Continuing with life as normal:: positive psychological outcomes following spinal cord injury

Posttraumatic growth in palliative care settings: A scoping review of prevalence, characteristics and interventions

BACKGROUND

Posttraumatic growth refers to positive psychological change following trauma. However, there is a need to better understand the experience of posttraumatic growth in the palliative care setting as well as the availability and efficacy of interventions that target this phenomenon.

AIMS

To provide a review of the prevalence, characteristics and interventions involving posttraumatic growth in adults receiving palliative care and to collate recommendations for future development and utilisation of interventions promoting posttraumatic growth.

DESIGN

We performed a systematic scoping review of studies investigating posttraumatic growth in palliative care settings using the Arksey and O'Malley six-step scoping review criteria. We used the PRISMA guidelines for scoping reviews.

DATA SOURCES

Articles in all languages available on Ovid Medline [1946-2022], Embase [1947-2022], APA PsycINFO [1947-2022] and CINAHL [1981-2022] in November 2022.

RESULTS

Of 2167 articles located, 17 were included for review. These reported that most people report low to moderate levels of posttraumatic growth with a decline towards end-of-life as distress and symptom burden increase. Associations include a relationship between posttraumatic growth, acceptance and greater quality-of-life. A limited number of interventions have been evaluated and found to foster posttraumatic growth and promote significant psychological growth.

CONCLUSION

Posttraumatic growth is an emerging concept in palliative care where although the number of studies is small, early indications suggest that interventions fostering posttraumatic growth may contribute to improvements in psychological wellbeing in people receiving palliative care.

Co-design of an intervention exploring meaning and purpose after spinal cord injury

PURPOSE

Rebuilding a strong sense of meaning and purpose following trauma is a vital contributor to post-traumatic growth and adapting well to a spinal cord injury. This project aimed to develop an intervention that used the concept of post-traumatic growth to foster a stronger sense of meaning and purpose in people with a spinal cord injury.

METHODS

Using participatory action research methodology, the intervention was designed in an iterative process with health professionals and people with lived experience of spinal cord injury. We developed a ten-week online group program and delivered two pilot programs to 13 participants. We used their feedback to further refine the program before finalisation.

RESULTS

A participatory action research approach resulted in a positive intervention well received by participants and consumer organisations. Feedback suggests the intervention shows promise for improvements in functional and psychosocial outcomes and has long-term viability.

CONCLUSIONS

The project successfully developed and delivered a novel program that uses the concept of post-traumatic growth to foster a stronger sense of meaning and purpose. Further implementation of the program with larger numbers will allow for evaluation of the program's effectiveness.

Cognitive appraisals of disability in persons with traumatic spinal cord injury: a scoping review

STUDY DESIGN

Scoping review.

OBJECTIVES

To describe the meaning of cognitive appraisals, their relation with outcome. measures, and adapted appraisal scales after Spinal Cord Injury (SCI) in the existing literature.

METHODS

This review was performed according to the Arksey and O'Malley (2005) framework that consisted of five steps: setting the review question, searching the literature, selecting and classifying the studies, charting the data, and summarizing the results. Published articles from 1990 to 16 May 2020 related to cognitive appraisal, persons with traumatic SCI (TSCI), and persons older than 18 years were identified by searching by key terms in four databases (PubMed, Web of Science, Scopus, and Embase).

RESULTS

The included studies (n = 26) were categorized into three categories. Categories focused on the meanings of cognitive appraisals following TSCI (i.e., appraisals being complex and context-related, or in general definition how persons with TSCI interpret their disability and how they evaluate the resources available to respond to it), the relationship between cognitive appraisals and physical/psychological/social/ outcomes, and appraisals of disability (including the use of appraisals as a predictor of subsequent positive or negative consequences).

CONCLUSIONS

The results demonstrated that a cognitive appraisal of TSCI is critical to longer-term rehabilitation outcomes. A combination of physical and psychological-based interventions can help to modify negative or dysfunctional appraisals. Cognitive appraisal in TSCI seems to vary from person to person. To predict it and develop a rehabilitation plan, future research needs to focus on the relationship between cognitive appraisal and person-related factors, including demographic characteristics.

Exploring well-being services from the perspective of people with SCI: A scoping review of qualitative research

Objective

Well-being after spinal cord injury is affected by a range of factors, many of which are within the influence of rehabilitation services. Although improving well-being is a key aim of rehabilitation, the literature does not provide a clear path to service providers who seek to improve well-being. This study aimed to inform service design by identifying the experience and perspective of people with SCI about interventions targeting their well-being.

Method

The scoping review of qualitative literature used thematic analysis to identify and categorize themes related to service activities, valued aspects, limitations and perceived outcomes.

Results

Thirty-eight studies were selected, related to a range of service types. Most studies did not adopt a well-being conceptual framework to design and evaluate the services. People with SCI particularly valued being treated with dignity, positive expectations, increased autonomy and peer support. Improvements to well-being were reported, including many years post-SCI. However, people with SCI reported limited opportunities to engage in such services.

Conclusions

Rehabilitation services can improve well-being across the lifetime of people with SCI, but gaps in service provision are reported. The review identified valued aspects of services that may inform service design, including staff approach and positive expectations, having own skills and worth valued, peer support and interaction, autonomy in valued occupations, and long-term opportunities for gains.

The "Self" under COVID-19: Social role disruptions, self-authenticity and present-focused coping

Social role disruption is a state involving upheaval of social identities, routines and responsibilities. Such disruption is presently occurring at a global scale due to the COVID-19 pandemic, which poses a threat not only to health and security but also to the social roles that underlie people’s daily lives. Our collective response to combat the virus entails, for example, parents homeschooling children, friends socializing online, and employees working from home. While these collective efforts serve the greater good, people’s social roles now lack continuity from what was authentic to the roles before the pandemic began. This, we argue, takes a psychological toll. Individuals feel inauthentic, or alienated and out-of-touch from their “true” selves, to the extent their social roles undergo change. As evidence, we report survey (Studies 1 & 4) and experimental (Studies 2 & 3) evidence that COVID-19-related role changes indeed increase inauthenticity. This effect occurs independent of (a) how positively/negatively people feel about COVID-19 (Study 2) and (b) how positively/negatively people feel about the role change itself (Studies 3 & 4). Moreover, we identify two moderators of this effect. First, this effect occurs when (and ostensibly because) the social roles undergoing change are central to an individual’s sense of self (Study 2). Second, this effect depends on an individual’s temporal perspective. People can safeguard their self-authenticity in the face of changing social roles if they stay focused on the here-and-now (the present and immediate future), rather than focusing on the past (pre-COVID-19) or future (post-COVID-19) (Studies 3 & 4). This advantage for present-focused coping is observed in both the U.S.A. (Study 3) and Hong Kong (Study 4). We suggest that the reason people feel more authentically themselves when they maintain a present focus is because doing so makes the discontinuity of their social roles less salient.

Does being psychologically resilient assist in optimising physical outcomes from a spinal cord injury? Findings from a systematic scoping review

PURPOSE

To systematically search for current research on the role of resilience in the physical rehabilitation of SCI and describe the research to date.

MATERIALS AND METHODS

The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) approach was used. Five databases were searched for papers published up to March 2020. The sample included adults who have sustained an SCI; outcomes included a physical rehabilitation outcome and a measure of psychological or personal resilience/resilience training.

RESULTS

The initial search found 2074 studies. 12 studies were included. Six suggest positive effects of resilience on physical functioning/recovery, six report resilience as not affecting physical functioning/recovery.

CONCLUSIONS

Resilience may positively affect physical outcomes; however, the relationship is under-researched and contrasting findings may be due to measurements and methods employed by research. Future research may distinguish between two sources of resilience following an SCI: prior resilient experiences, and resilience as a product of the injury. Individuals' past events that triggered resilient behaviour may be able to promote a resilient response to an SCI. Focussing on emotional coping may result in poorer outcomes than building a sense of control. Resilience training may affect psychosocial rehabilitation; it is difficult to establish if it would affect physical outcomes. A negative approach to an injury can have negative effects on functioning; when identifying patients for psychoeducational training, those with the presence of negative appraisals of their injury are most in need.IMPLICATIONS FOR REHABILITATIONResilience may positively affect physical outcomes; however, the relationship is under-researched.Individuals' past events that triggered resilient behaviour may be able to promote a resilient response to an SCI.Focussing on emotional coping may result in poorer outcomes than building a sense of control.When identifying patients for psychoeducational training, it may be those with the presence of negative appraisals of their injury that are most in need.

Associations between post-traumatic growth and wisdom in people with long-term paraplegia - the role of disability appraisals and participation

PURPOSE

The number of people with long-term spinal cord injury (SCI) is growing but our knowledge about their successful functioning is still limited. The goal of this study was to investigate the correlations between posttraumatic growth (PTG) and wisdom in people with long-term paraplegia, exploring the mediating effect of disability appraisals, and participation/autonomy (P/A).

METHODS

One-hundred and sixty-six persons with paraplegia completed a set of questionnaires, which included: The three-dimensional Wisdom Scale; The Post-traumatic Growth Inventory; Appraisals of Disability Primary and Secondary Scale; Impact on Participation and Autonomy Questionnaire. Mediation was tested using bootstrapping and a multiple mediation model with two mediators.

RESULTS

Positive and significant correlations between PTG, disability appraisals (as determined resilience), P/A, and wisdom were found. PTG is associated with wisdom when disability appraisals and P/A are mediators. Higher PTG was related to higher determined resilience and smaller restrictions in participation, both of which were associated with higher wisdom.

CONCLUSIONS

The relationship between PTG and wisdom is complex and indirect in people with long-term paraplegia. The mediating variables of disability appraisals and P/A explained the variance in PTG, with P/A playing a more significant role. Findings suggest that long-term SCI may correlate with experiencing high levels of PTG and wisdom, and more positive disability appraisals.Implications for rehabilitationPTG is associated with life wisdom in people with long-term SCI, with a significant contribution of disability appraisal and P/A.Therapists can increase these people's awareness about the possibility of experiencing PTG and maintaining positive changes, despite long-term SCI.Therapists can support people with long-term SCI in maintaining or extending the possibilities of participation and autonomous decision-making about their daily activities, which in consequence may be important for increasing their life wisdom.

The experience and perspective of people with spinal cord injury about well-being interventions: a systematic review of qualitative studies

PURPOSE

Promoting well-being is a key aim of rehabilitation. The intentional design of interventions to address well-being requires an understanding of the factors that affect this complex phenomenon. A growing body of qualitative literature has identified determinants that people with SCI report affect their well-being. It is unclear whether or how rehabilitation interventions can influence these well-being determinants. This study sought to explore the experience and perspective of people with SCI about interventions that target their well-being.

METHOD

Systematic search of seven databases. Deductive analysis to categorize findings related to well-being determinants, and further inductive coding to identify sub-themes, relationships and additional findings.

RESULTS

Twenty studies were selected, involving a wide range of interventions. Each intervention influenced a number of well-being determinants, which were inter-related. People with SCI reported improvements in both subjective and psychological well-being. However, well-being was not always well defined in the studies and people with SCI reported lack of priority for, and opportunity to engage in, well-being interventions in the current rehabilitation system.

CONCLUSIONS

Rehabilitation interventions can influence well-being determinants. These determinants form a useful framework for the intentional design of well-being interventions, which should be informed by a broad understanding of well-being.IMPLICATIONS FOR REHABILITATIONWell-being can be influenced by rehabilitation interventions, and a more explicit focus on well-being in intervention design and evaluation is recommended.Conceptual frameworks used to define and measure well-being should adopt a broad understanding of well-being.Well-being interventions should address the determinants identified by people with SCI (engaging in occupation, responsibility, values and perspectives, self-worth, self-continuity, relationships and the environment).People with SCI want a greater priority placed on well-being interventions, and more opportunities to engage in these interventions, especially in the community.

Psychological morbidities and positive psychological outcomes in people with traumatic spinal cord injury in Mainland China

STUDY DESIGN

Cross-sectional survey.

OBJECTIVES

To explore the prevalences of three psychological morbidities (posttraumatic stress disorder, anxiety, and depression) and two positive psychological outcomes (resilience and posttraumatic growth) in people with spinal cord injury (SCI). To examine the relationships between the five aforementioned variables and to determine the predictors of the three psychological morbidities.

SETTING

Shanghai Sunshine Rehabilitation Center, Mainland China.

METHODS

Participants included 300 adults with SCI in one rehabilitation center in Shanghai. Standardized self-report measures were used. Sociodemographic, injury, and psychological variables were assessed. Descriptive analyses were used to calculate the prevalences of five psychological outcome variables. Pearson correlation analyses were conducted to examine the relationships between the five psychological variables and regression analyses were conducted to determine the predictors of posttraumatic stress disorder (PTSD), anxiety, and depression.

RESULTS

Of the 300 respondents, 35%, 29%, and 27% exceeded the clinical cutoff score for PTSD, anxiety, and depression, respectively. About 32% reported good resilience, and 51% reported moderate to high levels of posttraumatic growth (PTG). Three psychological morbidities showed positive correlations between each other while significant negative relationships with the resilience and PTG. Hierarchical regressions indicated that both the extent of environmental barriers and resilience were the significant predictors of PTSD, anxiety, and depression.

CONCLUSION

High prevalences of psychological morbidities were found in the SCI population in Mainland China. They should be identified and intervened early in the rehabilitation process. Some positive psychological techniques that focus on increasing resilience and promoting PTG would likely be beneficial for the SCI population.

The influence of clarification and threats on life situation: patients' experiences 1 year after TSCI

INTRODUCTION

The study was conducted at the Spinal Cord Injury Centre of Western Denmark (VCR). The aim of the study was to explore patients' experiences following traumatic spinal cord injury and to identify characteristics of positive versus negative life situation 1 year post discharge from hospital rehabilitation. This was a qualitative study conducted using inductive content analysis.

CASE PRESENTATION

In this qualitative study seven patients were interviewed one year after discharge from initial rehabilitation at the VCR. The interviews were analysed using inductive content analysis.

DISCUSSION

We found that two categories condensed the patients' experiences of their life situation 1 year post discharge: 'clarification in relation to overall life situation' and 'threat to core competences'. The transversal analysis across the derived categories identified different combinations of clarification and threats to core competences explaining the patients' experiences: high degree of clarification combined with low degree of threat to core competences was indicative of positive life situation. Also, positive life situation was seen when a high degree of clarification compensated for high degree of threats on core competencies. In contrast, an overall stressful and negative life situation was influenced by poor clarification combined with a high degree of threat to core competences. However, when core competences can be transformed into new skills, threats were manageable. This study revealed that clarification related to overall life situation in combination with threat to core competences may explain traumatic spinal cord injury patients' overall life situation 1 year post discharge. An appropriate balance characterises a positive life situation. There might be a need to pay attention to patients who are challenged by low degree of clarification and high degree of threats on core competencies 1 year post discharge as this may influence the life situation negatively.

Factors Which Facilitate or Impede Interpersonal Interactions and Relationships after Spinal Cord Injury: A Scoping Review with Suggestions for Rehabilitation

Interpersonal interactions and relationships can influence an individual's perceptions of health and quality of life in the presence of disability. In the case of people with spinal cord injury (SCI), positive interpersonal interactions and relationships have been shown to contribute to resilience and adaptability. Understanding factors which facilitate or impede the development and maintenance of relationships after SCI may form the basis for proactive relationship support for people with SCI. To gain a broad insight into these factors, a scoping review was undertaken. Databases were searched for English language studies published between 2000 and 2015 that informed the review question. Sixty-two (62) studies were identified. Thematic analysis was conducted on data extracted from the studies and 51 factors which may facilitate relationships and 38 factors which may impede relationships after SCI were noted. The majority of factors could be categorized as environmental or personal according to the domains of the International Classification of Functioning, Disability, and Health (ICF). The facilitating factors included partner and social support, reciprocity in relationships, and presenting oneself positively. Impeding factors included physical environmental barriers, real and perceived social biases, and poor self-image. Factors identified may inform the provision of supportive, holistic rehabilitation for people with SCI.

Understanding post-traumatic growth following pediatric-onset spinal cord injury: the critical role of coping strategies for facilitating positive psychological outcomes

AIM

The aim of this study was to explore positive psychological growth in individuals who had sustained spinal cord injuries (SCIs) in childhood, and to identify factors correlating with such growth.

METHOD

Data were drawn from ongoing research aimed at assessing the long-term outcomes of pediatric-onset SCIs in adults. Participants were assessed using measures of demographics, coping ability, post-traumatic growth, life satisfaction, happiness, and mental health. The study sample included 161 adults with a mean age of 33 years and 2 months (SD 7y 3mo, range 19-50y). The participants had sustained SCIs between the ages of 7 years and 18 years (mean 14y 10mo, SD 2y 6mo) and were injured for an average of 17 years and 9 months (SD 7y 7mo, range 1-36y). Sixty-four percent of participants were male, 81% were white, 63% had tetraplegia, and 70% had complete injuries.

RESULTS

The vast majority of participants (99%) recognized that at least one positive change had occurred in their life as a result of their SCI. Post-traumatic growth was significantly associated with behavioral (r=0.29, p<0.001) and cognitive (r=0.39, p<0.001) coping strategies, as well as with increased life satisfaction (r=0.18, p=0.024) and happiness (r=0.27, p=0.001), but was unrelated to psychological distress. Additional analyses indicated that post-traumatic growth mediated effects of cognitive coping on happiness, but not on life satisfaction.

INTERPRETATION

The majority of individuals with pediatric-onset SCIs experienced positive psychological growth. Coping strategies are crucial to this growth process.

The process of posttraumatic growth in individuals with traumatic spinal cord injury in Mainland China: An interpretative phenomenological analysis

This study aims to explore the process of posttraumatic growth for individuals who have sustained a traumatic spinal cord injury. Semi-structured interviews were conducted with 12 participants with spinal cord injury from the local community. Interviews were recorded on audiotape and transcribed verbatim. Transcripts were analyzed using interpretative phenomenological analysis. Three superordinate themes emerged: struggling in hopelessness, disentangling from disability, facing challenge, and achieving positive growth. Our findings reveal how individuals with spinal cord injury overcome their disability to achieve personal growth, and can contribute to clinicians' understanding of psychological responses to spinal cord injury while promoting physical and psychological recovery in these individuals.

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.