Quality of life among veterans with chronic spinal cord injury and related variables

A Systematic Review of the Impact of Spinal Cord Injury on Costs and Health-Related Quality of Life

OBJECTIVE

To systematically review the health-related quality of life (HRQoL) burden and costs of spinal cord injury (SCI) on health services, patients and wider society.

METHODS

A systematic review guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement was conducted in March 2021 through Scopus, PubMed and Embase databases. Inclusion criteria were quantitative studies on SCI reporting healthcare costs, social costs and/or HRQoL measured with the Euroqol EQ-5D or Short-Form 36. Risk of bias was assessed using the QualSyst tool. Descriptive analyses, random-effects direct meta-analysis and random-effects meta-regression were conducted.

RESULTS

A total of 67 studies were eligible for inclusion. SCI individuals tend to report higher HRQoL in mental than physical dimensions of the Short-Form 36. Neurological level of SCI negatively affects HRQoL. Cross-sectional studies find employment is associated with better HRQoL, but the effect is not observed in longitudinal studies. The estimated lifetime expenditure per individual with SCI ranged from US$0.7 million to US$2.5 million, with greater costs associated with earlier age at injury, neurological level, United States of America healthcare setting and the inclusion of non-healthcare items in the study.

CONCLUSIONS

SCI is associated with low HRQoL on mobility and physical dimensions. Mental health scores tend to be greater than physical scores, and most dimensions of HRQoL appear to improve over time, at least over the first year. SCI is associated with high costs which vary by country.

CLINICAL TRIALS REGISTRATION

This review was registered in PROSPERO (registration number: CRD42021235801).

Predictive factors and quality of life assessment among patients with spinal cord injury in the Middle East: a systematic review

PURPOSE

Spinal cord injury (SCI) is impairment of the spinal cord that adversely affects patients' health and quality of life (QoL). The aim of the study was to assess the quality of life (QoL) and related factors in patients with traumatic spinal cord injury in Middle Eastern countries.

METHODS

PubMed, Ovid Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), EBSCOhost, psycINFO, and Google Scholar were systematically searched for eligible studies published in peer-reviewed journals up till October 2023.

RESULTS

Out of 1060 papers found in the literature, only 18 studies from Iran, Lebanon, and Turkey met the inclusion criteria. The majority of the studies employed the SF-36 scale to assess for QoL. In general, all SCI patients had reduced QoL scores when compared to the healthy population. Some of the factors such as age, education level, the level of injury, time since injury onset, marriage, and job opportunities were correlated with SCI subjects QoL. Our papers were assessed and found to be of both good and high quality.

CONCLUSION

This review emphasizes the significant shortage of QoL studies among SCI patients in the Middle East countries and highlights the importance of improving the QoL of this marginalized population. This work should enhance the governments to establish rehabilitation centers, social and economic support systems, and mental health services to diminish complications arising from SCI.

Recent Advances in the Treatment of Spinal Cord Injury

Spinal cord injury (SCI) is a complex, multifaceted, progressive, and yet incurable complication that can cause irreversible damage to the individual, family, and society. In recent years strategies for the management and rehabilitation of SCI besides axonal regeneration, remyelination, and neuronal plasticity of the injured spinal cord have significantly improved. Although most of the current research and therapeutic advances have been made in animal models, so far, no specific and complete treatment has been reported for SCI in humans. The failure to treat this complication has been due to the inherent neurological complexity and the structural, cellular, molecular, and biochemical characteristics of spinal cord injury. In this review, in addition to elucidating the causes of spinal cord injury from a molecular and pathophysiological perspective, the complexity and drawbacks of neural regeneration that lead to the failure in SCI treatment are described. Also, recent advances and cutting-edge strategies in most areas of SCI treatment are presented.

Evaluation of clinical outcomes and employment status in veterans with dual diagnosis of traumatic brain injury and spinal cord injury

PURPOSE

To examine clinical outcomes and employment status in Veterans with and without a dual diagnosis of traumatic brain injury (TBI) and spinal cord injury (SCI).

METHODS

This cross-sectional study examined a national sample of Veterans enrolled in the VA Million Veteran Program who completed the Comprehensive TBI Evaluation (CTBIE) as part of the Veterans Health Administration's TBI Screening and Evaluation Program. Veterans (N = 12,985) were classified into the following TBI/SCI groups using CTBIE data: those with a dual diagnosis of TBI and SCI (TBI+/SCI+); those with a history of TBI but no SCI (TBI+/SCI-); and those with no history of TBI or SCI (TBI-/SCI-; i.e., the control group). CTBIE-derived outcomes included neurobehavioral symptoms, comorbid psychiatric symptoms, pain and pain interference, and employment status.

RESULTS

Chi-square analyses showed significant associations between TBI/SCI group and all clinical outcomes evaluated (all p's < .001; V = 0.07-0.11). In general, the TBI+/SCI+ and TBI +/SCI- groups endorsed comparable levels of neurobehavioral symptoms, psychiatric symptoms, and pain, but significantly greater rates of symptoms and pain relative to the TBI-/SCI- group. Effect sizes for all pairwise comparisons were small (φ = 0.01-0.11). Finally, there was no significant association between TBI/SCI group and employment status (p = .170; V = 0.02), with all three groups showing relatively comparable rates of unemployment.

CONCLUSIONS

Regardless of SCI status, Veterans with TBI history endorsed poorer clinical outcomes than Veterans without TBI and SCI. However, rates of unemployment were similarly high across all three groups. Findings suggest that any Veteran completing the CTBIE may be at risk for poor clinical and employment outcomes.

Chronic pain among Lebanese individuals with spinal cord injury: Pain interference and impact on quality of life

Background: Chronic pain is one of the most disabling consequences of spinal cord injury (SCI). Although studies have identified a link between chronic pain and decreased quality of life (QOL) among this population, few studies have looked into the experience of chronic pain in Lebanese individuals with SCI and the impact of pain characteristics on QOL. Thus, the present study evaluated the chronic pain experience and its associated factors among Lebanese individuals with SCI in order to determine the impact of pain on QOL. Methods: A cross-sectional study was conducted on 81 Lebanese individual with SCI between August 1st and October 31, 2022. The collected information included sociodemographic characteristics, SCI-related information, pain-related variables, and the 12-item Short Form Health Survey (SF-12). Factors associated with pain interference were evaluated using a linear regression model. One-way ANOVA and independent sample t-test were used to evaluate the association of different baseline and pain characteristics with QOL. Results: In the present study, 81.5% of participants reported chronic pain with the majority of them having neuropathic pain type. Employment status (P = 0.034), type of pain (P = 0.009), and pain severity (P = 0.028) were significantly associated with pain interference. Unemployed participants and those with severe chronic pain, particularly neuropathic pain, had lower QOL. Conclusion: Chronic pain was found to be highly prevalent among Lebanese patients with SCI. Pain interference and QOL were significantly affected by employment status and pain type. Therefore, targeting chronic pain and its associated factors in rehabilitation practice is warranted.

Health-related quality of life and related characteristics of persons with spinal cord injury in Nigeria

Background: Spinal cord injury (SCI) is impairment of the spinal cord resulting in numerous health problems that considerably affect the quality of life (QOL) of the patients. Moreover, a number of sociodemographic and clinical characteristics may influence the persons' health-related quality of life (HRQOL). However, there is limited information on the HRQOL and related characteristics among affected persons living in Nigeria. This study explores the HRQOL and related characteristics of persons with SCI in Kano, Northwestern Nigeria. Methods: A prospective cross-sectional survey of 41 subjects with SCI and 40 age and gender matched healthy subjects was conducted from January to December 2016. Subjects' sociodemographic and clinical characteristics and HRQOL (using the SF-36 questionnaire) were collected and analyzed. Results: The majority of the subjects were men in both the SCI (85.4%) and healthy (82.5%) groups. The mean injury duration was 28.4 ± 20.2 months. Road traffic accident (46.3%) was the leading cause of injury with paraplegia (70.7%) being the most frequent level of injury. A greater number of the subjects (43.9%) had a complete impairment. Subjects with SCI had significantly lower HRQOL in the domains of general health, physical functioning, bodily pain, social functioning, role-emotional, and mental health compared to healthy controls. Gender, level of injury, and severity of injury were commonly found to be related to lower HRQOL scores. Conclusion: Persons with SCI from Kano, Northwestern Nigeria have lower HRQOL across various domains compared to healthy controls. Common factors related to lower HRQOL scores were gender, level of injury, and severity of injury. There is a need for optimal rehabilitation for persons with SCI in Kano, Northwestern Nigeria.

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.

Impact of bladder, bowel and sexual dysfunction on health status of people with thoracolumbar spinal cord injuries living in the community

OBJECTIVE

The disruption of autonomic function following a spinal cord injury (SCI) is common and can negatively affect quality of life. The objective of this study was to describe the prevalence of bladder/bowel incontinence and sexual dysfunction in community-dwelling individuals with a thoracolumbar SCI and examine the impact on general physical and mental health status.

METHODS

Participants who sustained a traumatic SCI to the thoracolumbar region of the spinal cord and classified as American Spinal Injury Association Impairment Scale (AIS) A to D were recruited. Demographic, injury data, MRI classification and neurological data were collected on admission. At follow-up, the neurological data, a questionnaire collecting participant-reported secondary health conditions (SHCs) (e.g. bladder incontinence, depression etc.) following SCI and health status measured by Short Form-36 were obtained. Regression models determined the association of health status with demographic/injury-related data, types and number of SHCs.

RESULTS

Of the 51 participants, 58.8% reported bladder incontinence, 54.0% bowel incontinence, 60.8% sexual dysfunction and 29.4% had all three. The regression models demonstrated that age at injury, bowel incontinence, sexual dysfunction, presence of pain, motor score at follow-up and the number of SHCs were significant predictors of health status. The number of SHCs was more predictive than all other demographic and injury variables for health status.

CONCLUSION

Results highlight the high prevalence of self-reported bowel/bladder incontinence and sexual dysfunction in the traumatic thoracolumbar SCI population and support the need for standardized assessments. Several demographic, injury-related and SHCs impacted health status and should be considered for the management of individuals living in the community.

C-reactive protein as an available biomarker determining mental component of health-related quality of life among individuals with spinal cord injury

OBJECTIVES

C-reactive protein (CRP) has been shown to correlate with health-related quality of life (HRQL) in some chronic medical conditions. However, these associations have not yet described in spinal cord injury (SCI). In this study, we tried to identify biomarkers associated with HRQL in SCI.

DESIGN

Cross-sectional.

SETTING

Tertiary rehabilitation center.

PARTICIPANTS

Referred patients to Brain and Spinal Cord Injury Research Center between November 2010 and April 2013.

OUTCOME MEASURE

Blood samples were taken to measure circulatory CRP, leptin, adiponectin, ferritin, parathyroid hormone, calcitonin, thyroid hormones, fasting plasma glucose and lipid profile. All the analyses were performed with adjustment for injury-related confounders (level of injury, injury completeness and time since injury) and demographic characteristics. HRQL was measured with Short Form health survey (SF-36).

RESULTS

The initial inverse association between CRP and total score of SF-36 (P: 0.006, r = -0.28) was lost after adjustment for confounders. However, the negative correlation between CRP and Mental Component Summary (MCS) remained significant (P: 0.0005, r = -0.38). Leptin level was inversely correlated with Physical Component Summary (PCS) (P: 0.02, r = -0.30).

CONCLUSION

Although CRP and leptin levels were not related with total scores of SF-36 questionnaire, CRP can be more useful in determining mental component of HRQL whereas leptin can be a determinant of physical component. The combined consideration of these two biomarkers may help to predict HRQL in individuals with SCI.

Is Level of Injury a Determinant of Quality of Life Among Individuals with Spinal Cord Injury? A Tertiary Rehabilitation Center Report

OBJECTIVES

The role of injury-related variables in determining health-related quality of life (HRQOL) among Iranian persons with spinal cord injury (SCI) has not yet been fully described. In this study, we compared HRQOL between individuals with injury at cervical level and those with injury at thoracolumbar sections and evaluated the discriminating value of injury level as a determinant of HRQOL among Iranian people with SCI.

METHODS

Individuals with SCI, who were referred to Brain and Spinal Cord Injury Research Center, were invited to participate in this investigation. HRQOL was assessed using the Short Form (SF-36) questionnaire to determine the quality of life (QOL) in eight domains: physical functioning (PF), role limitation due to physical problems (RP), bodily pain (BP), general health (GH), vitality (VT), social functioning (SF), role limitation due to emotional problems (RE), and mental health (MH).

RESULTS

Ninety patients with paraplegia and 94 quadriplegic patients participated in this investigation. The mean score of PF domain was significantly lower in patients with injury at cervical level (p < 0.0001). There was no significant difference in other domains of SF-36 between subjects with paraplegia and quadriplegia (p = 0.670, 0.700, 0.910, 0.710, 0.730, 0.290 and 0.850 for RP, RE, VT, MH, SF, BP and GH, respectively). Similarly, the mean physical component summary (PCS) score was significantly higher among individuals with injury at thoracolumbar sections (p < 0.0001). The mean mental component summary (MCS) score did not differ between the two groups (p = 0.720).

CONCLUSIONS

Patients with SCI at the cervical level have similar mental health compared to those with injury at thoracolumbar sections, which shows proper mental adaptability in quadriplegic individuals. Injury level can be used as a major determinant of the physical component of QOL among people with SCI.

Physical Activity and Quality of Life among Adults with Paraplegia in Odisha, India

OBJECTIVES

The complete rehabilitation of patients with spinal cord injuries (SCI) comprises both physical and psychosocial factors. This study therefore aimed to assess physical activity and quality of life (QOL) among paraplegic patients with SCI in Odisha, India.

METHODS

This cross-sectional prospective study was conducted between March 2010 and December 2013. All paraplegic patients treated at the Swami Vivekanand National Institute of Rehabilitation Training & Research in Odisha, India, during the study period who met the inclusion criteria were invited to participate in the study (n = 364). Structured face-to-face interviews were held with participants and QOL and physical activity were assessed using the abbreviated World Health Organization QOL instrument and the Physical Activity Scale for Individuals with Physical Disabilities, respectively.

RESULTS

A total of 84 people participated in the study (response rate: 23.1%). The mean age was 32.54 ± 10.75 years and 90.5% of the participants were male. Participants had a low mean metabolic equivalent score (18.18 ± 10.68 hours/day). Additionally, low mean scores were noted for the physical health, psychological well-being, social relationships and environment QOL domains (49.76 ± 18.74, 48.57 ± 17.04, 57.88 ± 17.04 and 49.85 ± 17.77, respectively). There was a strong positive association between levels of physical activity and all QOL domains (P <0.050). Physical activity and employment status were significant predictors of all QOL domains (P <0.001).

CONCLUSION

Low physical activity levels and QOL were noted among the paraplegic subjects. Interventions promoting physical activity and employment may help to improve QOL among this patient group.

Quality of Life and Related Factors Among People With Spinal Cord Injuries in Tehran, Iran

Background:

Spinal Cord Injury (SCI) is one of the biggest health problems. Disabilities resulting from injuries such as spinal disability requires special attention because of their potential reduced to cause adverse effects in different systems of the body. Today, improving the Quality of Life (QOL) in patients with SCIs is an important goal of treatment.

Objectives:

The purpose of this study was to determine the QOL and related factors among people with SCIs.

Patients and Methods:

In this cross-sectional descriptive study, 106 patients with SCI were selected through sampling based on census. Data were collected using a demographic questionnaire and a Short-Form 36 (SF-36) health survey questionnaire for measuring the QOL among patients. Data were analyzed using SPSS 14 software and descriptive and inferential statistics. P < 0.05 was considered statistically significant.

Results:

The mean QOL in these patients was 37.1 ± 1.7 years (21 - 65 years) and mean disease duration was 7.3±6 years. The most common injury was paraplegia. Most of the patients have moderate QOL (54.7 %). The results showed a significant relationship between QOL and marital status and employment status (P < 0.05). Also, results showed a significant relationship between QOL and education levels (P = 0.002), age (P = 0.001), and duration of illness (P = 0.001).The highest and lowest scores were 64 ± 7.1 and 36 ± 5.3 for understanding General Health (GH) and role physical, respectively.

Conclusions:

The results show that patients with SCI have a moderate health-related QOL Determining the QOL is needed to focus on the strengths and weaknesses of patients with spinal cord injuries. Planning principles is recommended in order to reform the disability.

Injury-related characteristics and quality-of-life among Iranian individuals with spinal cord injury

BACKGROUND

Health-related quality-of-life (HR-QOL) may be affected by various factors including injury-related characteristics among individuals with spinal cord injury (SCI). However, the impact of the influence of these variables has not yet been fully described in Iranian population. Here, we assessed the relationships between injury-related characteristics and HR-QOL among Iranian people with SCI.

METHODS

HR-QOL was assessed using short-form health survey (SF-36). Referred patients to Brain and Spinal Injury Research Center between 2010 and 2012 were invited to participate in this investigation. Injury-related characteristics including injury level and completeness, time since injury, plegia type, and American Spinal Injury Association (ASIA) Impairment Scale were evaluated.

RESULTS

Total of 104 patients (85 men and 19 women) entered the study. The majority of patients had a complete injury (77.9%). The most frequent ASIA score was A (75%), and the most common level of injury was at thoracic sections (61.5%). Lower injury levels were associated with higher scores in physical component summary (P = 0.040), mental component summary (P = 0.010) and subsequently total score (P = 0.006). Mean age and time since injury were 52.58 ± 12.69 and 10.88 ± 16.68 years, respectively, and were not related with HR-QOL (P = 0.70 and 0.220, respectively). There was no difference in terms of HR-QOL between patients with complete and incomplete injury. Paraplegic individuals had significantly higher scores in the domain of physical functioning compared to patients with tetraplegia (P = 0.007).

CONCLUSION

lower injury level is a significant predictor of better QOL among individuals with SCI whereas other injury-related characteristics including completeness, time since injury and plegia type may not influence HR-QOL.

The Zarit Caregiver Burden Interview Short Form (ZBI-12) in spouses of Veterans with Chronic Spinal Cord Injury, Validity and Reliability of the Persian Version

BACKGROUND

To test the psychometric properties of the Persian version of Zarit Burden Interview (ZBI-12) in the Iranian population.

METHODS

After translating and cultural adaptation of the questionnaire into Persian, 100 caregiver spouses of Iran- Iraq war (1980-88) veterans with chronic spinal cord injury who live in the city of Mashhad, Iran, invited to participate in the study. The Persian version of ZBI-12 accompanied with the Persian SF-36 was completed by the caregivers to test validity of the Persian ZBI-12.A Pearson`s correlation coefficient was calculated for validity testing. In order to assess reliability of the Persian ZBI-12, we administered the ZBI-12 randomly in 48 caregiver spouses again 3 days later.

RESULTS

Generally, the internal consistency of the questionnaire was found to be strong (Cronbach's alpha 0.77). Intercorrelation matrix between the different domains of ZBI-12 at test-retest was 0.78. The results revealed that majority of questions the Persian ZBI_12 have a significant correlation to each other. In terms of validity, our results showed that there is significant correlations between some domains of the Persian version the Short Form Health Survey -36 with the Persian Zarit Burden Interview such as Q1 with Role Physical (P=0.03),General Health (P=0.034),Social Functional (0.037), Mental Health (0.023) and Q3 with Physical Function (P=0.001),Viltality (0.002), Socil Function (0.001).

CONCLUSIONS

Our findings suggest that the Zarit Burden Interview Persian version is both a valid and reliable instrument for measuring the burden of caregivers of individuals with chronic spinal cord injury.

Correlation between health-related quality of life in veterans with chronic spinal cord injury and their caregiving spouses

Background:

Recently, investigations have indicated that caring of a chronically ill family member strongly influences the health status and the quality of life (QOL) of the caregiving family members.

Objectives:

The purpose of this study was to examine the relationship between health-related QOL of veterans with chronic spinal cord injury and their caregiving spouses.

Patients and Methods:

We designed a cross-sectional study including two groups; veterans with chronic spinal cord injury and their caregiving wives who were living in the city of Mashhad, Iran. The patients with spinal cord injury were veterans from the Iran-Iraq war (1980-1988). All the participants filled out the short form 36 (SF-36) health survey questionnaire. A Pearson correlation coefficient was calculated for the scales of the two groups.

Results:

The mean age and standard deviation of veterans and their spouses were 48.5 ± 5.9 and 44.8 ± 7.2, respectively and their number of children ranged between 0-6. Our data analysis showed that there was a significant difference between the two groups in some domains of the SF-36, including PF, MH, PCS, MCS, BP and GH (P < 0.05), but there was no significant difference in RP, VT, SF and RE between the two groups.

Conclusions:

The results indicate that a decrease in health status level of veterans, physically and mentally, can affect the health-related QOL of their caregiving spouses.