Life satisfaction is not one single thing — it is made up of many different areas. This paper looks at eight of them in detail for people living with SCI: money, health, work and activities, close relationships, personal safety and independence, involvement in the community, emotional wellbeing, and spirituality.
For each area, it examines what the research shows, why scores are high or low, and what could be done differently. Some findings are surprising — for example, the fact that even people with very severe injuries can report relatively high levels of emotional wellbeing. Others confirm what many people with SCI already know: that financial pressure, loss of independence, and barriers to community involvement are among the biggest ongoing challenges.
This article is intended both for people living with SCI, who may recognise their own experience in these findings, and for clinicians and policymakers, who can use them to better target rehabilitation efforts.
The Eight Domains
The following eight areas of life were identified by Cummins (1996) as the most comprehensive representation of what quality of life means across cultures and populations. Scores from multiple surveys of people with SCI were averaged and expressed as a percentage of the maximum possible score (%SM). The general population norm is approximately 73–75% across all domains.
52.2% Material Well-being
Financial satisfaction received the lowest score in the SCI literature — and the reasons are straightforward. Living with paralysis carries significant ongoing costs: medical supplies and evaluations, specialised equipment and wheelchairs, home modifications, transport, attendant care, and clothing adaptations. These expenses continue and often increase with age.
At the same time, gaining and maintaining employment is harder after SCI — which means income is often reduced precisely when expenses are rising. The combination reliably produces financial stress. Research by Levi et al. (1995) found that financial worry was significantly higher in people with SCI than in the general population, even in Sweden — a country renowned for its social support system.
Paid income has been found to offset these difficulties (Boschen, 1996), and SCI rehabilitation programmes that include vocational planning and financial guidance may have a meaningful impact on this domain.
59.3% Health
The health outcomes for people with SCI have improved dramatically over the past century. During World War One, around 80% of servicemen with SCI died soon after their injury. By the end of World War Two this figure was around 50%. Today, survival is the norm rather than the exception, and life expectancy after SCI has approached that of the general population.
Despite this progress, health satisfaction scores remain significantly below the general population average. The main reasons are secondary conditions — medical complications that arise not from the injury itself but from living with paralysis over time. These include urinary tract infections, pressure sores, spasticity, respiratory complications, and chronic pain.
Pain deserves particular attention. Studies report that between 46% and 80% of people with SCI experience moderate to severe pain, depending on the study and how pain is defined. Pain is negatively related to life satisfaction (Lundquist et al., 1991) and is a significant predictor of depression following discharge from rehabilitation (Craig et al., 1994).
The research also makes clear that many secondary conditions are preventable. Individuals who take an active, vigilant approach to their own health — regular check-ups, skin care, bladder management — experience fewer complications. The responsibility for long-term health rests significantly with the individual, though adequate professional support is essential.
52.1% Productivity
Productivity covers more than paid employment — it includes volunteering, recreation, education, and any activity through which a person makes meaningful use of their time. Satisfaction in this domain was the second-lowest in the SCI literature.
Around 30% of people with SCI are in paid employment (Castle, 1994; Krause et al., 1998). Being employed is positively associated with life satisfaction across multiple studies. Barriers to employment include discriminatory hiring practices, lack of accessible transport, loss of attendant care benefits when earning an income, and the difficulty of retraining for less physically demanding roles — a process that takes an average of over three years (Engel et al., 1998).
Education plays an important protective role. Higher levels of education are consistently associated with better employment outcomes and higher life satisfaction after SCI. This makes educational support a valuable rehabilitation goal, not just a vocational one.
Importantly, a longitudinal study by Krause et al. (1990) found that people with SCI who died prematurely had led relatively narrow lives with few varied experiences. This underlines the importance of promoting a wide range of activities — not only employment — as a foundation for long-term wellbeing.
66.5% Intimacy
Close relationships — with family, partners, and friends — were consistently the most important source of satisfaction for people with SCI, and produced the highest satisfaction score across all eight domains. This mirrors the general population, where intimacy is also ranked most important.
Families typically provide around 70% of personal care after SCI, the majority of it unpaid (Marini, 1992). They are also the primary source of emotional support, financial assistance, and social connection. Research by Warren & Wrigley (1996) found that closeness to family was significantly associated with life satisfaction, as well as with reductions in anxiety, helplessness, and social isolation.
However, family relationships can also become strained. Over-involvement, unrealistic expectations for recovery, role confusion, and caregiver burnout are documented challenges. The balance between receiving care and maintaining a reciprocal, equal relationship is difficult to sustain over time.
Regarding marriage, people who were married consistently reported higher life satisfaction across multiple studies. The first few years after injury carry the highest risk of relationship breakdown, as both partners adjust to dramatically changed circumstances. In relationships that survive this period, relationship satisfaction has been found to be comparable to that of the general population (Kreuter et al., 1994).
Sexual satisfaction deserves specific mention. The mean satisfaction score with sexual life across seven SCI surveys was 44.5%SM — the lowest sub-domain score across the entire literature. Loss of sensation and mobility creates significant challenges that require open communication, professional support, and partner understanding to navigate effectively.
65.3% Safety — Not significantly different from the general population
Safety covers personal control, independence, privacy, autonomy, residential stability, and knowledge of one's rights. Despite the physical constraints that SCI imposes, satisfaction in this domain was not significantly lower than the general population — a finding that stands out given how much independence is affected by paralysis.
The ability to control one's own environment, particularly through independence in daily activities, is a strong predictor of psychological wellbeing (Brenner, 1990). Being able to feed oneself and to drive a vehicle were specifically identified as activities closely linked to life satisfaction. Independent housing is also strongly and consistently associated with higher wellbeing.
The fact that safety scores are comparable to the general population may reflect the effectiveness of modern rehabilitation in helping people establish functional independence — the majority of people with SCI in Western countries return to private residential accommodation after rehabilitation.
64.3% Place in Community
This domain covers social integration, community involvement, social support, and the sense of belonging to something beyond one's immediate household. Satisfaction here was significantly lower than the general population norm.
Physical barriers — inaccessible buildings, public transport that cannot accommodate wheelchairs, and streets designed without disability in mind — are a direct and ongoing obstacle to community participation. But attitudinal barriers are just as significant. Research by Bates et al. (1993) found that when people encountered someone using a wheelchair, they tended to maintain greater physical distance, engage for shorter periods, and engage in more negative self-talk than in interactions with non-wheelchair users.
Full community participation is not just about access — it is about being a meaningful, active participant, not a spectator (Kopkstein, 1999). Rehabilitation programmes that target community reintegration skills, social confidence, and civic engagement may address one of the most persistently underserved aspects of life after SCI.
63.4% Emotional Well-being — Not significantly different from the general population
This is perhaps the most surprising finding in the literature. Despite the profound losses associated with SCI, average emotional wellbeing scores across the SCI population were not significantly lower than in the general population.
Depression is common in the early years after injury — studies estimate that 20–45% of people experience moderate to severe depression in the first two years. However, depression is not inevitable, and it is not the permanent state of most people living long-term with SCI. Earlier theories proposing that everyone with SCI passes through predictable stages of grief and adjustment — similar to Kübler-Ross's model of mourning — have been largely set aside. The evidence instead points to highly individual responses shaped by personality, social support, control strategies, and practical circumstances.
There is also evidence that rehabilitation staff consistently overestimate the psychological distress of their patients. Bach & Tilton (1994) found this even among experienced staff. In one documented case, a patient who was genuinely happy to have survived a life-threatening injury was referred for psychiatric review because staff did not believe his positive mood was authentic. Objective, standardised assessment tools are more reliable than clinical impression alone.
Recreational activity plays an important role in emotional wellbeing — promoting physical health, social connection, and a sense of mastery. Research suggests that people with SCI often develop new recreational interests after injury that they had not previously considered, and that this broadening of experience is associated with higher wellbeing.
63.7% Spirituality
Spirituality — understood broadly as a sense of meaning, purpose, and connection to something greater than oneself — was significantly lower in the SCI population than in the general population norm. However, it was one of the more resilient domains, and the qualitative research in this study found something striking: not a single participant stated that spirituality or religion made coping more difficult. Every spiritual or religious reference made by participants was about what helped them.
Research by Riley et al. (1998) found that people with SCI who identified as spiritual or religious reported significantly higher life satisfaction than those who did not. Schulz et al. (1985) documented numerous reports of personal growth following injury — increased awareness of self and others, greater patience and compassion, and a deepened appreciation of life.
Activities that may foster a sense of spirituality — meditation, time in nature, creative arts, meaningful relationships, prayer, journal writing — appear to offer a genuine protective resource for people living with SCI.
Across eight domains of life, the SCI population consistently reported lower life satisfaction than the general population — but the gaps were largest in material well-being and productivity, and smallest in safety and emotional well-being. These patterns point to where rehabilitation should focus its efforts most urgently.
Olson, J. M. — Deakin University, 2001Domain-level scores were derived from the meta-analytic database of 41 SCI surveys described in Chapter 2. All scores are expressed as mean percentage of scale maximum (%SM) ± standard deviation. Statistical significance was assessed using two-tailed t-test comparisons against general population norms. The eight-domain framework follows the ComQol model (Cummins, 1997), which was validated against 27 quality of life definitions in the social scientific literature. The domain of safety as defined here encompasses personal control, privacy, independence, autonomy, competence, knowledge of rights, and residential stability — a broader conception than physical security alone.