Quality of Life Research

, Volume 26, Issue 10, pp 2633–2645 | Cite as

Relationships between environmental factors and participation in adults with traumatic brain injury, stroke, and spinal cord injury: a cross-sectional multi-center study

  • Alex W. K. WongEmail author
  • Sheryl Ng
  • Jessica Dashner
  • M. Carolyn Baum
  • Joy Hammel
  • Susan Magasi
  • Jin-Shei Lai
  • Noelle E. Carlozzi
  • David S. Tulsky
  • Ana Miskovic
  • Arielle Goldsmith
  • Allen W. Heinemann



To develop and evaluate a model of environmental factors-participation relationships for persons with traumatic brain injury (TBI), stroke, and spinal cord injury (SCI), and test whether this model differed across three diagnostic groups, as well as other demographic and clinical characteristics.


A cross-sectional observational study included 545 community-dwelling adults with neurological disorders (TBI = 166; stroke = 189; SCI = 190) recruited at three academic medical centers. Participants completed patient-reported measures of environmental factors and participation.


The final structural equation model had acceptable fit to the data (CFI = 0.923; TLI = 0.898; RMSEA = 0.085; SRMR = 0.053), explaining 63% of the variance in participation in social roles and activities. Systems, services, and policies had an indirect influence on participation and this relation was mediated by social attitudes and the built and natural environment. Access to information and technology was associated with the built and natural environment which in turn influence on participation (ps < 0.001). The model was consistent across sex, diagnosis, severity/type of injury, education, race, age, marital status, years since injury, wheelchairs use, insurance coverage, personal or household income, and crystallized cognition.


Social and physical environments appear to mediate the influence of systems, services, and policies on participation after acquired neurological disorders. These relations are stable across three diagnostic groups and many personal and clinical factors. Our findings inform health and disability policy, and provide guidance for implementing the initiatives in Healthy People 2020 in particular for people with acquired neurological disorders.


Environment Participation Stroke Spinal cord injury Traumatic brain injury 



Americans with Disabilities Act


Access to information and technology


Built and natural environment


Confirmatory factor analysis


Comparative Fit Index


Community Participation Indicators


Environmental Factors Item Banks


Glasgow Coma Scale


International Classification of Functioning, Disability and Health


Patient-Reported Outcomes Measures


Patient-Reported Outcomes Measurement Information System


Quality of life


Root mean square error of approximation


Spinal cord injury


Structural equation modeling


Social roles and activities


Standardized Root Mean Square Residual


Systems, Services and Policies


Traumatic brain injury


Tucker-Lewis index


World Health Organization



The contents do not necessarily represent the policy of the Department of Health and Human Services or the Craig H. Neilsen Foundation. We certify that all financial and material support for this research and work are clearly identified in the title page of the manuscript. The first and last authors had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. We acknowledge Patrick Semik, BS at the Rehabilitation Institute of Chicago for data management and analysis. Additionally, we would like to acknowledge Megen Devine, MA, and Ojoyi Agbo, BS at Washington University School of Medicine for their editorial assistance.


This study was supported by the National Institute on Disability, Independent Living, and Rehabilitation Research, the Administration on Community Living, the U.S. Department of Health and Human Services to the Rehabilitation Institute of Chicago (Grant No. H133B090024) and to Washington University in St. Louis (Grant No. H133F140037), and by the Craig H. Neilsen Foundation to Washington University in St. Louis (Grant No. 290474).

Compliance with ethical standards

Conflict of Interest

All authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Supplementary material

11136_2017_1586_MOESM1_ESM.docx (31 kb)
Supplementary material 1 (DOCX 31 kb)


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Copyright information

© Springer International Publishing Switzerland 2017

Authors and Affiliations

  • Alex W. K. Wong
    • 1
    • 2
    Email author
  • Sheryl Ng
    • 2
    • 3
  • Jessica Dashner
    • 1
  • M. Carolyn Baum
    • 4
  • Joy Hammel
    • 5
  • Susan Magasi
    • 6
  • Jin-Shei Lai
    • 7
  • Noelle E. Carlozzi
    • 8
  • David S. Tulsky
    • 9
  • Ana Miskovic
    • 10
  • Arielle Goldsmith
    • 10
  • Allen W. Heinemann
    • 10
    • 11
  1. 1.Program in Occupational Therapy and Department of NeurologyWashington University School of MedicineSt. LouisUSA
  2. 2.Program in Occupational TherapyWashington University School of MedicineSt. LouisUSA
  3. 3.Saw Swee Hock School of Public HealthNational University of SingaporeSingaporeSingapore
  4. 4.Program in Occupational Therapy, Department of Neurology and George Warren Brown School of Social WorkWashington UniversitySt. LouisUSA
  5. 5.Departments of Occupational Therapy and Disability and Human DevelopmentUniversity of Illinois at ChicagoChicagoUSA
  6. 6.Department of Occupational TherapyUniversity of Illinois at ChicagoChicagoUSA
  7. 7.Departments of Medical Social Science and PediatricNorthwestern University Feinberg School of MedicineChicagoUSA
  8. 8.Department of Physical Medicine and RehabilitationUniversity of Michigan Medical SchoolAnn ArborUSA
  9. 9.Department of Physical TherapyUniversity of DelawareNewarkUSA
  10. 10.Center for Rehabilitation Outcomes ResearchRehabilitation Institute of ChicagoChicagoUSA
  11. 11.Department of Physical Medicine and RehabilitationNorthwestern University Feinberg School of MedicineChicagoUSA

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