of the project. They also were asked when they were employed (Questions 3-5): employment status before their injury, employment status after their injury but before participating in the NVWG, and current employment status. The second page of the survey contained questions about whether participating in NVWG made a difference Table 1 Demographics of survey participants (n ¼ 302) Description Gender Male Female Age, y, mean; SD 25-54 55-64 64þ Education (graduation level) High school College Postcollege Other Diagnosis Traumatic brain injury Stroke Multiple sclerosis Amputations Spinal cord injury Paraplegic Tetraplegic Years since injury, mean; SD Times attending the NVWG, mean; SD Values are n (%) unless otherwise noted. NVWG ¼ National Veterans Wheelchair Games.
Numerical Values 274 (91) 28 (9) 54.8; 12.12 138 (46) 92 (30) 72 (24) 93 160 43 6
(31) (53) (14) (2)
20 (7) 9 (3) 25 (8) 49 (16) 227 (75) 146 66 20.6; 14.8 6.7; 6.8
W. Kim et al. / PM R XXX (2017) 1-6 Table 2 Employment status of survey participants (n ¼ 302). Status Working PI Yes No Working PN Yes No Working C Yes No Volunteer PI Yes No Volunteer PN Yes No Volunteer C Yes No
n (%) 214 (71) 88 (29) 84 (28) 218 (72) 47 (16) 255 (84) 18 (6) 284 (94) 45 (15) 257 (85) 59 (20) 243 (80)
PI ¼ prior to injury; PN ¼ after injury but prior to participating in the NVWG; NVWG ¼ National Veterans Wheelchair Games; C ¼ current status.
in terms of attaining employment (Questions 6-7). If they answered “yes” to Question 6, then they were asked the follow-up question with how it helped them attain employment (Question 7). Question 7 had 10 choices (“networking opportunities,” “motivation,” “improved my mood and morale,” “sense of accomplishment from the games,” “increased awareness of my own functional capabilities,” “broadened knowledge of my condition,” “challenge myself to go beyond my limitations,” “increased confidence in myself,” “rekindled the fighting spirit,” and “others”) in a Likert scale format with a score of “5” being most helpful and score of “0” being not helpful at all.
3
Question 8 contained 2 parts: first, it asked whether the participants currently were receiving any financial compensation/aid. If they answered “yes,” then they were asked whether this compensation influenced them to be less motivated to seek employment. Data Analysis Descriptive analyses were generated based on the responses to the survey. Continuous variables were expressed as means, standard deviations, and ranges. Categorical variables were expressed by their frequencies and percent makeup of the sample. To assess whether a positive effect on employment exists due to participation in the NVWG, several patient characteristics were compared against the patient’s response to the relevant question in the survey. A discriminant analysis was used to analyze differences in characteristics among patients who had differing opinions on whether the NVWG influenced employment. MannWhitney U tests for nonparametric data and c2 tests for categorical data were used to assess the differences between groups. Relative ratios were derived from the c2 to describe the relationship between patient characteristics and the outcome. P values of less than .05 were viewed as significant. Statistical Analysis System (SAS) 0.4 (SAS Institute Inc, Cary, NC) was used to complete all analyses. Results The basic demographics and injury diagnoses are outlined in Table 1. Of the 643 veterans who registered at the site for the 2015 NVWG, 338 participated in the survey. Of the 338 survey results, 36 were disregarded because of survey incompletion. Of 302 participants,
Figure 1. Likert scale distribution on how veterans perceived NVWG helped to attain employment. 0: Did not help at all; 5: Most helpful.
4
Impact of Participation in the NVWG on Employment
274 (91%) were male and 28 (9%) were female. The mean age of the survey participants was 54.8 years (standard deviation or SD ¼ 12.12). About two-thirds (67%) had college education. For diagnosis, about three-quarters of the participants had SCI (75%); 146 (64%) of them were paraplegic, whereas 66 (29%) of them were tetraplegic. Other diagnoses included amputation (16%), multiple sclerosis (8%), TBI (7%), and stroke (3%). The average number of years since injury was 20.6 years (SD ¼ 14.8), and the average number of times attending the NVWG was 6.7 (SD ¼ 6.7). In Table 2, the participants’ employment status in the past and present are outlined. “PI” stands for status before injury, “PN” stands for status after injury but before participating in the NVWG, and “C” stands for current status. Thirty-two percent reported that they currently were working and/or volunteering at the time of the survey, and 16% reported that they currently were working. The total number of participants who stated that the NVWG made a difference in terms of attaining employment was 150 (50%). Figure 1 represents the frequency of Likert scale responses when asked how different factors helped to attain employment. Most of the veterans answered with “5” (most helpful) in all categories. Table 3 presents data on whether participants were receiving any financial compensation/aid at the time of the survey and whether this had an influence in their motivation to seek employment. Of the 302 participants, 267 (88%) stated that they received financial compensation. Of those 267, 39 (15%) admitted that their motivation to seek employment was lessened by their current financial compensation. Table 4 shows the results for positive NVWG effect on employment by diagnosis. Veterans with SCI were 8% more likely to say that the NVWG had a positive effect on employment than veterans with other diagnosis, but this was not statistically significant (P > .2). Similarly, veterans with TBI were 6% more likely to say that the NVWG had a positive effect on employment than veterans with other diagnosis, but this was also not statistically significant (P > .5). Table 5 shows the results for positive NVWG effect on employment by employment status. A total of 70% of veterans who currently were working stated that the NVWG positively influenced their employment status, whereas 46% of veterans not currently working stated that the NVWG positively influenced their employment Table 3 Participants receiving financial compensation n (%) Financial compensation (n ¼ 302) Yes No Compensation and motivation (n ¼ 267) Yes No
267 (88) 35 (12) 39 (15) 228 (85)
Table 4 RRs for positive NVWG effect on employment by diagnosis Diagnosis
A
Amputation MS SCI Stroke TBI
23 9 117 4 11
B (47%) (36%) (52%) (44%) (55%)
127 141 33 146 139
(50%) (51%) (44%) (50%) (49%)
RR
95% CI
0.92 0.63 1.18 0.89 1.12
0.67-1.27 0.35-1.12 0.89-1.57 0.54-2.36 0.74-1.70
A indicates the number of participants in that diagnosis who stated that the Games had a positive impact on employment (with percentage); B indicates the number of participants in the other diagnoses who stated that the Games had a positive impact on employment (with percentage). RR ¼ relative ratio; NVWG ¼ National Veterans Wheelchair Games; CI ¼ confidence interval; MS ¼ multiple sclerosis; SCI ¼ spinal cord injury; TBI ¼ traumatic brain injury.
status. Those who currently were working were almost 1.5 times more likely to say that the NVWG have a positive influence on employment (RR 1.52, P < .01). Similarly, 76% of veterans who currently were volunteering stated that the NVWG positively influenced their employment status, whereas 43% of veterans not currently volunteering stated that the NVWG positively influenced their employment status. Those who currently were volunteering were about 1.7 times more likely to say that the NVWG have a positive influence on employment (RR 1.77, P < .001). Table 6 shows the results for positive NVWG effect on employment by financial compensation. Those who were receiving financial aid were about 1.4 times more likely to say that the NVWG had a positive influence on employment, but this was not a statistically significant finding (RR 1.38, P > .1). Table 7 lists some of the subject characteristics as well as the difference between those that stated that NVWG had a positive impact and those who did not believe in a positive impact. Veterans who felt that the NVWG had a positive effect on employment had attended about 3-4 more NVWG on average than those who felt that the NVWG did not have an impact on Table 5 RRs for positive NVWG effect on employment by employment status Status
A
Work PI Work PN Work C* Volunteer PI Volunteer PN* Volunteer C*
110 49 33 13 33 45
B (51%) (58%) (70%) (72%) (73%) (76%)
40 101 117 137 117 105
(45%) (46%) (46%) (48%) (45%) (43%)
RR
95% CI
1.13 1.27 1.52 1.50 1.63 1.77
0.87-1.48 1.01-1.60 1.21-1.92 1.10-2.05 1.31-2.03 1.45-2.17
A indicates the number of participants in that working status who stated that games had a positive impact on employment (with percentage); B indicates the number of participants in the other working groups who stated that games had a positive impact on employment (with percentage). RR ¼ relative ratio; NVWG ¼ National Veterans Wheelchair Games; CI ¼ confidence interval; PI ¼ prior to injury; PN ¼ after injury but prior to participating in the NVWG; C ¼ current status. * P < .01.
W. Kim et al. / PM R XXX (2017) 1-6 Table 6 RR for positive NVWG effect on employment by financial compensation
Financial compensation
A
B
RR
95% CI
137 (51%)
13 (37%)
1.38
0.46-1.13
A indicates the number of participants receiving financial compensation (with percentage); B indicates the number of participants not receiving financial compensation (with percentage). RR ¼ relative ratio; NVWG ¼ National Veterans Wheelchair Games; CI ¼ confidence interval.
employment (P < .001). In addition, veterans who felt that NVWG had a positive effect on employment were on average suffered from injury about 4 years more than those who felt that the NVWG did not have an impact on employment (P ¼ .02). No statistical significance was noted in the age of the veterans and their thoughts on the NVWG and employment. Discussion To our knowledge, this is the first study to explore veterans’ perceptions of employment opportunities through participating in the NVWG. Nearly one half of those who participated in the study claimed that participating in NVWG helped them attain employment. This figure was greater than what the authors expected. When asked how (by grading each factor from a scale of 0-5), bulk of the answers were favorable, suggesting that all different factors took part in attaining employment with participation in the NVWG. It is worth noting that veterans believed NVWG took a more significant role in their character development (sense of accomplishment, awareness of their limitations, boosting confidence, and motivation) than opportunities to form connections with different veterans and participants. In this study, the percentage of those working was 16%, which was low compared with that of the 2015 National Employment and Disability Survey report and other published studies in the SCI literature [11-13]. Many studies mention that employment and return-towork rates have been varied throughout different studies because of the heterogeneity of study design and patient demographics [14,18]. In our study, a quarter of the participants were older than the age of 65 years. Likely, they were retired at the time of the survey and hence explains the low working rate. One of the key findings from the study was that longterm involvement with the NVWG had a more favorable
5
response to perceived employment outcome. Veterans who felt that the NVWG had a positive effect on employment had attended about 3-4 more NVWG on average. A possible explanation is that through years of participation in the NVWG, where veterans are challenged in a competitive environment and engage in a collaborative teamwork, they become more aware of their own functional limitations and learn to cope with their limitations via improving their skills of using adaptive equipment and sharing the moments of hardships with each other. Studies have shown that those who share similar characteristics are more comfortable with each other, and this intended environment of camaraderie among veterans is one of the major goals of NVWG [4]. As they gradually build confidence in the event participation and in themselves, they develop a different outlook in life and envision new goals such as looking for employment. There were some findings in the study that were different from the authors’ expectations. For example, type of injury did not play a role in whether the veterans believe the NVWG have a positive effect on their employment. The authors expected that different functional limitations in those with different diagnosis (functional limitations seen in SCI and amputations versus the cognitive limitations seen in TBI and/or stroke) will lead to different perspectives about obtaining employment. However, this was not apparent in our study. In addition, financial aid did not have a significant correlation with regard to participants’ impression about employment outcome, suggesting that their current earnings did not influence their answer to the survey question. There were a few limitations in the study. The authors did not consider retirement as mentioned previously. In the survey questionnaire, the participants were asked if they were retired at the time of the survey. However, many of the participants skipped this section of the survey, and because of incompletion, this was not reflected in our data analysis. If this was taken into consideration, there likely would have been a greater percentage of those who were currently working at the time of NVWG. In addition, the Likert scale responses were limited in explaining how the NVWG helped the veterans attain employment. This may have been more informative if open-ended questions were implemented or questions were focused more towards how the NVWG assisted the veterans to overcome physical obstacles or accessibility issues in public areas.
Table 7 Comparisons between subjects who felt NVWG had a positive or no impact
Age, y No. NVWG Years since injury
All Subjects
A: Positive Impact
B: No Impact
Delta
P Value
54.8 (12.1) 6.7 (6.81) 20.6 (14.8)
54.9 (11.4) 8.5 (7.4) 22.7 (14.5)
54.6 (12.8) 4.9 (5.62) 18.6 (14.9)
0.3 3.6 4.1
.84 <.0001 .02
Data presented as mean (SD). Delta indicates difference in means (A-B). NVWG ¼ National Veterans Wheelchair Games.
6
Impact of Participation in the NVWG on Employment
Conclusion Overall, veterans in the study reported a positive influence in their employment pursuit by participating in an adaptive sports program like the NVWG. The study also identified some of the key psychosocial elements (self-esteem, morale, networking/bonding) that were deemed invaluable by the participants for their motivation to seek employment. There are many studies that explain how the complex medical, functional, and psychosocial consequences of musculoskeletal and neurological injury bring multiple barriers to employment. However, the authors of this study believe in the therapeutic value of these adaptive sporting programs, and through our study, hope to provide an optimistic prospect to this special patient population. Acknowledgments The authors thank Dr Ru-Jeng Teng for secondary review. Supplementary Data Supplementary data associated with this article canbe found in the online version at https://doi.org/ 10.1016/j.pmrj.2017.09.002. References 1. Curtis KA, Dillon DA. Survey of wheelchair athletic injuries: Common patterns and prevention. Spinal Cord 1985;23:170-175. 2. National Veterans Wheelchair Games [Internet]. Department of Veterans Affairs; 2015. Available at http://wheelchairgames. org/35th-annual-national-veterans-wheelchair-games. Accessed June 24, 2015. 3. Wetterhahn KA, Hanson C, Levy CE. Effect of participation in physical activity on body image of amputees. Am J Phys Med Rehabil 2002;81:194-201.
4. Sporner ML, Fitzgerald SG, Dicianno BE, et al. Psychosocial impact of participation in the National Veterans Wheelchair Games and Winter Sports Clinic. Disabil Rehabil 2009;31:410-418. 5. Gioia MC, Cerasa A, Di Lucente L, Brunelli S, Castellano V, Traballesi M. Psychological impact of sports activity in spinal cord injury patients. Scand J Med Sci Sports 2006;16:412-416. 6. Hicks AL, Martin KA, Ditor DS, et al. Long-term exercise training in persons with spinal cord injury: Effects on strength, arm ergometry performance and psychological well-being. Spinal Cord 2003;41: 34-43. 7. Kennedy P, Taylor N, Hindson L. A pilot investigation of a psychosocial activity course for people with spinal cord injuries. Psychol Health Med 2006;11:91-99. 8. Tasiemski T, Kennedy P, Gardner BP, Taylor N. The association of sports and physical recreation with life satisfaction in a community sample of people with spinal cord injuries. NeuroRehabilitation 2005;20:253-265. 9. Zabriskie RB, Lundberg NR, Groff DG. Quality of life and identity: The benefits of a community-based therapeutic recreation and adaptive sports program. Ther Recreation J 2005;39:176. 10. Hanson CS, Nabavi D, Yuen HK. The effect of sports on level of community integration as reported by persons with spinal cord injury. Am J Occup Ther 2001;55:332-338. 11. 2015 National employment and disability survey [Internet]. Kessler Foundation; 2015. Available at https://kesslerfoundation.org/ kfsurvey15. Accessed December 10, 2015. 12. Krause JS, Kewman D, Michael J, et al. Employment after spinal cord injury: An analysis of cases from the Model Spinal Cord Injury Systems. Arch Phys Med Rehabil 1999;80:1492-1500. 13. Krause JS. Years to employment after spinal cord injury. Arch Phys Med Rehabil 2003;84:1282-1289. 14. Grauwmeijer E, Heijenbrok-Kal MH, Haitsma IK, Ribbers GM. A prospective study on employment outcome 3 years after moderate to severe traumatic brain injury. Arch Phys Med Rehabil 2012;93: 993-999. 15. Curtis KA, McClanahan S, Hall KM, Dillon D, Brown KF. Health, vocational, and functional status in spinal cord injured athletes and nonathletes. Arch Phys Med Rehabil 1986;67:862-865. 16. Foreman PE, Cull J, Kirkby RJ. Sports participation in individuals with spinal cord injury: Demographic and psychological correlates. Int J Rehabil Res 1997;20:159-168. 17. Noreau L, Shephard RJ. Return to work after spinal cord injury: The potential contribution of physical fitness. Spinal Cord 1992;30: 563-567. 18. Tasiemski T, Bergstro ¨m E, Savic G, Gardner BP. Sports, recreation and employment following spinal cord injuryda pilot study. Spinal Cord 2000;38:173-184.
Disclosure W.K. Department of Physical Medicine and Rehabilitation, Medical College of Wisconsin, 9200 W. Wisconsin Avenue, Milwaukee, WI 53226; and Division of Spinal Cord Injury, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI. Address correspondence to: W.K.; e-mail: [email protected] Disclosure: nothing to disclose L.L. Case Western Reserve University, Cleveland, OH; and Division of Spinal Cord Injury, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI Disclosure: nothing to disclose D.L. Department of Research and Development, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI Disclosure: nothing to disclose
D.T. Department of Veterans Affairs Central Office, Washington, DC Disclosure: nothing to disclose K.L. Medical College of Wisconsin, Milwaukee; and Division of Spinal Cord Injury, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI Disclosures related to this publication: grant, Paralyzed Veterans of AmericaeWisconsin Chapter (money to institution) This work was presented at the 2016 American Academy of Physical Medicine and Rehabilitation Annual Assembly as a poster presentation. This study received research grant from Paralyzed Veterans of America e Wisconsin Chapter (grant ID: WPVA RG#100). Submitted for publication February 1, 2017; accepted September 2, 2017.