Impact of Fatigue on the Health-Related Quality of Life in Persons With Spinal Cord Injury

Intermittent hypoxia enhances voluntary activation and reduces performance fatigability during repeated lower limb contractions

Prior research has highlighted the therapeutic benefits of acute intermittent hypoxia (AIH) in enhancing motor performance after motor incomplete spinal cord injury and in able-bodied individuals. Although studies in rodents and humans indicate that AIH may facilitate motor excitability, the relationship between excitability changes and functional performance remains unclear. In addition, discrepancies in the effects of AIH on excitability in able-bodied individuals merit further investigation. Understanding the concurrent impact of repetitive AIH on voluntary activation and spinal reflex excitability may clarify the functional implications of AIH for muscle force production. High voluntary activation is vital for sustaining torque production during activities that require repeated muscle contractions. We hypothesized that repetitive AIH would attenuate decreases in both voluntary activation and maximum torque production typically observed during fatiguing contractions. To test this hypothesis, we examined the effects of four consecutive days of AIH on voluntary activation and torque generation during repeated maximal plantar flexion contractions. We assessed changes in voluntary activation using the central activation ratio by calculating the ratio of voluntary torque to the torque produced with supramaximal electrical stimulation. Consistent with our hypothesis, we show that repetitive AIH significantly increases both voluntary activation and peak torque during fatiguing contractions. We did not observe any changes in resting spinal reflex excitability or antagonist muscle coactivation during fatiguing contractions post-AIH. Together, these findings suggest that repetitive AIH reduces performance fatigability through enhanced descending neural drive. Optimizing voluntary activation is critical for facilitating the recovery of functional walking skills after neurological injury.NEW & NOTEWORTHY This study shows that repetitive acute intermittent hypoxia (AIH) significantly increases both voluntary activation and peak torque during fatiguing lower limb contractions. However, resting spinal reflex excitability and antagonist muscle coactivation during fatiguing contractions did not change following repetitive AIH. Together, these observations indicate that repetitive AIH reduces performance fatigability through enhanced descending neural drive. These findings underscore the therapeutic potential of AIH for promoting motor recovery after neurological injury.

Cognitive Failure in Adults with Spinal Cord Injury: A Valuable Adjunct Measure for Enhancing Cognitive Assessment and Rehabilitation Outcomes

Cognitive impairment is common in persons with spinal cord injury (SCI), impacting their daily functioning and rehabilitation. This study assesses the extent of self-reported cognitive failures in everyday life in persons with SCI and its relationships with objective neurocognitive measures and psychosocial factors, including depressive mood, anxiety, perceived control, and fatigue. The differences between forty-one adults with a chronic SCI and forty-one able-bodied controls were examined. The participants completed the Cognitive Failures Questionnaire (CFQ) to assess cognitive failure and neurocognitive tests assessing attention and executive functions, as well as a psychosocial assessment. The SCI group reported higher cognitive failure rates than the able-bodied group (31.7% versus 19%, p > 0.05). Objective neurocognitive tests did not significantly correlate with the CFQ scores in either group. However, the CFQ scores were positively associated with most psychosocial factors, even after controlling for covariates. The CFQ scores were significantly associated with depressive mood in persons with SCI. These findings highlight the importance of incorporating self-reported cognitive measures into neurocognitive assessments and rehabilitation planning for adults with SCI. Self-reports capture everyday cognitive challenges that objective tests may miss. Additionally, this study highlights the strong connections between cognitive failures and psychosocial issues, particularly mood disorders, emphasizing the need for comprehensive rehabilitation and psychosocial support post-SCI, addressing both cognitive and emotional wellbeing.

Cognitive Reserve and Its Association with Cognitive and Mental Health Status following an Acute Spinal Cord Injury

BACKGROUND

Mild cognitive impairment (MCI) is a common secondary condition associated with spinal cord injury (SCI). Cognitive reserve (CR) is believed to protect against cognitive decline and can be assessed by premorbid intelligence (pmIQ). Despite the potential utility of pmIQ as a complementary metric in the evaluation of MCI in SCI, this approach has been infrequently employed. The purpose of this study was to examine the association between MCI and pmIQ in adults with SCI with the aim of exploring the potential value of pmIQ as a marker of CR in this population.

METHODS

Cognitive function was assessed on three occasions in adults with SCI over a 12-month period post-injury, and pmIQ was assessed once at baseline. Demographic and mental health measures were also collected, and logistic regression was conducted to determine the strength of association between pmIQ and MCI while adjusting for factors such as mental health and age.

RESULTS

The regression analysis revealed that at the time of admission to SCI rehabilitation, the MCI assessed by a valid neurocognitive screen was strongly associated with pmIQ. That is, if a person has MCI, there was 5.4 greater odds (p < 0.01) that they will have poor pmIQ compared to a person without MCI after adjustment for age and mental health.

CONCLUSIONS

The assessment of CR is an important area that should be considered to improve the process of diagnosing MCI in adults with an acute SCI and potentially facilitate earlier intervention to slow or prevent cognitive decline.

Factors Associated With Fatigue in People With Spinal Cord Injury: A Systematic Review and Meta-analysis

OBJECTIVE

To investigate the association between fatigue and clinical and demographic variables in people with spinal cord injury (SCI).

DATA SOURCES

Five databases (MEDLINE, Physiotherapy Evidence Database, Cochrane, Google Scholar, Cumulative Index to Nursing and Allied Health) were searched up to November 2021.

STUDY SELECTION

Observational studies that reported the association between fatigue and clinical and demographic variables in English or Spanish were eligible. Reviews, qualitative research studies, and nonoriginal articles were excluded. Twenty-three of the 782 identified studies met the inclusion criteria for the meta-analysis.

DATA EXTRACTION

Two researchers independently extracted the data. The strength of the association between each factor and fatigue was determined by the effect size. When the results of the effect size were expressed with different statistics, the correlation coefficient was the preferred estimation. The risk of bias was assessed using the Appraisal Tool for Cross-Sectional Studies and the Newcastle-Ottawa Scale.

DATA SUMMARY

A pooled analysis of the associations between fatigue and 17 factors was performed. A direct association was found between fatigue and 9 factors (sorted by effect size): anxiety (r=0.57; 95% CI, 0.29-0.75), stress (r=0.54; 95% confidence interval [CI], 0.26-0.74), depression (r=0.47; 95% CI, 0.44-0.50), pain (r=0.34; 95% CI, 0.16-0.50), analgesic medication (r=0.32; 95% CI, 0.28-0.36), assistive devices (r=0.23; 95% CI, 0.17-0.29), lesion level (r=0.15; 95% CI, 0.07-0.23), incomplete SCI (r=0.13; 95% CI, 0.05-0.22), and medication (r=0.12; 95% CI, 0.01-0.23). An inverse association was found with 3 factors (sorted by effect size): self-efficacy (r=-0.63; 95% CI, -0.81 to -0.35), participation (r=-0.32; 95% CI, -0.58 to -0.001), and physical activity (r=-0.17; 95% CI, -0.28 to -0.05). No association was found with age, sex, educational level, time since injury, and spasticity.

CONCLUSIONS

Several factors were associated with fatigue in people with SCI, with those related to mental health showing the strongest associations. These results should be interpreted with caution because of the high heterogeneity observed in some factors.

A Mobile Phone Text Messaging Intervention to Manage Fatigue for People With Multiple Sclerosis, Spinal Cord Injury, and Stroke: Development and Usability Testing

BACKGROUND

Fatigue significantly affects daily functioning in persons with disabilities. Fatigue management can be challenging, and the information provided during routine physician visits to manage fatigue can be overwhelming. One way to address fatigue is to increase knowledge, skills, and confidence for self-management (ie, patient activation). Self-management programs have shown promising effects in targeting fatigue in persons with disabilities. However, satisfaction with self-management programs is low for persons with disabilities, and tailoring interventions to personalized needs has been recommended. SMS text messaging is increasingly being used to implement health behavior change interventions in a person's natural environment. Little has been done to link mobile health approaches with patient activation and self-management to address fatigue in persons with disabilities.

OBJECTIVE

This study aimed to develop and test a mobile phone-based fatigue self-management SMS text messaging intervention targeting patient activation in 3 groups of persons with disabilities: persons with multiple sclerosis, persons who had a stroke, and persons with a spinal cord injury.

METHODS

We used evidence-based resources and input from a consumer advisory board (CAB; composed of 2 participants from each of the 3 disability groups) and a neurologist to develop the intervention. The study was conducted using a 4-step process: development of the initial SMS text messaging library and categorization of the content into 9 content areas, review and modification of the SMS text messages by the neurologist and CAB, integration of the content library into a digital platform, and utility testing by CAB members.

RESULTS

A total of 6 CAB participants rated SMS text messages covering 9 domain areas of fatigue self-management with good clarity (mean ratings=3.5-5.0 out of 5) and relevance (mean ratings=3.2-5.0 out of 5). Overall, SMS text messaging content was reported by CAB participants as helpful, clear, and well suited for a mobile health intervention. The CAB reached consensus on the time of day that SMS text messages should be sent (morning) and their frequency (once per day). This feedback led the research team to narrow down the program to deliver 48 SMS text messages, 1 per day, Monday through Thursday only, a total of 4 SMS text messages per week, over a 12-week period. The final set of SMS text messages was programmed into a digital platform with a predefined delivery schedule. The usability of the intervention was high, with 55 (83%) out of 66 responses endorsing the highest rating.

CONCLUSIONS

This study demonstrates a step-by-step process for developing a fatigue self-management SMS text messaging intervention for persons with disabilities. For this population, whose access to health services is often limited, this intervention provides an alternative delivery model to increase access to fatigue information and deliver content that aligns with the person's needs.

Hand Motor Fatigability Induced by a Simple Isometric Task in Spinal Cord Injury

This study aimed: (1) to evaluate the hand motor fatigability in people with spinal cord injury (SCI) and compare it with measurements obtained form an able-bodied population; (2) to compare the hand motor fatigability in people with tetraplegia and in people with paraplegia; and (3) to analyse if motor fatigability is different in people with SCI with and without clinical significant perceived fatigability. Materials and Methods: 96 participants with SCI (40 cervical and 56 thoracolumbar) and 63 able-bodied controls performed a simple hand isometric task to assess motor fatigability. The Fatigue Severity Scale was used for perceived fatigability evaluation. Results: The main results of this study can be summarized as follows: (1) the waning in muscle force (motor fatigability) during a fatiguing task is similar in controls and participants with SCI; (2) the motor fatigability is influenced by the maximal muscle force (measured at the beginning of the task); and (3) the perceived fatigability and the motor fatigability are largely independent in the individuals with SCI. Conclusion: Our findings suggest that the capability to maintain a prolonged effort is preserved in SCI, and this capacity depends on the residual maximal muscle force in people with SCI.

Investigating Dynamics of the Spinal Cord Injury Adjustment Model: Mediation Model Analysis

Spinal cord injury (SCI) is a severe neurological injury that results in damage to multiple bodily systems. SCI rehabilitation requires a significant focus on improving adjustment to the injury. This paper presents a detailed description of the Spinal Cord Injury Adjustment Model (SCIAM), which clarifies how individuals adjust to SCI and contends that adjustment to SCI is a multifactorial process involving non-linear dynamic adaptation over time. Evidence supporting SCIAM is also discussed. Mediation analyses were conducted to test the mediator dynamics proposed by the model. The analyses tested the relationship between two moderators (self-care and secondary health conditions), mediators (two self-efficacy items and appraisal of quality of life or QoL), and positive versus negative vitality/mental health as outcomes. Results showed that higher self-efficacy and perceived QoL was related to greater independence in self-care and reduced negative impacts of secondary health conditions. This study supported the mediation role of self-efficacy and other appraisals such as perceived QoL in enhancing self-care and buffering the negative impact of health challenges. In conclusion, it is important to employ a holistic model such as SCIAM to conceptualise and increase understanding of the process of adjustment following a severe neurological injury such as SCI.

Trans-Spinal Electrical Stimulation Therapy for Functional Rehabilitation after Spinal Cord Injury: Review

Spinal cord injury (SCI) is one of the most debilitating injuries in the world. Complications after SCI, such as respiratory issues, bowel/bladder incontinency, pressure ulcers, autonomic dysreflexia, spasticity, pain, etc., lead to immense suffering, a remarkable reduction in life expectancy, and even premature death. Traditional rehabilitations for people with SCI are often insignificant or ineffective due to the severity and complexity of the injury. However, the recent development of noninvasive electrical neuromodulation treatments to the spinal cord have shed a ray of hope for these individuals to regain some of their lost functions, a reduction in secondary complications, and an improvement in their life quality. For this review, 250 articles were screened and about 150 were included to summarize the two most promising noninvasive spinal cord electrical stimulation methods of SCI rehabilitation treatment, namely, trans-spinal direct current stimulation (tsDCS) and trans-spinal pulsed current stimulation (tsPCS). Both treatments have demonstrated good success in not only improving the sensorimotor function, but also autonomic functions. Due to the noninvasive nature and lower costs of these treatments, in the coming years, we expect these treatments to be integrated into regular rehabilitation therapies worldwide.

COVID-19 lockdowns' effects on the quality of life, perceived health and well-being of healthy elderly individuals: A longitudinal comparison of pre-lockdown and lockdown states of well-being

PURPOSE

. The concept of lockdown in relation to COVID-19 is thought to have an indirect impact on the quality of life and well-being of the elderly due to its consequences on the physical, psychological, and cognitive health of individuals. However, previous published studies on this subject are limited in terms of methodological approach used, including the absence of pre-confinement status and the type of experimental design, which is often cross-sectional. The present study proposes a longitudinal design with pre-confinement measures. It assesses changes in quality of life, perceived health, and well-being by comparing the period before lockdown (T1 = December 2019), three months after the start of the first lockdown (T2 = June 2020), and during the second lockdown (T3 = January 2021) due to COVID-19.

MATERIALS AND METHODS

. This study is conducted with a group of 72 healthy elderly persons. They completed an electronic (online) survey assessing personal factors, activities, and participation as well as responding to the EuroQol-5D and Warwick-Edinburgh Mental Well-being Scale.

RESULTS

. A decrease in quality of life, perceived health and well-being was observed between T1 and T2 and between T1 and T3, but no difference was reported between the two lockdown periods. The variables associated with these changes included energy level, level of happiness, physical activity, change in medical condition, memory difficulties, level of perceived isolation and age.

CONCLUSION

. This study will help to target variables that may have a deleterious effect on older adults for consideration in future confinement settings and for preventive purposes.

Assessment of the unmediated relationship between neurological impairment and health-related quality of life following spinal cord injury

Objective: To assess the unmediated association between neurological impairment and quality of life (QoL) among persons with spinal cord injury (SCI), in the context of both early post-acute and long-term rehabilitation settings.Design: An observational prospective cross-sectional study.Setting: Two neurological rehabilitation centers, specializing in spinal cord injury, within a university hospital.Methods: 156 adults with spinal cord injury in the early post-acute and chronic stages of rehabilitation.Outcome Measures: Participants were categorized into tetraplegia or paraplegia groups based on neurological level of injury, and into complete or incomplete groups based on American Spinal Injury Association (ASIA) Impairment Scale (AIS) score. QoL was assessed by means of the World Health Organization Quality of Life Assessment-BREF (WHOQOL-BREF), Satisfaction with Life Scale (SWLS), Life Satisfaction Questionnaire (LISAT-9), and Personal Well-Being Index (PWI).Results: WHOQOL-BREF and PWI predicted Level of Injury group classification and WHOQOL-BREF predicted Setting group classification. None of the questionnaires differentiated between the Type of Injury groups. At the early post-acute stage of rehabilitation, the QoL scores of participants with tetraplegia and paraplegia did not differ significantly, while significantly higher QoL scores were revealed in paraplegics in the long-term setting group.Conclusions: A direct, unmediated effect of severity of neurological impairment was revealed with the WHOQOL-BREF, which distinguished between the tetraplegia and paraplegia groups, but not between the complete and incomplete injuries. QoL was significantly higher in paraplegia than in tetraplegia following the early post-acute stage of rehabilitation.

How Do Fluctuations in Pain, Fatigue, Anxiety, Depressed Mood, and Perceived Cognitive Function Relate to Same-Day Social Participation in Individuals With Spinal Cord Injury?

OBJECTIVE

This study aimed to examine same-day associations of pain, fatigue, depressed mood, anxiety, and perceived cognitive function with social participation in the daily lives of adults with spinal cord injury (SCI).

DESIGN

Observational study used a combination of baseline surveys and 7 end-of-day (EOD) diaries.

SETTING

General community.

PARTICIPANTS

Individuals with SCI (N=168; mean age, 49.8y; 63% male, 37% female).

MAIN OUTCOME MEASURES

Patient-Reported Outcomes Measurement Information System short form measures (Ability to Participate in Social Roles and Activities, Pain Intensity, Depression, Anxiety, Cognitive Function Abilities) were adapted for daily administrations as EOD diaries.

RESULT

Results of multivariable model showed that daily increases in fatigue (B=-0.10; P=.004) and depressive symptoms (B=-0.25; P=<.001) and decreases in perceived cognitive function (B=0.11; P=<.001) were significantly related to worse same-day social participation. Daily fluctuations in anxiety and pain were unrelated to same-day social participation.

CONCLUSIONS

This is the first study that shows within-person associations of common SCI symptoms with social participation in the daily lives of adults with SCI. Results from the current study may help to develop more effective individualized treatments of symptoms and symptom effect aimed at improving social participation.

Evidence on definitions, concepts, outcome instruments, and interventions for chronic fatigue in spinal cord injury: a scoping review protocol

OBJECTIVE

The objective of this review is to review the existing evidence on definitions, concepts, measurement instruments, and interventions for chronic fatigue in spinal cord injury.

INTRODUCTION

Chronic fatigue in people with spinal cord injury is an under-studied issue that affects between 25% and 56.6% of people with spinal cord injury. There are questions about how it is defined and managed due to its complex, multifactorial nature and relationship with related conditions. No overview of chronic fatigue in spinal cord injury exists and we are in need of a shared definition of chronic fatigue, as well as a comprehensive review of concepts and evidence supporting outcome instruments and interventions.

INCLUSION CRITERIA

This review will include empirical and non-empirical studies that focus on definitions, concepts, measurement instruments, and interventions for chronic fatigue in spinal cord injury. Studies that focus on peripheral muscle fatigue will only be included if they include chronic fatigue as a secondary outcome.

METHODS

This review will be done in three phases. Phase I will provide an overview of definitions of chronic fatigue in spinal cord injury and will include a qualitative analysis of concept attributes and characteristics. Phase II will focus on factors related to chronic fatigue and measurement instruments used to measure chronic fatigue, and phase III will focus on interventions. Full texts will be screened by two independent reviewers against inclusion criteria. Results will be presented in tabular form with a narrative summary.

Neuropsychological Study in Patients with Spinal Cord Injuries

The present investigation was designed to determinate the nature, pattern, and extent of cognitive deficits in a group of participants with subacute and chronic spinal cord injury (SCI). Methods: A cross-sectional study was conducted in both patients with subacute and chronic SCI. Different cognitive functions were evaluated through a neuropsychological protocol designed for this purpose, taking into account the patient’s emotional state. Results: A total of 100 patients suffering a spinal cord injury were evaluated. There were no differences between the two groups when age, sex, level of education, and region of origin were studied. The chronic injured patients obtained lower scores in the neuropsychological evaluation protocol respective to the subacute injured patients. Conclusions: Subjects with chronic spinal cord injury presented a cognitive profile that differed greatly in the number of altered cognitive functions as well as in their magnitude from the subacute spinal cord injured patient profile. Moreover, cognitive dysfunction may be important beyond the end of the first stage of rehabilitation as it can affect an individual’s quality of life and possible integration in society.

Association between health related quality of life (HRQOL) and activity of daily living (ADL) among elderly in an urban setting of Assam, India

Background:

Ensuring better quality of life to an increasing number of elderly people is emerging as a stiff public health challenge in India. There is paucity of data on impact of functional health on health-related quality of life (HRQOL) in India.

Objectives:

The aim of this study is to explore the functional status and its association with different dimensions of HRQOL among elderly individuals in an urban setting of Assam, India.

Materials and Methods:

A total of 300 elderly were recruited in a cross-sectional study from the city of Dibrugarh, Assam, India. Eight domains of HRQOL of participants were assessed using short form 36 (SF-36). Functional status was assessed by using Barthel activity of daily living (ADL) tool. ANOVA test and binary logistic regression analysis was performed to examine the relationship between ADL status and HRQOL.

Results:

In all, 34.7% (n = 104) of participants had limitations in one or more ADL items. We also observed a strong graded relationship between ADL and HRQOL scores. Those who scored perfect 100 ADL score also scored highest in all eight HRQOL scales, whereas those with least ADL score scored lowest in all the HRQOL scales. In age- and sex-adjusted logistic regression analysis, the probability of poor health increased with decreasing level of ADL scores.

Conclusion:

Findings of the study suggest that decline in ADL can negatively impact different dimensions of HRQOL among elderly individuals. The findings indicate that there is need to pay proper attention for restoring functional health at later life in order to improve quality of life among elderly in India.

Impact Of Spinal Cord Injury On Sleep: Current Perspectives

Sleep disorders are commonly encountered in people living with spinal cord injury (SCI). Primary sleep disorders such as sleep-disordered breathing (SDB), sleep-related movement disorders, circadian rhythm sleep-wake disorders, and insomnia disorder are common conditions after SCI but remain under-recognized, underdiagnosed and therefore remain untreated for a majority of patients. Sleep disturbances in people living with SCI are associated with significant impairments of daytime function and quality of life. Previous reviews have described findings related mainly to SDB but have not examined the relationship between other sleep disorders and SCI. This narrative review examines various sleep abnormalities and related functional and physical impairments in people living with SCI. It discusses new evidence pertaining to management, highlights existing limitations in the literature and recommends future directions for research.

Daytime sleepiness and its relationships to fatigue and autonomic dysfunction in adults with spinal cord injury

OBJECTIVE

To determine the extent of daytime sleepiness in adults with spinal cord injury (SCI) and investigate the contribution of fatigue and autonomic function to sleepiness status.

METHODS

Participants included 45 adults with SCI attending outpatient services or living in the community and 44 able-bodied controls. The Oxford Sleep Resistance Test (OSLER) was used to assess daytime sleepiness, while eye blink rate duration (electrooculography) and the Iowa Fatigue Scale assessed fatigue. Heart rate variability (HRV) was used to assess autonomic function. Survival analysis (Kaplan Meier) was used to estimate the rate of loss in participation in the OSLER task, as a measure of daytime sleepiness. Repeated measures ANOVA was used to determine HRV differences between groups. Regression analysis was used to establish factors that contributed to daytime sleepiness.

RESULTS

Participants with high lesions ("T3 and above") had significantly increased daytime sleepiness. OSLER results revealed only 33% of those with high lesions remained awake during the task. Those with high lesions also had significantly reduced sympathetic activity while no differences in parasympathetic activity were found between groups. Lesion completeness had no effect. Standardized variation in heart rate, slow eye blinks, low frequency HRV and self-reported fatigue contributed to daytime sleepiness.

CONCLUSION

Neurological lesions at "T3 or above" have an increased risk of daytime sleepiness, impacting on independence in daily functional tasks and work performance. Autonomic imbalance alters cardiovascular control, affecting health and wellbeing. The interaction of these factors requires further investigation.

Fatigability during volitional walking in incomplete spinal cord injury: cardiorespiratory and motor performance considerations

Fatigability describes the decline in force production (i.e., performance fatigability) and/or changes in sensations regulating performance (i.e., perceived fatigability) during whole-body activity and poses a major challenge to those living with spinal cord injuries (SCI). After SCI, the inability to overcome disruptions to metabolic homeostasis due to cardiorespiratory limitations and physical deconditioning may contribute to increased fatigability severity. The increased susceptibility to fatigability may have implications for motor control strategies and motor learning. Locomotor training approaches designed to reduce fatigability and enhance aerobic capacity in combination with motor learning may be advantageous for promoting functional recovery after SCI. Future research is required to advance the understanding of the relationship between fatigability, cardiorespiratory function and motor performance following SCI.

Reduced Quality of Life, Fatigue, and Societal Participation After Polytrauma

Objective:

This cross-sectional study analyzed associations between and determinants for health-related quality of life (HRQoL), fatigue, and societal participation in polytrauma patients.

Summary of background data:

More polytrauma patients survive their injuries, often resulting in long-term disabilities. HRQoL is therefore an important outcome of trauma care. Fatigue and societal participation may be related to HRQoL. Also, their relation to severe injuries has not been studied to date.

Methods:

A total of 283 polytrauma patients (injury severity score ≥ 16) admitted to the Dutch level 1 Trauma Centre West were analyzed. HRQoL was measured by the physical component summary (PCS) and mental component summary (MCS) scores of the SF-36, fatigue by the multidimensional fatigue inventory, and societal participation by the Utrecht scale for evaluation of rehabilitation-participation. Age, sex, comorbidity, injury pattern, injury severity, and time since trauma were analyzed as potential determinants.

Results:

A total of 122 patients (43%) responded after a median follow-up of 15 (range, 10–23) months after polytrauma; 44% reported reduced physical health (PCS &lt; 45) and 47% reported reduced mental health (MCS &lt; 45). HRQoL was highly correlated with all fatigue and participation subscales. Severe head injury was associated with worse mental health. Female patients reported more general and mental fatigue and were less satisfied with their ability to perform daily activities. Patients with pre-existing comorbidity experienced worse physical health, more fatigue, and reduced societal participation.

Conclusions:

One to 2 years after trauma, polytrauma patients report reduced HRQoL, which is associated with more fatigue and reduced societal participation. Trauma rehabilitation strategies should focus on early recognition of reduced HRQoL, fatigue, and societal participation and facilitate early intervention to improve these outcomes.

Cognitive performance of people with traumatic spinal cord injury: a cross-sectional study comparing people with subacute and chronic injuries

STUDY DESIGN

Cross-sectional study.

OBJECTIVES

To assess the impact of spinal cord injury (SCI) on cognitive function in individuals with subacute and chronic SCI.

SETTING

National Hospital for SCI patients (Spain).

METHODS

The present investigation was designed to determine the nature, pattern, and extent of cognitive deficits in a group of participants with subacute (n = 32) and chronic (n = 34) SCI, using a comprehensive battery of reliable and validated neuropsychological assessments to study a broad range of cognitive functions. Twenty-seven able-bodied subjects matched to the groups with SCI for age and educational level formed the control group.

RESULTS

The neuropsychological assessment showed alterations in the domain of attention, processing speed, memory and learning, executive functions, and in recognition in participants with SCI. The prevalence of cognitive dysfunction in the chronic stage was also confirmed at the individual level. The comparison of the neuropsychological assessment between the groups with subacute and chronic SCI showed a worsening of cognitive functions in those with chronic SCI compared to the group with subacute SCI.

CONCLUSIONS

In participants with SCI, cognitive dysfunctions are present in the subacute stage and worsen over time. From a clinical point of view, we confirmed the presence of cognitive dysfunction that may interfere with the first stage of rehabilitation which is the most intense and important. Moreover, cognitive dysfunction may be important beyond the end of the first stage of rehabilitation as it can affect an individual's quality of life and possible integration to society.

Gut Microbiota Are Disease-Modifying Factors After Traumatic Spinal Cord Injury

Spinal cord injury (SCI) disrupts the autonomic nervous system (ANS), impairing its ability to coordinate organ function throughout the body. Emerging data indicate that the systemic pathology that manifests from ANS dysfunction exacerbates intraspinal pathology and neurological impairment. Precisely how this happens is unknown, although new data, in both humans and in rodent models, implicate changes in the composition of bacteria in the gut (i.e., the gut microbiota) as disease-modifying factors that are capable of affecting systemic physiology and pathophysiology. Recent data from rodents indicate that SCI causes gut dysbiosis, which exacerbates intraspinal inflammation and lesion pathology leading to impaired recovery of motor function. Postinjury delivery of probiotics containing various types of "good" bacteria can partially overcome the pathophysiologal effects of gut dysbiosis; immune function, locomotor recovery, and spinal cord integrity are partially restored by a sustained regimen of oral probiotics. More research is needed to determine whether gut dysbiosis varies across a range of clinically relevant variables, including sex, injury level, and injury severity, and whether changes in the gut microbiota can predict the onset or severity of common postinjury comorbidities, including infection, anemia, metabolic syndrome, and, perhaps, secondary neurological deterioration. Those microbial populations that dominate the gut could become "druggable" targets that could be manipulated via dietary interventions. For example, personalized nutraceuticals (e.g., pre- or probiotics) could be developed to treat the above comorbidities and improve health and quality of life after SCI.

The association between bladder-emptying methods and health-related quality of life among Iranian individuals with spinal cord injury

OBJECTIVES

In this study, we compared the health-related quality of life (HRQoL) among patients with spinal cord injury (SCI) using different bladder emptying methods including normal spontaneous micturition (NSM), micturition with assisted maneuvers (MAM), aseptic intermittent catheterization by patient (IC-P), aseptic IC by an attendant/caregiver (IC-A) and indwelling catheterization.

DESIGN

Cross-sectional.

SETTING

Tertiary rehabilitation center.

PARTICIPANTS

Patients referred to Brain and Spinal Cord Injury Research Center between 2012 and 2014.

OUTCOME MEASURES

HRQoL was assessed by Short Form Health Survey (SF-36). Hierarchical regression analysis with adjustment for probable confounders (demographic and injury-related variables) was performed to assess the relationship between bladder-emptying method and total SF-36 score.

RESULTS

Patients with injury at cervical sections had significantly lower scores in domain of physical functioning (PF), physical component summary (PCS) and total score (P: 0.001, <0.0001 and 0.027, respectively). Longer time since injury was associated with better scores of PCS, Mental component summary (MCS) and total score (P: 0.002, <0.0001 and 0.003, respectively). Regression analysis showed that the effect of bladder-emptying method on total score of SF-36 was significant (P < 0.0001) and this relationship remained significant after adjustment for probable confounders in the second step of hierarchical regression analysis (R: 0.923, R²: 0.852, Adjusted R²: 0.847, P < 0.0001). Patients with NSM had the highest scores in SF-36 instrument and individuals with indwelling catheterization had the poorest HRQoL in all domains.

CONCLUSION

This study shows that the type of bladder management method affects HRQoL significantly in patients with SCI. Intermittent catheterization are recommended to be administered instead of indwelling catheterization to improve HRQoL.

Evaluation of a specialized yoga program for persons with a spinal cord injury: a pilot randomized controlled trial

Objectives

The purpose of this randomized controlled trial was to evaluate the effects of a specialized yoga program for individuals with a spinal cord injury (SCI) on pain, psychological, and mindfulness variables.

Materials and methods

Participants with SCI (n=23) were outpatients or community members affiliated with a rehabilitation hospital. Participants were randomized to an Iyengar yoga (IY; n=11) group or to a 6-week wait-list control (WLC; n=12) group. The IY group participated in a twice-weekly 6-week seated IY program; the WLC group participated in the same yoga program, after the IY group’s yoga program had ended. Pain, psychological, and mindfulness measures were collected at two time points for both groups (within 1–2 weeks before and after program 1 and at a third time point for the WLC group (within 1 week after program 2).

Results

Linear mixed-effect growth models were conducted to evaluate the main effects of group at T2 (postintervention), controlling for T1 (preintervention) scores. T2 depression scores were lower (F_1,18=6.1, P<0.05) and T2 self-compassion scores higher (F_1,18=6.57, P< 0.05) in the IY group compared to the WLC group. To increase sample size and power, the two groups were combined and analyzed across time by comparing pre- and postintervention scores. Main effects of time were found for depression scores, (F_1,14.83=6.62, P<0.05), self-compassion, (F_1,16.6=4.49, P<0.05), mindfulness (F_1,16.79=5.42, P<0.05), mindful observing (F_1,19.82=5.06, P<0.05), and mindful nonreactivity, (F_1,16.53=4.92, P<0.05), all showing improvement after the intervention.

Discussion

The results indicated that a specialized 6-week yoga intervention reduced depressive symptoms and increased self-compassion in individuals with SCI, and may also have fostered greater mindfulness.

Depressive mood in adults with spinal cord injury as they transition from an inpatient to a community setting: secondary analyses from a clinical trial

STUDY DESIGN

Prospective cohort controlled trial design.

OBJECTIVES

(i) To investigate mood benefits of adding group cognitive behaviour therapy (group-CBT) to standard spinal cord injury (SCI) inpatient rehabilitation (SR) that included access to antidepressant medication and individually delivered CBT on demand. (ii) To determine whether those with elevated depressive mood during inpatient rehabilitation significantly improve.

SETTING

SCI rehabilitation and community settings in New South Wales, Australia.

METHODS

Participants included 50 adults with SCI who completed SCI rehabilitation that included group-CBT compared with 38 participants who also completed SCI rehabilitation that did not contain group-CBT. Comprehensive assessment occurred after admission, within 2 weeks of discharge and 12 months post-injury. Multivariate repeated measures analyses were conducted to examine differences between groups and over time.

RESULTS

The addition of group-CBT to SR did not result in significant improvement in mood. However, participants with clinically elevated depressive mood assessed during inpatient rehabilitation experienced significant reductions in depressive mood when assessed in the community regardless of CBT dosage. Anxiety correlated with mood while no sociodemographic/injury factors correlated with mood at any time period except education level.

CONCLUSION

There were no mood advantages over time of adding group-CBT to inpatient SCI rehabilitation that contains individually delivered CBT on demand and access to antidepressant medication. However, findings showed those with elevated depressive mood during inpatient rehabilitation significantly improved when assessed in the community; however, their levels of depressive mood remain high. Future research should investigate the efficacy of providing individual preferences for managing depression in people with SCI.

Cognitive Impairment and Mood States after Spinal Cord Injury

Spinal cord injury (SCI) is believed to be associated with high rates of cognitive impairment, which can result in complications in recovery. This study concerned two groups of adults with SCI. The first sample involved 150 participants with SCI who were assessed once for cognitive capacity with comparisons made with 45 able-bodied adults. Sample 2 were drawn from Sample 1, and included 88 participants with SCI who were prospectively assessed for mood states (anxiety, depressive mood, and fatigue) and pain intensity at three time periods: at admission to SCI rehabilitation, at discharge, and 6 months after transition into the community. Results showed that the SCI sample had significantly lower cognitive performance than the able-bodied control group. Further, almost 29% of the adults with SCI had lowered cognitive performance believed to be indicative of cognitive impairment. The risk of an adult with SCI having cognitive impairment was almost 13 times that of someone without an SCI. Results from Sample 2 revealed that the development of negative mood states was a significant problem in those with cognitive impairment after they transitioned into the community, a time when personal resources are severely challenged. Findings suggest all adults with SCI admitted to rehabilitation should receive a cognitive screen, and that rehabilitation strategies should then be guided by the cognitive performance of the person. Special attention should also be given to improving skills of those with cognitive impairment before they transition into the community, so as to reduce risk of comorbid mental health problems.

Prevalence of depression, fatigue, and sleep disturbances in patients with myelopathy: Their relation with functional and neurological recovery

OBJECTIVES

To observe the prevalence of fatigue, depression, and sleep disturbance in patients with myelopathy and their correlation with neurological and functional recovery.

PATIENTS AND METHODS

Study conducted in a university tertiary research hospital with 127 patients with myelopathy (92 males) admitted to neurorehabilitation unit between January 2010 and December 2013. Mean age was 32.71 ± 13.08 years (range 15-65 years), and mean duration of injury was 76.22 ± 82.5 days (range 14-365 days). Functional status and impairments were assessed using Barthel Index and Spinal Cord Independence Measures. Depression, fatigue, and sleep disturbances were assessed using Hospital Anxiety and Depression Scale, Fatigue Severity Scale, and Pittsburgh Sleep Quality Index scales, respectively. Neurological recovery was assessed using American Spinal Injury Association's impairment scale.

RESULTS

Forty-four out of 104 (42%) patients had borderline or confirmed depression, 36/108 (33%) had significant fatigue, and 62/106 (58%) had significant sleep disturbances at admission. Significant correlation was observed between change in fatigue and depression scores with change in functional status scores (P < 0.05) but no correlation (P > 0.05) between change in sleep disturbance scores and functional status score and neurological recovery (P > 0.05). Similarly, change in fatigue and depression scores had no correlation with neurological status improvement. Fatigue, depression, and sleep disturbance scores showed significant improvement, that is, admission vs. discharge scores (P < 0.05) with significant correlation between improvement in all three variables (P < 0.05).

CONCLUSIONS

Study variables showed significant improvement in the present study with myelopathy patients but not necessarily correlating with functional and neurological recovery.

Psychological impact of injuries sustained in motor vehicle crashes: systematic review and meta-analysis

OBJECTIVE

The aim of this meta-analysis was to determine the psychological impact associated with motor vehicle crash (MVC)-related physical injuries.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Multiple search engines included MEDLINE (via OVID), PsycINFO and Embase, and studies were sourced from scientific journals, conference papers and doctoral theses.

STUDY SELECTION

A high-yield search strategy was employed. Terms like 'psychological distress', 'depression', 'PTSD' and 'motor vehicle accident' were employed. These key words were run primarily and secondary searches were then conducted in association with the major injury types. Studies needed to compare psychological distress in people injured in an MVC with uninjured controls who had not recently experienced an MVC.

DATA EXTRACTION

Searches resulted in the identification of 2537 articles, and after eliminating duplicates and studies not meeting inclusion criteria, 24 studies were selected involving 4502 injured participants. These studies were entered into separate meta-analyses for mild to moderate traumatic brain injury (mTBI), whiplash-associated disorder (WAD) and spinal cord injury (SCI).

RESULTS

Elevated psychological distress was associated with MVC-related injuries with a large summary effect size in WAD (0.90), medium to large effect size in SCI (0.69) and small to medium effect size in mTBI (0.23). No studies meeting inclusion criteria were found for burns, fractures and low back injury. Increased psychological distress remains elevated in SCI, mTBI and WAD for at least 3 years post-MVC.

CONCLUSIONS

Rehabilitation strategies are needed to minimise distress subsequent to MVC-related physical injuries and the scientific robustness of studies requires improvement.

Influence of neurological lesion level on heart rate variability and fatigue in adults with spinal cord injury

STUDY DESIGN

Group cohort design.

OBJECTIVES

To determine the influence of spinal cord injury (SCI) and neurological level on heart rate variability (HRV) and associations with fatigue.

SETTING

SCI rehabilitation outpatient and community settings in New South Wales, Australia.

METHODS

Participants included 45 adults with SCI living in the community and 44 able-bodied controls. Socio-demographic, neurological injury, psychological, HRV and eye blink variables were assessed. Multivariate analysis of variance and post hoc protected t-tests were used to determine differences in HRV and fatigue as a function of the neurological level. Pearson's correlation analysis was used to determine the relationships between these factors.

RESULTS

Participants with SCI had significantly reduced sympathetic activity. Those with tetraplegia had lowered sympathetic activity compared with those with paraplegia and able-bodied controls. Neither were differences in parasympathetic activity found between groups nor were there any significant differences found for the time domain or non-linear domains. Higher levels of fatigue were found in the SCI sample, and participants with tetraplegia had higher fatigue levels compared with those with paraplegia. Fatigued participants were more likely to have altered autonomic function-that is, reduced sympathetic activity.

CONCLUSIONS

Higher levels of neurological impairment in people with SCI are more likely to result in disordered cardiovascular control involving reduced sympathetic activity, whereas elevated fatigue was found to be associated with increased sympathetic dysfunction. Findings highlight the need to address risks associated with this dysfunction, such as improved HRV and fatigue screening for people with SCI and improved education on cardiovascular risk factors.

Adjustment following chronic spinal cord injury: Determining factors that contribute to social participation

OBJECTIVES

Spinal cord injury (SCI) is a catastrophic event that may result in diminished physical, social, and mental health. The main objective of this research was to establish inpatient factors that contribute to social participation following discharge into the community.

DESIGN

Prospective longitudinal design with measures taken three times, soon after admission to rehabilitation (N = 88), at discharge from the inpatient phase (N = 81) and 6 months following discharge (N = 71).

METHODS

Participants included adults with SCI admitted into three SCI units over a 33-month period. Assessment included demographic, injury, and psychosocial health measures. Adjustment was defined by the extent of social re-integration or participation post-discharge after 6 months in the community. Social participation was measured by the Impact on Participation and Autonomy Questionnaire (IPAQ). Logistic regression models were used to establish inpatient factors that significantly predicted social participation 6 months post-discharge.

RESULTS

Six months after discharge, around 55% of the sample had difficulties with social participation. The odds against being employed for an adult with poor social participation was found to be 8.4 to 1. Factors that predicted social participation included a younger age, having less severe secondary medical complications like bladder and bowel dysfunction, having a higher cognitive capacity, perceiving one has control (self-efficacy) over one's life and environment, and having greater perceived social support.

CONCLUSIONS

These results provide direction for enhancing existing psychosocial health strategies within SCI rehabilitation, affording an opportunity for every person who sustains a permanent SCI to have optimal capacity for social participation. Statement of contribution What is already known on this subject? Spinal cord injury (SCI) is associated with significant challenges to wellbeing, including a high risk of secondary chronic illnesses, risk of co-morbid mental health problems, financial insecurity and social isolation. Research has shown poor social participation can lead to problems in re-integration into society following discharge from inpatient rehabilitation. Research to date has examined various factors related to poor social participation, but the majority of this research has been survey based with convenience samples. What does this study add? This study adds results of prospective longitudinal research on adjustment following SCI, where adjustment was defined by the rate of social participation when living in the community. About one-third of SCI participants were found to have very poor social participation, and only one-third had found some form of employment 6 months after discharge. Multiple factors were found to predict and contribute to poor social participation, including older age when injured, more severe medical complications, cognitive deficits, poor perceptions of control or self-efficacy, and poor social support.

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.

A review of factors influencing participation in social and community activities for wheelchair users

OBJECTIVE

To systematically identify factors associated with participation in social and community activities for adult wheelchair users (WCUs).

DATA SOURCES

PubMed/MEDLINE, CINAHL, PsycINFO and EMBASE.

STUDY SELECTION

Quantitative and qualitative peer-reviewed publications were included, which were written in English, reported original research and investigated factors associated with social and community participation in adult WCUs.

DATA EXTRACTION

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used. Factors were organized using the International Classification of Functioning, Disability and Health (ICF).

DATA SYNTHESIS

Thirty-five studies were selected: two of power WCUs, 10 of manual WCUs and 23 of both. Six qualitative studies, ranging in quality from 8/10 to 9/10 and 29 quantitative studies were included, ranging in quality from 4/15 to 11/15. Fifteen body function, 4 activity, 5 participation, 15 environmental and 14 personal factors were found to be associated with social and community participation.

CONCLUSIONS

Social and community participation of WCUs is associated with factors from all ICF domains. Wheelchair factors, accessibility, skills with wheelchair use, pain, finances and education are modifiable factors frequently reported to be associated with participation. Experimental research focusing on modifiable factors is needed to further our understanding of factors influencing participation among WCUs. Implications for Rehabilitation Wheelchair factors, including comfort and durability, are associated with participation and may be targeted in clinical intervention. Wheelchair skills are clinically modifiable and have been shown to improve participation in manual wheelchair users. Body functions (e.g. confidence, depression and fatigue) and personal factors (e.g. finances and level of education) may be considered for clinical intervention.

Bone marrow mesenchymal stem cells with Nogo-66 receptor gene silencing for repair of spinal cord injury

We hypothesized that RNA interference to silence Nogo-66 receptor gene expression in bone marrow mesenchymal stem cells before transplantation might further improve neurological function in rats with spinal cord transection injury. After 2 weeks, the number of neurons and BrdU-positive cells in the Nogo-66 receptor gene silencing group was higher than in the bone marrow mesenchymal stem cell group, and significantly greater compared with the model group. After 4 weeks, behavioral performance was significantly enhanced in the model group. After 8 weeks, the number of horseradish peroxidase-labeled nerve fibers was higher in the Nogo-66 receptor gene silencing group than in the bone marrow mesenchymal stem cell group, and significantly higher than in the model group. The newly formed nerve fibers and myelinated nerve fibers were detectable in the central transverse plane section in the bone marrow mesenchymal stem cell group and in the Nogo-66 receptor gene silencing group.

Pain and fatigue as mediators of the relationship between mobility aid usage and depressive symptomatology in ambulatory individuals with SCI

STUDY DESIGN

Cross-sectional cohort study.

OBJECTIVES

To investigate a mediational model where pain (intensity and interference) and fatigue mediate the relationship between the use of mobility aids and moderate-to-severe depressive symptomatology among ambulatory participants with spinal cord injury (SCI).

SETTING

A medical university in the southeastern United States.

METHODS

Ambulatory adults (N=652) with chronic SCI responded to a mail-in survey. The Patient Health Questionnaire-9 was used to assess moderate-to-severe depressive symptomatology. The Brief Pain Inventory was used to assess pain intensity and interference, and the Modified Fatigue Impact Scale-5-item version was used to assess fatigue. Participants self-reported use of mobility aids.

RESULTS

On examining mobility aids used for ambulation, 65% were found to have used at least one aid. Severe pain intensity was reported by 11%, and 14% reported severe pain interference. Disabling fatigue was reported by 10% of the participants. Twenty-one percent (n=138) reported moderate-to-severe levels of depressive symptoms. On examining the relationships between mobility aids and depressive symptomatology, using people as a mobility aid was associated with increased odds of depressive symptomatology (2.6) and always using a wheelchair was associated with lower odds (0.3). However, these relationships were no longer significant after controlling for the mediating variables pain intensity, pain interference and fatigue.

CONCLUSIONS

Pain and fatigue mediate the relationship between usage of certain mobility aids and depressive symptomatology. The use of people to assist in ambulation is associated with greater odds of moderate-to-severe depressive symptomatology, while always using a wheelchair is associated with lower odds.

Pain intensity and its association with negative mood States in patients with spinal cord injury

Introduction

Chronic and persistent pain is a prevalent and debilitating secondary condition in patients with a neurological injury such as spinal cord injury (SCI). Patients with SCI have an increased risk of developing other co-morbid conditions such as elevated negative mood states. Arguably, the presence of chronic pain would act to intensify the chances of developing negative mood states as opposed to resilient mental states. The objective of this research was to investigate the association between pain intensity and levels of negative mood states in adult patients with SCI.

Methods

Participants included 107 adults with SCI living in the community who completed an assessment regimen in a relaxed environment. Mean pain intensity over a period of 1 week and the Profile of Mood States, a validated psychometric measure of mood states (anxiety, depressed mood, anger, vigor, fatigue, confusion and total negative mood score) were used to determine associations between pain intensity and mood states. The sample was divided into a low pain intensity sub-group (<4 where 0 = no pain; 10 = worst pain imaginable) and a clinically significant or high pain intensity sub-group (≥4), allowing negative mood to be compared between the sub-groups.

Results

Mean age was 47.1 years, and 87% of the sample was male. Clinically significant pain intensity over the week prior to assessment was found in 52% of the 107 participants. The high pain intensity sub-group was found to have significantly elevated anxiety, depressed mood, anger, fatigue, confusion and significantly reduced vigor.

Conclusion

These results provide further evidence that patients with SCI experience clinically elevated negative mood states if they have intense levels of pain over extended periods of time. In contrast, patients without intense pain have mood states similar to those in the able-bodied community. Implications for the treatment of SCI are discussed.

Developing a model of associations between chronic pain, depressive mood, chronic fatigue, and self-efficacy in people with spinal cord injury

Chronic pain, chronic fatigue, and depressive mood are prevalent conditions in people with spinal cord injury (SCI). The objective of this research was to investigate the relationship between these conditions in adults with SCI. Multivariate analysis of variance, contingency analyses, and hierarchical regression were used to determine the nature of the relationship, as well as the contribution to this relationship of self-efficacy, a potential mediator variable. Seventy participants with SCI living in the community completed an assessment regimen of demographic and psychometric measures, including validated measures of pain, fatigue, depressive mood, and self-efficacy. Results indicated that participants with high levels of chronic pain had clinically elevated depressive mood, confusion, fatigue, anxiety and anger, low vigor, and poor self-efficacy. Participants with high chronic pain had 8 times the odds of having depressive mood and 9 times the odds of having chronic fatigue. Regression analyses revealed that chronic pain contributed significantly to elevated depressive mood and that self-efficacy mediated (cushioned) the impact of chronic pain on mood. Furthermore, both chronic pain and depressive mood were shown to contribute independently to chronic fatigue. Implications of these results for managing chronic pain in adults with SCI are discussed.

PERSPECTIVE

The relationship between pain, negative mood, fatigue, and self-efficacy in adults with SCI was explored. Results support a model that proposes that chronic pain lowers mood, which is mediated (lessened) by self-efficacy, whereas pain and mood independently increase chronic fatigue. Results provide direction for treating chronic pain in SCI.

Impact of blood pressure dysregulation on health-related quality of life in persons with spinal cord injury: development of a conceptual model

OBJECTIVES

To identify medically relevant aspects of blood pressure dysregulation (BPD) related to quality of life in individuals with spinal cord injury (SCI), and to propose an integrated conceptual framework based on input from both individuals with SCI and their clinical providers. This framework will serve as a guide for the development of a patient-reported outcome (PRO) measure specifically related to BPD.

DESIGN

Three focus groups with individuals with SCI and 3 groups with SCI providers were analyzed using grounded-theory based qualitative analysis to ascertain how blood pressure impacts health-related quality of life (HRQOL) in individuals with SCI.

SETTING

Focus groups were conducted at 2 Veterans Affairs medical centers and a research center.

PARTICIPANTS

Individuals with SCI (n=27) in 3 focus groups and clinical providers (n=25) in 3 focus groups.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Not applicable.

RESULTS

Qualitative analysis indicated that all focus groups spent the highest percentage of time discussing symptoms of BPD (39%), followed by precipitators/causes of BPD (16%), preventative actions (15%), corrective actions (12%), and the impact that BPD has on social or emotional functioning (8%). While patient/consumer focus groups and provider focus groups raised similar issues, providers spent more time discussing precipitators/causes of BPD and preventative actions (38%) than patient/consumer groups (24%).

CONCLUSIONS

These results suggest that BPD uniquely and adversely impacts HRQOL in persons with SCI. While both individuals with SCI and their providers highlighted the relevant symptoms of BPD, the SCI providers offered additional detailed information regarding the precipitators/causes and what can be done to prevent/treat BPD. Further, the results suggest that persons with SCI are aware of how BPD impacts their HRQOL and are able to distinguish between subtle signs and symptoms. These findings exemplify the need for a validated and sensitive clinical measurement tool that can assess the extent to which BPD impacts HRQOL in patients with SCI.

Fatigue and tiredness in people with spinal cord injury

OBJECTIVE

Fatigue is a common symptom in people with neurological injury such as spinal cord injury (SCI), though its nature and occurrence in people with SCI are not well understood. The objective of this research was to investigate fatigue and its relationship to factors such as mood states and self efficacy in adult people with SCI compared to able-bodied controls.

METHODS

Participants included 41 adults with SCI living in the community and 41 able-bodied controls matched for age and sex ratios and education. All participants first completed a comprehensive psychological assessment and were then asked to take part in a 2-3 hour session composed of a regimen of cognitive tasks that required constant concentration and attention. Participants were assessed after completing this task.

RESULTS

The SCI group was found to have significantly elevated levels of fatigue, as well as elevated depressive mood, anxiety and poor self-efficacy. The SCI group was also found to suffer excessive levels of tiredness as a consequence of the 2-3 hour task. Factors such as depressive mood and poor self-efficacy were shown to increase the risk of excessive tiredness.

CONCLUSION

People with a neurological injury such as SCI have a high risk of having fatigue and are susceptible to experiencing excessive tiredness when performing extended tasks, and the presence of elevated depressive mood or poor expectations towards self management will increase this susceptibility. Implications for managing fatigue and improving social access in SCI populations are discussed.