Introduction
pinal cord injury (SCI) is a severe condition that disrupts motor, sensory, and autonomic functions, significantly impacting social, psychological, and physical aspects of health [1, 2]. Patients must undergo a challenging rehabilitation process to regain independence [3]. Access to information, involvement in rehabilitation planning, and emotional support are the primary concerns of patients regarding their recovery [4]. In this process, external perceptions and expectations, especially those of family members and the therapy team, play a pivotal role in shaping patients’ self-concept and motivation [1, 2]. The scarcity of psychiatrists and psychologists to provide emotional support often leads to close relationships between SCI patients and rehabilitation specialists [5, 6]. Rehabilitation specialists, while managing complex biomedical conditions, also address the patients’ psychosocial needs, thus ensuring the overall physical and mental health of the patient [7]. External factors include the attitudes and beliefs of family members, therapists, and society in general. These factors can directly or indirectly influence the patient’s rehabilitation experience [3, 4]. Unrealistic expectations of patients and a lack of empathy from professionals can lead to conflict and reduced treatment outcomes [8]. Treatment effectiveness depends on addressing patients’ motivations [9]. Empathy, honesty, sensitivity, acceptance, and effective communication skills (such as active listening) are essential. Additionally, studies have shown a correlation between a decrease in perceived stress levels in patients and the provision of psychological support to families [10-13].
An individual’s perspective on their health and quality of life when faced with a disability is significantly influenced by their interpersonal interactions and relationships [14]. Qualitative research has shown that individuals with SCI benefit from compassionate interactions with medical staff and family, leading to improved well-being, independence, autonomy, and hope [4, 15]. The outcomes of rehabilitation are examined from physical, psychological, and social perspectives. Physically, successful rehabilitation can lead to improvements in motor and sensory function [5]. Psychologically, increased self-confidence, reduced stress, and improved self-concept are among the most important psychological outcomes of rehabilitation [6]. Finally, from a social standpoint, effective rehabilitation can enhance social participation and improve quality of life [7]. In Iran, individuals with SCI typically return home for post-discharge care, which is provided by family members. After discharge, patients have the most contact with therapists (including hospital therapists and physiotherapists) and their families. The average length of hospital stay for these patients is 5-7 days, which may not be sufficient for comprehensive education on proper care techniques. As a result, family members often resort to trial and error, personal experience, and consultation with other caregivers to manage the patient’s needs. While Iran has a universal healthcare system, resources for specialized SCI rehabilitation may be limited depending on the location, but Iran does have a strong network of patient support groups, such as families [16]. Additionally, physical barriers and societal attitudes can limit the social participation of individuals with SCI [17]. Therefore, staff in spinal cord units and rehabilitation centers must understand what individuals are experiencing.
Research studies increasingly emphasize the critical role of individual participation in decision-making, particularly concerning family and the therapy team [14, 16-18]. For example, Hammell’s study (2007) showed that positive interactions with family and healthcare professionals can increase patients’ motivation, while a lack of empathy and unrealistic expectations from these individuals can lead to decreased patient self-confidence [19]. Additionally, research by Van Leeuwen et al. (2012) examined the quality of life of individuals with SCI after hospital discharge and found that emotional and psychological support from family and therapists had a significant impact on improving the quality of life of these individuals [20]. Various studies, such as DeJong et al.’s (2013) research, indicate that the role of the therapy team extends beyond the management of patients’ biomedical conditions and includes providing psychosocial support. This study specifically concluded that empathy and psychological support from the therapy team can help reduce the rate of patient readmission [21]. However, some studies have highlighted deficiencies such as insufficient attention to the emotional and psychological needs of patients by healthcare professionals, which can lead to negative outcomes in the rehabilitation process. A study conducted by Shamshiri et al. (2021) shows that the role of the family in the rehabilitation process of individuals with SCI is critical [22]. These studies emphasize that families serve as primary sources of emotional and practical support for patients. In some cases, incorrect perceptions or unrealistic expectations of families can lead to psychological stress on patients and disrupt their rehabilitation process.
Although numerous studies have examined the impact of interpersonal relationships on the rehabilitation process of individuals with SCI, most existing research has generally focused on the influence of these relationships on quality of life, readmission rates, or depression. However, there has been a notable lack of research specifically investigating how external perceptions and expectations (such as those of family and the therapy team) influence self-concept during the rehabilitation journey. Research that has delved deeper into this topic is limited, highlighting the need for further studies in this area. Moreover, the majority of SCI research has been conducted in Western countries, and due to cultural and societal differences, the results may not be fully generalizable to other cultural contexts, such as Iran. In Iran, given the prominent role of family in post-discharge care and the limitations of specialized rehabilitation services, there is a pressing need for more qualitative studies to gain a deeper understanding of patients’ experiences within this context. Considering the dynamic and subjective nature of achieving independence and overcoming social barriers for individuals with SCI, qualitative research methods are essential for comprehending their unique experiences. This study investigates how the perspectives and beliefs of individuals with SCI’s social circles, particularly family members and therapists, influence their self-concept and beliefs.

Materials and Methods
This study employed a qualitative approach with a focus on conventional content analysis [23]. The research methodology and reporting adhere to the guidelines outlined in the consolidated criteria for reporting qualitative studies [24].

Study participants
This study employed purposeful sampling to recruit Iranian individuals with SCI residing in their homes. In collaboration with managers of SCI associations, potential eligible individuals were identified for participation in the research. After providing comprehensive information to the volunteers about the study objectives, those who expressed interest in participating and were at least 18 years old and had experienced the injury and its associated complications for at least six months were included in the study. The participants who did not wish to continue or whose interviews could not be analyzed were excluded from the study. For inclusion in this study, the participants were required to have a functional independence measure score of FIM5-FIM7 [25]. The study included 19 participants (10 females and 9 males), with a mean age of 37.4 years (27-50 years), a mean duration of disability of 7.5 years, and a mean interview duration of 101 min. Table 1 presents the demographic characteristics of the participants.



Data collection 
Individual interviews were conducted with people with SCI from September 2022 to May 2023. These interviews took place in a quiet and private setting, guided by a researcher using a semi-structured interview approach. The process began with a broad question about participants’ experiences, feelings, and concerns following their SCI, encouraging them to share meaningful information based on their perspectives [26]. A detailed interview guide (including all interview questions, probing techniques, and saturation criteria) is provided in the Supplementary 1.
To delve deeper into participants’ responses, exploratory probes were used to enrich the data. These probes were tailored to individual participants’ answers. The interviews underwent a sequential analysis process. Insights from previous interviews, such as identifying response patterns, emerging key concepts, and unanswered questions, along with careful review by the research team, were used to formulate new questions and refine the structure of subsequent interviews. This sequential analysis approach enabled us to progressively reach greater depths of participants’ experiences and enhance the comprehensiveness of the collected data. The author (Ali Sadeghi Akbari), a nurse and doctoral student, conducted the in-depth interviews, and their involvement in assisting individuals with spinal cord injuries was disclosed as part of the research.
In qualitative research, data saturation refers to the point at which no new categories or insights emerge, and the collected information becomes repetitive and confirmatory [27]. After conducting 24 interviews with 19 participants, no new information emerged; therefore, theoretical sampling was halted as data saturation was achieved.

Data analysis
Data analysis was conducted concurrently with data collection, following the grounded theory approach outlined by Lindgren et al. [28]. An inductive content analysis was employed to explore the wide range of themes emerging from the interviews, focusing on both explicit statements (manifest content) and implicit meanings (latent content). Initially, interviews were listened to repeatedly, transcribed verbatim, and then carefully examined. The interview text was repeatedly revisited to ensure a comprehensive and accurate understanding of the data. Adhering to established guidelines for inductive content analysis [28], transcripts underwent a systematic analysis process. In the subsequent phase, meaning units were extracted as open codes and searched for constant comparison of differences and similarities between codes, categorized into subcategories, and further aggregated into categories with similar shared properties. To facilitate data analysis, techniques such as comparing data points, questioning assumptions, delving deeper into emerging themes, and exploring potential topics were utilized. To ensure maximal internal homogeneity within categories and maximal differences between categories, ongoing comparison and revision with the research team were conducted. The aim was to identify segments where participants discussed aspects, such as self-related feelings and the impact of family and therapist perspectives and attitudes on the rehabilitation and recovery process. For initial analysis, in vivo coding and open coding were used to examine sentences and phrases. The data analysis process occurred concurrently with data collection, and this process continued until theoretical saturation was achieved. Finally, to ensure the validity and reliability of the findings, the extracted codes and themes were returned to the participants to seek their feedback and confirmation regarding the appropriateness and accuracy of the codes. The MAXQDA software, version 2020 was used to manage data throughout the analysis process.

Data rigor and validity
To ensure the reliability of the data, four criteria proposed by Lincoln and Guba (1985) - credibility, transferability, dependability, and confirmability - were used [29]. To enhance the credibility of the findings, several techniques were employed. The study findings were discussed with the advisors and professors familiar with qualitative research methods. In pursuit of deep engagement, lengthy and repeated interviews were conducted with the participants, and a safe and trusting environment was created to facilitate the free expression of their experiences. Additionally, by allocating sufficient time (9 months) for data collection, a more in-depth examination of the phenomenon under study was made possible. To ensure member checking, after each stage of analysis, the initial findings and interpretations were shared with the participants to verify the accuracy of the analysis, and subsequent interviews were modified based on their feedback if necessary. To assess the reliability of the data, the interview transcripts were reviewed again by the research team after a few days. In this process, the coding and the resulting findings were compared with the initial coding. Furthermore, sections of the recorded interviews and their transcripts, along with the extracted codes, subcategories, and categories, were evaluated by research colleagues and two external reviewers familiar with qualitative research methods. After confirming the coding and categorization, the reliability of the data was verified. To ensure confirmability, efforts were made to avoid any preconceptions, the exclusion of unexpected findings, or the distortion of the obtained data throughout the research, and scientific integrity was maintained at all stages of the research. To strengthen dependability, all stages of the study were meticulously documented, and the characteristics of the study population were described transparently. To reduce cognitive bias, the researchers’ awareness of this issue was continuously increased, and efforts were made to use systematic and structured methods during data analysis. By using purposive sampling and striving to maximize participant diversity, the generalizability of the findings was increased. This allowed us to gain a more.

Result
In this study, 19 participants, including 9 individuals with quadriplegia and 10 paraplegic individuals, were involved. After a comprehensive analysis, three main categories emerged. These categories, along with their relevant subcategories, can be seen in Table 2, and detailed explanations for each are provided below.



The existential affirmation on traversing recovery
This theme, ranging from being influenced by therapists and those around the spinal cord individual to confronting external “You cannot do this” and setting low goal ceilings, emphasizes the complex interplay between external definitions, inferences, and beliefs and personal achievements. Individuals grapple with the expectations and limitations imposed by others while striving to define their abilities, beliefs, and aspirations within the constraints of their circumstances. Ultimately, these themes illuminate the intricate dynamics of self-awareness, agency, and resilience in the face of adversity and underscore the crucial role of external influences in shaping individual experiences and outcomes.

Creating a new identity based on willpower and effort
This passage highlights the significant role that recognition, validation, and encouragement received from others play in shaping one’s self-perception, belief in abilities, and motivation to persevere in the face of challenges. The definitions provided by others, whether through acknowledging strength, recognizing progress, validating chosen paths, or acknowledging efforts, have a profound impact on individuals’ experiences and perspectives on their journey of recovery from spinal cord injuries.
Being seen as a symbol of resilience and determination
This theme emphasizes the external recognition of the strength and determination of individuals with SCI in overcoming the challenges associated with their injury. They often see themselves as symbols of perseverance and willpower in the eyes of others. This perspective from others can influence how they perceive themselves and their path to recovery.
“If you check my social media page, you’ll see that many of my family and friends have admired my willpower. They say that some of us should take inspiration from me (Female. 50-year-old, Paraplegia, 6 years post-injury [F/50/P/6])”. “A large percentage of people around me believe in me, and now I have become a role model for others. It has gotten to the point where people around me come to me for advice when they are struggling (F/40/Q/8).”

Self-satisfaction derived from positive physician feedback
The emphasis on medical validation and endorsement throughout the healing process is highlighted by this paragraph. Individuals experience self-satisfaction when they receive positive feedback from their healthcare providers, particularly regarding their progress and strength. Such validation bolsters their morale and reinforces their belief in their ability to overcome obstacles and improve their condition.
“The doctor was shocked to see me walking so well despite my SCI. He could not believe it! He even said it was a miracle. But he said it was not a miracle, it was all your hard work and determination that got you to this point (F/28/Q/8).”
Rightness of the path reflected in the mirror of therapist’s and others’ definitions
The influence of external perspectives, particularly those of therapists and other individuals involved in the rehabilitation process, plays a significant role in shaping an individual’s belief in their chosen path. The validation and affirmation received from these sources serve as a mirror, reflecting the correctness of their journey, thereby bolstering their self-confidence and determination to continue pursuing their chosen course of recovery.
“My friends also tell me this, they say, do not compare yourself to others. My friends encourage me, they say you are Hamid, you are not someone else. They tell me, we know Hamid, we know he has never given up. We know that you will succeed, and it made me believe in myself more. (M/33/P/6).” “Other people’s compliments made me believe in myself more. It was like, I can do this. Nothing is going to stop me (M/27/P/8).”

Observing the impact of efforts on defining and encouraging others
This subject underscores the importance of observing the tangible impact of an individual’s efforts on the feedback and encouragement received from others. When individuals afflicted with spinal cord injuries witness the positive effects of their actions on the perceptions and attitudes of those around them, their sense of efficacy is strengthened along the path of improvement.
Seeing the happiness on their faces is a huge encouragement for me. It is like a confirmation that I am on the right path (F/46/P/16).” “Those who know me, who have seen me and witnessed my work and life, say, ‘Masha ‘Allah’ (an expression of admiration and praise), she can do it! Indeed, she cannot walk, but she is no less capable than anyone else who has legs (M/41/Q13).” 

Therapist Empathy and Support in the Rehabilitation Process
The impact of therapist empathy, support, and guidance on individuals’ experiences and progress throughout their rehabilitation journey is profound. Compassionate communication enhances trust and creates a space for individuals to explore their concerns, fears, and aspirations. Therapists play a fundamental role in influencing individuals’ perceptions, behaviors, and decisions, providing not only physical rehabilitation but also emotional support and guidance. Through empathetic companionship, therapists empower individuals to overcome the complexities arising from spinal cord injuries with flexibility, hope, and self-confidence.

Therapist’s empathy and support in the personal journey
Therapists who demonstrate empathy create a nurturing environment in which individuals feel understood and supported. Accompaniment signifies the therapist’s commitment to accompanying the individual, providing guidance, encouragement, and emotional support during the challenges of rehabilitation.
“He did not charge me anything. I would go there and he would work with me for 2 h. Since he had students during the day, we would arrive at 10 pm and he would stay until midnight to see us. Dr. Soltani is empathetic, kind, respectful of your wishes, does not give off negative energy, is good with kids, works from the heart, and motivates you (M/29/Q/4).” 

Being influenced by therapists in rehabilitation
This passage highlights the significant impact that therapists have on individuals throughout the rehabilitation process. This influence extends beyond physical rehabilitation to encompass emotional support, coping strategies, and their overall recovery trajectory. Individuals rely on their therapists, who shape their perceptions, behaviors, and attitudes towards their injury and rehabilitation efforts.
“He said that because he sees it in me, he knows it is possible. I kept saying, ‘Catch me so I do not fall.’ He replied, ‘ I am behind you.’ I took the first step, and he said, ‘Bring the camera and see and film our daughter, who can do it.’ He was pleased and said, ‘You were great. Now go and sit down’ (F/40/Q/8).” 

Finding power in overcoming challenges
Individuals face hurdles ranging from expectations about ability and effort to grappling with external constraints and accepting their disability, all of which compel them to push boundaries. Despite encountering “Cannots” imposed by others or self-imposed limitations, individuals leverage these challenges as fuel for growth and development, ultimately propelling them forward on the path of recovery and adaptation.

Expectation of recognizing individual capacities and efforts
This passage emphasizes the importance of healthcare professionals and individuals involved in the rehabilitation process, expecting to see the individual’s capacity, will, and effort.
“His words hurt and upset me. I was close to tears. Why would he say that to me when I am trying my best? I am wearing this Ankle Foot Orthosis (AFO), something I never thought I would have to do. Now that I have an AFO on my leg, why could not he believe me? (F/35/Q/9)”

Overcoming external “can’t-dos”
This section delves into the challenges faced by spinal cord injuries in confronting external limitations or perceived impossibilities imposed upon them by others. Despite these external “Can’t-dos,” individuals are compelled to devise strategies to navigate and overcome such obstacles.
“I get up and prop myself up, not to shut her up, but to remind myself that I am not just a lifeless body, I can still sit up (M/40/Q/6).” “Like when they say, ‘That’s all you are,’ it just pushes me to do it more. When that person says that, it makes me want to prove them wrong even more (M/42/P/5).”

Promoting individual ownership in the rehabilitation
This concept emphasizes the crucial role individuals play in their healing journey. While the support and guidance of healthcare professionals and loved ones are invaluable, individuals ultimately bear the responsibility of owning their rehabilitation path.
“You have to fight and become strong, otherwise you will just sit in a corner and not die, but you will wish you were dead. So, you have to fight and become strong (M/47/P/7).”

Inducing false beliefs and stereotypes in patients
Healthcare professionals may set low goal ceilings for individuals with spinal cord injuries, potentially limiting their aspirations and hindering progress. However, individuals can use these low targets as motivation to challenge expectations.
“We had these false beliefs that you should get better and become independent, but you will not get well, and you will not walk. It is enough to just do your things, not that you want to walk (F/50/P/6).”

Discussion
This study underscores the significant impact of external factors on the rehabilitation outcomes of individuals with spinal cord injuries. The findings highlight the intricate interplay between external perceptions, expectations, and limitations imposed by therapists, family, friends, and society at large, and how these factors influence an individual’s self-awareness, agency, and ultimately, their progress.
The research emphasizes the importance of encouragement and validation from therapists, family, and friends. Recognition of strength, progress, and effort serves as a powerful motivator, boosting self-belief and perseverance [7, 30, 31]. Individuals thrive when seen as symbols of resilience, drawing inspiration from the admiration of others. Positive reinforcement from medical professionals, like therapists and doctors, is particularly impactful. Their validation strengthens individuals’ resolve and reinforces their belief in their ability to improve. Therapists act as mirrors, reflecting an individual’s progress and chosen path, fostering self-confidence and a sense of being on the right track. Witnessing the positive impact of their efforts on others further strengthens an individual’s determination and sense of efficacy. The concept of being seen as a symbol of resilience aligns with the psychological concept of self-efficacy, a crucial factor in rehabilitation success [32-34].
Therapists play a pivotal role in shaping rehabilitation experiences.  Their empathy, support, and guidance create a safe space for individuals to explore challenges and aspirations. They go beyond physical rehabilitation, providing emotional support and guidance, influencing individuals’ perceptions, behaviors, and decisions.  This aligns with research, which suggests that overcoming challenges fosters determination and a sense of accomplishment [12, 35]. Therapists who demonstrate empathy create a safe space for exploration, fostering trust and empowering individuals to navigate the complexities of SCI recovery, as noted in a previous study [14, 31]. Therapists who demonstrate empathy foster a nurturing environment where individuals feel understood and supported.  Their unwavering accompaniment throughout the rehabilitation journey provides crucial encouragement and emotional support. Therapists can empower individuals by believing in their potential, like the therapist who motivated an individual to take their first steps by offering unwavering support.
The study also explores how individuals confront external limitations and “Cannots” imposed by others or themselves.  These challenges catalyze growth and progress.  This aligns with research on resilience, which suggests that overcoming challenges fosters determination and a sense of accomplishment [33, 36, 37]. Individuals grapple with expectations about ability and effort, battling external constraints and internalizing their disability.  However, they leverage these obstacles as fuel to push boundaries and propel themselves forward on their path to recovery and adaptation. Individuals emphasize the importance of healthcare professionals acknowledging their capacity, willpower, and effort. Facing external limitations imposed by others ignites a fire within them to overcome those limitations and prove themselves.  Individuals play a central role in their healing journey, taking ownership of their rehabilitation path.  While external support is invaluable, their determination and fight are the driving forces behind their progress.  Interestingly, even low goal ceilings set by healthcare professionals can be used as a springboard to challenge expectations and achieve more.
This study offers valuable insights into the Iranian sociocultural context of SCI rehabilitation. The emphasis on therapist-individual relationships and the importance of family support may reflect cultural values of respect for authority and close-knit social networks.

Conclusion
This study underlines the profound influence external factors have on SCI rehabilitation outcomes. Positive reinforcement, therapist support, and the ability to turn challenges into motivation are all crucial elements for maximizing individual progress and fostering a sense of self-belief and resilience.  By acknowledging the power of external perceptions, expectations, and limitations, healthcare professionals can create a more supportive and empowering environment for individuals navigating the complexities of SCI rehabilitation. 

Study strengths and limitations
The study, involving a nurse who cared for traumatic SCI patients, has limitations due to the lead investigator’s nursing background. The data was transparent, but participants’ awareness of the investigator’s background may have influenced their responses. The study analyzed the experiences of individuals with SCI and persistent impairments using an audit trail and reflective journal. A thematic guide and systematic analysis were conducted, with intentional sample selection to ensure maximum variation in injury and demographic factors.

Disclosure Statement
No potential conflict of interest was reported by the authors.

Ethical Considerations

Compliance with ethical guidelines
Ethical approval (Code of Ethics: IR.BUMS.REC.1401.305) and permission to conduct the study were obtained from Birjand University of Medical Sciences. The study’s objectives, data collection methods, audio recording during interviews, data confidentiality, and the anonymity of reports were explained to participants. Written informed consent was obtained from all participants who agreed to take part in the study.

Funding
This study is a part of the doctoral dissertation of Ali Sadeghi Akbari, a student in the Department of Nursing at Birjand University of Medical Sciences. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Authors' contributions
Conceptualization, Data Curation, Study Investigation, Project Administration, Resources, and Software: Ali Sadeghi Akbari; Supervision, Validation: Gholamhossein Mahmoudirad;Formal Analysis, and Methodology: All Authors.

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
The study expresses gratitude to all participants who provided valuable insights and experiences, contributing to the rich data that forms the basis of this research. We are grateful to Simin Sharafi and Mohammadreza Miri for providing constructive criticism that improved the quality of this work.
 

 

1. Fehlings MG, Tetreault LA, Wilson JR, Kwon BK, Burns AS, Martin AR, et al. A clinical practice guideline for the management of acute spinal cord injury: Introduction, rationale, and scope. Global Spine Journal. 2017; 7(3 Suppl):84S-94S. [DOI:10.1177/2192568217703387] [PMID] 
2. Noonan VK. A look at spinal cord injury in canada: rick hansen spinal cord injury registry (RHSCIR)-2021 SCI data summary. Topics in Spinal Cord Injury Rehabilitation. 2023; 29(Supplement):165-70. [DOI:10.46292/sci23-00031S] [PMID] 
3. Roy RR, Harkema SJ, Edgerton VR. Basic concepts of activity-based interventions for improved recovery of motor function after spinal cord injury. Archives of Physical Medicine and Rehabilitation. 2012; 93(9):1487-97. [DOI:10.1016/j.apmr.2012.04.034] [PMID]
4. Sand Å, Karlberg I, Kreuter M. Spinal cord injured persons’ conceptions of hospital care, rehabilitation, and a new life situation. Scandinavian Journal of Occupational Therapy. 2006; 13(3):183-92. [DOI:10.1080/11038120500542187] [PMID]
5. Collis Pellatt G. Patient-professional partnership in spinal cord injury rehabilitation. British Journal of Nursing. 2004; 13(16):948-53.  [DOI:10.12968/bjon.2004.13.16.15966] [PMID]
6. Kroll T, Groah S, Gilmore B, Neri M. Consumer-directed teaching of health care professionals involved in the care of people with spinal cord injury: The consumer-professional partnership program. The Journal of Continuing Education in Nursing. 2008; 39(5):228-34. [DOI:10.3928/00220124-20080501-05] [PMID]
7. House L, Russell H, Kelly E, Gerson A, Vogel L. Rehabilitation and future participation of youth following spinal cord injury: Caregiver perspectives. Spinal Cord. 2009; 47(12):882-6.  [DOI:10.1038/sc.2009.64] [PMID]
8. Davidson D, Noonan VK, Dvorak MF, Zhang H, Fisher CG. The impact of patient expectations on outcome following treatment for spinal trauma: Part 1: What are spine surgeons telling their patients? Spine. 2010; 35(19):1807-11. [DOI:10.1097/BRS.0b013e3181c15b5d] [PMID]
9. Dorstyn D, Mathias J, Denson L. Efficacy of cognitive behavior therapy for the management of psychological outcomes following spinal cord injury a meta-analysis. Journal of Health Psychology. 2011; 16(2):374-91. [DOI:10.1177/1359105310379063] [PMID]
10. Donnelly C, Eng JJ, Hall J, Alford L, Giachino R, Norton K, et al. Client-centred assessment and the identification of meaningful treatment goals for individuals with a spinal cord injury. Spinal Cord. 2004; 42(5):302-7. [DOI:10.1038/sj.sc.3101589] [PMID] 
11. Kinter ET, Prior TJ, Carswell CI, Bridges JF. A comparison of two experimental design approaches in applying conjoint analysis in patient-centered outcomes research: A randomized trial. The Patient: Patient-Centered Outcomes Research. 2012; 5(4):279-94. [DOI:10.1007/BF03262499] [PMID]
12. Moroni L, Colangelo M, Gallì M, Bertolotti G. [A "I would like to give him my life": Results of a psychological support intervention to caregivers of patients undergoing neuromotor rehabilitation (Italian)]. Giornale Italiano di Medicina del Lavoro ed Ergonomia. 2007; 29(3 Suppl B):B5-17. [PMID]
13. Mothabeng D, Malinga, CP, van der Merwe, C., Qhomane, PT,, Motjotji S. The views of patients with spinal cord injuries on their rehabilitation experience. South African Journal of Physiotherapy. 2007;63(3):22.  [DOI:10.4102/sajp.v63i3.139]
14. Amsters D, Schuurs S, Pershouse K, Power B, Harestad Y, Kendall M, et al. Factors which facilitate or impede interpersonal interactions and relationships after spinal cord injury: A scoping review with suggestions for rehabilitation. Rehabilitation Research and Practice. 2016; 2016:9373786. [DOI:10.1155/2016/9373786] [PMID] 
15. Lucke KT. Outcomes of nurse caring as perceived by individuals with spinal cord injury during rehabilitation. Rehabilitation Nursing. 1999; 24(6):247-53. [DOI:10.1002/j.2048-7940.1999.tb02191.x] [PMID]
16. Galehdar N, Heydari H. Explaining the challenges of Iranian caregivers in provision of home health care to spinal cord injury patients: A qualitative study. BMC Nursing. 2024; 23(1):142. [DOI:10.1186/s12912-024-01797-0] [PMID] 
17. Dalvand S, Hammam N, Mirzaei N, Gheshlagh RG. Health-related quality of life of patients with spinal cord injury in Iran: A systematic review and meta-analysis. Shiraz E-Medical Journal. 2020; 21(1):e91402. [DOI:10.5812/semj.91402]
18. Sullivan J. Surviving uncertainty and projecting recovery: a qualitative study of patients' and family members' experiences with acute spinal cord injury. SCI Nursing. 2001; 18(2):78-86. [PMID]
19. Whalley Hammell K. Experience of rehabilitation following spinal cord injury: A meta-synthesis of qualitative findings. Spinal cord. 2007; 45(4):260-74. [DOI:10.1038/sj.sc.3102034] [PMID]
20. Van Leeuwen CM, Post MW, Van Asbeck FW, Bongers-Janssen HM, Van Der Woude LH, De Groot S, et al. Life satisfaction in people with spinal cord injury during the first five years after discharge from inpatient rehabilitation. Disability and Rehabilitation. 2012; 34(1):76-83. [DOI:10.3109/09638288.2011.587089] [PMID]
21. DeJong G, Tian W, Hsieh C-H, Junn C, Karam C, Ballard PH, et al. Rehospitalization in the first year of traumatic spinal cord injury after discharge from medical rehabilitation. Archives of Physical Medicine and Rehabilitation. 2013; 94(4):S87-S97. [DOI:10.1016/j.apmr.2012.10.037] [PMID]
22. Shamshiri M, Eskandar Oghli B, Vafaee M, Molaei B. [Adaptive coping strategies in patients with spinal cord injury: A phenomenological study (Persian)]. Iranian Journal of Psychiatry and Clinical Psychology. 2021; 26(4):478-89. [DOI:10.32598/ijpcp.26.3.2975.1]
23. Hennink M, Hutter I, Bailey A. Qualitative research methods. Thousand Oaks: Sage Publications; 2020. [Link]
24. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups. International Journal for Quality in Health Care. 2007; 19(6):349-57. [DOI:10.1093/intqhc/mzm042] [PMID]
25. Silva GAd, Schoeller SD, Gelbcke FL, Carvalho ZMF, Silva EMJP. Functional assessment of people with spinal cord injury: use of the functional independence measure-FIM. Texto & Contexto-Enfermagem. 2012; 21(4):929-36. [DOI:10.1590/S0104-07072012000400025]
26. Hsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qualitative Health Research. 2005; 15(9):1277-88. [DOI:10.1177/1049732305276687] [PMID]
27. Speziale HS, Streubert HJ, Carpenter DR. Qualitative research in nursing: Advancing the humanistic imperative. London: Lippincott Williams & Wilkins; 2011. [Link]
28. Lindgren BM, Lundman B, Graneheim UH. Abstraction and interpretation during the qualitative content analysis process. International Journal of nursing studies. 2020; 108:103632. [DOI:10.1016/j.ijnurstu.2020.103632] [PMID]
29. Lincoln YS, Guba EG. Naturalistic inquiry. Thousand Oaks: Sage; 1985. [Link]
30. AlHuthaifi F, Krzak J, Hanke T, Vogel LC. Predictors of functional outcomes in adults with traumatic spinal cord injury following inpatient rehabilitation: A systematic review. The Journal of Spinal cord Medicine. 2017; 40(3):282-94. [DOI:10.1080/10790268.2016.1238184] [PMID] 
31. Consortium for Spinal Cord Medicine. Outcomes following traumatic spinal cord injury: Clinical practice guidelines for health-care professionals. The Journal of Spinal Cord Medicine. 2000; 23(4):289-316. [PMID]
32. McGonigal K. Yoga for pain relief: Simple practices to calm your mind and heal your chronic pain. Oakland: New Harbinger Publications; 2009. [Link]
33. Min JA, Lee CU, Hwang SI, Shin JI, Lee BS, Han SH, et al. The moderation of resilience on the negative effect of pain on depression and post-traumatic growth in individuals with spinal cord injury. Disability and Rehabilitation. 2014; 36(14):1196-202. [DOI:10.3109/09638288.2013.834985] [PMID]
34. Newton-John TR, Mason C, Hunter M. The role of resilience in adjustment and coping with chronic pain. Rehabilitation Psychology. 2014; 59(3):360. [DOI:10.1037/a0037023] [PMID]
35. Pellatt GC. Patients, doctors, and therapists perceptions of professional roles in spinal cord injury rehabilitation: Do they agree? Journal of Interprofessional Care. 2007; 21(2):165-77. [DOI:10.1080/13561820701195567] [PMID]
36. Mohammadi F, Oshvandi K, Bijani M, Borzou SR, Khodaveisi M, Masoumi SZ. Perception of facing life’s challenges in patients with spinal cord injury in Iran: a qualitative study. BMC Psychology. 2022; 10(1):202. [DOI:10.1186/s40359-022-00909-2] [PMID] 
37. Kashdan TB, Kane JQ. Post-traumatic distress and the presence of post-traumatic growth and meaning in life: Experiential avoidance as a moderator. Personality and Individual Differences. 2011; 50(1):84-9. [DOI:10.1016/j.paid.2010.08.028] [PMID]

Supplementary 1. Interview Guide
Interview guide
1) Thank you for participating in this interview. 2) The purpose of this interview is to understand your experiences following your SCI, how you have overcome obstacles, and how you have taken steps towards independence despite the challenges. 3) Completing this interview will take approximately 45 to 60 min.
Before we begin
1) Please let me know if you do not understand any questions during the interview. 2) There are no right or wrong answers; therefore, please feel free to answer honestly and openly. 3) I am not looking for scientific opinions, and I would like you to express what you have personally experienced. 4) If there is a question you do not wish to answer, we can move on to the next one. 5) You may stop at any time without giving a reason. 6) The interview will be recorded, but the data will be securely stored and deleted after analysis. 7) Your responses and quotes will remain anonymous and will not be reproduced in any way to reveal your identity. 8) Do you have any questions or concerns about the interview? 9) Do you still agree to have the interview recorded (even if written consent has been obtained)?
The interview will cover one main area
The role that your family, friends, and therapists have played in your recovery or in creating challenges in your rehabilitation process, and how you have overcome the obstacles around you and taken steps towards independence despite the difficulties.
Background
1) Can you tell me the story of your accident? The impact of the injury? 2) How has this injury affected your life? 3) Can you talk about your coping and recovery processes after the SCI? 4) Can you describe any changes you have experienced since the SCI (e.g. about yourself, your relationships, your beliefs about the injury, or the impact of others on you)? 5) Can you describe a turning point in your life after the SCI? Were there any specific factors that helped or hindered your transformation? 6) Has this injury changed what is important to you now and in the future? How have others influenced that? 7) How have you coped with or accepted or rejected the looks and words of others?
In subsequent interviews (in addition to the previous questions), the dimensions and characteristics of the results identified in previous interviews will be examined, and as the dimensions and characteristics of the concepts emerge, the questions for the next interview will be guided.
1) In previous interviews, people identified... 2) Is this important to you? Why? 3) Is this the same thing you would describe... or would you have a similar or different experience?
Ending question: Is there anything else you would like to say about your experiences with a SCI that we have not had a chance to discuss yet?
Probes: Probes may include:
1) “Can you give me an example?” 2) “When you said..., what did you mean?” 3) “Please elaborate on...” Silence was also used as a probe to encourage participants to continue.