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. Author manuscript; available in PMC: 2022 Aug 5.
Published in final edited form as: Rehabil Psychol. 2022 May 5;67(3):337–343. doi: 10.1037/rep0000430

Pain, Mental Health, Life Satisfaction, and Understanding From Others in Veterans With Spinal Cord Injury

Jack D K Watson 1,2, Scott D McDonald 1,2,3, Richard S Henry 1, Mickeal Pugh Jr 1, Duygu Kuzu 1,4, Paul B Perrin 1,2,3
PMCID: PMC9353782  NIHMSID: NIHMS1809929  PMID: 35511570

Abstract

Purpose/Objective:

This study evaluated the relationships among pain, mental health symptom severity, life satisfaction, and understanding from others in veterans with spinal cord injury (SCI).

Research Method/Design:

A sample of 221 individuals with SCI were interviewed by a psychologist during their annual evaluation in a Veterans Affairs medical center in an urban Mid-Atlantic region. Participants completed single-item, Likert-scale measures of life satisfaction (McGuire Health Impact on Participation [M-HIP]), pain severity (M-HIP), and understanding of others (from a modified Appraisals of DisAbility Primary and Secondary Scale-Short Form [ADAPSS-sf]), along with the Patient Health Questionnaire-4 (PHQ-4), a measure of mental health symptom severity.

Results:

In linear regression models, pain (β = .29, p < .001) and understanding from others (β = −.28, p < .001) were significantly associated with mental health symptom severity with a marginally significant interaction effect (β = −.32, p = .099). Pain (β = −.33, p < .001) and understanding from others (β = .32, p < .001) were also significantly associated with life satisfaction; however, there was no significant interaction (β = .22, p = .234).

Conclusion/Implications:

This study showed that understanding from others and pain are important factors related to mental health and life satisfaction for veterans with SCI and highlights interventions targeting these relations.

Keywords: mental health, pain, spinal cord injury, understanding from others

Introduction

Eighteen thousand individuals experience a new spinal cord injury (SCI) each year in the United States, with roughly 294,000 Americans living with SCI (NSCISC, 2020). Following injury, individuals with SCI often experience emotional distress (Vissers et al., 2008), isolation and social disconnectedness (Newman et al., 2016), and pain (Putzke et al., 2002; Warren et al., 2013). Individuals with SCI are surviving their injuries and living longer (O’Connor, 2005); this, in turn, means that many individuals are also living with these symptoms for longer than they once were.

Pain, which commonly co-occurs with SCI (Putzke et al., 2002), has been found to be negatively associated with depression and anxiety (von Korff & Simon, 1996). Research suggests pain predicts both depression and anxiety at similar rates (von Korff & Simon, 1996). It is possible pain and mental health symptoms have a compounding and reciprocal effect, exacerbating each other (von Korff & Simon, 1996). This interaction is highly important for the veteran population who experience depression at a higher rate than the general population (Wilson et al., 2018). Thus, breaking this cycle is of paramount importance for assisting and providing health care services to veterans, particularly those with SCI experiencing pain.

Pain has also been linked to life satisfaction (Budh & Osteråker, 2007), a component of subjective well-being (Diener, 2009). Some research suggests subjective quality of life (i.e., life satisfaction) is closely associated with rehabilitation outcomes (Fuhrer, 2000). Whiteneck (1994) contends that most successful rehabilitation patients are well integrated into the community and maintain a high satisfaction with life. It is important, then, to find ways to improve satisfaction with life in individuals with SCI experiencing pain.

One way to improve both psychological well-being and life satisfaction might be to help individuals with SCI experiencing pain feel more understood. Empathy is the ability to share or understand the emotional states of others (Bernhardt & Singer, 2012; Decety, 2011). Research demonstrates that perceived physician empathy is positively associated with beneficial health outcomes (Attar & Chandramani, 2012). Research has also found a positive relationship between perceived (physician) empathy and patients’ optimism and positive health outcomes for individuals with chronic pain (Cánovas et al., 2018). Empathy also improves individuals’ resilience in the face of pain (Cánovas et al., 2018).

Empathy is a largely emotional experience, activating pain’s affective (emotional) qualities, rather than its sensory (physical) qualities (Singer et al., 2004). There is a successive associated cognitive response (Decety, 2011; Decety & Jackson, 2004; Singer & Lamm, 2009), and the interaction of the affective and cognitive systems then determines the accuracy of that empathetic response (Zaki et al., 2009). This could indicate that at least one important piece of understanding is missing, an experiential component: the person empathizes and makes a cognitive decision to act but may not fully understand the person’s challenges and abilities, in part because the empathizing person does not have a sensorial (physical) understanding of SCI pain. One might colloquially say “I understand what you’re going through,” thus attempting to empathize, without actually understanding, either owing to a lack of factual knowledge of the condition (not truly understanding what SCI is or its manifold impacts) or a lack of experience (never having experienced an SCI and the accompanying pain). Understanding from others, then, encompasses a broad range of types of understanding including, but not limited to, empathetic, factual, experiential, and sensorial-physical domains.

We seek to build on this literature by broadening the examination of empathy to include understanding. While most empirical literature examines health care provider empathy, we examine understanding from all “people in [the] life” (McDonald et al., 2019) of the individual with SCI, not just health care providers. To our knowledge, this is the first study to examine understanding specifically—not just empathy—and to investigate its possible interactions with pain, mental health, and life satisfaction. Given that previous literature has linked pain to lower life satisfaction (Budh & Osteråker, 2007) and depression (Cairns et al., 1996) and empathy to positive health outcomes (Attar & Chandramani, 2012; Cánovas et al., 2018), we hypothesized that pain and understanding from others would be closely associated with both mental health symptom severity and life satisfaction. Furthermore, understanding from others would moderate the relationship between pain and mental health, as well as pain and life satisfaction, in people with SCI; thus, as pain increases, mental health symptom severity increases and life satisfaction decreases, but at a lower rate for those with greater understanding from other people in their life.

Method

Participants

We used retrospective data from 221 individuals with SCI in the outpatient Spinal Cord Injuries and Disorders (SCI/D) annual evaluation clinic of an urban VA Medical Center on the East Coast. We gathered all demographic data from the VA’s electronic medical records system, the Spinal Cord Injury and Disorders Outcomes (SCIDO), and VA administrative billing data.

Procedure

Prior to conducting this retrospective study, we received institutional review board approval at the host medical center. Clinical psychologists or advanced clinical psychology trainees performed unstructured clinical interviews and screened patients for mental health issues during their SCI annual evaluation, which involves a series of appointments (generally scheduled in a single day and outpatient) wherein all individuals seen through the SCI service return to the medical center for a full evaluation. All individuals interviewed this way completed all relevant measures; thus, there were no missing data. Most patients (67%) were seen alone, but some did have a family member or caregiver present. In statistical analyses, “evaluated alone” is a demographic variable representing whether or not the individual with SCI had another person in the room with them while being evaluated (e.g., spouse or caregiver). Clinical psychologists or master’s level trainees administered all measures to the patient then recorded the patient’s responses. All patients completed the measures listed below, as well as a few other measures not reported here. Demographic and injury information can be seen in Table 1.

Table 1.

Sample Characteristics

Characteristics (N = 221)
Age, M (SD) 58.58 (12.72)
Age at injury, M (SD) 42.17 (16.28)
Years between injury and baseline, M (SD) 16.41 (13.66)
Sex, n (%)
 Male 214 (96.83)
 Female 7 (3.17)
Race, n (%)
 White 112 (50.68)
 Black 96 (43.44)
 Unknown/Refused 8 (3.62)
 Native Hawaiian or Pacific Islander 3 (1.36)
 American Indian of Native Alaskan 2 (.90)
Category of injury severity, n (%)
 AISA D 142 (64.25)
 Paraplegia 53 (23.98)
 Low tetraplegia (C5–8) 18 (8.14)
 High tetraplegia (C1–4) 6 (2.71)
 Unknown/Refused 2 (.90)
Education, n (%)
 High school graduate 93 (42.08)
 Some college AA/AS/technical 65 (29.41)
 College graduate 42 (19.00)
 Graduate or professional school 12 (5.43)
 Less than high school 6 (2.71)
 Unknown/Refused 3 (1.36)
Injury type, n (%)
 Traumatic 137 (62)
 Nontraumatic 84 (38)
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Measures

Mental Health Symptom, Severity

We used the Patient Health Questionnaire-4 (PHQ-4; Kroenke et al., 2009) to assess mental health symptom severity. The PHQ-4 is a four-item brief self-report instrument that measures depressive and anxiety symptoms based on the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV). The brief self-report questionnaire is a combination of the GAD-2 shown to be valid in assessing anxiety (Plummer et al., 2016), and the PHQ-2 shown to be valid in assessing depression (Löwe et al., 2005). It is structured with response options ranging from 0 (not at all) to 3 (nearly every day). Higher total scores on the PHQ-4 indicate greater mental health symptom severity (0 to 12). The measure demonstrated good reliability with a Cronbach’s alpha of .82.

Understanding From Others

We used an adaptation of the Appraisals of DisAbility: Primary and Secondary Scale-Short Form (ADAPSS-sf; McDonald et al., 2018). to measure understanding from others. The ADAPSS-sf is a six-item scale used to assess appraisals of disability in people with SCI. The scale has three negative and positive appraisals which are rated on a 6-point scale ranging from 1 (strongly disagree) to 6 (strongly agree). Higher scores indicate less adaptive appraisals about disability. For the current study, we added one item to assess understanding from others: “People in my life do not fully understand my health challenges and abilities.” For the current analyses, we reverse-coded this item such that higher scores reflect greater understanding from others.

Pain and Life Satisfaction

We used the McGuire Health Impact on Participation Survey (M-HIP; [McDonald et al., 2019]) to assess pain and life satisfaction. The M-HIP is a measure of health problem interference and was used to measure pain severity via a single item: “Within the past 4 weeks, pain has generally been…,” including responses of 1 (non-existent) to 4 (severe). We also assessed life-satisfaction using a single item: “Within the past 4 weeks, I have been satisfied with my day-to-day life,” with responses of 1 (not at all) to 6 (all the time).

Statistical Analyses

We used IBM SPSS 27 for all statistical analyses. We calculated a correlation matrix to examine bivariate associations among all continuous or dichotomous study variables, including for potential demographic covariates in the successive regression analyses linking them to the mental health symptoms and life satisfaction. These specific demographic variables were chosen because prior literature had generally shown them to be associated with mental health, or they had a theoretically relevant connection to one of the other variables (e.g., evaluated alone and understanding from others). Where appropriate, we used Pearson’s product moment correlations, point-biserial correlations, and phi coefficients. For categorical variables (sex and evaluated alone), we ran two analyses of variance (ANOVAs) to determine whether there were associations with mental health symptoms or life satisfaction.

All regression assumptions were met (no uni- or multivariate outliers, variance inflation factor < 10 and tolerance > .10, etc.), except that mental health symptom severity exceeded recommended skewness (2.11) and kurtosis (4.34) cutoffs of 2.0. Inspection of a histogram revealed that 61.5% of individuals reported no mental health symptoms, resulting in a 0 inflation of the distribution. As a result of the zero inflation of the mental health variable, we added a value of 1 to all mental health symptom severity total scores and used a natural log transformation. This resulted in the variable having skewness (1.07) and kurtosis (−.22) coefficients within traditional cutoffs, and we used this transformed mental health symptom severity score for all subsequent analyses.

We performed two linear regressions analyses. In the first, we assessed the relations among pain (independent variable; IV), understanding from others (IV), and mental health symptom severity (dependent variable; DV), and in the second, we assessed the relations among pain (IV), understanding from others (IV), and life satisfaction (DV), both controlling for covariates that had been found to be associated in a bivariate manner with the outcomes. In each regression, the final hierarchical step included an interaction term between pain and understanding with others to examine whether understanding from others moderated the effect of pain on the respective outcome. To examine potential reciprocal directionality of the linear associations between IVs and DVs, we ran the regression analyses in the opposite direction with pain as the outcome. A post hoc power analysis using G*Power 3.1 suggested that the current sample size could identify all effects within each regression (with five IVs) at an overall small, medium, or large effect size of greater thanf2 = .060.

Results

Preliminary Analyses

Results of the bivariate correlation indicated understanding from others and life satisfaction had negative relationships with mental health symptoms and pain and a positive relationship with each other, and pain and mental health symptoms had a positive relationship with each other (see Table 2). Mental health symptoms were negatively associated with age and time since injury, and life satisfaction was positively associated with age and time since injury (see Table 3). All other demographics variables were not significantly associated with either outcome. Further, results from both ANOVAs suggested that education level was not significantly associated with either mental health symptoms or life satisfaction.

Table 2.

Main Study Variable Correlations, Means, and Standard Deviations

Variable 1 2 3 M SD
1. Understanding from others 3.65 1.84
2. Mental health −.31** 1.29 2.23
3. Pain −.15* .35** 2.40 0.97
4. Life satisfaction .38** −.59** −.38** 4.81 1.2
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Note. For the mental health mean and SD, the raw values were reported for interpretive reasons rather than the natural log transformation.

*

p < .05.

**

p < .01.

Table 3.

Covariate Correlation Table

Variable 1 2 3 4 5
1. MH symptom severity
2. Life satisfaction −.61**
3. Age −.18** .15*
4. Sex (male 0; female 1) −.02 −.01 .01
5. Evaluated alone (alone 0; not alone 1) −.09 .07 .00 −.06
6. Time since injury −.14* .14* .24** −.06 .08
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*

p < .05.

**

p < .01.

Primary Analyses

Mental Health Symptom, Severity

In this model, the IVs were pain, understanding from others, and the pain*understanding from others interaction term, as well as the covariates of age and time since injury. We entered the covariates in Step 1, pain and understanding in Step 2, and the interaction term in Step 3. In Step 1, the overall model was significant, F(2, 218) = 4.98, p = .008, R2 = .04, and age was the only significant IV. In Step 2, the overall model was significant, F(4, 216) = 15.86, p < .001, R2 = .23, with a delta ΔR2 = .18, accounting for an additional 18% of the variance. Age remained significant in Step 2, and both pain and understanding were significant as well. However, in the third step, F(5, 215) = 13.34, p < .001, R2 = .24, whereas age and pain remained significant, understanding did not, and the interaction term was marginally significant. The third step, ΔR2 = .01, accounted for an additional 1% of variance in mental health symptom severity. Statistical results of all three steps are shown in Table 4.

Table 4.

Pain, Understanding, and Mental Health Symptom Severity Regression (Transformed)

Measure β p b SE LCI UCI
Step 1
 Age −.16 .023 −.00 .00 −.00 −.00
 Time since injury −.11 .120 −.00 .00 −.00 .00
Step 2
 Age −.14 .024 −.00 .00 −.01 .00
 Time since injury −.08 .201 −.00 .00 −.01 .00
 Pain .29 <.001 .09 .02 .06 .13
 Understanding −.28 <.001 −.05 .01 −.07 −.03
Step 3
 Age −.14 .027 −.00 .00 −.01 .00
 Time since injury −.08 .180 −.00 .00 .01 .00
 Pain .19 <.001 .16 .04 .07 .24
 Understanding −.02 .910 −.00 .03 −.06 .05
 Pain × Understanding −.32 .099 −.02 .01 −.04 .00
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Life Satisfaction

In this model, the IVs were pain, understanding from others, and the pain*understanding from others interaction term, as well as the covariates of age and time since injury. In Step 1, the overall model was significant, F(2, 218) = 3.81, p = .024, R2 = .03, but neither covariate was significant. In Step 2, the overall model was again significant, F(4, 216) = 15.86, p < .001, R2 = .23 with a ΔR2 = .24, accounting for an additional 24% of the variance, and both pain and understanding were significant as well. However, in the third step, F(5, 215) = 16.60, p < .001, R2 = .28, pain was the only significant IV. The third step, ΔR2 = .00, accounted for an additional 0% of variance in life satisfaction. Statistical results of all three steps are shown in Table 5.

Table 5.

Pain, Understanding, and Life Satisfaction Regression

Measure β p b SE LCI UCI
Step 1
 Age .12 .074 .01 .01 −.00 .02
 Time since injury .11 .110 .01 .01 −.00 .02
Step 2
 Age .11 .084 .01 .01 −.00 .02
 Time since injury .08 .182 .01 .01 −.00 .02
 Pain −.33 <.001 −.41 .07 −.55 −.26
 Understanding .32 <.001 .21 .04 .13 .29
Step 3
 Age .10 .089 .01 .01 −.00 .02
 Time since injury .08 .169 .01 .01 −.00 .02
 Pain −.47 <.001 −.58 16 −.89 −.26
 Understanding .14 .384 .06 .11 −.12 .30
 Pain × Understanding .22 .234 .05 .04 −.03 .13
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Reciprocal Effects

We ran the above regressions in reverse (by swapping pain and the DVs) with pain as the outcome to investigate the possibility of reciprocal effects. For the first exploratory regression, we entered mental health symptom severity and understanding from others in the first step and the interaction term between these two variables in the second step. In the first step, F(2, 218) = 14.39, p < .001, R2 = .12, mental health symptom severity was significant (β = .33, p < .001), but understanding from others was not (β = −.04, p = .520). In the second step F(3, 217) = 9.58, p < .001, R2 = .12, ΔR2 = .00, mental health symptom severity remained significant (β = .30, p < .041), but neither understanding from others (β = −.05, p − .482) nor the interaction term (β = .04, p = .772) was significant.

For the second exploratory regression, we entered life satisfaction and understanding from others in the first step and the interaction term between the two in the second step. In the first step F(2, 218) = 18.75, p < .001, R2 = .15, life satisfaction was significant (β = −.38, p < .001), but understanding from others was not (β = −.01, p = .917). In the second step F(3, 217) = 12.46, p < .001, R2 = .15, ΔR2 = .00, life satisfaction remained significant (β = −.40, p = .005), but neither understanding from others (β = −.06, p = .849) nor the interaction term (β = .07, p = .863) were significant.

Discussion

In the current study, we examined the relations among pain, mental health symptom severity, life satisfaction, and understanding from others in veterans with SCI. We found that as pain increased, life satisfaction decreased and mental health symptom severity increased. Conversely, as understanding from others increased, life satisfaction increased and mental health symptom severity decreased. There was no significant moderating effect of understanding from others on pain to life satisfaction or mental health symptom severity, although the buffering effect was marginally significant for mental health symptom severity.

The current study’s findings that pain was associated with lower life satisfaction and greater mental health symptom severity dovetail with previous research documenting the relationship between pain and satisfaction with life (Budh & Osteråker, 2007), as well as pain and depression (Cairns et al., 1996) and anxiety (von Korff & Simon, 1996). The current findings extend this literature by identifying these relationships among veterans with SCI, who have been shown to have higher rates of depression compared with civilians (Wilson et al., 2018).

The current findings of a salubrious connection between understanding from others with mental health symptoms severity and life satisfaction, as well as a marginally significant moderating effect on the relation between pain and mental health symptom severity, adds to the SCI rehabilitation and coping literature. Previous research has shown that perceived understanding from a physician predicts better health-related outcomes (Attar & Chandramani, 2012), and the current findings showed that this process may extend beyond physicians and health care personnel and apply to mental health and life satisfaction as well. Indeed, research has shown that empathy in the therapeutic patient-provider relationship is associated with better mental and physical health in veterans and civilians with SCI (LaVela et al., 2017). Stroud and colleagues (2006) also found that romantic partner negative responses to pain behaviors (but not understanding specifically) predicted pain-related activity interference and depressive symptoms. Thus, the current study expands on the previous literature by highlighting the importance of assessing understanding from others as a key predictor of psychological outcomes and supporting the notion that perceived understanding from others, not just health care providers, is associated with mental health and life satisfaction for individuals with SCI experiencing pain.

It is not surprising that both mental health symptom severity and life satisfaction were significantly associated with pain. The most novel finding, however, is the significant association between understanding from others and mental health symptom severity and life satisfaction which demonstrates an important connection among the three constructs with clinical and research implications. We also uncovered a marginally significant moderating effect of understanding from others on the relation between pain and mental health symptom severity; however, owing to the marginal nature, more research is needed to determine appropriate clinical or research implication. Furthermore, while a reciprocal and compounding effect may occur, this interaction was not present or even marginal when pain was the predicted outcome. This may indicate a unique role for validating and supportive responses and behaviors for individuals with SCI experiencing negative mental health symptoms.

Clinical and Research Implications

The current study findings have several implications for clinical practice and future research. Results suggest that understanding from others is an important variable in both life satisfaction and mental health symptom severity. Thus, it is recommended that rehabilitation clinicians evaluate the degree to which individuals with SCI receive empathic and understanding responses from important people in their lives. Many individuals with SCI have a formal and/or informal caregiver, and these findings could inform collaborative efforts that facilitate more validating and affirming responses from the caregiver. Clinicians and rehabilitation specialists, especially those working closely with caregivers, may wish to incorporate exercises and training modules designed to help caregivers communicate empathy, understanding, and validation. Furthermore, health care facilities may introduce or expand training for staff that increases knowledge of SCI and helps facilitate empathic and caring interactions with individuals with SCI.

These findings can also inform couples therapy work helping to promote empathic emotional support thus reducing mental health concerns among individuals with SCI. A recent review by McDonald, Pugh, and Mickens reported that the SCI rehabilitation literature has extensively highlighted resilience as a positive coping trait, and the current study findings contribute to the strength-based research that evaluates potential buffers to negative functional outcomes following SCI (McDonald et al., 2020). Such findings can create a shift in the literature that continues to build on identifying, cultivating, and maintaining strengths that serve as protective factors for individuals with SCI, especially considering couples and interpersonal contexts.

Limitations and Future Directions

Although these study findings yield several important clinical and research implications, the current findings should be interpreted within the context of several limitations. One limitation is that data were cross-sectional, thus these results do not account for longitudinal effects and make interpretation of causality less clear. The interpretation of causality becomes even more difficult when accounting for the possible reciprocal effects, though we did not find this relation in the current study. Research has shown that post-SCI functioning is malleable and subject to change due to a cluster of characteristics (Burns & Ditunno, 2001; New, 2005). Thus, it is recommended that future research evaluate the long-term outcomes associated with psychological and SCI-related functioning, particularly within the scope of understanding of others and in the context of pain. It may also be worth exploring whether there is a compounding effect such that greater mental health symptom severity or decreased life satisfaction interferes with the individual’s ability to perceive understanding from other people. The opposite may also be true: individuals with less severe mental health symptoms or greater life satisfaction may perceive greater understanding from individuals in their life even though there may be no difference in the actual level of understanding. Another limitation of the current study is that it may have been unclear for participants whether they were asked to endorse the degree they felt understood by others or if they were rating whether other individuals objectively understand the condition of SCI or both. Thus, it is recommended that future research clarify the distinction and objectively assess each type of understanding. Additionally, the use of single-item measures rather than psychometrically established scales could be interpreted as a limitation; however, there is growing evidence supporting the use of single-item measures, particularly for life satisfaction (Cheung & Lucas, 2014).

Although this study’ s implications for this population are important, the current study may have limited generalizability to larger SCI patient populations. Future research should include samples that are more diverse with respect to age, race, geography, and so forth, and include veterans, active service members, and civilian populations, who have sustained SCI. Doing so may provide more nuance for examining the presence of racial/ethnic, gender, or other demographic differences. Finally, this study contributes important context to the rehabilitation literature and suggests that individuals with SCI may meet functional outcomes differentially, as a function of their perceived empathic feedback. Subsequent researchers should evaluate what underlying mechanisms of understanding from others contribute to patterns similar to these findings.

Conclusion

Although the current study findings are consistent with previous literature that has documented the relation between pain and mental health symptom severity and life satisfaction, these findings emphasize the role of understanding of others as a key piece of both life satisfaction and mental health symptom severity. Despite the potential pain associated with daily functional tasks, individuals with SCI possess strengths that can serve as protective factors to negative mental health outcomes. It is recommended that rehabilitation clinicians use these results to inform clinical practice by implementing understanding-building interventions among individuals with SCI and their caregivers, partners, or loved ones.

Impact and Implications.

The current study highlights the importance of assessing empathy/understanding from others as a key predictor of psychological outcomes for individuals with SCI. Clinicians and rehabilitation specialists may wish to expand practices geared toward facilitating understanding of SCI for caregivers and other individuals with close relationships to people with SCI. Clinicians and rehabilitation specialists, especially those working closely with caregivers, may wish to incorporate exercises and training modules designed to help caregivers communicate empathy, understanding, and validation. Health care facilities may introduce or expand training for staff that increases knowledge of SCI and helps facilitate empathic and caring interactions with individuals with SCI.

Acknowledgments

Special thanks to Megan Bailes who assisted with database management. Duygu Kuzu was supported by a postdoctoral fellowship award funded by the University of Michigan’s Advanced Rehabilitation Research Training Program in Community Living and Participation from the National Institute of Disability, Independent Living, and Rehabilitation Research, Administration for Community Living (NIDILRR; Grant 90ARCP0003). Because Scott D. McDonald and Paul B. Perrin are employees of the U.S. Government and contributed to the article “Pain, Mental Health, Life Satisfaction, and Understanding From Others in Veterans With Spinal Cord Injury” as part of their official duties, the work is not subject to U.S. copyright. This material is the result of work supported with resources and the use of facilities at the Hunter Holmes McGuire Medical Center. The contents do not represent the views of the U.S. Department of Veterans Affairs or the United States Government. The authors have no additional conflicts of interest to disclose.

Footnotes

Data are available on request by contacting the corresponding author.

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