Associations between psychological factors and quality of life ratings in persons with spinal cord injury: a systematic review

Experiences with euthanasia requests of persons with SCI in Belgium

Introduction

Living with SCI remains a challenge and some patients fear or are faced with an inability to master this challenge sufficiently to regain a satisfactory quality of life. The suicide rate within the population with SCI is elevated compared with the general population. Especially now that life expectancy of persons with SCI and age at onset of SCI are increasing, caregivers of persons with SCI can be confronted with requests for end-of-life care or even assistance in dying. Euthanasia remains worldwide a controversial topic, but has rarely been discussed in the context of SCI.

Case presentation

The medical history and the results of in-depth interviews with three persons with tetraplegia, between 36 and 88 years old, with a profound and repeated request for euthanasia testify of the importance of an open-minded dialogue concerning end-of-life questions, in which all options can be considered, and limits of patients' capacities and best care results are acknowledged.

Conclusion

These cases suggest that a well-regulated strictly controlled legal framework, handled with prudence and proficiency, can be an added value to the care for persons with SCI.

Coping Flexibility as Predictor of Distress in Persons With Spinal Cord Injury

OBJECTIVES

Examine whether coping flexibility at admission to first spinal cord injury (SCI) rehabilitation was predictive of distress 1 year after discharge.

DESIGN

Longitudinal inception cohort study.

SETTING

Rehabilitation center.

PARTICIPANTS

Of the 210 people admitted to their first inpatient SCI rehabilitation program, 188 met the inclusion criteria. n=150 (80%) agreed to participate; the data of participants (N=113) with a complete dataset were used in the statistical analysis.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Coping flexibility was operationalized by (1) flexible goal adjustment (FGA) to given situational forces and constraints and (2) tenacious goal pursuit (TGP) as a way of actively adjusting circumstances to personal preference. The Assimilative-Accommodative Coping Scale was used to measure FGA and TGP. The Hospital Anxiety and Depression Scale was used to assess distress.

RESULTS

Scores on FGA and TGP measured at admission were negatively associated with the scales depression (r= -.33 and -.41, respectively) and anxiety (r= -.23 and -.30, respectively) 1 year after discharge. All demographic and injury-related variables at admission together explained a small percentage of the variance of depression and anxiety. FGA, TGP, and the interaction term together explained a significant additional 16% of the variance of depression and 10% of anxiety.

CONCLUSIONS

The tendency to pursue goals early postonset of the injury seems to have a protecting effect against distress 1 year after discharge. People with low TGP may experience protection against distress from high FGA.

Self-Management and Self-Efficacy in Patients With Acute Spinal Cord Injuries: Protocol for a Longitudinal Cohort Study

Background

People with recently acquired spinal cord injury (SCI) experience changes in physical, social and psychological aspects of their lives. In the last decades, attention has grown for aspects of self-management and self-efficacy in SCI research. However, we still do not know what the self-management and self-efficacy outcomes of first rehabilitation are and whether utilizing these skills may prevent secondary health conditions (SHCs) and increase participation and psychological adjustment early after SCI.

Objective

To describe the course and determinants of self-management and self-efficacy during and after first SCI rehabilitation; and to determine theory-based associations between self-management and self-efficacy with SHCs, participation and psychological adjustment.

Methods

Multicenter prospective longitudinal cohort study. All people with a newly acquired SCI admitted to one of the 8 specialized SCI rehabilitation centers in the Netherlands will be considered for inclusion in this study. Main assessments will take place during the first and last week of admission and 3, 6 and 12 months after discharge. The target sample is 250 participants. The primary outcomes are self-management (knowledge and execution of self-care) and self-efficacy (confidence in the ability to manage the consequences of SCI and of self-care). Secondary outcome measures are SHCs, participation and psychological adjustment to SCI.

Results

The first results with the complete set of data are expected in June 2019.

Conclusions

This protocol describes the SELF-SCI cohort study investigating self-management and self-efficacy of initial inpatient SCI rehabilitation. Second, associations will be investigated with SHCs, participation and psychological adjustment early after onset of SCI, until 1 year after discharge. The results will be used to test theories about motivation to perform health-promoting behaviors and adjustment to SCI.

Caregiver burden in amyotrophic lateral sclerosis: A systematic review

BACKGROUND

Informal caregivers of patients with amyotrophic lateral sclerosis experience increased levels of caregiver burden as the disease progresses. Insight in the factors related to caregiver burden is needed in order to develop supportive interventions.

AIM

To evaluate the evidence on patient and caregiver factors associated with caregiver burden in amyotrophic lateral sclerosis informal caregivers.

DESIGN

A systematic review.

DATA SOURCES

Four electronic databases were searched up to 2017. Studies that investigated quantitative relations between patient or caregiver factors and caregiver burden were included. The overall quality of evidence for factors was assessed using the Grading of Recommendations Assessment, Development and Evaluation approach.

RESULTS

A total of 25 articles were included. High quality of evidence was found for the relation between caregiver burden and the factor "behavioral impairments." Moderate quality of evidence was found for the relations between caregiver burden and the factors "feelings of depression" of the caregiver and "physical functioning" of the patient. The remaining rated caregiver factors-"feelings of anxiety," "distress," "social support," "family functioning," and "age"-and patient factors-"bulbar function," "motor function," "respiratory function," "disease duration," "disinhibition," "executive functioning," "cognitive functioning," "feelings of depression," and "age"-showed low to very low quality of evidence for their association with caregiver burden.

CONCLUSION

Higher caregiver burden is associated with greater behavioral and physical impairment of the patient and with more depressive feelings of the caregiver. This knowledge enables the identification of caregivers at risk for caregiver burden and guides the development of interventions to diminish caregiver burden.

Diferencias de sexo en el uso de estrategias de afrontamiento en personas con lesión medular

Objetivo: profundizar en la experiencia de afrontamiento en personas con lesión medular (LM), teniendo en cuenta tanto el afron- tamiento actual como el afrontamiento durante momentos iniciales tras sufrir la LM. Materiales y métodos: estudio transversal de encuesta. Participaron 127 personas con LM de larga evolución, 95 hombres y 32 mujeres. Los datos fueron recogidos por medio de un cuestionario online con información sociodemográfica y el Cuestionario de Afrontamiento del Estrés (CAE). Se han realizado análisis descriptivos, pruebas t de Student y análisis multivariados de la varianza (Manovas) Resultados: las comparaciones intrasujetos muestran que la estrategia de focalización en solución de problemas se usa más en el afrontamiento actual. La autofocalización negativa es más utilizada en el afrontamiento pasado, en los momentos iniciales tras sufrir la LM. Los resultados de los Manovas muestran que no existen diferencias en función del sexo en el afrontamiento rememorado ni en el actual. Los Anova de seguimiento para el afrontamiento actual evidencian que las mujeres utilizan más las estrategias de búsqueda de apoyo social y expresión emocional abierta. Conclusiones: no hay diferencias de sexo en el uso de las estrategias de afrontamiento en la LM. Se sugiere seguir investigando cómo el género puede actuar en este proceso.

Attachment Style Is Related to Quality of Life for Assistance Dog Owners

Attachment styles have been shown to affect quality of life. Growing interest in the value of companion animals highlights that owning a dog can also affect quality of life, yet little research has explored the role of the attachment bond in affecting the relationship between dog ownership and quality of life. Given that the impact of dog ownership on quality of life may be greater for assistance dog owners than pet dog owners, we explored how anxious attachment and avoidance attachment styles to an assistance dog affected owner quality of life (n = 73). Regression analysis revealed that higher anxious attachment to the dog predicted enhanced quality of life. It is suggested that the unique, interdependent relationship between an individual and their assistance dog may mean that an anxious attachment style is not necessarily detrimental. Feelings that indicate attachment insecurity in other relationships may reflect more positive aspects of the assistance dog owner relationship, such as the level of support that the dog provides its owner.

Personal and familial predictors of depressive feelings in people with orthopedic disability

<b>Background</b><br /> People with orthopedic disability experience limitations in physical ability, which can cause psychological problems such as depressive feelings. This paper investigates the role of family environment, caregiver characteristics, and personal resources in the acceptance of disability and depressive feelings of persons with orthopedic disability.<br /> <br /> <b>Participants and procedure</b><br /> Data were collected from 161 Turkish people with orthopedic disability (mean age = 35.60 years, SD = 10.18) and their family caregivers (e.g., parent, spouse). The participants with disability completed scales for functional independence, acceptance of disability, family environment, locus of control, learned resourcefulness, and depression. The family caregivers completed measures of social support, their own depression, burden of caregiving, and acceptance-rejection of their care recipient.<br /> <br /> <b>Results</b><br /> Analyses via multivariate statistics and SEM showed that depressive feelings of individuals with orthopedic disability and their acceptance of the disability were predicted by multiple factors, including the affected persons’ learned resourcefulness and locus of control, family environment, and interactions with their family caregiver, but not by their functional independence.<br /> <br /> <b>Conclusions</b><br /> Overall, a supportive family environment and acceptance of disability appear to lower the risk of having depression for individuals with orthopedic disability. Family caregivers’ attitudes towards their care recipients were related to the family environment, and feelings of burden appeared to impair the affected individuals’ acceptance of their condition.

Construct Validity of the EUROHIS-QOL for Rehabilitation Assessment

The use of the EUROHIS as a brief measure of quality of life (QOL) in applied settings is increasingly commonplace, including in rehabilitation assessment contexts. However, there are concerns about the validity of data produced by the measure, chief amongst which is the latent structure underlying scores. This article reports on research conducted to investigate the dimensionality of scores derived from the EUROHIS. In addition, the factorial invariance of the retained model across gender as well as latent mean differences in QOL over age, employment status, and psychiatric severity were examined. Based on 251 responses to the EUROHIS by compensable accident victims, support was found for a complex one-factor model, which was found to be partially replicable across gender. Some evidence for differential item functioning across gender, age, and employment status was found. Finally, a U-shaped effect of age on QOL, characterized by a mid-life nadir, as well as effects of psychiatric severity on QOL, and a marginally significant effect of employment status were evident. Collectively, though the results of the present study yield validation data for the EUROHIS, they also raise concerns about the measure. We offer some tentative guidelines for working with the measure for both researchers and practitioners.

Risk of Dementia in Patients with Spinal Cord Injury: A Nationwide Population-Based Cohort Study

Spinal cord injury (SCI) can cause physical disability and psychological distress; however, whether SCI is a risk factor for dementia is unclear. This study evaluated the incidence of dementia in patients with SCI. Study participants were recruited from a nationwide cohort during 2004-2007 and categorized into SCI (patients diagnosed with SCI; n = 941) and non-SCI (age- and sex-matched controls; n = 5060) cohorts. Each participant was followed for 7 years until diagnosis of dementia or December 31, 2010, whichever occurred first. Data were subjected to Kaplan-Meier and Cox regression analyses. The incidence of dementia was significantly higher in the SCI cohort (1106 per 100,000 person-years) than in the non-SCI cohort (p < 0.001). Patients with SCI had a significantly higher risk of dementia than did those without SCI (crude hazard ratio [HR] = 2.14, 95% confidence interval [CI], 1.57-2.92, p < 0.001 vs. adjusted HR = 1.95, 95% CI, 1.43-2.67, p < 0.001). Further analysis found that there is no statistical significance of higher risk for developing Alzheimer's disease among SCI patients, but that SCI patients were at higher risk of developing other types of dementia than the control cohort (crude HR = 1.88, 95% CI, 1.33-2.63, p < 0.001 vs. adjusted HR = 1.90, 95% CI, 1.35-2.68, p < 0.001). In conclusion, patients with SCI are at high risk of dementia, and effective dementia prevention strategies are recommended for comprehensive SCI care.

Effects of a Tailored Positive Psychology Intervention on Well-Being and Pain in Individuals With Chronic Pain and a Physical Disability: A Feasibility Trial

OBJECTIVES

To determine the feasibility, acceptability, and efficacy of a computer-based positive psychology intervention in individuals with a physical disability and chronic pain.

METHODS

Individuals with spinal cord injury, multiple sclerosis, neuromuscular disease, or postpolio syndrome and chronic pain were randomly assigned to a positive psychology or a control condition. Participants in the intervention group were instructed to practice 4 personalized positive psychology exercises. Participants in the control group were instructed to write about life details for 8 weeks. Participants completed online well-being and pain-related questionnaires at baseline, posttreatment, and at the 2.5-month follow-up, and rated treatment satisfaction at posttreatment.

RESULTS

Ninety-six participants were randomized and 68 (70%) completed follow-up assessments. Participants in the positive psychology intervention group reported significant pretreatment to posttreatment improvements in pain intensity, pain control, pain catastrophizing, pain interference, life satisfaction, positive affect, and depression. Improvements in life satisfaction, depression, pain intensity, pain interference, and pain control were maintained to the 2.5-month follow-up. Participants in the control group reported significant pretreatment to posttreatment improvements in life satisfaction, and pretreatment to follow-up improvements in pain intensity and pain control. Significant between-group differences, favoring the treatment group, emerged for pretreatment to posttreatment improvements in pain intensity and pain control. Participants were similarly satisfied with both treatments.

DISCUSSION/CONCLUSIONS

The results support the feasibility, acceptability, and potential efficacy of a computer-based positive psychology intervention for improving well-being and pain-related outcomes in individuals with physical disabilities and chronic pain, and indicate that a full trial of the intervention is warranted.

Five-Year Quality of Life Trajectories for Persons With Disabilities

The current study identified the longitudinal quality of life (QOL) trajectories of individuals with disabilities as well as the predictors of those trajectories. It examined a secondary data set, the Panel Survey of Employment for the Disabled (PSED), conducted by the Korea Employment Agency for the Disabled (KEAD). Data were gathered over 5 years from individuals with disabilities and analyzed using growth mixture modeling to identify the best QOL trajectory model. Covariates, physical dependence, experience of discrimination, emotional stability, self-esteem, religion, and degenerative type of disability were explored as trajectory predictors. Analysis revealed four latent classes: a high and stable QOL class, a high and varied QOL class, a low and stable QOL class, and a low and varied QOL class. Analysis of predictors indicated degenerative type of disability, physical dependence, discrimination, emotional stability, and self-esteem differentiated the high and stable QOL group from other groups. Significance, limitations, and implications for future practice and research are also discussed.

Associations between psychological factors and health-related quality of life and global quality of life in patients with ALS: a systematic review

OBJECTIVE

To systematically identify and appraise evidence on associations between psychological factors (moods, beliefs, personality) and Health-related QoL (HRQoL) and/or global QoL in patients with Amyotrophic Lateral Sclerosis (ALS).

METHODS

A systematic review was conducted in several online databases (PsycINFO, EMBASE, PubMed and CINAHL) up to October 2015. Articles were included if they reported associations between psychological factors (moods, beliefs and personality) and HRQoL and/or global QoL in an ALS population. The search was limited to empirical studies, published in English, which provided quantitative data. The methodological quality of the included articles was assessed.

RESULTS

In total, 22 studies were included. Mood was investigated in 14 studies, beliefs in 11 studies and personality in one study. Fifteen different psychological factors were extracted and assessed using 24 different measures. Twelve different QoL measures were used in the selected studies, subdivided into seven different HRQoL measures and five different global QoL measures. Higher levels of anxiety and depression appeared to be related to a poorer HRQoL, whereas a higher level of religiosity seemed to be associated with better global QoL. No conclusive associations were found for confusion-bewilderment (mood), spirituality, mindfulness, coping styles, hopelessness, perception of burden, cognitive appraisal (beliefs), neuroticism, extraversion, openness, agreeableness and conscientiousness (personality), due to insufficient or inconsistent evidence. Religiosity and spirituality appeared to become more positively associated over time.

CONCLUSIONS

Our results suggest that higher levels of anxiety and depression are related to a poorer HRQoL, whereas higher levels of religiosity appeared to be related to better global QoL. Associations might change during the disease course. This review supports the importance of psychological factors with regard to ALS care. Further research is needed to supplement the available evidence and to investigate how psychological factors can be modified to improve QoL.

REVIEW REGISTRATION NUMBER

PROSPERO 2015:CRD42015027303.

Psychosocial aspects of spinal cord injury pain: a meta-analysis

STUDY DESIGN

Meta-analysis.

OBJECTIVES

Although the association between modifiable psychosocial factors and spinal cord injury (SCI) pain has been identified, the full range of psychological and social difficulties for those who experience acute and/or persistent pain remains unclear. This meta-analysis consolidates the available evidence, using the International Classification of Functioning, Disability and Health (ICF) as a reference framework.

METHODS

Nineteen studies that examined persistent neuropathic, nociceptive or mixed pain subtypes in adults with a SCI (newly acquired and chronic; Nparticipants=2934) were identified from electronic database searches. Standardised mean differences between SCI pain and no-pain groups on self-reported psychosocial outcomes were calculated, along with 95% confidence intervals, fail-safe Ns and heterogeneity statistics.

RESULTS

Twenty individual outcomes were grouped into nine ICF-related categories. Emotional functions were the most frequent (100%) psychosocial outcomes assessed, with pain contributing to heightened stress (d=-0.85), depression (d=-2.49) anxiety (d range=-0.85 to -1.45), poor self-efficacy (d=-0.77), lowered wellbeing (d range=-0.67 to -1.02) and decreased use of adaptive coping, such as illness acceptance (d=-0.85). Activity limitations and participation restriction were examined by seven studies (43%), although these findings were largely characterised by single studies.

CONCLUSIONS

Multicomponent treatments that target mood disturbance and foster community connections are important in SCI pain management. However, to improve the comparability of future studies, SCI pain research must adopt definitions of pain consistent with the International Spinal Cord Injury Pain Classification along with validated outcomes that map onto the ICF framework.

Global meaning in people with spinal cord injury: Content and changes

BACKGROUND

After spinal cord injury (SCI), people are confronted with abrupt discontinuity in almost all areas of life, leading to questions on how to live a meaningful life again. Global meaning refers to basic ideas and goals that guide people in giving meaning to their lives, in specific situations. Little is known about global meaning relating to SCI and whether global meaning changes after SCI.

PURPOSE

The purpose of this study was twofold: (i) to explore the content of global meaning of people with SCI, and (ii) to explore whether or not global meaning changes after SCI.

METHODS

In-depth semi-structured interviews were conducted with 16 people with SCI. Interviews were analyzed according to the method of grounded theory.

RESULTS

(i) Five aspects of global meaning were found: core values, relationships, worldview, identity and inner posture. (ii) Overall, little change in the content of global meaning was found after SCI; specific aspects of global meaning were foregrounded after SCI.

CONCLUSION

Five aspects of global meaning were found in people with SCI. Global meaning seems hardly subject to change.

Preinjury coping, emotional functioning, and quality of life following uncomplicated and complicated mild traumatic brain injury

OBJECTIVE

To identify preinjury coping profiles among adults with uncomplicated mild traumatic brain injury (mTBI) and complicated mTBI and to determine whether preinjury coping profiles contribute to the prediction of emotional functioning and quality of life (QOL) 3 months post-mTBI.

PARTICIPANTS

One hundred eighty-seven persons with medically documented mTBI (uncomplicated mTBI, n = 89; complicated mTBI, n = 98) were recruited from the emergency center of a level I trauma center and followed in community 3 months post-mTBI.

MEASURES

The Ways of Coping Questionnaire was administered within 2 weeks of injury. Cluster analysis was used to group participants on basis of their preinjury use of problem-focused and avoidant coping strategies. The Brief Symptom Inventory and the 36-item Short-Form Health Survey were administered 3 months postinjury.

RESULTS

Cluster analysis distinguished 3 distinct preinjury coping profiles that were differentially associated with outcomes. Participants who used avoidant coping showed the worse emotional functioning and QOL outcomes, although this cluster also reported high usage of problem-focused strategies. Preinjury coping profiles explained a significant proportion of the variance in depression, anxiety, and mental health QOL at 3 months postinjury beyond that accounted for by demographic characteristics and mTBI severity.

CONCLUSIONS

Cluster analysis holds practical value in illustrating the pattern of coping strategies used by person with uncomplicated and complicated mTBI. It appears worthwhile to address coping in future trials of interventions that are aimed at improving emotional functioning after mTBI.

Toward an evidence-based patient-provider communication in rehabilitation: linking communication elements to better rehabilitation outcomes

Background:

There is a growing interest in linking aspects of patient-provider communication to rehabilitation outcomes. However, the field lacks a conceptual understanding on: (a) ‘how’ rehabilitation outcomes can be improved by communication; and (b) through ‘which’ elements in particular. This article elaborates on the conceptual developments toward informing further practice and research.

Methods:

Existing models of communication in healthcare were adapted to rehabilitation, and its outcomes through a comprehensive literature review.

Results:

After depicting mediating mechanisms and variables (e.g. therapeutic engagement, adjustment toward disability), this article presents the ‘4 Rehab Communication Elements’ deemed likely to underpin rehabilitation outcomes. The four elements are: (a) knowing the person and building a supportive relationship; (b) effective information exchange and education; (c) shared goal-setting and action planning; and (d) fostering a more positive, yet realistic, cognitive and self-reframing.

Discussion:

This article describes an unprecedented, outcomes-oriented approach toward the design of rehabilitation communication, which has resulted in the development of a new intervention model: the ‘4 Rehab Communication Elements’. Further trials are needed to evaluate the impact of this whole intervention model on rehabilitation outcomes.

Measuring positive affect and well-being after spinal cord injury: Development and psychometric characteristics of the SCI-QOL Positive Affect and Well-being bank and short form

OBJECTIVE

To develop an item response theory (IRT)-calibrated spinal cord injury (SCI)-specific Positive Affect and Well-being (PAWB) item bank with flexible options for administration.

DESIGN

Qualitative feedback from patient and provider focus groups was used to expand on the Neurological Disorders and Quality of Life (Neuro-QOL) positive affect & well-being item bank for use in SCI. New items were created and revised based on expert review and patient feedback and were then field tested. Analyses included confirmatory factor analysis, graded response IRT modeling and evaluation of differential item functioning (DIF).

SETTING

We tested a 32-item pool at several rehabilitation centers across the United States, including the University of Michigan, Kessler Foundation, Rehabilitation Institute of Chicago, the University of Washington, Craig Hospital and the James J. Peters/Bronx Department of Veterans Affairs hospital.

PARTICIPANTS

A total of 717 individuals with SCI answered the PAWB questions.

RESULTS

A unidimensional model was observed (Confirmatory Fit Index=0.947; Root Mean Square Error of Approximation=0.094) and measurement precision was good (reliability in theta of -2.9 to 1.2 is roughly equivalent to classical reliability of 0.95 or above). Twelve items were flagged for DIF, however, after examination of effect sizes, the DIF was determined to be negligible and would have little practical impact on score estimates. The final calibrated item bank resulted in 28 retained items

CONCLUSIONS

This study indicates that the Spinal Cord Injury--Quality of Life PAWB bank represents a psychometrically robust measurement tool. Short form items are also suggested and a computer adaptive test is available.

Measuring self-esteem after spinal cord injury: Development, validation and psychometric characteristics of the SCI-QOL Self-esteem item bank and short form

OBJECTIVE

To describe the development and psychometric properties of the Spinal Cord Injury-Quality of Life (SCI-QOL) Self-esteem item bank.

DESIGN

Using a mixed-methods design, we developed and tested a self-esteem item bank through the use of focus groups with individuals with SCI and clinicians with expertise in SCI, cognitive interviews, and item-response theory-(IRT) based analytic approaches, including tests of model fit, differential item functioning (DIF) and precision.

SETTING

We tested a pool of 30 items at several medical institutions across the United States, including the University of Michigan, Kessler Foundation, the Rehabilitation Institute of Chicago, the University of Washington, Craig Hospital, and the James J. Peters/Bronx Department of Veterans Affairs hospital.

PARTICIPANTS

A total of 717 individuals with SCI completed the self-esteem items.

RESULTS

A unidimensional model was observed (CFI=0.946; RMSEA=0.087) and measurement precision was good (theta range between -2.7 and 0.7). Eleven items were flagged for DIF; however, effect sizes were negligible with little practical impact on score estimates. The final calibrated item bank resulted in 23 retained items.

CONCLUSION

This study indicates that the SCI-QOL Self-esteem item bank represents a psychometrically robust measurement tool. Short form items are also suggested and computer adaptive tests are available.

Comparison of mental health between individuals with spinal cord injury and able-bodied controls in Neiva, Colombia

Although research has investigated the mental health of individuals with spinal cord injury (SCI), an overwhelming majority of this research has been conducted in the United States, Western Europe, and other developed countries. The purpose of this study was to compare the mental health of individuals with SCI with able-bodied controls in Neiva, Colombia, South America. Subjects included 40 Colombians with SCI and 42 age- and sex-matched controls (N = 82). The groups did not differ based on age, sex, years of education, or socioeconomic status. However, controls were twice as likely to be married. Four measures assessed mental health, including satisfaction with life (Satisfaction with Life Scale), depressive symptoms (Patient Health Questionnaire-9), self-esteem (Rosenberg Self-Esteem Scale), and anxiety (State-Trait Anxiety Inventory). In comparison with able-bodied controls, individuals with SCI reported significantly lower mental health on both depressive symptoms and satisfaction with life. These effect sizes were medium and large, respectively. The groups did not differ significantly on measures of self-esteem or anxiety. Mental health of individuals with SCI should be considered a central part of SCI rehabilitation interventions, particularly in Latin America.

Postacute rehabilitation quality of care: toward a shared conceptual framework

There is substantial interest in mechanisms for measuring, reporting, and improving the quality of health care, including postacute care (PAC) and rehabilitation. Unfortunately, current activities generally are either too narrow or too poorly specified to reflect PAC rehabilitation quality of care. In part, this is caused by a lack of a shared conceptual understanding of what construes quality of care in PAC rehabilitation. This article presents the PAC-rehab quality framework: an evidence-based conceptual framework articulating elements specifically pertaining to PAC rehabilitation quality of care. The widely recognized Donabedian structure, process, and outcomes (SPO) model furnished the underlying structure for the PAC-rehab quality framework, and the International Classification of Functioning, Disability and Health (ICF) framed the functional outcomes. A comprehensive literature review provided the evidence base to specify elements within the SPO model and ICF-derived framework. A set of macrolevel-outcomes (functional performance, quality of life of patient and caregivers, consumers' experience, place of discharge, health care utilization) were defined for PAC rehabilitation and then related to their (1) immediate and intermediate outcomes, (2) underpinning care processes, (3) supportive team functioning and improvement processes, and (4) underlying care structures. The role of environmental factors and centrality of patients in the framework are explicated as well. Finally, we discuss why outcomes may best measure and reflect the quality of PAC rehabilitation. The PAC-rehab quality framework provides a conceptually sound, evidence-based framework appropriate for quality of care activities across the PAC rehabilitation continuum.

Dynamic testing of learning potential in adults with cognitive impairments: A systematic review of methodology and predictive value

Dynamic testing includes procedures that examine the effects of brief training on test performance where pre- to post-training change reflects patients' learning potential. The objective of this systematic review was to provide clinicians and researchers insight into the concept and methodology of dynamic testing and to explore its predictive validity in adult patients with cognitive impairments. The following electronic databases were searched: PubMed, PsychINFO, and Embase/Medline. Of 1141 potentially relevant articles, 24 studies met the inclusion criteria. The mean methodological quality score was 4.6 of 8. Eleven different dynamic tests were used. The majority of studies used dynamic versions of the Wisconsin Card Sorting Test. The training mostly consisted of a combination of performance feedback, reinforcement, expanded instruction, or strategy training. Learning potential was quantified using numerical (post-test score, difference score, gain score, regression residuals) and categorical (groups) indices. In five of six longitudinal studies, learning potential significantly predicted rehabilitation outcome. Three of four studies supported the added value of dynamic testing over conventional testing in predicting rehabilitation outcome. This review provides preliminary support that dynamic tests can provide a valuable addition to conventional tests to assess patients' abilities. Although promising, there was a large variability in methods used for dynamic testing and, therefore, it remains unclear which dynamic testing methods are most appropriate for patients with cognitive impairments. More research is warranted to further evaluate and refine dynamic testing methodology and to further elucidate its predictive validity concerning rehabilitation outcomes relative to other cognitive and functional status indices.

Understanding Quality of Life in Adults with Spinal Cord Injury Via SCI-Related Needs and Secondary Complications

BACKGROUND

Understanding the factors that can predict greater quality of life (QoL) is important for adults with spinal cord injury (SCI), given that they report lower levels of QoL than the general population.

OBJECTIVES

To build a conceptual model linking SCI-related needs, secondary complications, and QoL in adults with SCI. Prior to testing the conceptual model, we aimed to develop and evaluate the factor structure for both SCI-related needs and secondary complications.

METHODS

Individuals with a traumatic SCI (N = 1,137) responded to an online survey measuring 13 SCI-related needs, 13 secondary complications, and the Life Satisfaction Questionnaire to assess QoL. The SCI-related needs and secondary complications were conceptualized into factors, tested with a confirmatory factor analysis, and subsequently evaluated in a structural equation model to predict QoL.

RESULTS

The confirmatory factor analysis supported a 2-factor model for SCI related needs, χ(2)(61, N = 1,137) = 250.40, P <.001, comparative fit index (CFI) = .93, root mean square error of approximation (RMSEA) = .05, standardized root mean square residual (SRMR) = .04, and for 11 of the 13 secondary complications, χ(2)(44, N = 1,137) = 305.67, P < .001, CFI = .91, RMSEA = .060, SRMR = .033. The final 2 secondary complications were kept as observed constructs. In the structural model, both vital and personal development unmet SCI-related needs (β = -.22 and -.20, P < .05, respectively) and the neuro-physiological systems factor (β = -.45, P < .05) were negatively related with QoL.

CONCLUSIONS

Identifying unmet SCI-related needs of individuals with SCI and preventing or managing secondary complications are essential to their QoL.

Comparing Antonovsky's sense of coherence scale across three UK post-industrial cities

OBJECTIVES

High levels of 'excess' mortality (ie, that seemingly not explained by deprivation) have been shown for Scotland compared to England and Wales and, especially, for its largest city, Glasgow, compared to the similarly deprived English cities of Liverpool and Manchester. It has been suggested that this excess may be related to differences in 'Sense of Coherence' (SoC) between the populations. The aim of this study was to ascertain whether levels of SoC differed between these cities and whether, therefore, this could be a plausible explanation for the 'excess'.

SETTING

Three post-industrial UK cities: Glasgow, Liverpool and Manchester.

PARTICIPANTS

A representative sample of more than 3700 adults (over 1200 in each city).

PRIMARY AND SECONDARY OUTCOME MEASURES

SoC was measured using Antonovsky's 13-item scale (SOC-13). Multivariate linear regression was used to compare SoC between the cities while controlling for characteristics (age, gender, SES etc) of the samples. Additional modelling explored whether differences in SoC moderated city differences in levels of self-assessed health (SAH).

RESULTS

SoC was higher, not lower, among the Glasgow sample. Fully adjusted mean SoC scores for residents of Liverpool and Manchester were, respectively, 5.1 (-5.1 (95% CI -6.0 to -4.1)) and 8.1 (-8.1 (-9.1 to -7.2)) lower than those in Glasgow. The additional modelling confirmed the relationship between SoC and SAH: a 1 unit increase in SoC predicted approximately 3% lower likelihood of reporting bad/very bad health (OR=0.97 (95% CI 0.96 to 0.98)): given the slightly worse SAH in Glasgow, this resulted in slightly lower odds of reporting bad/very bad health for the Liverpool and Manchester samples compared to Glasgow.

CONCLUSIONS

The reasons for the high levels of 'excess' mortality seen in Scotland and particularly Glasgow remain unclear. However, on the basis of these analyses, it appears unlikely that a low SoC provides any explanation.

Mediators of the Relationship Between Core Self-Evaluations and Life Satisfaction in Individuals With Spinal Cord Injuries

The objective of this study was to test a meditational model of the relationship between core self-evaluations (CSE) and life satisfaction in persons with spinal cord injuries. A quantitative descriptive design using multiple regression analysis was used. Two hundred forty-seven persons with spinal cord injuries participated in the online study. Hope, perceived health, autonomy, and social support were found to partially mediate the relationship between CSE and life satisfaction. CSE affected life satisfaction by first increasing hopeful thinking, positive health perceptions, a sense of autonomy, and support from others in persons with spinal cord injuries. Future research should explore the development of interventions to increase CSE to increase the positive variables that affect life satisfaction in individuals with spinal cord injuries.

Mediating effects of social support and self-concept on depressive symptoms in adults with spinal cord injury

STUDY DESIGN

Cross-sectional, correlational design.

OBJECTIVES

To examine the effects of individual demographics, activities of daily living, social support, and self-concept on depressive symptoms in people with spinal cord injury (SCI).

SETTING

A convenience sample of 135 adults with SCI was recruited from medical and rehabilitation centres in Taiwan.

METHODS

Face-to-face, structured interviews were employed to collect information. Study questionnaires included a demographic sheet, the Barthel scale, the modified Social Support Inventory, the Huang self-concept scale and the Beck Depression Inventory. Data were analysed by structural equation modelling (SEM).

RESULTS

The average age of the participants was 43.3 years (±11.98), the mean duration of injury was 114 months (±93.78), and most were males. Emotional support (r=-0.173, P<0.05) and appraisal support (r=-0.261, P<0.01) were negatively correlated with depressive symptoms. The best fitted SEM model included individual demographics and physical function, social support and self-concept as significant predictors of depressive symptoms, with self-concept acting as a mediator in this relationship. Participants' characteristics and social support both contributed substantial indirect effects on depressive symptoms via self-concept. Self-concept also mediated the relationship between education, income, physical functioning and participants' depressive symptoms.

CONCLUSION

For this sample, the more negative that individuals perceived themselves, the more likely they were to report worsening depressive symptoms. The more social support that individuals have, the more likely they were to report less depressive symptoms. Further longitudinal research will help clarify the direction of these relationships.

Physical therapy after spinal cord injury: a systematic review of treatments focused on participation

Context Over the last four decades, the focus of spinal cord injury (SCI) rehabilitation has shifted from medical management to issues that affect quality of life and community participation. Physical therapists (PTs) need to design and implement interventions that result in maximal participation to provide an individual with SCI an effective rehabilitation program. Objective The aim of this review is to assess the extent, content, and outcomes of physical therapy (PT) interventions focused on improving the participation of individuals with SCI. Methods A search was conducted in Medline, Embase, CENTRAL, CINAHL, PEDro, and PsycINFO. We included studies, of all designs, focused on improving the participation of individuals with SCI using PT interventions.The primary author and a reviewer independently selected articles for inclusion, assessed articles quality, and extracted the data. Results Five studies met the inclusion criteria. The interventions applied were 9- and 12-month body weight-supported treadmill training in two studies, a supervised 9-month exercise program, a 12-week home exercise program, and a 10-week multidisciplinary cognitive behavioral program for coping with chronic neuropathic pain. Four of five PT interventions positively impacted the individual's perceived participation and satisfaction with participation. Conclusion The body of research by PTs on interventions to improve participation is limited. PTs must document the effects of interventions with a valid outcome tool to enable more research that examines participation. Expanding participation research will allow PTs to meet the needs of individuals with SCI and identify what interventions best facilitate integration into the community.

Mental health and risk of secondary medical complications in adults with pediatric-onset spinal cord injury

OBJECTIVE

To investigate mental health problems in adults with pediatric-onset spinal cord injury (SCI) and explore how these problems relate to the risk of negative outcomes over time.

METHOD

The study included 466 adults who sustained an SCI prior to age 19 years and had been injured for at least 1 year. Participants were interviewed on an approximately annual basis using a study-specific questionnaire and standardized measures of depression, anxiety, substance use, and community involvement. Generalized estimating equations were used to assess the risk of negative outcomes across time as a function of depression, anxiety, and substance misuse.

RESULTS

Of the participants who reported on each domain of mental health, 26% reported misuse of alcohol or drugs (122/466), 21% reported problems with depression (78/360), and 29% reported problems with anxiety (49/168). Depression was associated with increased odds of pressure ulcers, urinary tract infections, hospitalizations, pain, and smoking and lower levels of economic independence and mobility. Anxiety was associated with increased odds of hospitalization, pain, and smoking. Substance misuse predicted an increased risk of pressure ulcers, pain, and smoking and decreased odds of occupational involvement. When examining the effect of mental health with time, results showed that depression accelerated the risk of urinary tract infections, respiratory complications, and hospitalizations and anxiety and depression accelerated risk for lower occupational independence.

CONCLUSIONS

The added burden that mental health difficulties pose for medical and psychosocial outcomes highlight the importance of monitoring and treating mental health symptoms in pediatric-onset SCI.

Evaluating a spinal cord injury-specific model of depression and quality of life

OBJECTIVES

To determine whether demographic, injury, health, and functional factors similarly have the same predictive relation with both somatic and nonsomatic symptoms of depression, as well as whether somatic and nonsomatic symptoms of depression have the same association with quality of life (QOL).

DESIGN

Secondary analysis of cross-sectional survey data.

SETTING

Community

PARTICIPANTS

Patients with traumatic spinal cord injury (N=4976) who completed an interview at 1 year postinjury between 2006 and 2011.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Somatic and nonsomatic symptoms of depression from the Patient Health Questionnaire-9 and QOL measured by the Satisfaction With Life Scale.

RESULTS

Structural equation modeling showed that the hypothesized model provided a good fit to the data, but modification of the model led to a significant improvement in model fit: Δχ(2)(1)=226.21, P<.001; comparative fit index=.976; χ(2)(199)=585.39, P<.001; root mean square error of approximation=.027 (90% confidence interval, .025-.030). The health-related factors including pain severity, pain interference, and health status were similarly associated with both somatic and nonsomatic symptoms of depression. QOL was negatively associated with nonsomatic symptoms of depression but was unrelated to somatic symptoms of depression.

CONCLUSIONS

Assessment of depression after spinal cord injury should include a careful assessment of health concerns given the relation between health-related factors and both somatic and nonsomatic symptoms of depression. Treatments of depressive symptoms may be improved by targeting health concerns, such as pain, along with a specific focus on nonsomatic symptoms to improve the QOL.

Associations between social support and stroke survivors' health-related quality of life--a systematic review

OBJECTIVE

Social support to stroke survivors has been recognized as an important determinant of their health-related quality of life (HRQoL), but this relationship is not clarified to date. More insight in the relationships between various types (i.e. emotional, instrumental, or informational support) and sources (i.e. partner, children) of social support and HRQoL might target post-stroke educational and counseling interventions to strengthen patient's social networks and supportive relationships.

METHODS

Systematic review.

RESULTS

11 original articles could be included. Most of these articles studied the overall perceived social support without further specification of type or source. They show a positive relation between perceived social support and stroke survivors' HRQoL. Relations between perceived social support and HRQoL seems to be more often significant and were stronger than relationships between specific social support types or sources and HRQoL.

CONCLUSION

Due to the small number of studies and the heterogeneity in methods of assessing social support, a clear statement about the specific influence of social support source or type could not be made.

PRACTICE IMPLICATIONS

Attention should be paid to promoting social support on the short and long term. Further research is needed to clarify the influence of social support type and source.

The Influence of Psychological Factors on Health-Related Quality of Life after Stroke: A Systematic Review

Background and purpose

Many stroke patients experience problems with health-related quality of life, but much of the variance of health-related quality of life after stroke remains unexplained. Health-related quality of life may be influenced by psychological factors, as these factors reflect the way people approach situations and react to stressful situations. The aim of this study was to systematically examine the relationship between psychological factors and health-related quality of life after stroke.

Summary of review

A systematic literature search was conducted in online databases PubMed, Embase, PsycINFO, and CINAHL in November 2011. A total of nine studies were included. Personality (i.e. problems of temperament and personality functions and neuroticism) was moderately negatively associated with health-related quality of life ( r = 0·26–0·49). Coping (i.e. situational and personal adaptation), internal locus of control, self-worth (i.e. self-esteem and self-efficacy), and hope and optimism were moderately positively associated with health-related quality of life ( r = 0·026–0·81). No evidence was found for an association between extraversion and health-related quality of life.

Conclusions

There is still a paucity of studies on psychological determinants of poststroke health-related quality of life. The reviewed studies supported the importance of psychological factors, but further research is needed to supplement the available evidence and to examine how psychological factors can be modified to improve health-related quality of life, and at what moment after the stroke these interventions should be given.

Exploring positive adjustment in people with spinal cord injury

This study explored adjustment in people with spinal cord injury; data from four focus groups are presented. Thematic analysis revealed four themes, managing goals and expectations, comparison with others, feeling useful and acceptance, showing participants positively engaged in life, positively interpreted social comparison information and set realistic goals and expectations. These positive strategies show support for adjustment theories, such as the Cognitive Adaptation Theory, the Control Process Theory and Response Shift Theory. These results also provide insight into the adjustment process of a person with spinal cord injury and may be useful in tailoring support during rehabilitation.

Impact of quality improvement strategies on the quality of life and well-being of individuals with spinal cord injury: a systematic review protocol

BACKGROUND

After a spinal cord injury, quality of life, as well as the determinants of quality of life, has been widely assessed. However, to date, there have been no systematic reviews on the impact of quality improvement strategies, including self-management strategies, on the quality of life and well-being of individuals with a spinal cord injury. The current protocol outlines a strategy for a systematic review that aims to identify, assess, and synthesize evidence on the impact of quality improvement strategies on the quality of life and physical and psychological well-being of individuals with spinal cord injury.

METHODS/DESIGN

All study designs, except qualitative studies will be included. Studies reporting on quality improvement including audit and feedback, case management, team changes, electronic patient registries, clinician education, clinical reminders, facilitated relay of clinical information to clinicians, patient education, (promotion of) self-management, patient reminder systems, and continuous quality improvement among individuals with spinal cord injury will be included. The primary outcome is quality of life. The secondary outcomes are physical and psychological well-being. Studies will be included regardless of publication status, year of dissemination, or language of dissemination. Potentially relevant articles not written in English will be translated. We will search Medline, CINAHL, EMBASE, and PsycINFO. The use of these databases will be supplemented by other data sources, including unpublished data. Two independent reviewers will conduct all levels of screening, data abstraction, and quality appraisal. Results will be grouped according to the target group of the varying quality improvement strategies (that is, health system, health-care professionals, or patients) and/or by any other noteworthy grouping variable, such as etiology of spinal cord condition or by sex. If deemed appropriate, a meta-analysis will be conducted.

DISCUSSION

This systematic review will identify those quality improvement strategies aimed at the health system, health-care professionals, and patients that impact the quality of life and well-being of individuals with spinal cord injury. Knowledge and application of such quality improvement strategies may reduce inappropriate health-care utilization costs, such as acute care inpatient readmission in the years post injury. Prospero registry number: CRD42012003058.

Active LifestyLe Rehabilitation interventions in aging spinal cord injury (ALLRISC): a multicentre research program

BACKGROUND

With today's specialized medical care, life expectancy of persons with a spinal cord injury (SCI) has considerably improved. With increasing age and time since injury, many individuals with SCI, however, show a serious inactive lifestyle, associated with deconditioning and secondary health conditions (SHCs) (e.g. pressure sores, urinary and respiratory tract infections, osteoporosis, upper-extremity pain, obesity, diabetes, cardiovascular disease) and resulting in reduced participation and quality of life (QoL). Avoiding this downward spiral, is crucial.

OBJECTIVES

To understand possible deconditioning and SHCs in persons aging with a SCI in the context of active lifestyle, fitness, participation and QoL and to examine interventions that enhance active lifestyle, fitness, participation and QoL and help prevent some of the SHCs.

METHODS

A multicentre multidisciplinary research program (Active LifestyLe Rehabilitation Interventions in aging Spinal Cord injury, ALLRISC) in the setting of the long-standing Dutch SCI-rehabilitation clinical research network.

RESULTS

ALLRISC is a four-study research program addressing inactive lifestyle, deconditioning, and SHCs and their associations in people aging with SCI. The program consists of a cross-sectional study (n = 300) and three randomized clinical trials. All studies share a focus on fitness, active lifestyle, SHCs and deconditioning and outcome measures on these and other (participation, QoL) domains. It is hypothesized that a self-management program, low-intensity wheelchair exercise and hybrid functional electrical stimulation-supported leg and handcycling are effective interventions to enhance active life style and fitness, help to prevent some of the important SHCs in chronic SCI and improve participation and QoL.

CONCLUSION

ALLRISC aims to provide evidence-based preventive components of a rehabilitation aftercare system that preserves functioning in aging persons with SCI.

A Longitudinal Cohort Study on Quality of Life in Stroke Patients and Their Partners: Restore4Stroke Cohort

Background

Stroke is a major cause of disability in the Western world. Its long-term consequences have a negative impact on the quality of life of both the patients and their partners.

Aim

The aim of the Restore4Stroke Cohort study is to investigate the changes in quality of life of stroke patients and their partners over time, and to determine factors predicting quality of life in several domains, especially personal and environmental factors.

Method

Multicentre prospective longitudinal cohort study. Inclusion and the first assessment take place during hospital stay in the first week post-stroke. Follow-up assessments take place at two months, six months, one year, and two years post-stroke. Recruitment of 500 patients from stroke units in six participation hospitals is foreseen. If the patient has a partner, he or she is also asked to participate in the study.

Outcomes

The main outcome is quality of life, considered from a health-related quality of life and domain-specific quality of life perspective. Factors predicting long-term quality of life will be determined by taking into account the health condition (pre-stroke health condition and stroke-related health condition), personal factors (e.g. coping and illness cognitions), and environmental factors (e.g. caregiver burden and social support).

Discussion

This study is expected to provide information about the changes in quality of life of stroke patients and their partners over time. Furthermore, the identification of factors predicting quality of life can be used to improve rehabilitation care and develop new interventions for stroke patients and their partners.

Trajectories and predictors of the course of mental health after spinal cord injury

OBJECTIVE

To study the course and predictors of mental health in the period between the start of active spinal cord injury (SCI) rehabilitation and 5 years after discharge. The hypothesis was that different mental health trajectories would be identified.

DESIGN

Multicenter prospective cohort study with measurements at the start of active rehabilitation, after 3 months, at discharge, 1, 2, and 5 years after discharge.

SETTING

Eight Dutch rehabilitation centers with specialized SCI units.

PARTICIPANTS

Persons (N=206) with recently acquired SCI aged between 18 and 65 years.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

The 5-item Mental Health Index with a total score between 0 (lowest mental health) and 100 (highest mental health).

RESULTS

Levels of mental health increased between the start of active rehabilitation and 3 months later, remained stable thereafter, and increased again between 2 and 5 years after discharge. Latent class growth mixture modeling revealed 5 trajectories: (1) high scores (above 80) at all time-points (52%), (2) low scores (≤60) at all time-points (4%), (3) early recovery from 40 to scores above 70 (13%), (4) intermediate scores from 60 to scores above 70 (29%), and (5) severe deterioration of scores above 70 to scores below 30 (2%). Pain, sex, and education level were predictors to distinguish between the 5 trajectories.

CONCLUSIONS

Five different mental health trajectories were identified between the start of active rehabilitation and 5 years after discharge. About one third of the persons with SCI still perceived moderate to severe mental health problems 5 years after discharge. Pain, sex, and education level only predicted a small part of the variance in mental health trajectories.