Risk factors for posttraumatic stress disorder in persons with spinal cord injury

The role of clinical and demographic predictors for understanding the cognitive impairment in Spinal Cord Injury (SCI) patients

STUDY DESIGN

Using a cross-sectional design, we extracted sociodemographic and clinical data from 488 Spinal Cord Injury (SCI) patients during their initial assessment before receiving intensive rehabilitation treatment.

OBJECTIVES

The primary objectives of this study were to ascertain the prevalence of cognitive impairment in the study sample and specify the key clinical and demographic predictors of cognitive functioning in SCI patients.

SETTING

Lucy Montoro Rehabilitation Institute (LMRI), University of Sao Paulo, Sao Paulo, Brazil.

METHODS

We utilized independent univariate and multivariate regression models with the Montreal Cognitive Assessment (MoCA) scale, adapted for individuals with visual impairment. Moreover, we consider scores from the execution tasks (visuospatial/executive) as the dependent variable.

RESULTS

Our findings demonstrate that approximately 80% of the evaluated study sample exhibited cognitive impairment. Through the multivariate regression models, we show that several factors, including age, education, depression levels, and the use of analgesics and/or opioids, are significant predictors of total cognitive scores. These factors are independent of the clinical features associated with SCI, such as age, sex, education, and time since the injury.

CONCLUSIONS

The results indicate a high prevalence of significant cognitive impairment within the sample, with age, education, depression levels, and the use of analgesics and/or opioids emerging as the primary predictors of total cognitive scores, independent of the clinical features correlated to SCI. These findings hold significant implications for both clinical research and practice, offering valuable guidance for comprehensive management throughout hospitalization and rehabilitation.

Post-traumatic stress disorder among individuals with traumatic spinal cord injury in Nepal: a cross-sectional study

STUDY DESIGN

Cross-sectional study OBJECTIVES: To identify the prevalence of posttraumatic stress disorder (PTSD) among the individuals with traumatic spinal cord injury (TSCI) and to examine the relationships between demographic and clinical characteristics, and PTSD.

SETTING

Spinal Injury Rehabilitation Center (SIRC) and Dhulikhel Hospital, Kathmandu University Hospital (DH, KUH), Kavrepalanchowk, Nepal.

METHODS

Individuals above 18 years of age with TSCI of at least one month from trauma and admitted to SIRC and DH, KUH from June 2019 to May 2021 were included. The specific stress version of the PostTraumatic Stress Disorder Checklist (PCL), was utilized. To classify the neurological status of TSCI individuals, International Standard for Neurological Classification of Spinal Cord Injury (ISNCSCI) was used. Hierarchical multiple regression analysis between independent variables and normalized PCL score was done to evaluate the predictors of PTSD.

RESULTS

Among 163 patients, the overall prevalence of PTSD was 27%, and the mean PCL score was 36 ± 13.9. Factors predictive of PTSD included gender, family type, ethnicity, and literacy rate. No significant association was found between the clinical characteristics and PTSD.

CONCLUSIONS

PTSD appears to be considerably prevalent among individuals with TSCI in Nepal. Females, individuals from nuclear families, individuals with lower literacy, and individuals from lower caste are significantly vulnerable to developing PTSD. However, clinical characteristics do not appear to be influential in the development of PTSD.

Suicidal ideation, post-traumatic stress disorder, and depression in traumatic spinal cord injury: What resilience tells us

OBJECTIVE

Identification of unmet psychiatric needs, protective and risk factors for suicide are crucial for people with traumatic spinal cord injury (SCI). In this study, we aimed to explore depression, post-traumatic stress disorder (PTSD) status (non-PTSD, partial-PTSD, full-PTSD), resilience, suicidal ideation (SI) and to examine predictors and clinical correlates of current SI in traumatic SCI.

METHOD

Sixty-three individuals with traumatic SCI who were at least 3 months post-injury were included in the study. The participants were evaluated in terms of PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (PCL-5), depression, SI, and resilience using the PCL-5, the Patient Health Questionnaire-9, the Brief Resilience Scale, and sociodemographic measures.

RESULTS

33% of our sample (n = 21) had SI over the past two weeks. 71.4% of the patients with SI (n = 15) had depression. A total of 52.4% of the patients with SI (n = 11) were diagnosed with full PTSD. Resilience was found to be significantly lower in individuals with depression and individuals with SI. While depression predicted SI in traumatic SCI, resilience stands as a protective factor against SI.

CONCLUSION

SI is quite common in individuals with traumatic SCI and is accompanied by substantial psychiatric comorbidities such as depression and PTSD. Along with depression and PTSD, resilience - which has protective and predictive values and is inversely associated with SI - constitutes a significant psychotherapeutic intervention and screening area.

Prevalence of Posttraumatic Stress Disorder Symptoms Following Traumatic Spinal Cord Injury: A Systematic Review and Meta-analysis

BACKGROUND

Limited evidence is currently available on the prevalence of posttraumatic stress disorder (PTSD) following traumatic spinal cord injury (SCI). This systematic review and meta-analysis aims to assess the prevalence and geographic distribution of PTSD symptoms after SCI.

METHODS

After a search in the MEDLINE, Embase, Scopus, and Web of Science databases, two reviewers independently summarized relevant studies published through 20 October 2021. Observational studies were included. The studies were eligible if they assessed PTSD symptoms using standard self-report or clinician-based instruments. Data and results were reported using the overall prevalence and the odds ratio (OR), with 95% confidence intervals (CIs).

RESULTS

24 articles (5646 patients) met the inclusion criteria. The prevalence of PTSD symptoms ranged from 6.33% (95% CI, 2.73-13.97) to 61.76% (95% CI, 52.07-70.61). Pooled analysis demonstrated that the overall prevalence of PTSD symptoms in SCI patients was significantly higher in developing countries (41.64%; 95% CI, 31.11-52.55) than in developed countries (19.35%; 95% CI, 14.66-24.51) (OR = 1.24; 95% CI, 1.08-1.42; p = .003). The highest prevalence of PTSD symptoms was reported in South Africa (56.25%; 95% CI, 47.01-65.08), followed by Sri Lanka (45.71%; 95% CI, 30.47-61.81), and Greece (43.55%; 95% CI, 31.94-55.91). By contrast, Norway (6.33%; 95% CI, 2.73-13.97), Switzerland/Germany (8.65%; 95% CI, 4.8-13.42), and Denmark (10.71%; 95% CI, 6.89-16.30) were found to have the lowest prevalence of PTSD symptoms after SCI.

CONCLUSION

Many traumatic SCI patients suffer from PTSD symptoms, and their prevalence seems to be higher in developing countries than in developed countries. These findings underscore the need to consider the psychological aspects of traumatic SCI.

Management and Mid-Term Outcome After "Real SCIWORA" in Children and Adolescents

STUDY DESIGN

Retrospective analysis.

OBJECTIVE

The SCIWORA Syndrome (Spinal Cord Injury Without Radiographic Abnormalities) is a rare but potentially severe injury with a peak in childhood and adolescence. With a better understanding of injury patterns and advances in MRI, there is ongoing discussion regarding the "Real SCIWORA" syndrome, a clinical picture of neurologic deficits on clinical examination but absence of radiographic pathologies even on MRI. The purpose of this study was to evaluate mid-term clinical outcome and the psychological impact of the "Real SCIWORA."

METHODS

In this retrospective analysis, we evaluated 32 patients treated for "Real SCIWORA" between 2007-2019. Inclusion criteria were: neurologic deficit after trauma, no other cerebral or skeletal injury and a lack of pathological findings in spinal MRI. All patients were followed until complete recovery from initial symptoms. 25/32 patients were re-evaluated after 6.9 years (1-14 years) using the Oswestry Disability Index, the Frankel Score, the EQ-5D score, and the Breslau Short Screening Scale for PTSD.

RESULTS

Initial neurologic presentation ranged from Frankel Grade A-D. All patients recovered neurologically during 1-13 days to a Frankel Grade E. The analysis of HR-QoL revealed no difference between the cohort of SCIWORA patients and the German population norm, Oswestry Disability Index showed only minimal disabilities. 4/25 patients showed signs of PTSD.

CONCLUSIONS

The "Real SCIWORA" syndrome is a diagnosis per exclusionem requiring a full spinal MRI to ensure exclusion of structural and potentially serious reasons of the neurologic impairment. Further clinical re-evaluation, psychological support seems to be essential.

LEVEL OF EVIDENCE

IV-retrospective study.

Health Outcomes Used to Determine Facets of Health-related Quality of Life for Post-9/11 Veterans Using Assistive Technology for A Combat-related Mobility Impairment: A Literature Review

INTRODUCTION

Novel rehabilitation methods, including distribution and adoption of assistive technology for lower extremity impairments, are becoming crucial to ensure positive quality of life in all individuals. The quality of life of post-9/11 combat veterans is not well understood, in comparison to research on other populations. The following essay describes a review on health outcomes used to determine health-related quality of life (HR-QoL) among combat-injured service members who require mobility-related assistive technology.

MATERIALS AND METHODS

Reviews pooled data from research on PubMed, EMBASE, CINAHL, and PsycINFO published after September 11, 2001, and included service members who sustained a mobility impairment because of involvement in a post-9/11 combat operation. Basic descriptors were extracted in addition to health outcomes used, which were then categorized and summarized by six domains for HR-QoL as defined by the World Health Organization.

RESULTS

This review found health outcomes that fit in the pain and discomfort, negative emotions, mobility, social relations, access to and quality of healthcare services, and religious/spiritual/personal beliefs subdomains. The categorized results detailed their application to track and model HR-QoL health states in those with mobility impairments using mobility-based assistive technology.

CONCLUSIONS

The research on combat-induced mobility impairments indicates assistive technology improves otherwise poor health states. The results model these domains and subdomains to determine overall HR-QoL and the quality of a healthcare intervention, though additional research is needed as only one study was identified to be experimental in design.

Post-traumatic stress disorder symptoms and pain intensity in persons with spinal cord injury

STUDY DESIGN

Cross-sectional.

OBJECTIVES

To examine the association between post-traumatic stress disorder (PTSD) symptoms and pain intensity, taking symptoms of anxiety and depression into account within persons with spinal cord injury (SCI).

SETTING

Persons with SCI, who visited a Dutch rehabilitation centre between 2005 and 2010, were invited to complete a survey.

METHODS

PTSD symptoms were measured with the Trauma Screening Questionnaire (TSQ), pain intensity with an 11-point Numerical Rating Scale (NRS), and symptoms of anxiety and depression with the Hospital Anxiety and Depression Scale (HADS). To determine associations between PTSD symptoms and pain intensity, linear regression analyses were performed. Confounding variables representing anxiety and depression were added to the final model.

RESULTS

In total, 175 participants (55.8% traumatic, 29.1% complete) were included (response rate of 31.7%). Of them, 11.4% had clinically relevant symptoms of probable PTSD (TSQ score ≥ 6) 69.8% experienced moderate to severe pain levels (NRS ≥ 4), 14.9% had symptoms of anxiety and 20.8% symptoms of depression (HADS scores ≥ 11). Levels of PTSD symptoms were strongly associated with symptoms of anxiety (0.54) and depression (0.49). Bivariate analyses showed a moderate significant association (0.30) between PTSD symptoms and pain intensity. This association became small (0.10) when anxiety and depression comorbidity were factored into the final regression model.

CONCLUSIONS

No independent association between PTSD symptoms and pain intensity was shown when adjusted for anxiety and depression. Results of this study suggest the usefulness of screening for PTSD in persons with SCI (regardless of injury cause or type/level) who score high on symptoms of anxiety/depression.

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.

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.

Increased psychological distress among individuals with spinal cord injury is associated with central neuropathic pain rather than the injury characteristics

STUDY DESIGN

Cross-sectional study.

OBJECTIVES

Central neuropathic pain (CNP) is common after spinal cord injury (SCI). The psychological impact of CNP is not clear. Previous studies reported depression and pain catastrophizing among patients with SCI and CNP; however, the lack of control groups prevented discerning whether these were attributed to CNP or to the SCI itself. The aim was to examine the psychological distress among individuals with SCI with and without CNP and controls to evaluate its impact and possible source.

SETTING

Outpatient clinic of a large rehabilitation center.

METHODS

Individuals with SCI and CNP (n = 27) and without CNP (n = 23), and able-bodied controls (n = 20) participated. Data collection included sociodemographics, SCI characteristics, and level of post-traumatic stress disorder (PTSD), anxiety, stress, depression, and pain catastrophizing. The sensory, affective, and cognitive dimensions of CNP were analyzed.

RESULTS

Individuals with SCI and CNP exhibited elevated levels of PTSD, anxiety, stress, depression, and pain catastrophizing compared to the two control groups, which presented similar levels. The psychological variables among the CNP group correlated positively only with the affective dimension of CNP. Neither CNP nor the psychological variables correlated with SCI characteristics.

CONCLUSIONS

Irrespective of CNP intensity, the affective dimension (suffering) is associated with increased psychological distress. Perhaps individual differences in the response to SCI and/or individual traits rather than the mere exposure to SCI may have a role in the emergence of CNP and psychological distress/mood dysfunction. Rehabilitation programs should prioritize stress management and prevention among individuals with SCI and CNP.

Examining the relationship between post-traumatic stress disorder and social participation among Veterans with spinal cord injuries and disorders

PURPOSE

The objectives of this study were to examine differences in social participation among Veterans with spinal cord injuries/disorders with and without post-traumatic stress disorder, and determine if lower social participation was independently associated with having post-traumatic stress disorder.

METHODS

A cross-sectional mailed national survey was sent to a national sample of Veterans with spinal cord injuries/disorders who received prior-year Veterans Affairs healthcare. Surveys provided data on: demographics, health conditions, injury characteristics, and social participation. Analyses included bivariate comparisons, and multivariate logistic regression to determine if lower social participation was independently associated with post-traumatic stress disorder.

RESULTS

Veterans with (vs. without) post-traumatic stress disorder (n = 896) reported lower social participation (40.2 vs. 43.9, p < 0.0001). Multivariate analyses showed that longer duration of injury (OR = 0.98, 95% CI: 0.97-1.00, p = 0.04) and white race (OR = 0.62, 95% CI: 0.38-1.01, p = 0.05) were associated with lower odds of post-traumatic stress disorder, while a greater number of health conditions (OR = 1.43, 95% CI: 1.25-1.64, p < 0.0001) was associated with greater odds. When controlling for covariates, lower social participation was independently associated with post-traumatic stress disorder (OR = 0.94, 95% CI: 0.90-0.98, p = 0.003).

CONCLUSIONS

Results indicate post-traumatic stress disorder is associated with lower social participation in Veterans with spinal cord injuries/disorders, independent of other factors that may impact participation. Efforts to screen for and treat post-traumatic stress disorder among persons with spinal cord injuries/disorders, regardless of injury-specific factors, are needed to improve participation. Implications for Rehabilitation Individuals with spinal cord injuries/disorders often have post-traumatic stress disorder; in Veterans with spinal cord injuries/disorders this may be compounded by trauma incurred through military experiences. Social participation, an important aspect of rehabilitation and community integration following spinal cord injury or disorder, may be hindered by symptoms of post-traumatic stress disorder. Our data show that post-traumatic stress disorder is associated with lower social participation in Veterans with spinal cord injuries/disorders, independent of other factors that may impact participation. These results indicate that efforts to screen for and treat post-traumatic stress disorder among persons with spinal cord injuries/disorders, regardless of injury-specific factors, are needed to improve participation in this patient population.

Event centrality as a unique predictor of posttraumatic stress symptoms and perceived disability following spinal cord injury

STUDY DESIGN

We conducted a cross-sectional study involving completion of self-report measures.

OBJECTIVES

Individuals who acquire a spinal cord injury (SCI) face numerous physical and psychological challenges, with the former receiving considerable less attention during the rehabilitation process. In this article, we examined event centrality as a unique predictor of psychological outcomes in a sample of individuals receiving rehabilitation for SCI. Event centrality refers to the extent to which individuals construe a stressful experience as a core part of their identity. In samples of individuals exposed to psychological traumas (for example, sexual assault or military combat), event centrality has emerged as a consistent and powerful predictor of posttraumatic stress symptoms (PTSSs). This is the first study to examine event centrality in an SCI sample.

SETTING

Inpatient rehabilitation program in a large urban city in the Southwestern United States.

METHODS

A sample of 55 participants in rehabilitation for a recent SCI completed measures of event centrality, PTSS, depressed mood and perceived disability.

RESULTS

Event centrality was significantly related to perceived disability (r=0.48) and PTSS (r=0.31) and accounted for unique variance in these two outcomes after controlling for demographics and depressed mood.

CONCLUSION

Event centrality is common among individuals with SCI and may be a unique contributor to worse psychological and functional outcomes. We hope our findings will alert health-care professionals to the importance of event centrality.

SPONSORSHIP

This study was supported by a grant from the Danish National Research Foundation (DNRF89).

Posttraumatic stress following spinal cord injury: a systematic review of risk and vulnerability factors

OBJECTIVES

To summarise quantitatively the available evidence relating to pretraumatic, peritraumatic and posttraumatic characteristics that may increase or decrease the risk of developing posttraumatic stress disorder (PTSD) following spinal cord injury (SCI).

STUDY DESIGN

Systematic review.

METHODS

Seventeen studies were identified from the PubMed, PsycInfo, Embase, Scopus, CINAHL, Web of Science and PILOTS databases. Effect size estimates (r) with associated 95% confidence intervals (CIs), P-values and fail-safe Ns were calculated.

RESULTS

Individual studies reported medium-to-large associations between factors that occurred before (psychiatric history r=0.48 (95% CI, 0.23-0.79) P=0.01) or at the time of injury (tetraplegia r=-0.36 (95% CI, -0.50 to -0.19) P<0.01). Postinjury factors had the strongest pooled effects: depressed mood (r_w=0.64, (95% CI, 0.54-0.72)), negative appraisals (r_w=0.63 (95% CI, 0.52-0.72)), distress (r_w=0.57 (95% CI, 0.50-0.62)), anxiety (r_w=0.56 (95% CI, 0.49-0.61)) and pain severity (r_w=0.35 (95% CI, 0.27-0.43)) were consistently related to worsening PTSD symptoms (P<0.01). Level of injury significantly correlated with current PTSD severity for veteran populations (Q_B (1)=18.25, P<0.001), although this was based on limited data.

CONCLUSION

Combinations of peri- and post-injury factors appear to be influential in the development of PTSD among persons with SCI. Further studies are needed to extrapolate these findings to the broader spinal cord-injured population. More longitudinal research, driven by multicausal models of causation such as the diathesis-stress model, is also needed to determine the temporality of PTSD risk factors.

Posttraumatic Stress Symptoms Among Spinal Cord Injury Patients in Trauma: A Brief Report

Background: Attention has recently focused on posttraumatic stress disorder (PTSD) among individuals with traumatic spinal cord injury (SCI). Purpose: To examine characteristics of individuals with and without symptoms of PTSD following acute SCI. Methods: Data were collected on 23 patients (age, 34.5 ± 14.4 years) at a Level I trauma center (14.35 ± 18.48 days following injury). Results: There were 52.2% (n = 12) who experienced symptoms of PTSD post injury, with a significant association in patients with a history of psychological disorders (p = .0094). Conclusion: Findings suggest that patients with SCI who present with PTSD symptoms in the acute trauma care settting should be provided with specific cognitive behavioral interventions.

Risk factors of severity of post-traumatic stress disorder among survivors with physical disabilities one year after the Wenchuan earthquake

On May 12, 2008, a devastating earthquake measuring 8.0 on the Richter scale struck Wenchuan County and surrounding areas in China. This study aimed to assess post-traumatic stress disorder (PTSD) in the aftermath of the earthquake, and to evaluate factors of severity of PTSD symptoms among survivors with physical disabilities. We conducted a population-based cross-sectional survey and recruited 817 survivors with physical disabilities in three stricken areas. Assessment measures included the PTSD Checklist-Civilian Version (PCL-C) and the 12-item General Health Questionnaire (GHQ-12). Our study showed that 27.42% of the survivors with physical disabilities had PTSD symptoms one year after the Wenchuan earthquake. In the regression model, geographic location, female, suffering from paralysis following the earthquake, and going into a coma in the earthquake were associated with severe PTSD symptoms. Our findings suggest that a substantial proportion of physically disabled survivors of a big earthquake may have severe PTSD symptoms. The associated factors of PTSD identified in our study could inform the implementation of preventive programs for this population and give hint on the way to cope with this kind of disaster in the future.

Measuring psychological trauma after spinal cord injury: Development and psychometric characteristics of the SCI-QOL Psychological Trauma item bank and short form

OBJECTIVE

To describe the development and psychometric properties of the SCI-QOL Psychological Trauma item bank and short form.

DESIGN

Using a mixed-methods design, we developed and tested a Psychological Trauma item bank with patient and provider focus groups, cognitive interviews, and item response theory based analytic approaches, including tests of model fit, differential item functioning (DIF) and precision.

SETTING

We tested a 31-item pool at several medical institutions 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 Veterans Administration hospital.

PARTICIPANTS

A total of 716 individuals with SCI completed the trauma items

RESULTS

The 31 items fit a unidimensional model (CFI=0.952; RMSEA=0.061) and demonstrated good precision (theta range between 0.6 and 2.5). Nine items demonstrated negligible DIF with little impact on score estimates. The final calibrated item bank contains 19 items

CONCLUSION

The SCI-QOL Psychological Trauma item bank is a psychometrically robust measurement tool from which a short form and a computer adaptive test (CAT) version are available.