Psychosocial outcome following spinal cord injury

Physical function, post-traumatic stress disorder, and quality of life in persons with spinal cord injury caused by the Wenchuan earthquake versus nondisaster trauma: a cross-sectional modeling study

STUDY DESIGN

Cross-sectional study.

OBJECTIVES

To compare physical function, post-traumatic stress disorder (PTSD) and quality of life (QOL) between individuals with spinal cord injury (SCI) caused by the Wenchuan earthquake and individuals with SCI caused by nondisaster trauma and to explore the relationship between physical function, PTSD and QOL.

SETTING

Community, Sichuan, China.

METHODS

Two hundred individuals with SCI (39 caused by the Wenchuan earthquake, 161 with other traumatic etiology) were surveyed. Physical function was assessed with the Spinal Cord Independence Measure-SR, PTSD with the PTSD Checklist-C, and QOL with the World Health Organization QOL-BREF. Independent sample t-tests and rank-sum tests were used to compare the two groups. Structural equation modeling (SEM) was used to analyze the relationship between physical function, PTSD and QOL.

RESULTS

QOL of the study participants was at a moderate to low level, physical function was at a medium level. The prevalence of PTSD in the group injured due to the Wenchuan earthquake was 64.1% as opposed to 10.0% in individuals with other traumatic etiology. In the SEM, earthquake-related etiology was strongly related to increased PTSD symptoms which negatively affected QOL. Earthquake-related etiology was however also associated with slightly increased physical function which was associated with better QOL and less PTSD symptoms CONCLUSIONS: Prevalence of PTSD in earthquake survivors with SCI was largely increased as compared with people with SCI of other traumatic etiology. In spite of this, the groups did not differ in QOL because of better physical function of earthquake survivors. Effective intervention for PTSD is still needed in earthquake survivors with SCI. Continuous rehabilitative measures to improve physical function and QOL in both groups are also recommended.

Exploring the relationship between self-reported urinary tract infections to quality of life and associated conditions: insights from the spinal cord injury Community Survey

STUDY DESIGN

Descriptive study OBJECTIVES: Urinary tract infections (UTIs) are one of the most frequent types of infections following spinal cord injury (SCI). Here we assess the relationship between frequency of UTIs and activity level/overall quality of life (QOL) measures, determine the frequency of temporally associated conditions associated with UTI and identify factors associated with frequent UTIs.

SETTING

Canada METHODS: The Spinal Cord Injury Community Survey was developed to assess major dimensions of community living and health outcomes in persons with chronic SCI in Canada. Participants were stratified by self-reported UTI frequency. The relationship between UTI frequency and QOL, health resource utilization, and temporally associated conditions were assessed. Results were analysed with cross tabulations, χ² tests, and ordinal logistic regression.

RESULTS

Overall 73.5% of participants experienced at least one self-reported UTI since the time of injury (mean 18.5 years). Overall QOL was worse with increasing frequency of these events. Those with frequent self-reported UTIs had twice as many hospitalizations and doctors' visits and were limited in financial, vocational and leisure situations, physical health and ability to manage self-care as compared with those with no UTIs. Self-reported UTIs were associated with higher incidence of temporally associated conditions including bowel incontinence, constipation, spasticity, and autonomic dysreflexia. Individuals who were younger and female were more likely to have frequent UTIs and those with constipation and autonomic dysreflexia had worse QOL.

CONCLUSIONS

Higher frequency self-reported UTIs is related to poor QOL of individuals with long-term SCI. These findings will be incorporated into SCI UTI surveillance and management guidelines.

Mental disorder prevalence among U.S. Department of Veterans Affairs outpatients with spinal cord injuries

OBJECTIVES

Depression and other mental disorders are more prevalent among individuals living with spinal cord injury (SCI) than in the community at large, and have a strong association with quality of life. Yet little is known about the prevalence and predictors of mental disorders among U.S. military Veterans living with SCI. The primary aim of this study was to present an estimate of mental disorder point prevalence in this population. The secondary aim was to examine the relationship of mental disorders to demographics, injury characteristics, and other clinically relevant features such as impairment from mental health problems and life satisfaction.

DESIGN

Cross-sectional.

SETTING

A SCI & Disorders Center at a U.S. Veterans Affairs Medical Center.

PARTICIPANTS/METHODS

Administrative and medical records of 280 Veterans who attended annual comprehensive SCI evaluations were evaluated. Demographics, injury characteristics, self-reported mental and emotional functioning (i.e. SF-8 Health Survey), and clinician-determined mental disorder diagnoses were attained.

RESULTS

Overall, 40% of patients received at least one mental disorder diagnosis, most commonly depressive disorders (19%), posttraumatic stress disorder (12%), and substance or alcohol use disorders (11%). Several patient characteristics predicted mental disorders, including age, racial minority identity, non-traumatic SCI etiology, and incomplete (i.e. AIS D) vs. complete injury. Mental disorders were associated with greater impairment from health and mental health-related problems and less satisfaction with life.

CONCLUSIONS

Mental disorders are common among outpatients receiving VA specialty care for SCI. These findings highlight the importance of having adequate and effective available mental health services available for Veterans with SCI.

Personal identity narratives of therapeutic songwriting participants following Spinal Cord Injury: A case series analysis

CONTEXT/OBJECTIVE

Spinal Cord Injury (SCI) patients face unique identity challenges associated with physical limitations, higher comorbid depression, increased suicidality and reduced subjective well-being. Post-injury identity is often unaddressed in subacute rehabilitation environments where critical physical and functional rehabilitation goals are prioritized. Therapeutic songwriting has demonstrated prior efficacy in promoting healthy adjustment and as a means of expression for post-injury narratives. The current study sought to examine the identity narratives of therapeutic songwriting participants.

DESIGN

Case-series analysis of the individual identity trajectories of eight individuals.

SETTING

Subacute rehabilitation facility, Victoria, Australia.

PARTICIPANTS

Eight individuals with an SCI; 7 males and 1 female.

INTERVENTION

Six-week therapeutic songwriting intervention facilitated by a music therapist to promote identity rehabilitation.

OUTCOME MEASURES

Identity, subjective well-being and distress, emotional state.

RESULTS

Three participants demonstrated positive trajectories and a further three showed negative trajectories; remaining participants were ambiguous in their response. Injury severity differentiated those with positive trajectories from those with negative trajectories, with greater injury severity apparent for those showing negative trends. Self-concept also improved more in those with positive trajectories. Core demographic variables did not however meaningfully predict the direction of change in core identity or wellbeing indices.

CONCLUSION

Identity-focused songwriting holds promise as a means of promoting healthy identity reintegration. Further research on benefits for those with less severe spinal injuries is warranted.

Anxiety prevalence following spinal cord injury: a meta-analysis

STUDY DESIGN

Meta-analysis.

OBJECTIVES

Prevalence estimates indicate that anxiety following spinal cord injury (SCI) is a common problem. However, methodological differences between studies may impact the clinical interpretation of these data.

METHODS

Data from 18 independent studies (Nparticipants=3158), which reported the prevalence of an anxiety disorder or associated symptoms, were identified from the Embase, PubMed and PsycInfo databases. Proportions were the primary effect size estimate. Confidence intervals, fail-safe Ns and the I(2) statistic were additionally calculated to identify the extent to which findings were robust and consistent across studies.

RESULTS

Five per cent of participants met the criteria for either GAD or panic disorder, with Agoraphobia identified in 2.5%. These diagnostic data were, however, limited to two studies. Higher rates were noted for self-reported 'caseness' of anxiety, with 27% reporting clinically significant symptoms. Anxiety prevalence estimates varied across the individual self-report measures (range: 15-32%). Method of administration (range: 26-32%) did not impact significantly on these estimates nor did recruitment source, with similarly high anxiety levels reported by hospital (27%) and community (29%) samples.

CONCLUSIONS

Early identification and treatment of anxiety are important in SCI rehabilitation, with a subgroup of individuals experiencing chronic symptoms. Further research is needed to establish guidelines for the interpretation of self-report data, including the use of clinical cutoffs.

Leisure repertoire among persons with a spinal cord injury: interests, performance, and well-being

OBJECTIVE

To explore and describe the leisure repertoire of persons with traumatic spinal cord injury (SCI) and how the repertoire is related to interest, performance, and well-being.

DESIGN

Cross-sectional study.

SETTING

A total of 97 persons with traumatic SCI were recruited from the non-profit national organization, RG Active Rehabilitation in Sweden.

OUTCOME MEASURE

Data were collected through a two-part postal survey. The first comprised of questions investigating socio-demographic variables and injury characteristics; the second part included an interest checklist with 20 areas of leisure activities.

RESULTS

The participants were mostly interested in, performed, and experienced well-being from social and culture activities and TV/DVD/movies. The areas of leisure activities in which they had most likely experienced changes after the SCI were outdoor activities, exercise, and gardening. Sex, age, and to some extent, time since injury were related to interest, performance, well-being, and changed performance.

CONCLUSIONS

The results provided an explanation and limited description of a changed leisure repertoire among persons after a traumatic SCI. The study showed that sex, age, and time since injury were more closely related to the choice of leisure activities to include in the leisure repertoire than the level of injury. This knowledge can be of importance when professionals in the field of rehabilitation are planning and implementing interventions concerning leisure activities for persons with SCI.

Psychosocial adjustment patterns of persons with spinal cord injury in Taiwan

PURPOSE

The purpose of this study was to examine the psychosocial adjustment patterns of a community sample of persons with spinal cord injury in Taiwan.

METHOD

A total of 102 participants were recruited from the Association of People with Spinal Cord Injury in Taipei City. Mean age of participants was 30.8 years (SD=11.39 years), and 77% were men. The participants were asked to complete a research packet containing a demographic questionnaire, the Psychosocial Adjustment to Illness Scale-Self Report Questionnaire, and the Sense of Coherence Questionnaire.

RESULTS

Four distinct groups were found, representing different levels of psychosocial adjustment: (i) Well adjusted, (ii) Moderately adjusted, (iii) Moderately adjusted and sexually inexperienced, and (iv) Poorly adjusted. Employment status, age at the time of onset, injury level, and current age, as well as the motivational and behavioural aspects of coping, were identified as the functions discriminating the groups based on the demographic characteristics and sense of coherence, respectively.

CONCLUSIONS

Vocational, sexual, and leisure areas of adjustment were found to be the most problematic for individuals with SCI in Taiwan. Counseling and other rehabilitation intervention efforts should focus on these identified needs of people with SCI in Taiwan.

Physical activity is related to lower levels of pain, fatigue and depression in individuals with spinal-cord injury: a correlational study

STUDY DESIGN

This was a prospective cross-sectional study for people with chronic spinal cord injury (SCI).

OBJECTIVES

To (1) evaluate the intensity level and nature of physical activity in community-dwelling individuals living with SCI, and (2) explore the relation between descriptive individual variables (for example, lesion level), secondary complications and participation in physical activity.

SETTING

Urban community setting.

METHODS

A total of 49 subjects with SCI who used a manual wheelchair for primary mode of mobility (mean years since injury, 11.8; mean age, 43.7 years; 67% paraplegia) completed the physical activity recall assessment for people with SCI (PARA-SCI).

RESULTS

Approximately 50% of reported physical activity among individuals with SCI is due to activities of daily living. The amount of physical activity was not related to lesion level, age, body mass index or waistline size. Greater heavy-intensity activity was related to lower levels of pain and fatigue and higher levels of self-efficacy, whereas higher amounts of mild-intensity activity and total activity were related to less depressive symptoms.

CONCLUSIONS

Activities of daily living are a large component for physical activity among individuals with SCI. It appears that greater physical activity is associated with less secondary complications (pain, fatigue and depression) in individuals with SCI.

Predictors of Psychosocial Adaptation Among People With Spinal Cord Injury or Disorder

OBJECTIVE

To examine the influence of disability-related medical and psychologic variables on psychosocial adaptation to spinal cord injury or disorder (SCI/D).

DESIGN

A structural equation modeling design linking 3 sets of predictive variables to an outcome measure of adaptation.

SETTING

Two outpatient SCI clinics (1 veteran, 1 civilian) in Texas.

PARTICIPANTS

Veterans (n=181) and civilians (n=132) with SCI/D.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The adaptation outcome was measured by 2 subscales (acknowledgment, adjustment) of the Reactions to Impairment and Disability Inventory (RIDI) and by the Quality of Life Scale. The predictive variables were measured by a demographic questionnaire, 3 subscales (intrusion, re-experiencing, hyperarousal) of the Purdue Posttraumatic Stress Disorder-Revised scale, the McMordie-Templer Death Anxiety Scale, and 3 subscales (anxiety, depression, denial) of the RIDI.

RESULTS

Goodness-of-fit indices suggested that a revised model of adaptation was a moderately good fit to the data. The revised model of adaptation indicated that there were medium total effects (direct plus indirect) on psychosocial adaptation by 2 latent variables (disability severity and impact, negative affectivity) and small total effects on psychosocial adaptation by disengagement coping. The latent factor of disengagement coping had the strongest direct effect on adaptation (although not statistically significant). Disability severity and impact had medium indirect effects and negative affectivity had small indirect effects on psychosocial adaptation. All of the aforementioned effects had a negative coefficient.

CONCLUSIONS

Negative emotional responses (eg, depression, anxiety) to SCI/D, disengagement-type coping (eg, disability denial, avoidance), and the severity and impact of disability were related to lower levels of adaptation to SCI/D.

Return to work after spinal cord injury in Taiwan: the contribution of functional independence

OBJECTIVE

To study the employment rate and determinants of return to work for persons with traumatic spinal cord injury (SCI) in Taiwan.

DESIGN

Cross-sectional.

SETTING

Taiwan community.

PARTICIPANTS

One hundred sixty-nine people who had sustained traumatic SCI, had been completely rehabilitated in a university hospital between 1989 and 2002, and who were between 18 and 60 years of age at the time of interview in 2003.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

A structured questionnaire was used to identify demographic and injury-related status, functional status, and pre- and postinjury work-related information.

RESULTS

At the time of survey, only 47% of the participants were engaged in remunerative employment. Cox regression analysis, with time elapsed between injury and survey as the underlying time axis, showed that education and functional independence were associated with employment. Subjects with a high school education had a 2.2-fold higher chance (95% confidence interval [CI], 1.3-3.8) of returning to work than those without. Subjects with higher scores on the Barthel Index and ability to use public or private transport independently had a 2.7-fold higher chance (95% CI, 1.5-4.9) of returning to work than those unable to travel independently. Other factors significantly associated with employment included marital status, with marriage having a favorable influence; age at injury, with age below 25 years being favorable; preinjury occupation; and vocational training after injury. The importance of functional independence training in rehabilitation is stressed.

CONCLUSIONS

Functional independence was a strong factor predicting return to work. Rehabilitation focused on education, vocational training, self-care ability, community mobility, and environmental modifications could improve employability after SCI.

Suicide in a spinal cord injured population: its relation to functional status

OBJECTIVE

To determine the relation between functional status and risk of suicide among individuals with spinal cord injury (SCI).

DESIGN

A follow-up study of all individuals who survived a traumatic SCI during the period from 1953 through 1990.

SETTING

An SCI center in eastern Denmark.

SUBJECTS

A total of 888 individuals with SCI, including 236 who died, 23 of whom committed suicide.

MAIN OUTCOME MEASURES

Standardized Mortality Ratios (SMRs) of suicides among individuals with SCI.

RESULTS

A 100% follow-up was established January 1, 1993. The total suicide rate among individuals with SCI was nearly five times higher than expected in the general population and lower for men than for women. The suicide rate doubled from an early inclusion period (1953-1971) to a later period (1972-1990). An unexpected finding was that the suicide rate in the group of marginally disabled persons was nearly twice as high as the group of functionally complete tetraplegic individuals.

CONCLUSION

Given the high frequency of suicide, there is a need for increased awareness by rehabilitation staff and general practitioners regarding depression and psychological adjustment difficulties. Such conditions should be given special attention during rehabilitation and follow-up, especially among women with SCI and the marginally disabled.

Spinal cord injury rehabilitation. 2. Medical complications

This self-directed learning module highlights new advances in understanding medical complications of spinal cord injury through the lifespan. It is part of the chapter on spinal cord injury rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article covers reasons for transferring patients to specialized spinal cord injury centers once they have been stabilized, and the management of common medical problems, including fever, autonomic dysreflexia, urinary tract infection, acute and chronic abdominal complications, deep vein thrombosis, pulmonary complications, and heterotopic ossification. Formulation of an educational program for prevention of late complications is also discussed, including late renal complications, syringomyelia, myelomalacia, burns, pathologic fractures, pressure ulcers, and cardiovascular disease. New advances covered in this section include new information on old problems, and a discussion of exercise tolerance in persons with tetraplegia, the pathophysiology of late neurologic deterioration after spinal cord injury, and a view of the care of these patients across the lifespan.

Depression following a spinal cord injury

OBJECT

Depression is a common problem following a spinal cord injury (SCI) and can greatly interfere with the rehabilitation process because of reduced energy, negative expectations, and social withdrawal. Understanding various factors which influence a vulnerability to depression may improve the diagnosis and treatment of depressive disorders and can improve rehabilitation outcome.

METHOD

A thorough literature search was conducted using Medline, PsychLit, Pyschinfo, and Social Science Citation Index to identify relevant articles published between 1967 and 1995.

RESULTS

A diathesis-stress model is proposed to explain the increased risk of depressive symptoms after a SCI. Biological changes associated with SCI and pre-existing cognitive biases may influence the individual's vulnerability to stressful life events following the injury. The nature and frequency of stressful life events following the injury can tax the individual's coping resources. Furthermore, the perceived quality of social support and the severity of conflict within the family can influence the individual's adaptation.

CONCLUSIONS

Social support and recent stressors should be assessed to identify patients at high risk for depression. Patients are less likely to become depressed if their independence is fostered and they are encouraged to develop new sources of self-esteem. Relatives can be counseled to help maintain supportive relationships within the family.