Real-world participation after spinal cord injury: longitudinal associations with return to work and long-term social integration

BACKGROUND: Participation after spinal cord injury (SCI) includes work reintegration and social integration, but their shared and distinct correlates remain unclear. AIM: To examine longitudinal associations with return to work and social integration after SCI, and to estimate the relative contribution of predictor blocks. DESIGN: Secondary analysis of a registry. SETTING: Community follow-up within the United States Spinal Cord Injury Model Systems Public Use Database (2021ARPublic). POPULATION: Adults with SCI; return-to-work analyses included participants working pre-injury and aged 18-64 years at injury, whereas social integration analyses included adult observations with valid Craig Handicap Assessment and Reporting Technique (CHART) Social Integration scores. METHODS: Generalized estimating equation models assessed competitive employment and CHART Social Integration. A year-5 Shapley-type block decomposition compared baseline/injury, function/mobility, and symptom-burden, psychosocial, and contextual blocks. RESULTS: Primary models included 16,574 observations from 10,195 participants for employment and 26,028 observations from 16,410 participants for social integration. Higher mobility, education, and life satisfaction were positively associated with both outcomes. Non-private residence and Non-Hispanic Black race were associated with less favorable participation in both domains. Pain severity was more clearly associated with lower employment odds, whereas depressive symptoms were more clearly associated with lower social integration. At year 5, function and mobility accounted for the largest share of explained variation for return to work (40.86%) and social integration (47.13%). CONCLUSIONS: Return to work and social integration overlap but are not interchangeable after SCI. These findings are associative rather than causal. CLINICAL REHABILITATION IMPACT: Mobility, education, psychosocial well-being, and residential context may help guide rehabilitation planning.