An online self-management program for spinal cord injury: a pilot randomised controlled trial of the SCI&U peer health coaching intervention

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Allin, B. Catherine Craven, Sara J.T. Guilcher, and 10 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5132773/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 28 Jan, 2026 Read the published version in Pilot and Feasibility Studies → Version 1 posted 5 You are reading this latest preprint version Abstract Background: The spinal cord injury and you (SCI&U) intervention aims to improve self-management skills for persons living with SCI using a web-based, peer health-coaching model. This study assessed the feasibility of conducting a future definitive trial of SCI&U, specifically the feasibility of recruitment and retention, usability and quality of the program, and estimates of effect sizes for a variety of self-management outcomes. Methods: A two-group, randomised, controlled, pilot trial with prospective recruitment, concealed group allocation, blinded outcome evaluation, and waitlist control was conducted in Canada. We aimed to recruit 60 participants who were 18 years and older living in the community at least six months post-injury, were able to speak and read English, and had a primary care physician. The intervention included online client-coach videoconferencing sessions, goal setting, action planning, and a sortable resource library. Data were collected at baseline, 2, 6 and 12 months post-randomisation. SCI&U was offered to the waitlist group at 12 months. Primary short-term self-management outcome was Skill and Technique Acquisition (STA), a subscale of the Health Education Impact Questionnaire. Primary long-term outcome was cumulative days rehospitalised. Results: Of 65 eligible individuals, 34 were randomised to waitlist control and 31 to intervention. Mean time since injury was 25.6 years for intervention and 20.2 years for control. Outcome data were gathered for 86% of participants at 6 months and 89% at 12 months. The usability and quality of the program were highly rated. The difference in STA between intervention and control was 0.56 (95% CI -0.41, 1.52) at 6 months and 0.72 (95% CI -0.28, 1.72) at 12 months. Other subscales also had large effect sizes: Self-monitoring and insight 1.51 (95% CI 0.39, 2.69); and Emotional distress -1.40 (95% CI -3.04, 0.23). In the 12 months following recruitment, 5 intervention and 4 control participants spent median 11 (3-19) and 24 (5-95) nights in hospital, respectively. Conclusions: The trial methodology and procedures were feasible; the SCI&U intervention was acceptable to participants. The program positively impacted an individual’s ability to self-manage. Further research is needed to confirm these findings and evaluate the program on those with recently acquired SCI. Trial registration: ClinicalTrials.gov, NCT04474171, retrospectively registered 07/13/2020; https://clinicaltrials.gov/study/NCT04474171#study-record-dates Self-management spinal cord injury peer health coaching pilot trial Figures Figure 1 Key messages regarding feasibility Usability and quality of the SCI&U program were highly rated. SCI&U appeared beneficial. While it is feasible to implement an online peer health coaching program, some study participants may need technical support. The number of outcome measures should be limited in future studies. Most of the trial was conducted during the COVID-19 pandemic and results need to be confirmed. Findings warrant proceeding to a definitive trial, with further research needed to determine the impact of the SCI&U health coaching program on those living with recently acquired SCI. BACKGROUND Beyond the initial trauma and adjustment to activity limitations (motor, sensory and autonomic impairments), living with the consequences of spinal cord injury (SCI) is a life-long process (1). Within the first year of injury, more than 50% of people discharged with a SCI may require rehospitalisation due to a secondary complication, such as a urinary tract infection, pressure ulcer, or pneumonia. Even 20 years post-injury, rehospitalisation rates remain over 30% due to additional complications associated with aging, such as cardiovascular disease and diabetes (2, 3). One-year rehospitalisation rates in Canada have remained high, at over 27%, for more than 10 years (4); while, at the same time, length of stay in inpatient rehabilitation has decreased dramatically (5). The limited time for provision of health information and skill acquisition in the inpatient rehabilitation setting means that individuals with SCI are entering the community with fewer self-management skills to prevent secondary complications (6, 7). Families and others comprising informal support networks also have less time to adjust (8). Furthermore, individuals with SCI report that their primary care providers are not well-equipped to support their specialized needs (1, 9, 10). The result is higher rates of secondary complications, emergency department visits and rehospitalisation (4, 11, 12) and a growing demand to provide appropriate health information, skills and support for persons with SCI who are living in the community to better manage their health conditions across the lifespan. Self-management programs such as Stanford’s Chronic Disease Self-Management Program (CDSMP) (13) or the UK’s Expert Patient Program (14), comprised of peer-led health coaching and patient education (15), have been associated with improved self-efficacy, health behaviours and psychological health status (13-15), lower hospitalisation rates (13), and reduced health care expenditures (16). Despite these positive results, a qualitative study on the experiences of CDSMP participants with neurological conditions found participants with SCI reported the least program satisfaction and thus recommended a SCI-specific program (17). These findings were supported in our previous research wherein individuals with SCI and other knowledge users (family members/caregivers, health care professionals, consumer organizations and policy makers) emphasized the need for an SCI-specific online program led by peers (18-22). Only three methodologically rigorous studies of two peer-led, self-management programs for SCI have been published. A randomised controlled trial (RCT) (23) and an interrupted time series analysis (24) evaluated one program developed in Atlanta, Georgia, and another RCT evaluated a program developed in Boston, Massachusetts (25). Both of these programs demonstrated the value of peer health coaching in improving self-management in persons with SCI, but neither of these interventions were delivered virtually; one was in person in a rehabilitation hospital (23, 24) and the other was telephone-based (25). This gap led to the development of our online, peer-led, self-management program for SCI (SCI&U), which was identified as the preferred format in our earlier work because it simulates a face-to-face interaction and limits the need for in-person visits among a population with mobility challenges (26, 27). We followed the mHealth framework, an iterative process for the development and evaluation of mobile Health interventions (28). We used a participatory design approach that included users both as co-designers and key informants (29), which is consistent with the Integrated Knowledge Translation Guiding Principles for Conducting SCI research in partnership (30). Briefly, the SCI&U platform contains an integrated set of tools to support secure one-on-one online health coaching as well as tools to promote discussion of and access to health education resources (26, 27). During sessions, peer health coaches help participants frame self-management goals, create action plans, and solve problems related to their health. The peer coaches are trained to provide self-management education and support to others with SCI, which is an expanded application of SCI peer mentoring (31). The main goal of the program is to improve self-management skills among persons living with SCI. This study reports a randomised, controlled, pilot trial of the SCI&U intervention. The objectives were as follows: Evaluate feasibility of participant recruitment, participant retention with long-term follow-up, data collection, and program implementation. Examine participants’ assessment of usability and quality of the Estimate effect sizes for short-term (baseline to 2 months) and sustained or long-term (6 and 12 months) impacts of the program on primary outcomes (i.e. self-management skills, total days rehospitalised) and secondary outcomes (i.e. secondary health conditions, self-efficacy, health-related quality-of-life (HRQOL), and social/role activities limitations). METHODS Trial design A two-group, randomised, controlled, pilot trial with prospective recruitment, concealed group allocation, blinded outcome evaluation and waitlist control was conducted in Canada from January 2018 to March 2022. Research Ethics Board approval was obtained at the main coordinating site University of Toronto (Protocol Number 34808), and also at the University of Saskatchewan (Protocol Number 1228). All recruited individuals formally consented to participate in this study orally with a member of the research staff, who then signed and dated a paper copy retained at the research office. For consenting individuals, outcome data were gathered from questionnaires administered at baseline, and at 2, 6, and 12 months after baseline data collection. The trial was registered retrospectively on ClinicalTrials.gov (NCT04474171; 07/13/2020; https://clinicaltrials.gov/study/NCT04474171#study-record-dates). The CONSORT (Consolidated Standards of Reporting Trials) 2010 statement: extension to randomised pilot and feasibility trials (32) and the TIDieR checklist (33) were followed. Eligibility and recruitment of participants We targeted individuals 18 years and older living in the community who were at least six months post-injury, were able to speak and read English, and had a primary care physician. Subjects who were currently participating in another formal self-management program or had a self-report of physician-diagnosed concurrent traumatic brain injury were excluded. Recruitment for participants was nationwide across Canada with a focus on British Columbia (BC) and Ontario, where the research team had relationships with community-based SCI peer organizations, peer health coaches and research staff. A variety of methods were used for recruitment, including outreach by the SCI BC Peer Recruitment Coordinator, and advertisements by SCI consumer organizations on their websites, in newsletters, magazines, Facebook groups and via webinars to their members. In addition, recruitment information was placed on SCI&U social media accounts. Study co-investigators who worked at rehabilitation hospitals also informed clinicians about the study. Individuals interested in the study were asked to send an email to the coordinating centre. A research assistant then contacted the potential participant, screened them for eligibility, and obtained their consent to be randomised to the intervention or waitlist control group. Participants were also asked to complete baseline, 2-, 6- and 12-month assessments. Participants received $300 CAD if they completed all study procedures. Intervention The development, usability and pilot testing of SCI&U is published elsewhere (26, 27). The SCI&U digital platform prototype has a resource library, tools to support one-on-one health coaching with profiles of coaches (to facilitate matching of coaches with clients), and a structured interface for health coaching. Its major features include: 1. The ability to create and schedule secure “themed” videoconferencing sessions between coaches and clients. Themes (such as exercise and nutrition) dictate the scripts used to guide each session, as well as session-specific resources and self-care tips. 2. Goal setting and action planning forms. These record the goals and plans of clients as they are articulated during sessions. 3. A sortable resource library, containing themed educational material and resources with links to external websites and videos. 5. The ability for coaches and administrators to create and send customized reminders and emails to clients (e.g., session summaries). Implementation Following randomisation to SCI&U, participants were scheduled for a registration and orientation session to become better acquainted with the platform’s features and to troubleshoot any accessibility issues; participants were offered a Chromebook or tablet on loan if needed. Participants were then partnered with their health coach, who was over age 18 and had lived in the community with SCI for more than five years. To ensure consistency and quality of the intervention, all coaches were trained in Motivational Interviewing (34) and Brief Action Planning (BAP) (35) by the Centre for Collaboration, Motivation and Innovation. The coaches had three principal roles: role model, supporter and advisor (31). In the first videoconference session, which took place within one month following consent, participants identified priority issues related to their health. In subsequent sessions, they worked through goal setting, conducted problem solving activities, and created action plans for behaviour change that were securely stored by the interface and available to users to reflect upon and revise. Each online session conformed to a script; scripts were accessible to coaches via the online platform and included health management information drawn from guidelines as well as standardized protocols for BAP. Themes for sessions related to common health management concerns among the SCI population as indicated by a prior survey of the Canadian SCI community (18, 19); see Table 1 for a list of topics. Coaches could also take notes about clients during sessions, recommend relevant online resources, and arrange follow-up care plans (e.g., to send text message reminders of client goals or plans periodically). During the program, clients and coaches could engage in up to 14 online sessions. Based on two other similar effective health behaviour change interventions in SCI, Get in Motion (GIM) (36) and My Care My Call (MCMC) (25) that were telephone-based, we planned to implement the online sessions over 6 months with a tapered schedule (i.e., 8 weekly, 4 biweekly, and 2 monthly sessions) to gradually transition clients from dependency on the coach to independent self-regulation. Control The control group continued with their usual health care and were offered the SCI&U program at the end of the 12-month assessment period (wait-list control). Outcomes Trial feasibility Feasibility of recruitment was assessed by the number and proportion of consenting individuals per month in an 8-month recruitment period. Feasibility of data collection was evaluated as the percentage of participants with complete data on each measure at each evaluation time point with targets of >90% for baseline and 2-month and >80% for 6-month and 12-month evaluations. In the RCTs of peer-led interventions for SCI (23, 25), the loss to follow-up at 6 months was 13% (23) and 10% (25). Adherence was calculated as the percentage of coaching sessions that participants attended. Participants completing eight or more sessions were considered adherent based on findings from the GIM study to increase physical activity in those with SCI (36) and the MCMC study to improve self-management to prevent secondary conditions (25). Findings from GIM suggested that the first eight weeks of coaching may be a critical period for eliciting behaviour change. Withdrawal rate was assessed as the percentage of study participants who withdrew by the 2-, 6- and 12-months evaluation time points. As part of the feasibility evaluation, we also measured usability and quality of the program. Each participant in the intervention group was asked to complete the Mobile App Rating Scale (MARS) (37) after their last online session. The 21-item MARS has four subscales that assess software-related Quality, Functionality, Information and Behaviour Change; responses to each are measured on a five-point Likert scale. Participants were also asked to complete relevant questions from the “Health Education Impact Questionnaire” Version 3 (heiQ) about the quality of the program (38). The questionnaire has nine items with responses ranging from 1 to 4: strongly disagree (1), disagree (2), agree (3) and strongly agree (4). Primary short-term outcome measure: Skill and Technique Acquisition (STA) subscale of the Health Education Impact Questionnaire (heiQ) Self-management skills were measured with the STA subscale of the Health Education Impact Questionnaire (heiQ), a widely used tool to measure the quality and outcomes of chronic disease self-management programs (39). The heiQ has demonstrated high construct validity ranging from 0.70 to 0.83 for each of the dimensions and reliability >0.8 (38). It measures eight constructs by multi-item composite scales using a 4-point Likert scale: strongly disagree (1), disagree (2), agree (3) and strongly agree (4), with a mean score ranging from 1 to 4. The STA subscale has 4 items that aim to capture the knowledge-based skills and techniques that persons acquire (or re-learn) to help them cope with symptoms and health problems (e.g. “When I have symptoms, I have skills that help me cope”). It was chosen as the basis for the sample size calculation as skill building is a primary focus of the intervention (40). Primary long-term outcome measure: cumulative days rehospitalised 12 months after baseline assessment In an RCT by Gassaway et al., (23) evaluating a peer-mentoring self-management SCI program for patients receiving inpatient rehabilitation, cumulative days rehospitalised at 6 months after discharge from inpatient rehabilitation were significantly fewer for patients who received peer mentoring compared to controls (43% reduction, p<0.001), with a mean rehabilitation length of stay of approximately 2 months. In our study, since participants were already living in the community and the intervention period was 6 months, the primary long-term outcome measure of days rehospitalised 12 months after baseline was calculated by summing the answer to the question “How many total nights did you spend in hospital in the past 6 months?” at the 6-month time point and the 12-month time point. Secondary outcomes In addition to the STA subscale, we planned to collect the other seven subscales of the heiQ: Health Directed Behaviour; Positive and Active Engagement in Life; Emotional Distress; Self-monitoring and Insight; Constructive Attitudes and Approaches; Social Integration and Support; and Health Services Navigation (38). However, we noted considerable overlap in the content of three subscales in the heiQ. Thus, to reduce respondent burden and increase the probability of participants completing the measures, we did not collect three of the heiQ subscales: Health Directed Behaviour, Constructive Attitudes and Approaches, and Social Integration and Support. We also collected the Secondary Conditions Scale, a 16-item self-report measure that targets secondary conditions associated with SCI that impact health (41), and the University of Washington Self-Efficacy Short Form, a 6-item self-report questionnaire rating confidence in self-management skills validated for the SCI population (42). We measured Health Related Quality of Life (HRQOL) using the 3 questions from the International Spinal Cord Injury – Quality of Life (SCI QOL) basic dataset that rate satisfaction with general QOL, physical and psychological health (43) and the SCI-QOL Resilience Short Form, an 8-item measure of adaptation or adjustment after the injury (44). We also collected a measure of Social/Role Activities Limitations (45) and the 8-item Personal Health Questionnaire (PHQ) Depression Scale developed by the Stanford group to evaluate the CDSMP (46). Descriptive variables and covariates The following demographic and social characteristics were collected: age, gender, city/province of residence, language, employment status, education level, income level, marital status, and living arrangement. In addition, injury-related characteristics including time since injury, level of impairment and injury, completeness, traumatic or non-traumatic and primary mode of mobility were collected. Given the nature of the intervention, at baseline we also collected the eHealth Literacy scale assessing perceived skills locating and applying information about health from the internet (47). Data collection Data were collected at baseline and 2, 6, and 12 months after randomisation. Randomisation and Blinding A statistician prepared the group allocation schedule in advance of the study using an online tool. Blocking (block size of 4) was used to achieve an equal number of participants in each study group to maximize statistical efficiency (48). The order of group assignment within the block was randomised. To ensure blinding of outcome assessment, a research assistant blinded to group assignment was to collect the quantitative data over the phone at 2, 6, and 12 months. Sample size We proposed a sample size of 60 participants. If achieved, this would provide a reasonable bias-corrected estimate for an effect size of 0.5 for the definitive RCT (49). Effect size for group change was informed by the heiQ data on 2,157 participants of chronic disease self-management programs in Australia, where an effect size of 0.5 was shown to be the benchmark for change in the STA subscale (39). From baseline to 6-month follow-up, the effect size for our primary short-term heiQ outcome, the STA subscale, was 0.50 (95%CI 0.45-0.55). Analysis Feasibility outcomes were reported descriptively. Baseline data were reported using descriptive statistics. Continuous variables were summarized using means and standard deviations. Categorical variables were summarized using counts and percentages. When applicable, a total score was calculated for each scale by summing individual item scores. In cases where available, the T-score was calculated from the total score. Total scores and T-scores were summarized using means and standard deviations. Total scores at 6 months and 12 months were plotted against the value at baseline by treatment group. The Pearson correlation coefficient was calculated to quantify the relationship of the total score at 6 or 12 months with the baseline value. Analysis of covariance (ANCOVA) was used to estimate the effect of treatment on the scores while adjusting for the value of the score at baseline. Normally distributed outcomes were analyzed with ANCOVA models estimating the difference in outcome level at 6 and 12 months, controlling for baseline values. Treatment effects were reported with their 95% confidence intervals (CI). The treatment effect can be interpreted as the difference in score among persons in the treatment group versus those in the control group after adjusting for baseline score. This method was used for all continuous outcomes. The distribution of counts for the days hospitalised was both zero-inflated and over-dispersed, which severely limited analytical approaches that can be used beyond descriptive statistics. Due to small counts, a Fisher’s exact test was used to compare the numbers between groups. Because of the outliers, a non-parametric test for a difference in medians was performed. RESULTS Trial Feasibility Recruitment Figure 1 describes the flow of participants through the trial. Recruitment occurred between September 2019 and September 2020. A total of 86 individuals inquired about the study, 67 were screened for eligibility, and two were excluded because their tetraplegia was due to multiple sclerosis and not SCI. Of the 65 participants, 31 were allocated to the intervention and 34 to the waitlist control group; two participants withdrew, leaving 30 intervention and 33 controls. Participants remained in the group to which they were assigned. Participants were recruited from the community, through advertisements in SCI consumer organization newsletters and websites, peer health coach networks, and clinicaltrials.gov trial registration. No study participants were recruited from rehabilitation hospitals that have SCI units in Ontario, BC and Saskatchewan, due to COVID-19 restrictions. Feasibility of recruitment was to be assessed by the number and proportion of consenting individuals per month benchmarked against whether 66 participants could enter the trial in an 8-month recruitment period. This was determined to not be a useful measure given the impact of COVID-19 restrictions, which extended the recruitment period to 12 months. Respondent Characteristics Baseline demographic, social, and injury characteristics of participants in intervention and waitlist control groups are presented in Table 2. The mean age of the participants in the intervention group was 49.6 years compared to 48.7 years in the control group. The mean time since injury was 25.6 years among participants in the intervention and 20.2 years in the control group. This was a highly educated group, with only 7 of 63 (11%) participants reporting having high school or less education. There were no significant differences with respect to the amount of missing data across variables at any time point. The only baseline difference of note is that there were more participants with cervical injuries in the control group (19 versus 8 intervention) and more participants with thoracic/lumbar injuries in the intervention group (18 versus 8 control). Retention Of 30 intervention and 33 control participants who received the allocated intervention, 25 (83%) intervention and 29 (88%) control participants provided data at 6 months, and 27 (90%) intervention and 29 (88%) control participants provided data at 12 months. Remuneration (up to $300 CDN) was initially to be paid at the end of the study, but to incentivize participants to complete assessments we provided remuneration ($100 CDN per completed assessment) in the form of a gift card of their choice (grocery, drug store, department store) after they completed each of the assessments at baseline, 6 and 12 months. The overall retention rate at 12 months was 89% (56/63). SCI&U Implementation We had hoped to match coaches and participants with similar characteristics. To facilitate matching, we created profiles of the coaches for the platform. Matching with respect to the level of impairment was not possible, as all but one of the coaches were wheelchair users. We had planned to collect follow-up data at 2 months based on previous research on behaviour change for physical activity in an SCI population, which suggested that the first two months of coaching may be a critical period for eliciting behaviour change (36, 50). All online sessions for SCI&U were expected to be completed within 6 months, with the majority being completed after 2 months. However, intervals between sessions were allowed to vary to promote flexibility. Intervals were decided collaboratively between coach and client and ranged between one and two weeks. Thus many participants were still actively involved in the intervention and did not have the majority of their sessions completed at the 2-month data collection point, so part way through the trial we decided to forego collection of 2-month data. The mean ± SD number of coaching sessions was 12.6 ± 2.3 (median 13), and individual sessions lasted 55 ± 26 (median 57) minutes. Only one participant completed less than 8 coaching sessions. The most common topics discussed, in order of frequency, were aging with an SCI, pain, exercise, mental health, diet, bladder, and skin. As the pandemic progressed, COVID-19 also became a topic. Usability and Quality of the Program Twenty-five of 30 (83%) participants in the intervention group completed the MARS and the heiQ course quality questions after their last coaching session. Mean scores ± standard deviation on the MARS were 3.9 ± 0.8 for software functionality, 3.2 ± 0.7 for quality, 4.2 ± 0.7 for behaviour change, and 4.2 ± 0.7 for information. Users assigned the service 4 out of 5 stars for overall quality, on average, yet indicated program fees would be a potential barrier to program adoption. Mean scores for the course quality questions of the heiQ, measured on a 4-point Likert scale, ranged from 3.5 to 4.0. Primary short-term outcome: Skill and Technique Acquisition subscale of the Health Education Impact Questionnaire Table 3 provides the raw scores (i.e., T-scores) on primary and secondary outcomes by intervention group. Table 4 provides estimates of effect sizes of the intervention on the heiQ subscale scores at 6 and 12 months, adjusted for the subscale scores at baseline. After adjusting for the baseline subscale score, the difference in the 6-month STA subscale score between persons in the treatment group compared to those in the control group was 0.56 (95% CI: -0.41, 1.52). The difference in 12-month score between persons in the treatment group compared to those in the control group was 0.72 (95% CI: -0.28, 1.72). An effect size of 0.5 has been shown to be the benchmark for change in STA (39). Primary long-term outcome measure: cumulative days rehospitalised in the 12 months following baseline assessment At 6 and 12 months, data points were missing for 7 and 5 participants in the intervention group, respectively, compared to 13 and 12 participants in the waitlist control group, respectively (Table 5). Most participants at 12 months (17 intervention and 20 controls) had zero nights in hospital. Among the 9 persons for whom the information was available and who had spent at least one night in hospital, the median [95% CI] number of nights in hospital in the past 12 months was 11 [3-19] nights in the intervention group (n=5) and 24 [5-95] nights in the control group (n=4). There was no difference in rehospitalisation rates between groups at either 6- or 12-months post-intervention. Because most participants did not experience rehospitalisation, a secondary analysis comparing the proportion of persons in each group who experienced any rehospitalisations also found no difference in rates of rehospitalisation at 6 months (13% intervention versus 10% control) and at 12 months (20% intervention versus 19% control). Secondary Outcome Measures Of the other four heiQ subscales, Self-Monitoring and Insight had a significant treatment effect at 12 months (p=0.01; see Table 4). This construct captures the individuals’ ability to monitor their condition and their physical and/or emotional responses that lead to insight and appropriate actions to self-manage (e.g., “I carefully watch my health and do what is necessary to keep as healthy as possible”). The difference in the 12-month score between persons in the intervention group compared to those in the control group was 1.51 (95% CI: 0.39, 2.69). At 12 months follow-up, a greater proportion of the intervention group strongly agreed with the statements in the Self-Monitoring and Insight construct compared with the control group (Table 6). The other heiQ subscale with a large effect was Emotional Distress, with an effect estimate of -1.40 (95% CI -3.04,0.23) at 12 months (Table 4), although this difference was not significantly different (p=0.09). Minimal changes were observed for the subscale Positive and Active engagement in Life and for Health Services Navigation at 12 months. The other secondary outcomes demonstrated no notable differences between the control and intervention groups (Table 4). DISCUSSION This study examined the feasibility of conducting a definitive RCT to determine the effectiveness of an online self-management program using peer health coaches to improve self-management skills and reduce rehospitalisations for persons living with SCI. We found that, overall, the trial methodology and procedures were feasible, and the intervention was acceptable to participants. Several challenges identified in this feasibility trial are being changed to improve the delivery of the intervention and trial methodology in the definitive trial (Table 7). The majority of this pilot trial was conducted during the COVID-19 pandemic when indoor mask use was mandatory and restrictions were in place for nonessential travel, social gatherings, and businesses. The COVID-19 pandemic forced Canadians with SCI to adapt to a new level of physically distant health care, led to reduced access to numerous health care services, and increased self-isolation to prevent the spread of infection (51, 52). For the current pilot trial, the pandemic had major implications for recruitment sources, characteristics of study participants, and outcomes. Telehealth interventions were swiftly adopted during the pandemic due to the need for patients with SCI to safely access care (51). This might explain the acceptability of our program, as there were no concerns or health risks involved with traveling to appointments with an online program. In addition, participation in the coaching sessions was high, with a mean of 12.6 sessions out of a possible maximum of 14 sessions; perhaps the program was a way for patients to address social isolation. In the current pilot trial study, the five most common topics discussed were aging with an SCI, pain, exercise, mental health, and diet. In a recent needs assessment of 38 individuals with SCI who were primarily White (89.5%), male (63.2%), an average age of 47.2 years, and the majority more than 10 years out from injury, participants expressed that a self-management program would help them feel less alone and that their ‘cries of help” would be heard (53). In that study, with respect to topics, participants indicated that psychological health and coping was most important followed by pain, spasticity, and aging with SCI. These topic priorities are similar to our results. One of the outcome measures that had the most change in the current pilot trial was the heiQ subscale Emotional Distress. To this end, fear and anxiety of contracting COVID-19 and perceived vulnerability may be further contributors to worsening mental health. In the Mesa et al (51) post-COVID study of individuals with SCI living in the community in British Columbia, Canada, more than one-third of survey respondents reported probable depression. This rate of probable depression was greater than the rates found in the SCI population in other recent pre-pandemic studies (54). Due to pandemic restrictions, we were not able to recruit from rehabilitation hospitals and had to rely on community sources. This may explain why the majority of our participants were, on average, 25 years post-injury. At baseline, on the STA scale, which aims to capture the knowledge-based skills and techniques that persons acquire (or re-learn) to help them cope with symptoms and health problems (40), over 80% of intervention and control subjects agreed or strongly agreed that they had the skills to self-manage. For example, they reportedly had skills to help cope when symptoms arose, a very good idea of how to manage health problems, effective ways to prevent symptoms, and a good understanding of equipment needed to make life easier. This may explain why there was no difference in self-management skills between the intervention and control groups at 12 months, as this group would have already figured out how to manage their SCI given how long they were living with the injury. We did, however, note differences in self-monitoring and insight, which captures individuals’ ability to monitor their condition, and the physical and/or emotional responses that lead to insight and appropriate actions to self-manage. When we examined the responses to the individual items at 12-month follow-up, a greater proportion of the intervention group strongly agreed to the statements in the self-monitoring and insight construct (Table 7). This finding suggests that self-management support to promote self-monitoring and insight may be more appropriate than skill development for a group who has been managing their injury for a long time. For the definitive trial it may be important to recruit individuals who are newly injured, as they often describe feeling unprepared for returning home, physically and psychologically (55, 56). After returning home, people often experience isolation, depression and low levels of physical and psychosocial functioning, coupled with a perception of system abandonment, claiming the transition to be like “falling off a cliff” (11). Major depressive disorder occurs most commonly one to five years post-SCI, and approximately one-third of individuals have mental health problems that perpetuate into individuals’ lives even after five years following discharge (57, 58). The limited time for provision of health education and skill acquisition in the inpatient setting means that individuals with SCI are entering the community with deficits in knowledge and fewer self-management skills to enable successful community re-integration (59). Therefore, we need to develop recruitment methods to reach more recently injured individuals for the definitive trial, as they are also likely to benefit from a self-management program. Limitations Participants were not blinded to their group allocation, and this could have resulted in a bias in the reporting of the numerous self-report measures. The effects observed may be influenced by the study being conducted during the COVID-19 pandemic. Also, the generalizability of the findings is limited to individuals with SCI who were many years post-injury. Thus, the treatment effect observed for self-monitoring and insight could be spurious and will need to be confirmed. Additionally, participants were almost all White and well educated, so we are unable to comment on the applicability of the intervention and/or trial procedures for individuals with different ethnic and educational backgrounds. Finally, the hospitalisation data were difficult to interpret and difficult for participants to recall; results may have been affected by various COVID-19 policies. Conclusions The findings of this pilot randomised trial suggest that it was possible to achieve recruitment and retention targets for the SCI&U online peer health coaching program even during the COVID-19 pandemic. However, it was difficult to recruit individuals with recent SCI, such as within 5 years of injury. There were too many outcome measures to complete. Overall, the SCI&U platform was assessed as having good usability and the program being of high quality. This pilot study demonstrated that SCI&U had a medium effect on skill and technique acquisition, had a large effect on reducing emotional distress, and significantly improved self-monitoring and insight among a group of participants who were on average over 20 years post-injury. Given that most of the trial was conducted during the COVID-19 pandemic, these results need to be confirmed in a definitive trial, and further research is needed to determine the impact of the SCI&U peer health coaching program on those living with recently acquired SCI. Abbreviations ANCOVA Analysis of covariance BAP Brief Action Planning BC British Columbia CDSMP Chronic Disease Self-Management Program CI Confidence Interval CONSORT Consolidated Standards of Reporting Trials GIM Get In Motion heiQ Health Education Impact Questionnaire HRQOL Health-related quality of life MARS Mobile App Rating Scale MCMC My Care My Call PHQ Personal Health Questionnaire RCT Randomised controlled trial SCI Spinal Cord Injury SCI QOL Spinal Cord Injury – Quality of Life SCI&U Spinal Cord Injury and You STA Skill and Technique Acquisition Declarations Ethics approval and consent to participate Research Ethics Board approval was obtained at the University of Toronto (Protocol Number 34808) and the University of Saskatchewan (Protocol Number 1228). The trial was registered on ClinicalTrials.gov (NCT04474171). Consent for publication Not applicable Availability of data and materials The datasets generated and/or analysed during the current study are not publicly available due to small numbers and possible identification of individuals, but are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding Funding for this study was provided by the Canadian Institutes of Health Research (PJT 159728). The funder had no role in the conceptualization, design, data collection, analysis, decision to publish, or preparation of the manuscript. Authors’ contributions SBJ was the project lead and was responsible for the conceptual development, design, analysis, interpretation of results, and writing of all drafts SJA: conception and design of the work, acquisition, analysis, interpretation of data, drafted the work BCC: study design, participant recruitment, acquisition of data SJTG: study design, interpretation of data AGL: study design, participant recruitment, acquisition of data CBMcB: study design, participant recruitment, data collection RM: study design, analysis WBM: study design, participant recruitment, interpretation of data SM: study design, interpretation of data NMS: conception and design of the work, interpretation of data JDS: conception of the work, participant recruitment, data collection, interpretation of data SNS: study design, interpretation of data TT: participant recruitment, data collection JRT: conception of the work, study design, interpretation of data All authors critically revised the draft and have and approved the final manuscript. Acknowledgements The authors thank Dagmar Gross for assistance with copy-editing and preparation of this manuscript. NMS holds the Toronto Rehabilitation Institute Chair at the University of Toronto. BCC holds the Toronto Rehabilitation Institute / University of Toronto Chair in Spinal Cord Injury Rehabilitation. SJTG is supported by the University of Toronto Centre for the Study of Pain Scientist Salary Award. SNS is supported by a Canada Research Chair in Participation, Well-Being, and Physical Disability (Tier 2). References McColl MA, Shortt S, Godwin M, Smith K, Rowe K, O'Brien P, et al. Models for integrating rehabilitation and primary care: a scoping study. Arch Phys Med Rehab. 2009;90(9):1523–31. Cardenas DD, Hoffman JM, Kirshblum S, McKinley W. Etiology and incidence of rehospitalization after traumatic spinal cord injury: a multicenter analysis. Arch Phys Med Rehab. 2004;85(11):1757–63. Jensen MP, Truitt AR, Schomer KG, Yorkston KM, Baylor C, Molton IR. 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COVID-19: Stress and Resilience COVID-19: Respiratory Care Diet and Nutrition Evaluating Health Information Fatigue Goal Setting Incomplete SCI Leisure and Recreation Mobility Devices Pain Management Parenting and Fertility Parenting Older Children Physical Activity Problem Solving Relationships Skin Management Self-Advocacy Sexuality Shoulder Health Spasticity Stress, Anxiety, and Depression Women's Health Table 2 Baseline and injury characteristics of participants, reported as n and percentage, unless otherwise indicated. Characteristic Intervention (N = 30) Control (N = 33) Age (years) Mean (SD) 49.6 (11.1) 48.7 (14.1) Median (Minimum, Maximum) 49 (21, 76) 50 (29, 72) Missing 2 7 Time since injury (years) Mean (SD) 25.6 (13.3) 20.2 (13.5) Median (Minimum, Maximum) 24 (3, 58) 16 (1, 55) Missing 4 4 Gender Male 17 (57) 13 (43) Female 13 (43) 17 (57) Transgender/Gender neutral 0 0 Missing 0 3 Primary Language English 27 (96) 26 (93) French 1 (4) 0 (0) Other 0 (0) 2 (7) Missing 2 5 Province British Columbia 16 (53) 23 (70) Ontario 7 (23) 4 (12) Saskatchewan 5 (17) 4 (12) Other 2 (7) 2 (6) Missing 0 0 Employment Employed full-time 3 (12) 7 (24) Employed part-time 3 (12) 5 (17) Unemployed 19 (76) 17 (59) Missing 5 4 Highest level of Education High school or less 3 (12) 4 (15) College/Bachelor’s degree 16 (64) 19 (70) Postgraduate 6 (24) 4 (15) Missing 5 6 Marital Status Single/Never married 9 (35) 11 (39) Married/Partnered 11 (42) 10 (36) Separated/Divorced/Widowed 6 (23) 7 (5) Missing 4 5 Living arrangement Living alone 7 (26) 11 (38) Living with someone 17 (63) 15 (52) Other 3 (11) 2(7) Missing 3 4 eHealth Literacy Mean (SD) 30.6 (5.1) 29.9 (5.1) Median (Minimum, Maximum) 30.5 (22.0, 40.0) 31.0 (20.0, 40.0) Missing 2 5 Injury Characteristics Paraplegic 18 (69) 13 (50) Quadriplegic 8 (31) 13 (50) Missing 4 7 Traumatic 21 (78) 21 (81) Non-traumatic 5 (19) 4 (15) Other 1 (4) 1 (4) Missing 3 7 Complete 12 (44) 8 (31) Incomplete 15 (56) 18 (69) Missing 3 7 Cervical 8 (29) 19 (66) Thoracic 12 (43) 7 (24) Lumbar/Sacral 6 (22) 1 (3) Other 2 (7) 2(7) Missing 2 4 Mobility Manual wheelchair 16 (59) 12 (41) Powered wheelchair 7 (26) 11 (38) Walker/Cane/Other 4 (14) 6 (21) Missing 3 4 SD = standard deviation Table 3 Raw scores or T-scores for outcome variables for intervention and control groups at baseline, 6 months, and 12 months follow-up, reported as mean ± standard deviation. Baseline 6 Months 12 Months Intervention (N = 28) Control (N = 29) Intervention (N = 25) Control (N = 27) Intervention (N = 27) Control (N = 29) heiQ Subscales Skill and Technique Acquisition 2.9 ± 0.5 3.0 ± 0.5 3.2 ± 0.6 3.0 ± 0.5 3.2 ± 0.6 3.0 ± 0.4 Self-monitoring and Insight 3.0 ± 0.7 3.3 ± 0.4 3.3 ± 0.4 3.2 ± 0.4 3.4 ± 0.5 3.2 ± 0.5 Emotional Distress 2.6 ± 0.8 2.2 ± 0.7 2.4 ± 0.9 2.2 ± 0.7 2.4 ± 0.9 2.3 ± 0.9 Health Services Navigation 3.0 ± 0.7 3.1 ± 0.5 3.2 ± 0.6 3.2 ± 0.6 3.2 ± 0.6 3.2 ± 0.4 Positive and Engagement in Life 3.0 ± 0.7 3.2 ± 0.5 3.1 ± 0.6 3.1 ± 0.6 3.1 ± 0.6 3.1 ± 0.5 Other Outcome Variables Secondary Conditions Scale 19.5 ± 9.6 14.6 ± 7.8 17.2 ± 10.3 17.6 ± 10.2 14.1 ± 6.5 15.0 ± 7.8 University of Washington Self-Efficacy Scale T-score 44.2 ± 11.5 46.7 ± 9.1 47.7 ± 10.8 46.8 ± 10.1 46.5 ± 12.2 47.3 ± 9.4 Health Related Quality of Life 19.2 ± 8.6 20.2 ± 7.7 21.6 ± 8.6 21.0 ± 7.9 21.4 ± 7.7 21.4 ± 6.5 SCI QoL Resilience 47.4 ± 7.7 50.3 ± 8.2 49.0 ± 8.3 49.6 ± 7.1 49.7 ± 10.9 49.8 ± 7.8 Social/Role Limitations 8.0 ± 5.4 6.7 ± 5.8 6.3 ± 5.6 6.5 ± 5.4 6.7 ± 4.8 6.3 ± 5.4 PHQ-8 Patient Depression Questionnaire 8.4 ± 6.3 5.8 ± 4.5 6.5 ± 5.2 5.4 ± 4.4 7.2 ± 6.1 5.6 ± 4.3 heiQ = Health Education Impact Questionnaire; SCI = spinal cord injury; QoL = Quality of Life; PHQ = Personal Health Questionnaire Table 4 ANCOVA treatment effect estimates at 6 months and 12 months follow-up for outcome variables Outcome Variable 6 Months Follow-up 12 Months Follow-up Estimate 95% CI p-value Estimate 95% CI p-value heiQ Subscales Skill and Technique Acquisition 0.56 -0.4, 1.5 0.25 0.72 -0.3, 1.7 0.15 Self-Monitoring and Insight 0.94 -0.2, 2.1 0.11 1.51 0.3, 2.7 0.01 Emotional Distress -0.45 -2.0, 1.1 0.56 -1.40 -3.0, 0.2 0.09 Health Services Navigation 0.23 -1.0, 1.5 0.71 0.43 -0.8, 1.6 0.46 Positive and Active Engagement in Life -0.005 -0.9, 0.9 0.99 0.15 -0.9, 1.2 0.78 Other Outcome Variables Secondary Conditions Scale -0.40 -3.4, 2.7 0.79 -1.5 -4.3, 1.4 0.31 University of Washington Self-Efficacy Scale 1.85 -2.4, 6.1 0.39 0.83 -3.5, 5.2 0.71 Health Related Quality of Life -0.78 -2.8, 1.3 0.45 -0.46 -2.5, 1.6 0.66 SCI QoL Resilience 0.03 -2.0, 2.0 0.98 0.88 -1.8, 3.5 0.51 Social/Role Limitations -0.78 -2.8, 1.3 0.45 -0.46 -2.5, 1.6 0.66 PHQ-8 Patient Depression Questionnaire -0.06 -2.3, 2.2 0.96 − .20 -2.4, 2.0 0.85 heiQ = Health Education Impact Questionnaire; SCI = spinal cord injury; QoL = Quality of Life; PHQ = Personal Health Questionnaire Table 5 Cumulative days rehospitalised 6 and 12 months after baseline assessment Cumulative Days Rehospitalised Intervention (N = 30) Control (N = 33) 6 months after baseline assessment Mean (Standard Deviation) 1.5 (4.3) 4.3 (19.0) Median (Minimum, Maximum) 0 (0, 15) 0 (0, 85) Missing 7 13 12 months after baseline assessment Mean (Standard Deviation) 1.9 (5.2) 6.6 (21.1) Median (Minimum, Maximum) 0 (0, 19) 0 (0, 95) Missing 5 12 Table 6 Number and percentage of respondents in intervention and control groups at 12 months follow-up who strongly agree with each of the individual items on the Self-Monitoring and Insight scale. Item on Self-Monitoring and Insight Scale Intervention (N = 27) N (%) strongly agree at 12 months follow-up Control (N = 29) N (%) strongly agree at 12 months follow-up I have realistic expectations of what I can and cannot do 10 (37%) 7 (24%) I regularly monitor changes in my health 16 (59%) 8 (28%) I know what things can trigger my health problems and make them worse 16 (59%) 8 (28%) When I have health problems, I have a clear understanding of what I need to do to control them 16 (59%) 7 (24%) I have a very good understanding of when and why I am supposed to take my medication 14 (52%) 4 (14%) I carefully watch my health and do what is necessary to keep as healthy as possible 19 (70%) 16 (55%) Table 7 Changes to the intervention and trial methodology for definitive randomised trial Problem identified during the feasibility trial Change made for the definitive trial Could not recruit from inpatient rehabilitation hospitals due to pandemic restrictions. Have focused recruitment efforts for inpatient rehabilitation hospitals. Participants who enrolled in study were many years post-injury. Increase recruitment efforts to identify participants within 1–5 years of injury. There were more participants with cervical injuries in the control group and more participants with thoracic/lumbar injuries in the intervention group. Consider block randomisation. Some participants had incomplete injuries and were not wheelchair users, but all but one coach was a wheelchair user. Have a mix of coaches who are ambulatory or wheelchair users. Participants did not follow the proposed timing for the online coaching sessions –one-half of coaching sessions were expected to be completed within 2 months. All online sessions are expected to be completed within 6 months, but intervals between sessions will be allowed to vary in order to promote flexibility. Drop 2-month follow-up data collection. Online coaching sessions are expected to cover a health-related topic (e.g., bladder, bowel, skin, pain, healthy eating, physical activity or stress, anxiety and depression, etc.) and a self-management skill topic (e.g., action planning, goal setting, problem solving, mood management, navigating the health care system, communicating with health care providers). The selection of topics and the order in which they are addressed will be determined by the study participant, with input from their peer health coach when requested. To ensure we meet the unique needs of participants, the coach and participant will determine jointly how many sessions to spend on a topic. Sometimes had to use telephone for coaching due to a lack of high-speed internet connection among participants. Telephone option for coaching program will be available. Too many outcome measures to complete. Limit outcome measures to only those that showed potential for change MARS scale may be too long for definitive trial. Replace MARS with the 10-item System Usability Scale (60). Some participants reported struggling with the technical skills required to navigate the platform to complete the outcome measures. Have a research assistant help participants with completion of outcome measures to ensure completeness and quality. Largest effect sizes were for two heiQ subscales: Emotional Distress, and Self-Monitoring and Insight. Consider Emotional Distress and Self-Monitoring and Insight as primary outcomes. Wanted same distribution of males and females in intervention and control groups. Stratify by sex. Hospitalisation data skewed. Data on hospitalisations will not be collected. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5132773","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":379628883,"identity":"afb8f7c8-8ea2-4a18-abb6-44f3e72a2263","order_by":0,"name":"Susan B Jaglal","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/0lEQVRIiWNgGAWjYPACNgYGdgbGAx9I08LMwHBwBoMBiMfYQJwuoJbDPMRokZ+R/vBzAQOfvLwz84PDtm1/5Mzbe48/+MBgJ49Li8GNHGPpGQxshhsPsxkczm0zMJY5cy6xcQZDsiEuqwwkchikeRjYGDc2M4C1JM6QyDFs5mE4gNN1QIc9/g3UYr+xmf3DYUskLfY4PXQjwQxkS+J8Zh6Dw4xIWhJxOuzMGzNrHgO25A3MPAUHe84ZG0vwnDGcOcMgORmnw9rTH9/mqThmO7+9feODH2VychLsPQYfPlTY2eJ0GMSuYwwGB1BF8KoHgRoGefyGjoJRMApGwUgGAKHKUXF7crX1AAAAAElFTkSuQmCC","orcid":"https://orcid.org/0000-0002-2930-1443","institution":"University of Toronto","correspondingAuthor":true,"prefix":"","firstName":"Susan","middleName":"B","lastName":"Jaglal","suffix":""},{"id":379628884,"identity":"da82dddb-341d-4af4-82b1-4083735cc653","order_by":1,"name":"Sonya J. Allin","email":"","orcid":"","institution":"York University","correspondingAuthor":false,"prefix":"","firstName":"Sonya","middleName":"J.","lastName":"Allin","suffix":""},{"id":379628885,"identity":"c335b606-51e3-4331-9902-d8eb076bbc11","order_by":2,"name":"B. Catherine Craven","email":"","orcid":"","institution":"University of Toronto","correspondingAuthor":false,"prefix":"","firstName":"B.","middleName":"Catherine","lastName":"Craven","suffix":""},{"id":379628886,"identity":"951db388-348b-44cd-9375-4ec3b4863208","order_by":3,"name":"Sara J.T. Guilcher","email":"","orcid":"","institution":"University of Toronto","correspondingAuthor":false,"prefix":"","firstName":"Sara","middleName":"J.T.","lastName":"Guilcher","suffix":""},{"id":379628887,"identity":"dfb87c69-e529-4e37-a43c-b8b3ff80a816","order_by":4,"name":"A. Gary Linassi","email":"","orcid":"","institution":"University of Saskatchewan","correspondingAuthor":false,"prefix":"","firstName":"A.","middleName":"Gary","lastName":"Linassi","suffix":""},{"id":379628888,"identity":"d0ed9b2c-6257-4b2d-9f8c-cdf6558d4da7","order_by":5,"name":"Christopher B. McBride","email":"","orcid":"","institution":"Spinal Cord Injury BC","correspondingAuthor":false,"prefix":"","firstName":"Christopher","middleName":"B.","lastName":"McBride","suffix":""},{"id":379628889,"identity":"dbd782f8-3af9-41e3-bfc9-d8cfb8bd5d63","order_by":6,"name":"Rahim Moineddin","email":"","orcid":"","institution":"University of Toronto","correspondingAuthor":false,"prefix":"","firstName":"Rahim","middleName":"","lastName":"Moineddin","suffix":""},{"id":379628890,"identity":"f4056bea-908f-42b6-ba2e-9c5945acb5fd","order_by":7,"name":"W. Ben Mortenson","email":"","orcid":"","institution":"The University of British Columbia","correspondingAuthor":false,"prefix":"","firstName":"W.","middleName":"Ben","lastName":"Mortenson","suffix":""},{"id":379628891,"identity":"27897f86-2a8f-4a04-9ed6-1cf54da4a481","order_by":8,"name":"Sarah Munce","email":"","orcid":"","institution":"University of Toronto","correspondingAuthor":false,"prefix":"","firstName":"Sarah","middleName":"","lastName":"Munce","suffix":""},{"id":379628892,"identity":"cfef4acc-7b91-44e9-bc2d-796f71884be0","order_by":9,"name":"Nancy M. Salbach","email":"","orcid":"","institution":"University of Toronto","correspondingAuthor":false,"prefix":"","firstName":"Nancy","middleName":"M.","lastName":"Salbach","suffix":""},{"id":379628893,"identity":"3d3d51fa-c538-4c98-9418-120ccfdd3978","order_by":10,"name":"John D. Shepherd","email":"","orcid":"","institution":"University of Toronto","correspondingAuthor":false,"prefix":"","firstName":"John","middleName":"D.","lastName":"Shepherd","suffix":""},{"id":379628894,"identity":"aaa3a437-218f-4d9c-a4c9-f3a2ad702d8c","order_by":11,"name":"Shane N. Sweet","email":"","orcid":"","institution":"McGill University","correspondingAuthor":false,"prefix":"","firstName":"Shane","middleName":"N.","lastName":"Sweet","suffix":""},{"id":379628895,"identity":"d07eb9d0-188e-4dca-9c39-6fcfe1cff4f5","order_by":12,"name":"Teri Thorson","email":"","orcid":"","institution":"Spinal Cord Injury BC","correspondingAuthor":false,"prefix":"","firstName":"Teri","middleName":"","lastName":"Thorson","suffix":""},{"id":379628896,"identity":"a9d5bcef-cead-4a6f-8e3f-b8dd95acb0ab","order_by":13,"name":"Jennifer R. Tomasone","email":"","orcid":"","institution":"Queen's University","correspondingAuthor":false,"prefix":"","firstName":"Jennifer","middleName":"R.","lastName":"Tomasone","suffix":""}],"badges":[],"createdAt":"2024-09-22 14:01:38","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5132773/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5132773/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s40814-026-01769-y","type":"published","date":"2026-01-28T15:58:00+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":71809567,"identity":"0e53325a-36e8-40d2-9e9f-60b626d8b5af","added_by":"auto","created_at":"2024-12-18 18:08:34","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":49445,"visible":true,"origin":"","legend":"\u003cp\u003eCONSORT Flow Diagram\u003c/p\u003e","description":"","filename":"SCIUPilot2024Sep20Fig1FINAL.png","url":"https://assets-eu.researchsquare.com/files/rs-5132773/v1/8ed8486eae708fe7b56391a0.png"},{"id":101691951,"identity":"8580af45-55a2-40dc-8f6a-9eb76b229abf","added_by":"auto","created_at":"2026-02-02 16:16:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1324499,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5132773/v1/70d15be3-7e00-49ac-8246-824ebaab2f6d.pdf"},{"id":71809583,"identity":"aaddefa4-1aa5-4b12-a791-36e197e25f1f","added_by":"auto","created_at":"2024-12-18 18:08:34","extension":"doc","order_by":12,"title":"","display":"","copyAsset":false,"role":"supplement","size":222720,"visible":true,"origin":"","legend":"","description":"","filename":"CONSORT2010ChecklistCompleted2024Sep21.doc","url":"https://assets-eu.researchsquare.com/files/rs-5132773/v1/e9484a710a31203f4e09cb62.doc"}],"financialInterests":"","formattedTitle":"An online self-management program for spinal cord injury: a pilot randomised controlled trial of the SCI\u0026amp;U peer health coaching intervention","fulltext":[{"header":"Key messages regarding feasibility","content":"\u003cul\u003e\n \u003cli\u003eUsability and quality of the SCI\u0026amp;U program were highly rated.\u003c/li\u003e\n \u003cli\u003eSCI\u0026amp;U appeared beneficial. While it is feasible to implement an online peer health coaching program, some study participants may need technical support. The number of outcome measures should be limited in future studies.\u003c/li\u003e\n \u003cli\u003eMost of the trial was conducted during the COVID-19 pandemic and results need to be confirmed. Findings warrant proceeding to a definitive trial, with further research needed to determine the impact of the SCI\u0026amp;U health coaching program on those living with recently acquired SCI.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"BACKGROUND","content":"\u003cp\u003eBeyond the initial trauma and adjustment to activity limitations (motor, sensory and autonomic impairments), living with the consequences of spinal cord injury (SCI) is a life-long process (1). Within the first year of injury, more than 50% of people discharged with a SCI may require rehospitalisation due to a secondary complication, such as a urinary tract infection, pressure ulcer, or pneumonia. Even 20 years post-injury, rehospitalisation rates remain over 30% due to additional complications associated with aging, such as cardiovascular disease and diabetes (2, 3). One-year rehospitalisation rates in Canada have remained high, at over 27%, for more than 10 years (4); while, at the same time, length of stay in inpatient rehabilitation has decreased dramatically (5). The limited time for provision of health information and skill acquisition in the inpatient rehabilitation setting means that individuals with SCI are entering the community with fewer self-management skills to prevent secondary complications (6, 7). Families and others comprising informal support networks also have less time to adjust (8). Furthermore, individuals with SCI report that their primary care providers are not well-equipped to support their specialized needs (1, 9, 10). The result is higher rates of secondary complications, emergency department visits and rehospitalisation (4, 11, 12) and a growing demand to provide appropriate health information, skills and support for persons with SCI who are living in the community to better manage their health conditions across the lifespan.\u003c/p\u003e\n\u003cp\u003eSelf-management programs such as Stanford\u0026rsquo;s Chronic Disease Self-Management Program (CDSMP) (13) or the UK\u0026rsquo;s Expert Patient Program (14), comprised of peer-led health coaching and patient education (15), have been associated with improved self-efficacy, health behaviours and psychological health status (13-15), lower hospitalisation rates (13), and reduced health care expenditures (16). Despite these positive results, a qualitative study on the experiences of CDSMP participants with neurological conditions found participants with SCI reported the least program satisfaction and thus recommended a SCI-specific program (17). These findings were supported in our previous research wherein individuals with SCI and other knowledge users (family members/caregivers, health care professionals, consumer organizations and policy makers) emphasized the need for an SCI-specific online program led by peers (18-22).\u003c/p\u003e\n\u003cp\u003eOnly three methodologically rigorous studies of two peer-led, self-management programs for SCI have been published. A randomised controlled trial (RCT) (23) and an interrupted time series analysis (24) evaluated one program developed in Atlanta, Georgia, and another RCT evaluated a program developed in Boston, Massachusetts (25). Both of these programs demonstrated the value of peer health coaching in improving self-management in persons with SCI, but neither of these interventions were delivered virtually; one was in person in a rehabilitation hospital (23, 24) and the other was telephone-based (25). This gap led to the development of our online, peer-led, self-management program for SCI (SCI\u0026amp;U), which was identified as the preferred format in our earlier work because it simulates a face-to-face interaction and limits the need for in-person visits among a population with mobility challenges (26, 27). We followed the mHealth framework, an iterative process for the development and evaluation of mobile Health interventions (28). We used a participatory design approach that included users both as co-designers and key informants (29), which is consistent with the Integrated Knowledge Translation Guiding Principles for Conducting SCI research in partnership (30). Briefly, the SCI\u0026amp;U platform contains an integrated set of tools to support secure one-on-one online health coaching as well as tools to promote discussion of and access to health education resources (26, 27). During sessions, peer health coaches help participants frame self-management goals, create action plans, and solve problems related to their health. The peer coaches are trained to provide self-management education and support to others with SCI, which is an expanded application of SCI peer mentoring (31). The main goal of the program is to improve self-management skills among persons living with SCI.\u003c/p\u003e\n\u003cp\u003eThis study reports a randomised, controlled, pilot trial of the SCI\u0026amp;U intervention. The objectives were as follows:\u003c/p\u003e\n\u003col\u003e\n\u003cli\u003eEvaluate feasibility of participant recruitment, participant retention with long-term follow-up, data collection, and program implementation.\u003c/li\u003e\n\u003cli\u003eExamine participants\u0026rsquo; assessment of usability and quality of the\u003c/li\u003e\n\u003cli\u003eEstimate effect sizes for short-term (baseline to 2 months) and sustained or long-term (6 and 12 months) impacts of the program on primary outcomes (i.e. self-management skills, total days rehospitalised) and secondary outcomes (i.e. secondary health conditions, self-efficacy, health-related quality-of-life (HRQOL), and social/role activities limitations).\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"METHODS","content":"\u003cp\u003e\u003cstrong\u003eTrial design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA two-group, randomised, controlled, pilot trial with prospective recruitment, concealed group allocation, blinded outcome evaluation and waitlist control was conducted in Canada from January 2018 to March 2022. Research Ethics Board approval was obtained at the main coordinating site University of Toronto (Protocol Number 34808), and also at the University of Saskatchewan (Protocol Number 1228). All recruited individuals formally consented to participate in this study orally with a member of the research staff, who then signed and dated a paper copy retained at the research office. For consenting individuals, outcome data were gathered from questionnaires administered at baseline, and at 2, 6, and 12 months after baseline data collection. The trial was registered retrospectively on ClinicalTrials.gov (NCT04474171; 07/13/2020; https://clinicaltrials.gov/study/NCT04474171#study-record-dates). The CONSORT (Consolidated Standards of Reporting Trials) 2010 statement: extension to randomised pilot and feasibility trials (32) and the TIDieR checklist (33) were followed.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEligibility and recruitment of participants\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWe targeted individuals 18 years and older living in the community who were at least six months post-injury, were able to speak and read English, and had a primary care physician. Subjects who were currently participating in another formal self-management program or had a self-report of physician-diagnosed concurrent traumatic brain injury were excluded.\u003c/p\u003e\n\u003cp\u003eRecruitment for participants was nationwide across Canada with a focus on British Columbia (BC) and Ontario, where the research team had relationships with community-based SCI peer organizations, peer health coaches and research staff. A variety of methods were used for recruitment, including outreach by the SCI BC Peer Recruitment Coordinator, and advertisements by SCI consumer organizations on their websites, in newsletters, magazines, Facebook groups and via webinars to their members. In addition, recruitment information was placed on SCI\u0026amp;U social media accounts. Study co-investigators who worked at rehabilitation hospitals also informed clinicians about the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIndividuals interested in the study were asked to send an email to the coordinating centre. A research assistant then contacted the potential participant, screened them for eligibility, and obtained their consent to be randomised to the intervention or waitlist control group. Participants were also asked to complete baseline, 2-, 6- and 12-month assessments. Participants received $300 CAD if they completed all study procedures.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIntervention\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe development, usability and pilot testing of SCI\u0026amp;U is published elsewhere (26, 27). The SCI\u0026amp;U digital platform prototype has a resource library, tools to support one-on-one health coaching with profiles of coaches (to facilitate matching of coaches with clients), and a structured interface for health coaching. Its major features include:\u003c/p\u003e\n\u003cp\u003e1. The ability to create and schedule secure \u0026ldquo;themed\u0026rdquo; videoconferencing sessions between coaches and clients. Themes (such as exercise and nutrition) dictate the scripts used to guide each session, as well as session-specific resources and self-care tips.\u003c/p\u003e\n\u003cp\u003e2. Goal setting and action planning forms. These record the goals and plans of clients as they are articulated during sessions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e3. A sortable resource library, containing themed educational material and resources with links to external websites and videos.\u003c/p\u003e\n\u003cp\u003e5. The ability for coaches and administrators to create and send customized reminders and emails to clients (e.g., session summaries).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImplementation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFollowing randomisation to SCI\u0026amp;U, participants were scheduled for a registration and orientation session to become better acquainted with the platform\u0026rsquo;s features and to troubleshoot any accessibility issues; participants were offered a Chromebook or tablet on loan if needed. Participants were then partnered with their health coach, who was over age 18 and had lived in the community with SCI for more than five years. To ensure consistency and quality of the intervention, all coaches were trained in Motivational Interviewing (34) and Brief Action Planning (BAP) (35) by the Centre for Collaboration, Motivation and Innovation. The coaches had three principal roles: role model, supporter and advisor (31).\u003c/p\u003e\n\u003cp\u003eIn the first videoconference session, which took place within one month following consent, participants identified priority issues related to their health. In subsequent sessions, they worked through goal setting, conducted problem solving activities, and created action plans for behaviour change that were securely stored by the interface and available to users to reflect upon and revise. Each online session conformed to a script; scripts were accessible to coaches via the online platform and included health management information drawn from guidelines as well as standardized protocols for BAP. Themes for sessions related to common health management concerns among the SCI population as indicated by a prior survey of the Canadian SCI community (18, 19); see Table 1 for a list of topics. Coaches could also take notes about clients during sessions, recommend relevant online resources, and arrange follow-up care plans (e.g., to send text message reminders of client goals or plans periodically).\u003c/p\u003e\n\u003cp\u003eDuring the program, clients and coaches could engage in up to 14 online sessions. Based on two other similar effective health behaviour change interventions in SCI, Get in Motion (GIM) (36) and My Care My Call (MCMC) (25) that were telephone-based, we planned to implement the online sessions over 6 months with a tapered schedule (i.e., 8 weekly, 4 biweekly, and 2 monthly sessions) to gradually transition clients from dependency on the coach to independent self-regulation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eControl\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe control group continued with their usual health care and were offered the SCI\u0026amp;U program at the end of the 12-month assessment period (wait-list control).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOutcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTrial feasibility\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFeasibility of recruitment was assessed by the number and proportion of consenting individuals per month in an 8-month recruitment period. Feasibility of data collection was evaluated as the percentage of participants with complete data on each measure at each evaluation time point with targets of \u0026gt;90% for baseline and 2-month and \u0026gt;80% for 6-month and 12-month evaluations. In the RCTs of peer-led interventions for SCI (23, 25), the loss to follow-up at 6 months was 13% (23) and 10% (25). Adherence was calculated as the percentage of coaching sessions that participants attended. Participants completing eight or more sessions were considered adherent based on findings from the GIM study to increase physical activity in those with SCI (36) and the MCMC study to improve self-management to prevent secondary conditions (25). Findings from GIM suggested that the first eight weeks of coaching may be a critical period for eliciting behaviour change. Withdrawal rate was assessed as the percentage of study participants who withdrew by the 2-, 6- and 12-months evaluation time points.\u003c/p\u003e\n\u003cp\u003eAs part of the feasibility evaluation, we also measured usability and quality of the program. Each participant in the intervention group was asked to complete the Mobile App Rating Scale (MARS) (37) after their last online session. The 21-item MARS has four subscales that assess software-related Quality, Functionality, Information and Behaviour Change; responses to each are measured on a five-point Likert scale. Participants were also asked to complete relevant questions from the \u0026ldquo;Health Education Impact Questionnaire\u0026rdquo; Version 3 (heiQ) about the quality of the program (38). The questionnaire has nine items with responses ranging from 1 to 4: strongly disagree (1), disagree (2), agree (3) and strongly agree (4).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePrimary short-term outcome measure: Skill and Technique Acquisition (STA) subscale of the Health Education Impact Questionnaire (heiQ)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSelf-management skills were measured with the STA subscale of the Health Education Impact Questionnaire (heiQ), a widely used tool to measure the quality and outcomes of chronic disease self-management programs (39). The heiQ has demonstrated high construct validity ranging from 0.70 to 0.83 for each of the dimensions and reliability \u0026gt;0.8 (38). It measures eight constructs by multi-item composite scales using a 4-point Likert scale: strongly disagree (1), disagree (2), agree (3) and strongly agree (4), with a mean score ranging from 1 to 4. The STA subscale has 4 items that aim to capture the knowledge-based skills and techniques that persons acquire (or re-learn) to help them cope with symptoms and health problems (e.g. \u0026ldquo;When I have symptoms, I have skills that help me cope\u0026rdquo;). It was chosen as the basis for the sample size calculation as skill building is a primary focus of the intervention (40).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePrimary long-term outcome measure: cumulative days rehospitalised 12 months after baseline assessment\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn an RCT by Gassaway et al., (23) evaluating a peer-mentoring self-management SCI program for patients receiving inpatient rehabilitation, cumulative days rehospitalised at 6 months after discharge from inpatient rehabilitation were significantly fewer for patients who received peer mentoring compared to controls (43% reduction, p\u0026lt;0.001), with a mean rehabilitation length of stay of approximately 2 months. In our study, since participants were already living in the community and the intervention period was 6 months, the primary long-term outcome measure of days rehospitalised 12 months after baseline was calculated by summing the answer to the question \u0026ldquo;How many total nights did you spend in hospital in the past 6 months?\u0026rdquo; at the 6-month time point and the 12-month time point.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSecondary outcomes\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn addition to the STA subscale, we planned to collect the other seven subscales of the heiQ: Health Directed Behaviour; Positive and Active Engagement in Life; Emotional Distress; Self-monitoring and Insight; Constructive Attitudes and Approaches; Social Integration and Support; and Health Services Navigation (38). However, we noted considerable overlap in the content of three subscales in the heiQ. Thus, to reduce respondent burden and increase the probability of participants completing the measures, we did not collect three of the heiQ subscales: Health Directed Behaviour, Constructive Attitudes and Approaches, and Social Integration and Support. We also collected the Secondary Conditions Scale, a 16-item self-report measure that targets secondary conditions associated with SCI that impact health (41), and the University of Washington Self-Efficacy Short Form, a 6-item self-report questionnaire rating confidence in self-management skills validated for the SCI population (42). We measured Health Related Quality of Life (HRQOL) using the 3 questions from the International Spinal Cord Injury \u0026ndash; Quality of Life (SCI QOL) basic dataset that rate satisfaction with general QOL, physical and psychological health (43) and the SCI-QOL Resilience Short Form, an 8-item measure of adaptation or adjustment after the injury (44). We also collected a measure of Social/Role Activities Limitations (45) and the 8-item Personal Health Questionnaire (PHQ) Depression Scale developed by the Stanford group to evaluate the CDSMP (46).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eDescriptive variables and covariates\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe following demographic and social characteristics were collected: age, gender, city/province of residence, language, employment status, education level, income level, marital status, and living arrangement. In addition, injury-related characteristics including time since injury, level of impairment and injury, completeness, traumatic or non-traumatic and primary mode of mobility were collected. Given the nature of the intervention, at baseline we also collected the eHealth Literacy scale assessing perceived skills locating and applying information about health from the internet (47).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData were collected at baseline and 2, 6, and 12 months after randomisation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRandomisation and Blinding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA statistician prepared the group allocation schedule in advance of the study using an online tool. Blocking (block size of 4) was used to achieve an equal number of participants in each study group to maximize statistical efficiency (48). The order of group assignment within the block was randomised. To ensure blinding of outcome assessment, a research assistant blinded to group assignment was to collect the quantitative data over the phone at 2, 6, and 12 months.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSample size\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe proposed a sample size of 60 participants. If achieved, this would provide a reasonable bias-corrected estimate for an effect size of 0.5 for the definitive RCT (49). Effect size for group change was informed by the heiQ data on 2,157 participants of chronic disease self-management programs in Australia, where an effect size of 0.5 was shown to be the benchmark for change in the STA subscale (39). From baseline to 6-month follow-up, the effect size for our primary short-term heiQ outcome, the STA subscale, was 0.50 (95%CI 0.45-0.55).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAnalysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFeasibility outcomes were reported descriptively. Baseline data were reported using descriptive statistics. Continuous variables were summarized using means and standard deviations. Categorical variables were summarized using counts and percentages. When applicable, a total score was calculated for each scale by summing individual item scores. In cases where available, the T-score was calculated from the total score. Total scores and T-scores were summarized using means and standard deviations. Total scores at 6 months and 12 months were plotted against the value at baseline by treatment group. The Pearson correlation coefficient was calculated to quantify the relationship of the total score at 6 or 12 months with the baseline value. Analysis of covariance (ANCOVA) was used to estimate the effect of treatment on the scores while adjusting for the value of the score at baseline. Normally distributed outcomes were analyzed with ANCOVA models estimating the difference in outcome level at 6 and 12 months, controlling for baseline values. Treatment effects were reported with their 95% confidence intervals (CI). The treatment effect can be interpreted as the difference in score among persons in the treatment group versus those in the control group after adjusting for baseline score. This method was used for all continuous outcomes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe distribution of counts for the days hospitalised was both zero-inflated and over-dispersed, which severely limited analytical approaches that can be used beyond descriptive statistics. Due to small counts, a Fisher\u0026rsquo;s exact test was used to compare the numbers between groups. Because of the outliers, a non-parametric test for a difference in medians was performed.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003e\u003cstrong\u003eTrial Feasibility\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eRecruitment\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFigure 1 describes the flow of participants through the trial. Recruitment occurred between September 2019 and September 2020. A total of 86 individuals inquired about the study, 67 were screened for eligibility, and two were excluded because their tetraplegia was due to multiple sclerosis and not SCI. Of the 65 participants, 31 were allocated to the intervention and 34 to the waitlist control group; two participants withdrew, leaving 30 intervention and 33 controls. Participants remained in the group to which they were assigned.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eParticipants were recruited from the community, through advertisements in SCI consumer organization newsletters and websites, peer health coach networks, and clinicaltrials.gov trial registration. No study participants were recruited from rehabilitation hospitals that have SCI units in Ontario, BC and Saskatchewan, due to COVID-19 restrictions. Feasibility of recruitment was to be assessed by the number and proportion of consenting individuals per month benchmarked against whether 66 participants could enter the trial in an 8-month recruitment period. This was determined to not be a useful measure given the impact of COVID-19 restrictions, which extended the recruitment period to 12 months.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eRespondent Characteristics\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eBaseline demographic, social, and injury characteristics of participants in intervention and waitlist control groups are presented in Table 2. The mean age of the participants in the intervention group was 49.6 years compared to 48.7 years in the control group. The mean time since injury was 25.6 years among participants in the intervention and 20.2 years in the control group. This was a highly educated group, with only 7 of 63 (11%) participants reporting having high school or less education. There were no significant differences with respect to the amount of missing data across variables at any time point. The only baseline difference of note is that there were more participants with cervical injuries in the control group (19 versus 8 intervention) and more participants with thoracic/lumbar injuries in the intervention group (18 versus 8 control).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eRetention\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Of 30 intervention and 33 control participants who received the allocated intervention, 25 (83%) intervention and 29 (88%) control participants provided data at 6 months, and 27 (90%) intervention and 29 (88%) control participants provided data at 12 months. Remuneration (up to $300 CDN) was initially to be paid at the end of the study, but to incentivize participants to complete assessments we provided remuneration ($100 CDN per completed assessment) in the form of a gift card of their choice (grocery, drug store, department store) after they completed each of the assessments at baseline, 6 and 12 months. The overall retention rate at 12 months was 89% (56/63).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSCI\u0026amp;U Implementation\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWe had hoped to match coaches and participants with similar characteristics. To facilitate matching, we created profiles of the coaches for the platform. Matching with respect to the level of impairment was not possible, as all but one of the coaches were wheelchair users.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe had planned to collect follow-up data at 2 months based on previous research on behaviour change for physical activity in an SCI population, which suggested that the first two months of coaching may be a critical period for eliciting behaviour change (36, 50). All online sessions for SCI\u0026amp;U were expected to be completed within 6 months, with the majority being completed after 2 months. However, intervals between sessions were allowed to vary to promote flexibility. Intervals were decided collaboratively between coach and client and ranged between one and two weeks. Thus many participants were still actively involved in the intervention and did not have the majority of their sessions completed at the 2-month data collection point, so part way through the trial we decided to forego collection of 2-month data.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe mean \u0026plusmn; SD number of coaching sessions was 12.6 \u0026plusmn; 2.3 (median 13), and individual sessions lasted 55 \u0026plusmn; 26 (median 57) minutes. Only one participant completed less than 8 coaching sessions. The most common topics discussed, in order of frequency, were aging with an SCI, pain, exercise, mental health, diet, bladder, and skin. As the pandemic progressed, COVID-19 also became a topic.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eUsability and Quality of the Program\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTwenty-five of 30 (83%) participants in the intervention group completed the MARS and the heiQ course quality questions after their last coaching session. Mean scores \u0026plusmn; standard deviation on the MARS were 3.9 \u0026plusmn; 0.8 for software functionality, 3.2 \u0026plusmn; 0.7 for quality, 4.2 \u0026plusmn; 0.7 for behaviour change, and 4.2 \u0026plusmn; 0.7 for information. Users assigned the service 4 out of 5 stars for overall quality, on average, yet indicated program fees would be a potential barrier to program adoption. Mean scores for the course quality questions of the heiQ, measured on a 4-point Likert scale, ranged from 3.5 to 4.0.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePrimary short-term outcome: Skill and Technique Acquisition subscale of the Health Education Impact Questionnaire\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 3 provides the raw scores (i.e., T-scores) on primary and secondary outcomes by intervention group. Table 4 provides estimates of effect sizes of the intervention on the heiQ subscale scores at 6 and 12 months, adjusted for the subscale scores at baseline. After adjusting for the baseline subscale score, the difference in the 6-month STA subscale score between persons in the treatment group compared to those in the control group was 0.56 (95% CI: -0.41, 1.52). The difference in 12-month score between persons in the treatment group compared to those in the control group was 0.72 (95% CI: -0.28, 1.72). An effect size of 0.5 has been shown to be the benchmark for change in STA (39).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePrimary long-term outcome measure: cumulative days rehospitalised in the 12 months following baseline assessment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAt 6 and 12 months, data points were missing for 7 and 5 participants in the intervention group, respectively, compared to 13 and 12 participants in the waitlist control group, respectively (Table 5). Most participants at 12 months (17 intervention and 20 controls) had zero nights in hospital. Among the 9 persons for whom the information was available and who had spent at least one night in hospital, the median [95% CI] number of nights in hospital in the past 12 months was 11 [3-19] nights in the intervention group (n=5) and 24 [5-95] nights in the control group (n=4).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThere was no difference in rehospitalisation rates between groups at either 6- or 12-months post-intervention. Because most participants did not experience rehospitalisation, a secondary analysis comparing the proportion of persons in each group who experienced any rehospitalisations also found no difference in rates of rehospitalisation at 6 months (13% intervention versus 10% control) and at 12 months (20% intervention versus 19% control).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSecondary Outcome Measures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOf the other four heiQ subscales, Self-Monitoring and Insight had a significant treatment effect at 12 months (p=0.01; see Table 4). This construct captures the individuals\u0026rsquo; ability to monitor their condition and their physical and/or emotional responses that lead to insight and appropriate actions to self-manage (e.g., \u0026ldquo;I carefully watch my health and do what is necessary to keep as healthy as possible\u0026rdquo;). The difference in the 12-month score between persons in the intervention group compared to those in the control group was 1.51 (95% CI: 0.39, 2.69). At 12 months follow-up, a greater proportion of the intervention group strongly agreed with the statements in the Self-Monitoring and Insight construct compared with the control group (Table 6).\u003c/p\u003e\n\u003cp\u003eThe other heiQ subscale with a large effect was Emotional Distress, with an effect estimate of -1.40 (95% CI -3.04,0.23) at 12 months (Table 4), although this difference was not significantly different (p=0.09). Minimal changes were observed for the subscale Positive and Active engagement in Life and for Health Services Navigation at 12 months.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe other secondary outcomes demonstrated no notable differences between the control and intervention groups (Table 4).\u0026nbsp;\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis study examined the feasibility of conducting a definitive RCT to determine the effectiveness of an online self-management program using peer health coaches to improve self-management skills and reduce rehospitalisations for persons living with SCI. We found that, overall, the trial methodology and procedures were feasible, and the intervention was acceptable to participants. Several challenges identified in this feasibility trial are being changed to improve the delivery of the intervention and trial methodology in the definitive trial (Table 7).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe majority of this pilot trial was conducted during the COVID-19 pandemic when indoor mask use was mandatory and restrictions were in place for nonessential travel, social gatherings, and businesses. The COVID-19 pandemic forced Canadians with SCI to adapt to a new level of physically distant health care, led to reduced access to numerous health care services, and increased self-isolation to prevent the spread of infection (51, 52). For the current pilot trial, the pandemic had major implications for recruitment sources, characteristics of study participants, and outcomes. Telehealth interventions were swiftly adopted during the pandemic due to the need for patients with SCI to safely access care (51). This might explain the acceptability of our program, as there were no concerns or health risks involved with traveling to appointments with an online program. In addition, participation in the coaching sessions was high, with a mean of 12.6 sessions out of a possible maximum of 14 sessions; perhaps the program was a way for patients to address social isolation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn the current pilot trial study, the five most common topics discussed were aging with an SCI, pain, exercise, mental health, and diet. In a recent needs assessment of 38 individuals with SCI who were primarily White (89.5%), male (63.2%), an average age of 47.2 years, and the majority more than 10 years out from injury, participants expressed that a self-management program would help them feel less alone and that their \u0026lsquo;cries of help\u0026rdquo; would be heard (53). In that study, with respect to topics, participants indicated that psychological health and coping was most important followed by pain, spasticity, and aging with SCI. These topic priorities are similar to our results.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOne of the outcome measures that had the most change in the current pilot trial was the heiQ subscale Emotional Distress. To this end, fear and anxiety of contracting COVID-19 and perceived vulnerability may be further contributors to worsening mental health. In\u0026nbsp;the Mesa et al (51) post-COVID study of individuals with SCI living in the community in British Columbia, Canada, more than one-third of survey respondents reported probable depression. This rate of probable depression was greater than the rates found in the SCI population in other recent pre-pandemic studies (54).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDue to pandemic restrictions, we were not able to recruit from rehabilitation hospitals and had to rely on community sources. This may explain why the majority of our participants were, on average, 25 years post-injury. At baseline, on the STA scale, which aims to capture the knowledge-based skills and techniques that persons acquire (or re-learn) to help them cope with symptoms and health problems (40), over 80% of intervention and control subjects agreed or strongly agreed that they had the skills to self-manage. For example, they reportedly had skills to help cope when symptoms arose, a very good idea of how to manage health problems, effective ways to prevent symptoms, and a good understanding of equipment needed to make life easier. This may explain why there was no difference in self-management skills between the intervention and control groups at 12 months, as this group would have already figured out how to manage their SCI given how long they were living with the injury. We did, however, note differences in self-monitoring and insight, which captures individuals\u0026rsquo; ability to monitor their condition, and the physical and/or emotional responses that lead to insight and appropriate actions to self-manage. When we examined the responses to the individual items at 12-month follow-up, a greater proportion of the intervention group strongly agreed to the statements in the self-monitoring and insight construct (Table 7). This finding suggests that self-management support to promote self-monitoring and insight may be more appropriate than skill development for a group who has been managing their injury for a long time.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor the definitive trial it may be important to recruit individuals who are newly injured, as they often describe feeling unprepared for returning home, physically and psychologically (55, 56). After returning home, people often experience isolation, depression and low levels of physical and psychosocial functioning, coupled with a perception of system abandonment, claiming the transition to be like \u0026ldquo;falling off a cliff\u0026rdquo; (11). Major depressive disorder occurs most commonly one to five years post-SCI, and approximately one-third of individuals have mental health problems that perpetuate into individuals\u0026rsquo; lives even after five years following discharge (57, 58). The limited time for provision of health education and skill acquisition in the inpatient setting means that individuals with SCI are entering the community with deficits in knowledge and fewer self-management skills to enable successful community re-integration (59). Therefore, we need to develop recruitment methods to reach more recently injured individuals for the definitive trial, as they are also likely to benefit from a self-management program.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eLimitations\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParticipants were not blinded to their group allocation, and this could have resulted in a bias in the reporting of the numerous self-report measures. The effects observed may be influenced by the study being conducted during the COVID-19 pandemic. Also, the generalizability of the findings is limited to individuals with SCI who were many years post-injury. Thus, the treatment effect observed for self-monitoring and insight could be spurious and will need to be confirmed. Additionally, participants were almost all White and well educated, so we are unable to comment on the applicability of the intervention and/or trial procedures for individuals with different ethnic and educational backgrounds. Finally, the hospitalisation data were difficult to interpret and difficult for participants to recall; results may have been affected by various COVID-19 policies.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConclusions\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe findings of this pilot randomised trial suggest that it was possible to achieve recruitment and retention targets for the SCI\u0026amp;U online peer health coaching program even during the COVID-19 pandemic. However, it was difficult to recruit individuals with recent SCI, such as within 5 years of injury. There were too many outcome measures to complete. Overall, the SCI\u0026amp;U platform was assessed as having good usability and the program being of high quality. This pilot study demonstrated that SCI\u0026amp;U had a medium effect on skill and technique acquisition, had a large effect on reducing emotional distress, and significantly improved self-monitoring and insight among a group of participants who were on average over 20 years post-injury. Given that most of the trial was conducted during the COVID-19 pandemic, these results need to be confirmed in a definitive trial, and further research is needed to determine the impact of the SCI\u0026amp;U peer health coaching program on those living with recently acquired SCI.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eANCOVA\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Analysis of covariance\u003c/p\u003e\n\u003cp\u003eBAP\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Brief Action Planning\u003c/p\u003e\n\u003cp\u003eBC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;British Columbia\u003c/p\u003e\n\u003cp\u003eCDSMP\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Chronic Disease Self-Management Program\u003c/p\u003e\n\u003cp\u003eCI\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Confidence Interval\u003c/p\u003e\n\u003cp\u003eCONSORT\u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Consolidated Standards of Reporting Trials\u003c/p\u003e\n\u003cp\u003eGIM\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Get In Motion\u003c/p\u003e\n\u003cp\u003eheiQ\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Health Education Impact Questionnaire\u003c/p\u003e\n\u003cp\u003eHRQOL\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Health-related quality of life\u003c/p\u003e\n\u003cp\u003eMARS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Mobile App Rating Scale\u003c/p\u003e\n\u003cp\u003eMCMC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;My Care My Call\u003c/p\u003e\n\u003cp\u003ePHQ\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Personal Health Questionnaire\u003c/p\u003e\n\u003cp\u003eRCT\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Randomised controlled trial\u003c/p\u003e\n\u003cp\u003eSCI \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Spinal Cord Injury\u003c/p\u003e\n\u003cp\u003eSCI QOL\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Spinal Cord Injury \u0026ndash; Quality of Life\u003c/p\u003e\n\u003cp\u003eSCI\u0026amp;U\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Spinal Cord Injury and You\u003c/p\u003e\n\u003cp\u003eSTA \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Skill and Technique Acquisition\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eResearch Ethics Board approval was obtained at the University of Toronto (Protocol Number 34808) and the University of Saskatchewan (Protocol Number 1228). The trial was registered on ClinicalTrials.gov (NCT04474171).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analysed during the current study are not publicly available due to small numbers and possible identification of individuals, but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFunding for this study was provided by the Canadian Institutes of Health Research (PJT 159728). The funder had no role in the conceptualization, design, data collection, analysis, decision to publish, or preparation of the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSBJ was the project lead and was responsible for the conceptual development, design, analysis, interpretation of results, and writing of all drafts\u003c/p\u003e\n\u003cp\u003eSJA: conception and design of the work,\u0026nbsp;acquisition, analysis,\u0026nbsp;interpretation of data, drafted the work\u003c/p\u003e\n\u003cp\u003eBCC: study design, participant recruitment, acquisition of data\u003c/p\u003e\n\u003cp\u003eSJTG: study design, interpretation of data\u003c/p\u003e\n\u003cp\u003eAGL: study design, participant recruitment, acquisition of data\u003c/p\u003e\n\u003cp\u003eCBMcB: study design, participant recruitment, data collection\u003c/p\u003e\n\u003cp\u003eRM: study design, analysis\u003c/p\u003e\n\u003cp\u003eWBM: study design, participant recruitment, interpretation of data\u003c/p\u003e\n\u003cp\u003eSM: study design, interpretation of data\u003c/p\u003e\n\u003cp\u003eNMS: conception and design of the work, interpretation of data\u003c/p\u003e\n\u003cp\u003eJDS: conception of the work, participant recruitment, data collection, interpretation of data\u003c/p\u003e\n\u003cp\u003eSNS: study design, interpretation of data\u003c/p\u003e\n\u003cp\u003eTT: participant recruitment, data collection\u003c/p\u003e\n\u003cp\u003eJRT: conception of the work, study design, interpretation of data\u003c/p\u003e\n\u003cp\u003eAll authors critically revised the draft and have and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank Dagmar Gross for assistance with copy-editing and preparation of this manuscript. NMS holds the Toronto Rehabilitation Institute Chair at the University of Toronto. BCC holds the Toronto Rehabilitation Institute / University of Toronto Chair in Spinal Cord Injury Rehabilitation. SJTG is supported by the University of Toronto Centre for the Study of Pain Scientist Salary Award. SNS is supported by a Canada Research Chair in Participation, Well-Being, and Physical Disability (Tier 2).\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMcColl MA, Shortt S, Godwin M, Smith K, Rowe K, O'Brien P, et al. Models for integrating rehabilitation and primary care: a scoping study. Arch Phys Med Rehab. 2009;90(9):1523\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCardenas DD, Hoffman JM, Kirshblum S, McKinley W. Etiology and incidence of rehospitalization after traumatic spinal cord injury: a multicenter analysis. Arch Phys Med Rehab. 2004;85(11):1757\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJensen MP, Truitt AR, Schomer KG, Yorkston KM, Baylor C, Molton IR. Frequency and age effects of secondary health conditions in individuals with spinal cord injury: a scoping review. Spinal Cord. 2013;51(12):882\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJaglal SB, Munce SE, Guilcher SJ, Couris CM, Fung K, Craven BC, et al. Health system factors associated with rehospitalizations after traumatic spinal cord injury: a population-based study. Spinal Cord. 2009;47(8):604\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWhiteneck G, Gassaway J, Dijkers M, Backus D, Charlifue S, Chen D, et al. The SCIRehab project: treatment time spent in SCI rehabilitation. Inpatient treatment time across disciplines in spinal cord injury rehabilitation. J Spinal Cord Med. 2011;34(2):133\u0026ndash;48.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen D, Apple DF Jr., Hudson LM, Bode R. Medical complications during acute rehabilitation following spinal cord injury\u0026ndash;current experience of the Model Systems. Arch Phys Med Rehab. 1999;80(11):1397\u0026ndash;401.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcColl MA, Aiken A, McColl A, Sakakibara B, Smith K. Primary care of people with spinal cord injury: scoping review. Can Fam Physician. 2012;58(11):1207\u0026ndash;16.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGuilcher SJ, Casciaro T, Lemieux-Charles L, Craven C, McColl MA, Jaglal SB. Social networks and secondary health conditions: the critical secondary team for individuals with spinal cord injury. J Spinal Cord Med. 2012;35(5):330\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIezzoni LI, Davis RB, Soukup J, O'Day B. Quality dimensions that most concern people with physical and sensory disabilities. Arch Intern Med. 2003;163(17):2085\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVeltman A, Stewart DE, Tardif GS, Branigan M. Perceptions of primary healthcare services among people with physical disabilities - part 1: access issues. MedGenMed. 2001;3(2):18.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGuilcher SJ, Craven BC, Calzavara A, McColl MA, Jaglal SB. Is the emergency department an appropriate substitute for primary care for persons with traumatic spinal cord injury? Spinal Cord. 2013;51(3):202\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMunce SE, Guilcher SJ, Couris CM, Fung K, Craven BC, Verrier M, et al. Physician utilization among adults with traumatic spinal cord injury in Ontario: a population-based study. Spinal Cord. 2009;47(6):470\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLorig KR, Sobel DS, Stewart AL, Brown BW Jr., Bandura A, Ritter P, et al. Evidence suggesting that a chronic disease self-management program can improve health status while reducing hospitalization: a randomized trial. Med Care. 1999;37(1):5\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKennedy A, Reeves D, Bower P, Lee V, Middleton E, Richardson G, et al. The effectiveness and cost effectiveness of a national lay-led self care support programme for patients with long-term conditions: a pragmatic randomised controlled trial. J Epidemiol Community Health. 2007;61(3):254\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFoster G, Taylor SJ, Eldridge SE, Ramsay J, Griffiths CJ. Self-management education programmes by lay leaders for people with chronic conditions. 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BMC Neurol. 2016;16:11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMunce SEP, Allin S, Wolfe DL, Anzai K, Linassi G, Noonan VK, et al. Using the theoretical domains framework to guide the development of a self-management program for individuals with spinal cord injury: Results from a national stakeholder advisory group. J Spinal Cord Med. 2017;40(6):687\u0026ndash;95.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGassaway J, Jones ML, Sweatman WM, Hong M, Anziano P, DeVault K. Effects of Peer Mentoring on Self-Efficacy and Hospital Readmission After Inpatient Rehabilitation of Individuals With Spinal Cord Injury: A Randomized Controlled Trial. Arch Phys Med Rehab. 2017;98(8):1526\u0026ndash;e342.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJones ML, Gassaway J, Sweatman WM. Peer mentoring reduces unplanned readmissions and improves self-efficacy following inpatient rehabilitation for individuals with spinal cord injury. 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Br J Gen Pract. 2005;55(513):305\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGutnick D, Reims K, Davis C, Gainforth HL, Jay M, Cole S. Brief action planning to facilitate behavior change and support patient self-management. J Clin Outcomes Mgmt. 2014;21(1):17\u0026ndash;29.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTomasone JR, Arbour-Nicitopoulos KP, Latimer-Cheung AE, Martin Ginis KA. The relationship between the implementation and effectiveness of a nationwide physical activity telephone counseling service for adults with spinal cord injury. Disabil Rehabilitation. 2018;40(5):527\u0026ndash;37.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStoyanov SR, Hides L, Kavanagh DJ, Zelenko O, Tjondronegoro D, Mani M. Mobile app rating scale: a new tool for assessing the quality of health mobile apps. JMIR mHealth uHealth. 2015;3(1):e27.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOsborne RH, Elsworth GR, Whitfield K. The Health Education Impact Questionnaire (heiQ): an outcomes and evaluation measure for patient education and self-management interventions for people with chronic conditions. Patient Educ Couns. 2007;66(2):192\u0026ndash;201.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eElsworth GR, Osborne RH. Percentile ranks and benchmark estimates of change for the Health Education Impact Questionnaire: Normative data from an Australian sample. SAGE Open Med. 2017;5:2050312117695716.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eElsworth GR, Nolte S, Osborne RH. Factor structure and measurement invariance of the Health Education Impact Questionnaire: Does the subjectivity of the response perspective threaten the contextual validity of inferences? SAGE Open Med. 2015;3:2050312115585041.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKalpakjian CZ, Scelza WM, Forchheimer MB, Toussaint LL. Preliminary reliability and validity of a Spinal Cord Injury Secondary Conditions Scale. J Spinal Cord Med. 2007;30(2):131\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmtmann D, Bamer AM, Cook KF, Askew RL, Noonan VK, Brockway JA. University of Washington self-efficacy scale: a new self-efficacy scale for people with disabilities. Arch Phys Med Rehab. 2012;93(10):1757\u0026ndash;65.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCharlifue S, Post MW, Biering-S\u0026oslash;rensen F, Catz A, Dijkers M, Geyh S, et al. Spinal Cord. 2012;50(9):672\u0026ndash;5. International Spinal Cord Injury Quality of Life Basic Data Set.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVictorson D, Tulsky DS, Kisala PA, Kalpakjian CZ, Weiland B, Choi SW. Measuring resilience after spinal cord injury: Development, validation and psychometric characteristics of the SCI-QOL Resilience item bank and short form. J Spinal Cord Med. 2015;38(3):366\u0026ndash;76.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLorig K, Stewart A, Ritter P, Gonzalez V, Laurent D, Lynch J. Outcome measures for health education and other health care interventions. Thousand Oaks, California: Sage Publications; 1996 1996. 99 p.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKroenke K, Strine TW, Spitzer RL, Williams JB, Berry JT, Mokdad AH. The PHQ-8 as a measure of current depression in the general population. J Affect Disorders. 2009;114(1\u0026ndash;3):163\u0026ndash;73.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChung SY, Nahm ES. Testing reliability and validity of the eHealth Literacy Scale (eHEALS) for older adults recruited online. Comput Inf Nurs. 2015;33(4):150\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePiantadosi S, Clinical Trials. A Methodologic Perspective. 2nd Edition ed. New York: John Wiley \u0026amp; Sons, Inc.; 2005.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHertzog MA. Considerations in determining sample size for pilot studies. Res Nurs Health. 2008;31(2):180\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArbour-Nicitopoulos KP, Tomasone JR, Latimer-Cheung AE, Martin Ginis KA. Get in motion: an evaluation of the reach and effectiveness of a physical activity telephone counseling service for Canadians living with spinal cord injury. PM R. 2014;6(12):1088\u0026ndash;96.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMesa A, Grasdal M, Leong S, Dean NA, Marwaha A, Lee A, et al. Effect of the COVID-19 pandemic on individuals with spinal cord injury: Mental health and use of telehealth. PM R. 2022;14(12):1439\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSenthinathan A, Tadrous M, Hussain S, Craven BC, Jaglal SB, Moineddin R, et al. Examining the impact of COVID-19 on health care utilization among persons with chronic spinal cord injury/dysfunction: a population study. Spinal Cord. 2023;61(10):562\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKraus B, Wolf TJ. Needs Assessment of Self-Management for Individuals With Chronic Spinal Cord Injury/Disease. OTJR (Thorofare N J). 2024;44(1):57\u0026ndash;66.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWilliams R, Murray A. Prevalence of depression after spinal cord injury: a meta-analysis. Arch Phys Med Rehab. 2015;96(1):133\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDivanoglou A, Georgiou M. Perceived effectiveness and mechanisms of community peer-based programmes for Spinal Cord Injuries-a systematic review of qualitative findings. Spinal Cord. 2017;55(3):225\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBorg DN, Foster MM, Legg M, Jones R, Kendall E, Fleming J, et al. The Effect of Health Service Use, Unmet Need, and Service Obstacles on Quality of Life and Psychological Well-Being in the First Year After Discharge From Spinal Cord Injury Rehabilitation. Arch Phys Med Rehab. 2020;101(7):1162\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArango-Lasprilla JC, Ketchum JM, Starkweather A, Nicholls E, Wilk AR. Factors predicting depression among persons with spinal cord injury 1 to 5 years post injury. NeuroRehabilitation. 2011;29(1):9\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003evan Leeuwen CM, Hoekstra T, van Koppenhagen CF, de Groot S, Post MW. Trajectories and predictors of the course of mental health after spinal cord injury. Arch Phys Med Rehab. 2012;93(12):2170\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKrysa JA, Gregorio MP, Pohar Manhas K, MacIsaac R, Papathanassoglou E, Ho CH. Empowerment, Communication, and Navigating Care: The Experience of Persons With Spinal Cord Injury From Acute Hospitalization to Inpatient Rehabilitation. Front Rehabil Sci. 2022;3:904716.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrooke J. SUS: A quick and dirty usability scale. Usability Eval Ind. 1995;189.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cdiv id=\"Fig2\" class=\"Figure\"\u003e\u003cbr\u003e\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eList of self-management health coaching topics\u003c/div\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eAging\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eAutonomic Dysreflexia\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eBladder Management\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eBone Health\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eBowel Management\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eBuilding Your Healthcare Team\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eCannabis\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eCommunication with Health Care Professionals\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eCOVID-19: What is it?\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eCOVID-19: Stress and Resilience\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eCOVID-19: Respiratory Care\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eDiet and Nutrition\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eEvaluating Health Information\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eFatigue\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eGoal Setting\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eIncomplete SCI\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eLeisure and Recreation\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eMobility Devices\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003ePain Management\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eParenting and Fertility\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eParenting Older Children\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003ePhysical Activity\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eProblem Solving\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eRelationships\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eSkin Management\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eSelf-Advocacy\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eSexuality\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eShoulder Health\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eSpasticity\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eStress, Anxiety, and Depression\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eWomen\u0026apos;s Health\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eBaseline and injury characteristics of participants, reported as n and percentage, unless otherwise indicated.\u003c/div\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eCharacteristic\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eIntervention\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003e(N\u0026thinsp;=\u0026thinsp;30)\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eControl\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003e(N\u0026thinsp;=\u0026thinsp;33)\u003c/div\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eAge (years)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eMean (SD)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e49.6 (11.1)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e48.7 (14.1)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eMedian (Minimum, Maximum)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e49 (21, 76)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e50 (29, 72)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eMissing\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e2\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e7\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eTime since injury (years)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eMean (SD)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e25.6 (13.3)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e20.2 (13.5)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eMedian (Minimum, Maximum)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e24 (3, 58)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e16 (1, 55)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eMissing\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e4\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e4\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eGender\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eMale\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e17 (57)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e13 (43)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eFemale\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e13 (43)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e17 (57)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eTransgender/Gender neutral\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eMissing\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e3\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003ePrimary Language\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eEnglish\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e27 (96)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e26 (93)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eFrench\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1 (4)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0 (0)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eOther\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0 (0)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e2 (7)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eMissing\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e2\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e5\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eProvince\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eBritish Columbia\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e16 (53)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e23 (70)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eOntario\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e7 (23)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e4 (12)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eSaskatchewan\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e5 (17)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e4 (12)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eOther\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e2 (7)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e2 (6)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eMissing\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eEmployment\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eEmployed full-time\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e3 (12)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e7 (24)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eEmployed part-time\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e3 (12)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e5 (17)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eUnemployed\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e19 (76)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e17 (59)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eMissing\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e5\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e4\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eHighest level of Education\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eHigh school or less\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e3 (12)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e4 (15)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eCollege/Bachelor\u0026rsquo;s degree\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e16 (64)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e19 (70)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003ePostgraduate\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e6 (24)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e4 (15)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eMissing\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e5\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e6\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eMarital Status\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eSingle/Never married\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e9 (35)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e11 (39)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eMarried/Partnered\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e11 (42)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e10 (36)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eSeparated/Divorced/Widowed\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e6 (23)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e7 (5)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eMissing\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e4\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e5\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eLiving arrangement\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eLiving alone\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e7 (26)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e11 (38)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eLiving with someone\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e17 (63)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e15 (52)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eOther\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e3 (11)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e2(7)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eMissing\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e3\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e4\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eeHealth Literacy\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eMean (SD)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e30.6 (5.1)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e29.9 (5.1)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eMedian (Minimum, Maximum)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e30.5 (22.0, 40.0)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e31.0 (20.0, 40.0)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eMissing\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e2\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e5\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eInjury Characteristics\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eParaplegic\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e18 (69)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e13 (50)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eQuadriplegic\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e8 (31)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e13 (50)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eMissing\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e4\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e7\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eTraumatic\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e21 (78)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e21 (81)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eNon-traumatic\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e5 (19)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e4 (15)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eOther\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1 (4)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1 (4)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eMissing\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e3\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e7\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eComplete\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e12 (44)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e8 (31)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eIncomplete\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e15 (56)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e18 (69)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eMissing\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e3\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e7\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eCervical\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e8 (29)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e19 (66)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eThoracic\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e12 (43)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e7 (24)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eLumbar/Sacral\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e6 (22)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1 (3)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eOther\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e2 (7)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e2(7)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eMissing\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e2\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e4\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eMobility\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eManual wheelchair\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e16 (59)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e12 (41)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003ePowered wheelchair\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e7 (26)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e11 (38)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eWalker/Cane/Other\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e4 (14)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e6 (21)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eMissing\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e3\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e4\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003eSD\u0026thinsp;=\u0026thinsp;standard deviation\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eRaw scores or T-scores for outcome variables for intervention and control groups at baseline, 6 months, and 12 months follow-up, reported as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation.\u003c/div\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth colspan=\"2\" align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eBaseline\u003c/div\u003e\n \u003c/th\u003e\n \u003cth colspan=\"2\" align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e6 Months\u003c/div\u003e\n \u003c/th\u003e\n \u003cth colspan=\"2\" align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e12 Months\u003c/div\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eIntervention (N\u0026thinsp;=\u0026thinsp;28)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eControl\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003e(N\u0026thinsp;=\u0026thinsp;29)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eIntervention (N\u0026thinsp;=\u0026thinsp;25)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eControl\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003e(N\u0026thinsp;=\u0026thinsp;27)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eIntervention (N\u0026thinsp;=\u0026thinsp;27)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eControl\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003e(N\u0026thinsp;=\u0026thinsp;29)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Italic\"\u003eheiQ Subscales\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eSkill and Technique Acquisition\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e2.9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e3.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e3.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e3.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e3.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e3.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eSelf-monitoring and Insight\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e3.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e3.3\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e3.3\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e3.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e3.4\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e3.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eEmotional Distress\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e2.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e2.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e2.4\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e2.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e2.4\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e2.3\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eHealth Services Navigation\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e3.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e3.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e3.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e3.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e3.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e3.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003ePositive and Engagement in Life\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e3.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e3.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e3.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e3.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e3.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e3.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Italic\"\u003eOther Outcome Variables\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eSecondary Conditions Scale\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e19.5\u0026thinsp;\u0026plusmn;\u0026thinsp;9.6\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e14.6\u0026thinsp;\u0026plusmn;\u0026thinsp;7.8\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e17.2\u0026thinsp;\u0026plusmn;\u0026thinsp;10.3\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e17.6\u0026thinsp;\u0026plusmn;\u0026thinsp;10.2\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e14.1\u0026thinsp;\u0026plusmn;\u0026thinsp;6.5\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e15.0\u0026thinsp;\u0026plusmn;\u0026thinsp;7.8\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eUniversity of Washington Self-Efficacy Scale T-score\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e44.2\u0026thinsp;\u0026plusmn;\u0026thinsp;11.5\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e46.7\u0026thinsp;\u0026plusmn;\u0026thinsp;9.1\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e47.7\u0026thinsp;\u0026plusmn;\u0026thinsp;10.8\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e46.8\u0026thinsp;\u0026plusmn;\u0026thinsp;10.1\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e46.5\u0026thinsp;\u0026plusmn;\u0026thinsp;12.2\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e47.3\u0026thinsp;\u0026plusmn;\u0026thinsp;9.4\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eHealth Related Quality of Life\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e19.2\u0026thinsp;\u0026plusmn;\u0026thinsp;8.6\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e20.2\u0026thinsp;\u0026plusmn;\u0026thinsp;7.7\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e21.6\u0026thinsp;\u0026plusmn;\u0026thinsp;8.6\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e21.0\u0026thinsp;\u0026plusmn;\u0026thinsp;7.9\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e21.4\u0026thinsp;\u0026plusmn;\u0026thinsp;7.7\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e21.4\u0026thinsp;\u0026plusmn;\u0026thinsp;6.5\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eSCI QoL Resilience\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e47.4\u0026thinsp;\u0026plusmn;\u0026thinsp;7.7\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e50.3\u0026thinsp;\u0026plusmn;\u0026thinsp;8.2\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e49.0\u0026thinsp;\u0026plusmn;\u0026thinsp;8.3\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e49.6\u0026thinsp;\u0026plusmn;\u0026thinsp;7.1\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e49.7\u0026thinsp;\u0026plusmn;\u0026thinsp;10.9\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e49.8\u0026thinsp;\u0026plusmn;\u0026thinsp;7.8\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eSocial/Role Limitations\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e8.0\u0026thinsp;\u0026plusmn;\u0026thinsp;5.4\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e6.7\u0026thinsp;\u0026plusmn;\u0026thinsp;5.8\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e6.3\u0026thinsp;\u0026plusmn;\u0026thinsp;5.6\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e6.5\u0026thinsp;\u0026plusmn;\u0026thinsp;5.4\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e6.7\u0026thinsp;\u0026plusmn;\u0026thinsp;4.8\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e6.3\u0026thinsp;\u0026plusmn;\u0026thinsp;5.4\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003ePHQ-8 Patient Depression Questionnaire\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e8.4\u0026thinsp;\u0026plusmn;\u0026thinsp;6.3\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e5.8\u0026thinsp;\u0026plusmn;\u0026thinsp;4.5\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e6.5\u0026thinsp;\u0026plusmn;\u0026thinsp;5.2\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e5.4\u0026thinsp;\u0026plusmn;\u0026thinsp;4.4\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e7.2\u0026thinsp;\u0026plusmn;\u0026thinsp;6.1\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e5.6\u0026thinsp;\u0026plusmn;\u0026thinsp;4.3\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\"\u003eheiQ\u0026thinsp;=\u0026thinsp;Health Education Impact Questionnaire; SCI\u0026thinsp;=\u0026thinsp;spinal cord injury; QoL\u0026thinsp;=\u0026thinsp;Quality of Life; PHQ\u0026thinsp;=\u0026thinsp;Personal Health Questionnaire\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eANCOVA treatment effect estimates at 6 months and 12 months follow-up for outcome variables\u003c/div\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eOutcome Variable\u003c/div\u003e\n \u003c/th\u003e\n \u003cth colspan=\"3\" align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e6 Months Follow-up\u003c/div\u003e\n \u003c/th\u003e\n \u003cth colspan=\"3\" align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e12 Months Follow-up\u003c/div\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eEstimate\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e95% CI\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003ep-value\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eEstimate\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e95% CI\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003ep-value\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Italic\"\u003eheiQ Subscales\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eSkill and Technique Acquisition\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.56\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e-0.4, 1.5\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.25\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.72\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e-0.3, 1.7\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.15\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eSelf-Monitoring and Insight\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.94\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e-0.2, 2.1\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.11\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1.51\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.3, 2.7\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.01\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eEmotional Distress\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e-0.45\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e-2.0, 1.1\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.56\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e-1.40\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e-3.0, 0.2\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.09\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eHealth Services Navigation\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.23\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e-1.0, 1.5\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.71\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.43\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e-0.8, 1.6\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.46\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003ePositive and Active Engagement in Life\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e-0.005\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e-0.9, 0.9\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.99\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.15\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e-0.9, 1.2\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.78\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Italic\"\u003eOther Outcome Variables\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eSecondary Conditions Scale\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e-0.40\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e-3.4, 2.7\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.79\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e-1.5\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e-4.3, 1.4\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.31\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eUniversity of Washington Self-Efficacy Scale\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1.85\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e-2.4, 6.1\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.39\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.83\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e-3.5, 5.2\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.71\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eHealth Related Quality of Life\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e-0.78\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e-2.8, 1.3\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.45\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e-0.46\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e-2.5, 1.6\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.66\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eSCI QoL Resilience\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.03\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e-2.0, 2.0\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.98\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.88\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e-1.8, 3.5\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.51\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eSocial/Role Limitations\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e-0.78\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e-2.8, 1.3\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.45\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e-0.46\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e-2.5, 1.6\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.66\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003ePHQ-8 Patient Depression Questionnaire\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e-0.06\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e-2.3, 2.2\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.96\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u0026minus;\u0026thinsp;.20\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e-2.4, 2.0\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.85\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\"\u003eheiQ\u0026thinsp;=\u0026thinsp;Health Education Impact Questionnaire; SCI\u0026thinsp;=\u0026thinsp;spinal cord injury; QoL\u0026thinsp;=\u0026thinsp;Quality of Life; PHQ\u0026thinsp;=\u0026thinsp;Personal Health Questionnaire\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003ctable id=\"Tab5\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eCumulative days rehospitalised 6 and 12 months after baseline assessment\u003c/div\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eCumulative Days Rehospitalised\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eIntervention\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003e(N\u0026thinsp;=\u0026thinsp;30)\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eControl\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003e(N\u0026thinsp;=\u0026thinsp;33)\u003c/div\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e6 months after baseline assessment\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eMean (Standard Deviation)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1.5 (4.3)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e4.3 (19.0)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eMedian (Minimum, Maximum)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0 (0, 15)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0 (0, 85)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eMissing\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e7\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e13\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e12 months after baseline assessment\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eMean (Standard Deviation)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1.9 (5.2)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e6.6 (21.1)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eMedian (Minimum, Maximum)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0 (0, 19)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0 (0, 95)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eMissing\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e5\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e12\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab6\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eNumber and percentage of respondents in intervention and control groups at 12 months follow-up who strongly agree with each of the individual items on the Self-Monitoring and Insight scale.\u003c/div\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eItem on Self-Monitoring and Insight Scale\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eIntervention (N\u0026thinsp;=\u0026thinsp;27)\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eN (%) strongly agree at 12 months follow-up\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eControl (N\u0026thinsp;=\u0026thinsp;29)\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eN (%) strongly agree at 12 months follow-up\u003c/div\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eI have realistic expectations of what I can and cannot do\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e10 (37%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e7 (24%)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eI regularly monitor changes in my health\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e16 (59%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e8 (28%)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eI know what things can trigger my health problems and make them worse\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e16 (59%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e8 (28%)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eWhen I have health problems, I have a clear understanding of what I need to do to control them\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e16 (59%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e7 (24%)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eI have a very good understanding of when and why I am supposed to take my medication\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e14 (52%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e4 (14%)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eI carefully watch my health and do what is necessary to keep as healthy as possible\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e19 (70%)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e16 (55%)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003ctable id=\"Tab7\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 7\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eChanges to the intervention and trial methodology for definitive randomised trial\u003c/div\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eProblem identified during the feasibility trial\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eChange made for the definitive trial\u003c/div\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eCould not recruit from inpatient rehabilitation hospitals due to pandemic restrictions.\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eHave focused recruitment efforts for inpatient rehabilitation hospitals.\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eParticipants who enrolled in study were many years post-injury.\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eIncrease recruitment efforts to identify participants within 1\u0026ndash;5 years of injury.\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eThere were more participants with cervical injuries in the control group and more participants with thoracic/lumbar injuries in the intervention group.\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eConsider block randomisation.\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eSome participants had incomplete injuries and were not wheelchair users, but all but one coach was a wheelchair user.\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eHave a mix of coaches who are ambulatory or wheelchair users.\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eParticipants did not follow the proposed timing for the online coaching sessions \u0026ndash;one-half of coaching sessions were expected to be completed within 2 months.\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eAll online sessions are expected to be completed within 6 months, but intervals between sessions will be allowed to vary in order to promote flexibility. Drop 2-month follow-up data collection.\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eOnline coaching sessions are expected to cover a health-related topic (e.g., bladder, bowel, skin, pain, healthy eating, physical activity or stress, anxiety and depression, etc.) and a self-management skill topic (e.g., action planning, goal setting, problem solving, mood management, navigating the health care system, communicating with health care providers).\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eThe selection of topics and the order in which they are addressed will be determined by the study participant, with input from their peer health coach when requested. To ensure we meet the unique needs of participants, the coach and participant will determine jointly how many sessions to spend on a topic.\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eSometimes had to use telephone for coaching due to a lack of high-speed internet connection among participants.\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eTelephone option for coaching program will be available.\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eToo many outcome measures to complete.\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eLimit outcome measures to only those that showed potential for change\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eMARS scale may be too long for definitive trial.\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eReplace MARS with the 10-item System Usability Scale (60).\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eSome participants reported struggling with the technical skills required to navigate the platform to complete the outcome measures.\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eHave a research assistant help participants with completion of outcome measures to ensure completeness and quality.\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eLargest effect sizes were for two heiQ subscales: Emotional Distress, and Self-Monitoring and Insight.\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eConsider Emotional Distress and Self-Monitoring and Insight as primary outcomes.\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eWanted same distribution of males and females in intervention and control groups.\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eStratify by sex.\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eHospitalisation data skewed.\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eData on hospitalisations will not be collected.\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"pilot-and-feasibility-studies","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pafs","sideBox":"Learn more about [Pilot and Feasibility Studies](http://pilotfeasibilitystudies.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/PAFS/default.aspx","title":"Pilot and Feasibility Studies","twitterHandle":"@MedicalEvidence","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Self-management, spinal cord injury, peer health coaching, pilot trial","lastPublishedDoi":"10.21203/rs.3.rs-5132773/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5132773/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eThe spinal cord injury and you (SCI\u0026amp;U) intervention aims to improve self-management skills for persons living with SCI using a web-based, peer health-coaching model. This study assessed the feasibility of conducting a future definitive trial of SCI\u0026amp;U, specifically the feasibility of recruitment and retention, usability and quality of the program, and estimates of effect sizes for a variety of self-management outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e A two-group, randomised, controlled, pilot trial with prospective recruitment, concealed group allocation, blinded outcome evaluation, and waitlist control was conducted in Canada. We aimed to recruit 60 participants who were 18 years and older living in the community at least six months post-injury, were able to speak and read English, and had a primary care physician. The intervention included online client-coach videoconferencing sessions, goal setting, action planning, and a sortable resource library. Data were collected at baseline, 2, 6 and 12 months post-randomisation. SCI\u0026amp;U was offered to the waitlist group at 12 months. Primary short-term self-management outcome was Skill and Technique Acquisition (STA), a subscale of the Health Education Impact Questionnaire. Primary long-term outcome was cumulative days rehospitalised.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eOf 65 eligible individuals, 34 were randomised to waitlist control and 31 to intervention. Mean time since injury was 25.6 years for intervention and 20.2 years for control. Outcome data were gathered for 86% of participants at 6 months and 89% at 12 months. The usability and quality of the program were highly rated. The difference in STA between intervention and control was 0.56 (95% CI -0.41, 1.52) at 6 months and 0.72 (95% CI -0.28, 1.72) at 12 months. Other subscales also had large effect sizes: Self-monitoring and insight 1.51 (95% CI 0.39, 2.69); and Emotional distress -1.40 (95% CI -3.04, 0.23). In the 12 months following recruitment, 5 intervention and 4 control participants spent median 11 (3-19) and 24 (5-95) nights in hospital, respectively.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003eThe trial methodology and procedures were feasible; the SCI\u0026amp;U intervention was acceptable to participants. The program positively impacted an individual’s ability to self-manage. Further research is needed to confirm these findings and evaluate the program on those with recently acquired SCI.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration: \u003c/strong\u003eClinicalTrials.gov, NCT04474171, retrospectively registered 07/13/2020; https://clinicaltrials.gov/study/NCT04474171#study-record-dates\u003c/p\u003e","manuscriptTitle":"An online self-management program for spinal cord injury: a pilot randomised controlled trial of the SCI\u0026amp;U peer health coaching intervention","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-18 18:08:11","doi":"10.21203/rs.3.rs-5132773/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2025-06-23T12:46:58+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2025-02-11T04:20:03+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-11-18T18:08:20+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-10-27T22:24:20+00:00","index":"","fulltext":""},{"type":"submitted","content":"Pilot and Feasibility Studies","date":"2024-09-22T10:01:04+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"pilot-and-feasibility-studies","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pafs","sideBox":"Learn more about [Pilot and Feasibility Studies](http://pilotfeasibilitystudies.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/PAFS/default.aspx","title":"Pilot and Feasibility Studies","twitterHandle":"@MedicalEvidence","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d63dcd10-4294-480f-ba65-5708f97d2447","owner":[],"postedDate":"December 18th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-02-02T16:14:47+00:00","versionOfRecord":{"articleIdentity":"rs-5132773","link":"https://doi.org/10.1186/s40814-026-01769-y","journal":{"identity":"pilot-and-feasibility-studies","isVorOnly":false,"title":"Pilot and Feasibility Studies"},"publishedOn":"2026-01-28 15:58:00","publishedOnDateReadable":"January 28th, 2026"},"versionCreatedAt":"2024-12-18 18:08:11","video":"","vorDoi":"10.1186/s40814-026-01769-y","vorDoiUrl":"https://doi.org/10.1186/s40814-026-01769-y","workflowStages":[]},"version":"v1","identity":"rs-5132773","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5132773","identity":"rs-5132773","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}