Long-term psychological outcomes in spinal cord injured persons: results of a controlled trial using cognitive behavior therapy

Influence of Acceptance and Commitment Therapy Core Processes on Anxiety and Stress in Persons With Spinal Cord Injury: A Cross-sectional Study

OBJECTIVE

To explore the relationship between the core Acceptance and Commitment Therapy (ACT) processes (mindfulness, self as context, acceptance, defusion, values, and committed action) and anxiety and stress in a sample of individuals with spinal cord injury (SCI).

DESIGN

Variance accounted for by ACT on anxiety and stress as outcome variables was examined using multiple linear regression.

SETTING

Study measures were completed via online survey.

PARTICIPANTS

159 participants with a SCI completed self-report study measures relevant to the ACT core processes as well as measures of depression, anxiety, and perceived stress.

MAIN OUTCOME MEASURES

Outcome measures included the Spinal Cord Injury-Quality of Life Anxiety subdomain and the Perceived Stress Scale.

RESULTS

Higher reported engagement with acceptance (β=0.238, P=.004), pursuit of values (β=0.187, P<.008), and defusion (β=0.351, P<.001) related to less anxious distress. Perceived stress was predicted by depression (β = 0.230, P=.038) and the ACT core processes as a whole (P<.001).

CONCLUSIONS

The results of our study indicate that considerable variance in anxiety and stress in individuals with SCI is accounted for by the core processes of ACT. Lower levels of anxiety and stress were predicted by the ACT components as a whole. Anxiety was uniquely predicted by pursuit of values, acceptance, and defusion, indicating these 3 components of ACT may be particularly beneficial in the treatment of anxiety in SCI. These results may provide targeted treatment opportunities via tailored ACT-based interventions.

Cognitive behaviour therapy in adults with spinal cord injury: A scoping review

AIM

The aim of this study is to report on the extent and range of the research evaluating cognitive behaviour therapy (CBT) in adults with spinal cord injury.

BACKGROUND

Spinal cord injury is a devastating event that can lead to permanent neurologic deficit. Compared with the average person, spinal cord injury (SCI) patients are at twice the risk of developing mood disorders, highlighting vulnerability of SCI patients' mental states which can be easily hurt. CBT is the most commonly used psychosocial intervention.

DESIGN

This was a scoping review.

REVIEW METHOD

Five electronic databases (MEDLINE, CINAHL, EMBASE, PsycINFO and Airiti Library) were searched for articles published between 1990 and 2021. Google Scholar was utilized to search additional articles listed in the reference lists of included articles.

RESULTS

Overall, 16 articles met the inclusion criteria, with the majority reporting on CBT, that focused on psychological distress and neuropathic pain. The core concept of intervention included disease identification, cognitive distortion/modification and coping strategies.

CONCLUSIONS

There were significant knowledge gaps on the interventions' content and effectiveness for psychological distress of persons with SCI. Development of multifaceted cognitive behaviour interventions, especially to strengthen self-identity and to inspire patients' hope, is needed. Further research is required to investigate the long-term effectiveness of CBT.

Conception and development of Self-Management indicators to advance the quality of spinal cord injury rehabilitation: SCI-High Project

CONTEXT

Although self-management is linked to reduced secondary health complications (SHCs) and enhanced overall quality of life post-spinal cord injury or disease (SCI/D), it is poorly integrated into the current rehabilitation process. Promoting self-management and assuring equity in care delivery is critical. Herein, we describe the selection of Self-Management structure, process and outcome indicators for adults with SCI/D in the first 18 months after rehabilitation admission.

METHODS

Experts in self-management across Canada completed the following tasks: (1) defined the Self-Management construct; (2) conducted a systematic search of available outcomes and their psychometric properties; and (3) created a Driver diagram summarizing available evidence related to Self-Management. Facilitated meetings allowed development and selection following rapid-cycle evaluations of proposed structure, process and outcome indicators.

RESULTS

The structure indicator is the proportion of staff with appropriate education and training in self-management principles. The process indicator is the proportion of SCI/D inpatients who have received a self-management assessment related to specific patient self-management goal(s) within 30 days of admission. The outcome indicator is the Skill and Technique Acquisition, and Self-Monitoring and Insight subscores of the modified Health Education Impact Questionnaire.

CONCLUSION

The structure indicator will heighten awareness among administrators and policy makers regarding the need to provide staff with ongoing training related to promoting self-management skill acquisition. Successful implementation of the Self-Management process and outcome indicators will promote self-management education and skill acquisition as a rehabilitation priority, allow for personalization of skills related to the individual's self-management goal(s), and empower individuals with SCI/D to manage their health and daily activities while successfully integrating into the community.

Perception and predictors of health locus of control at rehabilitation discharge and 1 year after traumatic spinal cord injury

This retrospective study examined the perception and predictors of health locus of control (LOC) in 71 individuals with a spinal cord injury (SCI) at discharge from inpatient rehabilitation (average age 39 years, 77% male, 54% black, 51% cervical SCI, 51% incomplete SCI and average time post-SCI 20 days). We also determined if health LOC beliefs and predictors change over the 1st year after SCI in a representative subsample of 36 individuals. The participants completed surveys regarding the health LOC, self-esteem and depression whereas demographic and SCI information were retrieved from medical records. At inpatient discharge, 55% of SCI individuals endorsed the doctor LOC category compared to internal (14%), other people (6%), chance (3%) or multiple LOC categories (22%). A similar pattern was found at 1-year postinjury (doctor LOC 44% and non-doctor LOC combined 56%). A backward stepwise regression revealed that white race (P = 0.093), >12 years of education (P = 0.001) and cervical level of SCI (P = 0.033) were significant predictors of the doctor LOC category at inpatient discharge (overall classification accuracy 76%). Similarly, >12 years of education (P = 0.055), cervical level of SCI at inpatient discharge (P = 0.033) and higher self-esteem at 1-year post-SCI (P = 0.113) were significant predictors of the doctor LOC category at 1-year post-SCI (overall classification accuracy 78%). We conclude that health LOC remains stable over the 1st year after SCI with the majority of individuals believing that the control over outcomes of their health is in the hands of doctors. These findings have implications for the provision of rehabilitation services after SCI.

Regaining A Sense Of Me: a single case study of SCI adjustment, applying the appraisal model and coping effectiveness training

INTRODUCTION

Sustaining a spinal cord injury (SCI) has been shown to impose a significant physical and psychological challenge with threat to quality of life (QOL). Duff & Kennedy provide a SCI explanation of appraisals and the two-stage process of an individual's primary assessment of their experience, and their secondary appraisal of their perceived coping resource being key facilitators of adjustment and fundamental to longer term adaptation. King & Kennedy designed a group coping effectiveness training (CET) intervention with a framework of coping strategy selection fit to reduce use of threat appraisals/avoidance coping, and to promote development of challenge appraisals with consequent stress reduction and adjustment.

CASE PRESENTATION

This CET approach was applied within individual psychological therapy with a 74-year old woman who presented with symptoms of anxiety, reactivated PTSD, mood disturbance and difficulty adjusting after sustaining SCI. Psychological adjustment treatment enabled resolution of post-trauma symptoms, re-evaluation of appraisals and perceived loss of identity, and development of positive coping strategies, and promoted a new conceptualisation of independence.

DISCUSSION

Case studies of psychological treatment are rare within the SCI literature. This paper provides a detailed application of primary appraisals and coping strategy selection fit in individual therapy. Attention is drawn to the important impact appraisals have on long-term rehabilitation outcomes and the necessity of a multi-disciplinary team (MDT) approach to achieve optimal psychological and physical adjustment following SCI. Finally, the paper highlights the need for community education to reduce negative perceptions/taboo of disability.

A Scoping Review of Self-Management Interventions Following Spinal Cord Injury

Objective: To conduct a scoping review to identify what components of self-management are embedded in self-management interventions for spinal cord injury (SCI). Methods: In accordance with the approach and stages outlined by Arksey and O'Malley (2005), a comprehensive literature search was conducted using five databases. Study characteristics were extracted from included articles, and intervention descriptions were coded using Practical Reviews in Self-Management Support (PRISMS) (Pearce et al, 2016), Barlow et al (2002), and Lorig and Holman's (2003) taxonomy. Results: A total of 112 studies were included representing 102 unique self-management programs. The majority of the programs took an individual approach (52.0%) as opposed to a group (27.4%) or mixed approach (17.6%). While most of the programs covered general information, some provided specific symptom management. Peers were the most common tutor delivering the program material. The most common Barlow components included symptom management (n = 44; 43.1%), information about condition/treatment (n = 34; 33.3%), and coping (n = 33; 32.4%). The most common PRISMS components were information about condition and management (n = 85; 83.3%), training/rehearsal for psychological strategies (n = 52; 51.0%), and lifestyle advice and support (n = 52; 51.0%). The most common Lorig components were taking action (n = 62; 60.8%), resource utilization (n = 57; 55.9%), and self-tailoring (n = 55; 53.9%). Conclusion: Applying self-management concepts to complex conditions such as SCI is only in the earliest stages of development. Despite having studied the topic from a broad perspective, this review reflects an ongoing program of research that links to an initiative to continue refining and testing self-management interventions in SCI.

The Stanmore Nursing Assessment of Psychological Status (SNAPS): not just for spinal cord injury rehabilitation?

Spinal cord injury is an uncommon condition, potentially causing a wide range of consequences and requiring specialist rehabilitation to optimize health, activity and participation. Early psychological response to injury and relations with staff, as well as family, may set the foundations for long-term emotional adjustment, healthcare utilization and quality of life. The Stanmore Nursing Assessment of Psychological Status has been developed at the London Spinal Cord Injury Centre to empower nurses to adopt a consistently empathic approach to patient care, as part of a comprehensive range of rehabilitation team skills. Its use in other spinal cord injury centers and a broader range of clinical environments (hospital and community) should therefore be considered.

Implementing a multi-modal support service model for the family caregivers of persons with age-related macular degeneration: a study protocol for a randomised controlled trial

INTRODUCTION

Age-related macular degeneration (AMD) is a leading cause of blindness and low vision among older adults. Previous research shows a high prevalence of distress and disruption to the lifestyle of family caregivers of persons with late AMD. This supports existing evidence that caregivers are 'hidden patients' at risk of poor health outcomes. There is ample scope for improving the support available to caregivers, and further research should be undertaken into developing services that are tailored to the requirements of family caregivers of persons with AMD. This study aims to implement and evaluate an innovative, multi-modal support service programme that aims to empower family caregivers by improving their coping strategies, enhancing hopeful feelings such as self-efficacy and helping them make the most of available sources of social and financial support.

METHODS AND ANALYSIS

A randomised controlled trial consisting of 360 caregiver-patient pairs (180 in each of the intervention and wait-list control groups). The intervention group will receive the following: (1) mail-delivered cognitive behavioural therapy designed to improve psychological adjustment and adaptive coping skills; (2) telephone-delivered group counselling sessions allowing caregivers to explore the impacts of caring and share their experiences; and (3) education on available community services/resources, financial benefits and respite services. The cognitive behavioural therapy embedded in this programme is the best evaluated and widely used psychosocial intervention. The primary outcome is a reduction in caregiver burden. Secondary outcomes include improvements in caregiver mental well-being, quality of life, fatigue and self-efficacy. Economic analysis will inform whether this intervention is cost-effective and if it is feasible to roll out this service on a larger scale.

ETHICS AND DISSEMINATION

The study was approved by the University of Sydney human research ethics committee. Study findings will be disseminated via presentations at national/international conferences and peer-reviewed journal articles.

TRIAL REGISTRATION NUMBER

The trial registration number is ACTRN12616001461482; pre-results.

Seated Tai Chi to alleviate pain and improve quality of life in individuals with spinal cord disorder

CONTEXT

Previous research studies have confirmed therapeutic physical and psychological benefits of Tai Chi for both the able-bodied and disabled populations. However, given the limited availability of seated Tai Chi, there have not been any studies to date that have examined the effectiveness of seated Tai Chi in individuals with spinal cord disorder (SCD). We designed a customized seated Tai Chi program to meet the need for improved exercise options for individuals with SCD.

FINDINGS

Twenty-six participants were enrolled in a 12-week seated Tai Chi course consisting of weekly sessions. After each Tai Chi session, patients reported improved visual analog scale (VAS) monitoring pain (P) (3.18 v 2.93; P 1.63E-03), emotional sense of well-being (EWB) (2.61 vs 2.04; P 2.86E-07), mental distraction (MD) (3.13 v 2.29; P 9.36E-08), physical sense of well-being (PWB) (2.84 v 2.25; p 7.38E-08), and sense of spiritual connection (SC) (3.28 v 2.50; P 6.46E-08). In our limited follow-up of 9 participants who completed half of the sessions and the long term surveys after the 12-week course, there were no detectable differences in weekly P, EWB, MD, PWB, and SC before each session.

CONCLUSION AND CLINICAL RELEVANCE

Individuals with SCD demonstrated benefits in pain, emotional sense of well-being, mental distraction, physical sense of well-being, and sense of spiritual connection immediately after seated Tai Chi exercise sessions in our pilot study. More research in a larger population would be needed to study the long-term impact of seated Tai Chi.

Outcomes and Lessons Learned From a Randomized Controlled Trial to Reduce Health Care Utilization During the First Year After Spinal Cord Injury Rehabilitation: Telephone Counseling Versus Usual Care

OBJECTIVES

To describe the outcomes and lessons learned from a trial of telephone counseling (TC) to reduce medical complications and health care utilization and to improve psychosocial outcomes during the first year after spinal cord injury rehabilitation.

DESIGN

Single-site, single-blind, randomized (1:1) controlled trial comparing usual care plus TC with usual care (UC).

SETTING

Two inpatient rehabilitation programs.

PARTICIPANTS

Adult patients (N=168) discharged between 2007 and 2010.

INTERVENTIONS

The TC group (n=85, 51%) received up to eleven 30- to 45-minute scheduled telephone calls to provide education, resources, and support. The UC group (n=83, 49%) received indicated referrals and treatment.

MAIN OUTCOME MEASURES

The primary outcome was a composite of self-reported health care utilization and medical complications. Secondary outcomes were depression severity, current health state, subjective health, and community participation.

RESULTS

No significant differences were observed between TC and UC groups in the primary or secondary psychosocial outcomes.

CONCLUSIONS

This study had a number of strengths, but included potential design weaknesses. Intervention studies would benefit from prescreening participants to identify those with treatable problems, those at high risk for poor outcomes, or those with intentions to change target behaviors. Interventions focused on treatment goals and designed to work in collaboration with the participant's medical care system may lead to improved outcomes.

Depression Trajectories During the First Year After Spinal Cord Injury

OBJECTIVE

To determine the number and type of longitudinal depression trajectories during the first year after spinal cord injury (SCI) and to identify baseline predictors of these trajectories.

DESIGN

Cohort study.

SETTING

Rehabilitation and postacute community settings.

PARTICIPANTS

Of 168 consecutive admissions to inpatient rehabilitation for acute SCI, 141 (115 men, 26 women) patients were enrolled in a randomized controlled trial telephone follow-up intervention, which showed no outcome differences, and completed assessments on at least 2 of the 4 follow-up occasions (3, 6, 9, and 12 months after SCI). Participants were on average 41 years old, most were non-Hispanic (96%) and white (86%), and 61.7% had tetraplegia.

INTERVENTIONS

Data were drawn from the ineffective randomized controlled trial.

MAIN OUTCOME MEASURE

Patient Health Questionnaire-9 (PHQ-9).

RESULTS

Unconditional linear latent class growth analysis models of PHQ-9 total scores revealed an optimal 3-class solution: stable low depression (63.8%), mild to moderate depression (29.1%), and persistent moderate to severe depression (7.1%). Preinjury mental health history and baseline pain, quality of life, and grief predicted class membership.

CONCLUSIONS

The modal response to SCI was stable low depression, whereas persistent moderate to severe depression primarily represented a continuation or relapse of preinjury depression. This line of research has the potential to improve identification of subgroups destined for poor outcomes and to inform early intervention studies.

Return to Work Practices and Research with Spinal Cord Injury: An Australian Perspective

Post-injury return to work (RTW) is an important rehabilitation outcome regardless of injury type. With Spinal Cord Injury (SCI), the odds of successful RTW are lower than for the general population of work-injured. Australians living with a SCI have a higher RTW rate than many other developed countries, including the United States. Important influences on relatively higher post-injury RTW rates in the Australian context include its universal disability care policy, Australia's suite of no-fault accident insurance systems that allow for multi-faceted rehabilitation services to be provided to eligible individuals in addition to appropriate rewards for rehabilitation service providers. A combination of these systemic factors is important when delivering comprehensive rehabilitation services to those with catastrophic injuries, such as SCI. The empirical evidence on drivers of successful RTW post SCI is, however, limited in comparison to the evidence on interventions for enhanced coping following SCI. Future studies could consider the relative merits of specific RTW interventions with SCI contrasting policy and capitation systems as well as utilising study designs that take into account pre-morbid work participation and secondary health conditions.

A randomized controlled trial of venlafaxine XR for major depressive disorder after spinal cord injury: Methods and lessons learned

CONTEXT/OBJECTIVE

We describe the rationale, design, methods, and lessons learned conducting a treatment trial for major depressive disorder (MDD) or dysthymia in people with spinal cord injury (SCI).

DESIGN

A multi-site, double-blind, randomized (1:1) placebo controlled trial of venlafaxine XR for MDD or dysthymia. Subjects were block randomized and stratified by site, lifetime history of substance dependence, and prior history of MDD.

SETTING

Six SCI centers throughout the United States.

PARTICIPANTS

Across participating centers, 2536 subjects were screened and 133 were enrolled into the trial. Subjects were 18-64 years old and at least 1 month post-SCI. Interventions Twelve-week trial of venlafaxine XR versus placebo using a flexible titration schedule.

OUTCOME MEASURES

The primary outcome was improvement in depression severity at 12 weeks. The secondary outcome was improvement in pain.

RESULTS

This article includes study methods, modifications prompted by a formative review process, preliminary data on the study sample and lessons learned. We describe common methodological and operational challenges conducting multi-site trials and how we addressed them. Challenges included study organization and decision making, staff training, obtaining human subjects approval, standardization of measurement and treatment, data and safety monitoring, subject screening and recruitment, unblinding and continuity of care, database management, and data analysis.

CONCLUSIONS

The methodological and operational challenges we faced and the lessons we learned may provide useful information for researchers who aim to conduct clinical trials, especially in the area of medical treatment of depression in people with SCI.

Psychological therapies for the management of co-morbid depression following a spinal cord injury: a systematic review

The evidence about psychological therapies used to manage co-morbid depression after a spinal cord injury is presented here. A comprehensive search of five electronic databases identified nine studies (participants, n = 591) meeting inclusion criteria. Pooled statistical analyses were conducted in combination with narrative synthesis. Overall, multimodal cognitive behavioural therapy was found to be moderately effective (standardised mean difference = -0.52; 95% confidence interval = -0.85, -0.19). Activity scheduling, psychoeducation, problem solving and cognitive therapy may be particularly beneficial therapies within cognitive behavioural therapy. Further high-quality randomised controlled trials are needed to better substantiate these findings.

Developing and PilotingePACT: A Flexible Psychological Treatment for Depression in People Living With Chronic Spinal Cord Injury

Accessibility, stigma and adverse effects of self-reliance can hinder the receipt of psychological treatments, especially in people living with chronic illness or disability. The aim of this study was to develop and pilot a flexible online psychological treatment using CBT and positive-psychology based techniques, for individuals with spinal cord injury (SCI) who also lived with depression or both depression and anxiety. A multiple case study approach provided in-principle evidence of the acceptability of the Electronic Personal Administration of Cognitive Therapy:ePACT. Three adults living with SCI completed pre- and post-intervention interviews and multiple modules ofePACT. The interviews used the Structural Clinical Interview for DSM Disorders (SCID/-N/P) for diagnosis and the standardised survey instruments: Depression Anxiety and Stress Scale — short version (DASS-21), Personal Wellbeing Index 4th edition (PWI) and the Spinal Cord Lesion Emotional Wellbeing Questionnaire (SCL EWQ v1 Australia). The results indicated that the online program was acceptable, and they all showed some improvement in symptoms. All participants indicated that they would not have sought face-to-face therapy for reasons of access and stigma. They all had a strong sense of independence and felt this would have been questioned if they sought therapy.

Psychosocial issues in spinal cord injury: a review

STUDY DESIGN

Review.

OBJECTIVES

To review literature on subjective well-being (SWB; mental health and life satisfaction) and on psychological and social support factors associated with these outcomes in people with spinal cord injury (SCI), in order to identify gaps in scientific knowledge and recommend research priorities.

SETTING

Non applicable.

METHODS

Narrative review of the SCI literature on life satisfaction and mental health (depression, anxiety, post-traumatic stress syndrome) outcomes in people with SCI. Further, reviews were performed of the SCI literature on psychological and social support variables associated with SWB and on psychosocial interventions aimed to improve SWB.

RESULTS

People with SCI experience, on average, higher levels of distress and lower levels of life satisfaction compared with the general population. Individual differences, however, are large, and most people with SCI adapt well to their condition. A set of psychological and social support factors is strongly related to SWB. Intervention studies on cognitive behavioural therapy or coping effectiveness training to improve SWB show promising results, but suffer from methodological weaknesses (for example, lack of randomization and small sample size).

CONCLUSION

There is a need for cohort studies with sufficient sample size, which include people early after onset of SCI in order to enhance our understanding of the course of mental health and well-being after SCI. Cohort studies could also identify which people are at risk for long-term impairment of SWB. Finally, intervention studies on psychosocial interventions are needed to identify which interventions may improve SWB of people with SCI.

Promoting optimal functioning in spinal cord injury: the role of rehabilitation psychology

Comprehensive treatment and rehabilitation includes attention to the psychological needs of individuals with SCI and their families. This chapter is designed to familiarize neurologists and other practitioners with psychological issues and care in SCI. While psychologists play a key role, attention to psychosocial health is a responsibility shared by all members of the rehabilitation team, beginning with the patient and family, and including clinicians who are not formally identified as mental health providers. Treatment planning for a person with SCI begins with a thorough assessment of the cognitive, emotional, personality, and social factors that influence functioning and rehabilitation. Rehabilitation psychologists use a mixture of assessment tools, including clinical interviews, behavioral observations, and a wide range of standardized test instruments. Psychological interventions can involve direct intervention with the patient, in individual, family or group-based therapies. Other psychological strategies involve assistance through less direct methods - consultation and training to other rehabilitation team members or facilitating peer role-modeling and support groups. The chapter provides an overview of core clinical issues (emotional responses, substance use, pain, cognitive deficits, sexuality and vocational rehabilitation), delineates the process of psychological assessment and intervention, and provides guidance on incorporation of rehabilitation psychology into SCI rehabilitation.

Adjustment and coping in spousal caregivers following a traumatic spinal cord injury: an interpretative phenomenological analysis

Semi-structured interviews were conducted with 11 spousal caregivers to people with a traumatic spinal cord injury and were subjected to interpretative phenomenological analysis (IPA). Here, we present two inter-related master themes: (1) coping with the spousal caregiver role; and (2) putting the pieces back together again. Within these, the analysis describes how regular venting of emotion, social support and focusing on the positive aspects of the situation all promoted coping. Adjustment was reportedly hindered by the introduction of paid caregivers as this represented a loss of privacy and power for the participants. The findings are discussed in relation to the wider literature and recommendations for future caregiver support are highlighted.

A longitudinal study of depression from 1 to 5 years after spinal cord injury

OBJECTIVE

To describe rates of probable major depression and the development and improvement of depression and to test predictors of depression in a cohort of participants with spinal cord injury (SCI) assessed at 1 and 5 years after injury.

DESIGN

Longitudinal cohort study.

SETTING

SCI Model System.

PARTICIPANTS

Participants (N=1035) who completed 1- and 5-year postinjury follow-up interviews from 2000 to 2009.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Probable major depression, defined as Physician Health Questionnaire-9 score of 10 or higher.

RESULTS

Probable major depression was found in 21% of participants at year 1 and 18% at year 5. Similar numbers of participants had improvement (25%) or worsening (20%) of symptoms over time, with 8.7% depressed at both 1 and 5 years. Increased pain (odds ratio [OR], 1.10), worsening health status (OR, 1.39), and decreasing unsafe use of alcohol (vs no unsafe use of alcohol; OR, 2.95) are risk factors for the development of depression at 5 years. No predictors of improvement in depression were found.

CONCLUSION

In this sample, probable major depression was found in 18% to 21% of participants 1 to 5 years after injury. To address this high prevalence, clinicians should use these risk factors and ongoing systematic screening to identify those at risk for depression. Worsening health problems and lack of effective depression treatment in participants with SCI may contribute to high rates of chronic or recurrent depression in this population.

An evidence-based review of the effectiveness of cognitive behavioral therapy for psychosocial issues post-spinal cord injury

STUDY DESIGN

Systematic review.

OBJECTIVE

To examine the evidence supporting the effectiveness of cognitive behavioral therapy (CBT) for improving psychosocial outcomes in individuals with spinal cord injury (SCI).

METHOD

Electronic databases (MEDLINE, CINAHL, EMBASE, and PsycINFO) were searched for studies published between 1990 and October 2010. Randomized control trials (RCTs) and nonrandomized control trials (non-RCTs) utilizing a CBT intervention to improve psychosocial outcomes (depressive symptomatology, anxiety, coping, and adjustment to disability) in outpatient persons with SCI were included for review. Levels of evidence were assigned to each study using a modified Sackett scale. Effect size calculations for the interventions were provided where possible.

RESULTS

Nine studies met the inclusion criteria. The studies reviewed included two RCTs, six prospective controlled trials (PCTs) and one cohort study. All studies examined at least two groups. There is Level 1 and Level 2 evidence supporting the use of specialized CBT protocols in persons with SCI for improving outcomes related to depression, anxiety, adjustment, and coping.

CONCLUSIONS

CBT holds promise as an effective approach for persons with SCI experiencing depression, anxiety, adjustment, and coping problems. As CBT may involve many different components, it is important in the future to determine which of these elements alone or in combination is most effective in treating the emotional consequences of SCI.

Changes in blood volume pulse during exercise recovery in activity-based therapy for spinal cord injury

This paper presents the results of cardiovascular changes that occur during a novel rehabilitation strategy called activity based therapy (ABT). Blood volume pulse (BVP) signals were measured during functional electrical stimulation (FES)-induced cycling in adults with spinal cord injury (SCI) persons and results were compared to a passive cycling task and able-bodied controls performing normal cycling. BVP signals were compared during three conditions, a baseline pre-exercise condition, 5 minutes after exercise and after 30-minutes rest following exercise. Exercise recovery was evaluated using normalized inner products values in BVP signals. The results showed that FES-induced cycling in SCI participants resulted in a significantly greater peripheral resistance level and longer time to recover from exercise compared with passive cycling and normal cycling in able-bodied controls.

Efficacy of cognitive behavior therapy for the management of psychological outcomes following spinal cord injury: a meta-analysis

This meta-analysis evaluated the impact of cognitive behavior therapy (CBT) on the psychological adjustment of adults with spinal cord injury (SCI). A comprehensive search of six electronic databases identified 10 studies (424 participants) that met the inclusion criteria. Pre- and post-data for participants who received CBT were pooled and analyzed. Large and significant group differences were noted for measures of assertiveness, coping, self-efficacy, depression and quality of life. These data suggest that CBT has a significant positive impact on short-term psychological outcomes following SCI. However, further research is needed to establish the long-term benefits.

Psychological morbidity and spinal cord injury: a systematic review

STUDY DESIGN

A systematic review of the literature concerning the nature of the psychological morbidity in people with spinal cord injury (SCI).

OBJECTIVES

SCI is believed to place the individual at a high risk of psychological morbidity. The objective of this paper was to examine systematically the prevalence of negative psychological states in people with SCI, as well as to explore mediating and contextual factors.

METHODS

Search engines such as Medline and PsycInfo were systematically searched using specific key words, such as SCI, depression, anxiety and so on. Only studies that fulfilled certain criteria such as the use of valid measures in assessing psychological morbidity were used in the review process.

RESULTS

The systematic review revealed that clarification is still needed concerning the psychological consequences of people with SCI. However, findings suggest that approximately 30% of people with SCI are at risk of having a depressive disorder although in rehabilitation, and approximately 27% are at risk of having raised depressive symptoms when living in the community. The review also established that people with SCI have higher comparative risks of anxiety disorder, elevated levels of anxiety, feelings of helplessness and poor quality of life (QOL).

CONCLUSION

People with SCI have an increased risk of suffering debilitating levels of psychological morbidity. Future research needs to clarify the extent and nature of psychological morbidity following SCI by conducting prospective and comprehensive research in large heterogeneous samples of people with SCI during the rehabilitation phase and following reintegration into the community.

Spinal Cord Injury Pain: The Influence of Psychologic Factors and Impact on Quality of Life

OBJECTIVES

To examine chronic pain prevalence in a spinal cord injury (SCI) population, and to determine the influence of psychologic factors on SCI pain and impact of SCI pain on quality of life.

METHODS

Five hundred seventy-five persons with SCI were asked to participate in the study. Demographic, SCI, and pain characteristics were obtained. The Chronic Pain Grade, anger items of the Profile of Mood States, Illness Cognition Questionnaire, Pain Coping and Cognition List, and Patient Health Questionnaire were used. General health and well-being were assessed with 0-10 scales. The influence of psychologic factors was assessed with regression analyses controlling for person and injury characteristics and pain intensity.

RESULTS

Response rate was 49%. SCI pain prevalence was high (77.1%). More internal pain control and coping, less catastrophizing, higher level of lesion, and nontraumatic SCI cause were associated with less pain intensity. More pain was associated with higher pain-related disability. Lower catastrophizing was related to better health. Less SCI helplessness and catastrophizing, greater SCI acceptance and lower anger levels were related to higher well-being. Higher levels of SCI helplessness, catastrophizing, and anger were related to higher depression levels. Pain intensity showed no independent relationships with health, well-being, and depression in the regression analyses.

DISCUSSION

Chronic SCI pain and quality of life were both largely associated with several psychologic factors of which pain catastrophizing and SCI helplessness were most important. Psychologic intervention programs may be useful for persons suffering from chronic SCI pain to improve their quality of life.

Client-centered therapy vs exercise therapy for chronic low back pain: a pilot randomized controlled trial in Brazil

BACKGROUND

Psychological interventions targeting maladaptive pain behaviors and depressive symptoms are commonly used in the management of chronic pain.

OBJECTIVE

To compare the effectiveness of psychotherapy, based on client-centered therapy, and exercise for patients with chronic nonspecific low back pain (LBP).

SETTING

Outpatient physiotherapy and psychotherapy departments within a Brazilian academic institution.

DESIGN

Thirty-three patients with chronic nonspecific LBP were recruited and randomized to receive client-centered therapy (N = 16) or exercise (N = 17) for 9 weeks. OUTCOME MEASURES AND DATA ANALYSIS: Pain and disability were measured at baseline, 9 weeks, and 6 months by a 10-cm visual analog scale and by the Brazilian Roland-Morris Questionnaire, respectively. Depression was measured at baseline and 9 weeks by the Beck Depression Inventory. Multiple regression analyses with baseline scores as covariates were used to determine the effects of treatment on outcomes.

RESULTS

For all outcomes at each time point, the exercise group showed greater improvements than psychotherapy. The difference between groups was statistically and clinically significant for disability at 9 weeks (-4.9 points, 95% CI -9.08 to -0.72).

CONCLUSIONS

This was the first study to investigate the effects of client-centered therapy and exercise for patients with chronic LBP. Our results showed that client-centered therapy is less effective than exercise in reducing disability at short term.

A proposed algorithm for the management of pain following spinal cord injury

STUDY DESIGN

Review.

OBJECTIVES

To review published articles on the assessment, diagnosis and treatment of pain following spinal cord injury (SCI) and to synthesise evidence from these materials to formulate and propose a systematic approach to management.

METHODS

Relevant articles regarding the treatment of pain were identified from electronic databases using the search terms (('spinal cord injury' or 'spinal cord injuries') and 'pain') and both ('treatment') and ('randomised controlled trials'). Relevant articles were also identified through citations in indexed journal publications and book chapters on this topic.

RESULTS

Review of the literature indicates that there are a large variety of treatments used in the management of pain following SCI with a small number supported by strong evidence for effectiveness. A treatment algorithm is proposed based on identification of underlying pain contributors and application of appropriate treatment.

CONCLUSION

Although there are relatively few studies clearly indicating efficacy in this population, an algorithm for the management of pain following SCI might assist to maximise our effectiveness in the treatment of this condition. It is recognised that choice of treatment is also determined by factors such as medication availability, cost and side effects as well as the preferences and characteristics of the person being treated. Nevertheless, an algorithm is proposed as a way to synthesise our current level of knowledge, identify gaps for further study and aid in the management of this difficult problem.

The effectiveness of a hands-free environmental control system for the profoundly disabled

OBJECTIVE

To investigate the effectiveness of a hands-free environmental control system (ECS) that allows profoundly disabled persons to activate and control electric devices in their home by using consciously controlled changes in their brain signals.

DESIGN

A cohort study with a field trial testing of the ECS on 3 occasions.

SETTING

Participants' homes.

PARTICIPANTS

Ten profoundly disabled persons (mean age, 42.9 y), all of whom had very limited movement from the neck downward. Six had spinal cord injury with lesions ranging from C2 to C5-6. The other 4 had profound disability (1 each from polio, spinal muscular atrophy, multiple sclerosis, cerebral palsy).

INTERVENTIONS

Participants performed tasks on each of 3 test occasions. The tasks consisted of turning a television on at the beginning of the trial, changing channels (up, down), changing volume, and turning it off at the conclusion of each trial.

MAIN OUTCOME MEASURES

Time participants took to select the correct option and number of errors made in selecting the correct option. Measures were taken for each trial, so that any improvement in switching could be detected.

RESULTS

All participants effectively used the ECS to operate their television sets. Selecting a correct option took about 30 seconds (with the majority of this time attributed to machine cycling time), with an error rate of 1.8 per 5 options selected. The time taken to operate the ECS reduced slightly over the 3 trials and selection errors reduced by around 50% (to less than 1 error per 5 options).

CONCLUSIONS

With minimal training, profoundly disabled persons were able to use an ECS that uses changes in brain wave signals. This result demonstrates the efficacy of an additional and novel ECS in an area in which few switches are available.

Spinal cord patients benefit from massage therapy

The present study assessed the effects of massage therapy on depression, functionality, upper body muscle strength and range of motion on spinal cord injury patients. Twenty C5 through C7 spinal cord injury individuals recruited from a University outpatient clinic were randomly assigned to a massage therapy group or an exercise group. Patients in the massage therapy group received two 40-min massage therapy sessions per week for 5 weeks. Patients in the control group practiced a range of motion exercise routine targeting the arms, neck, shoulders, and back 2 times per week for 5 weeks. Although both the massage and exercise group appeared to benefit from treatment, only the massage group showed lower anxiety and depression scores and significantly increased their muscle strength and wrist range of motion.

The impact of coping on emotional adjustment to spinal cord injury (SCI): review of the literature and application of a stress appraisal and coping formulation

OBJECTIVES

This article reviews literature examining the psychological adjustment to Spinal Cord Injury (SCI) and illustrates the applicability of a Stress Appraisal and Coping model (SAC) for rehabilitation of this population.

METHOD

Articles concerning psychological adjustment to SCI from the previous three decades have been reviewed and critiqued. When possible the articles have been discussed in a SAC framework.

RESULTS

The literature indicates that psychological adjustment to SCI is largely predictable from psychological variables including coping, appraisal and psychosocial resources. Recent literature has suggested psychological intervention can promote positive psychological adjustment following SCI for those individuals at risk of developing clinical levels of depression.

CONCLUSION

The SAC model provides a comprehensive formulation to incorporate the heterogeneity of populations with SCI. Suggestions for future research include developing assessment and treatment regimes specifically tailored to the strengths and weaknesses of an individual as highlighted in the model.

Evaluation of post traumatic distress in the first 6 months following SCI

STUDY DESIGN

Cross-sectional questionnaire.

OBJECTIVES

To assess the degree of post traumatic stress symptomatology and its correlates amongst a group of new spinal cord injured patients.

SETTING

The National Spinal Injuries Centre, Stoke Mandeville Hospital NHS Trust.

METHOD

Eighty-five participants with an average age of 32.6 years were assessed between 6 and 24 weeks post injury. Seventeen participants were female. Seventy per cent had complete lesions. Forty per cent had paraplegia and 60% had tetraplegia. Road traffic accidents were the most common cause of injury followed by falls and then sporting accidents. The Impact of Event Scale was used to measure the experience of intrusive thoughts about the trauma and avoidance of trauma related stimuli. Anxiety (SAI), depression (BDI) and dependency (FIM) were also measured.

RESULTS

High levels of distress were evident in 14% of the sample. Trauma-related distress was significantly higher in female patients or patients with high levels of anxiety or depression.

CONCLUSION

In this sample, the rates of trauma-related distress following spinal cord injury were comparable to those found following other traumas and are of clinical significance.

Pain following spinal cord injury

Chronic pain is an important problem following spinal cord injury (SCI) and is a major impediment to effective rehabilitation. The reported prevalence of chronic SCI pain is variable but averages 65% with around one third of these people rating their pain as severe. The mechanisms responsible for the presence of pain are poorly understood. However, evidence from clinical observations and the use of animal models of SCI pain suggests that a number of processes may be important. These include functional and structural plastic changes in the central nervous system following injury, with changes in receptor function and loss of normal inhibition resulting in an increased neuronal excitability. A number of specific types of SCI pain can be distinguished based on descriptors, location and response to treatment. Nociceptive pain can arise from musculoskeletal structures and viscera and neuropathic pain can arise from spinal cord and nerve damage. The role of psychological and environmental factors also needs to be considered. Accurate identification of these pain types will help in selecting appropriate treatment approaches. Current treatments employ a variety of pharmacological, surgical, physical and psychological approaches. However, evidence for many of the treatments in use is still limited. It is hoped that future research will identify effective treatment strategies that accurately target specific mechanisms.

Depression measures in outcomes research

OBJECTIVE

To review critically the measures used to screen for depression for disability outcomes research and to recommend measures and needed research.

DATA SOURCES

Review of literature pertaining to the development, testing, and use of depression measures for outcomes research.

STUDY SELECTION

English language literature from scientists from a broad range of disciplines and research settings, focusing mainly on the Brief Symptom Inventory and the Center for Epidemiology Study-Depression scale.

DATA EXTRACTION

A literature review was completed through MEDLINE. Based on the review, instruments were selected according to their use among people with disability and the reliability and validity of the instrument. Two instruments were selected for a complete review, and 5 instruments were selected for a brief review.

DATA SYNTHESIS

A critical review of measures that have been and may be used to measure depressive symptomatology among people with disability.

CONCLUSIONS

Screening measures of depression are easy to administer and score. Almost all have low respondent burden and good face validity, thereby contributing to a high participation rate for most studies. Some problems exist with the application of these instruments to people with disability (ie, overlap of symptoms of depression and indicators of physical impairment).

Spinal cord injury research: review and synthesis

This article provides a substantive review and synthesis of major areas of emphasis in spinal cord injury (SCI) research. Comprehensive examination of the current status and future implications for SCI research includes consideration of investigations from the following arenas: epidemiology, functional classification and prediction, neurophysiologic testing, models of injury and recovery, psychosocial considerations, surgical strategies, animal laboratory research, economic implications, life expectancy, complication rates, gender differences, pharmacological management, and prevention. Synthesis of these research conclusions from a broad spectrum of laboratory, clinical, and scientific domains provides opportunity for improving SCI prevention, treatment, and adaptation.

Immunizing against depression and anxiety after spinal cord injury

OBJECTIVE

To further report on the effectiveness of early psychological intervention in reducing anxiety and depressive mood in persons with spinal cord injury 2 years after injury.

DESIGN

A nonrandomized, longitudinal, controlled trial. SETTING, OUTCOME MEASURES, AND INTERVENTION: Twenty-eight spinal cord injured persons participated in group cognitive behavior therapy during hospital rehabilitation. They were assessed for depressive mood and anxiety before, immediately after, and 12 and 24 months after treatment. The intervention group's responses on the measures were compared with a control group of 31 spinal cord injured persons who only received traditional rehabilitation services during their hospitalization.

RESULTS

Subjects in the treatment group with high depression and anxiety scores before treatment were significantly less depressed and reduced their anxiety to a greater extent 2 years after the injury in comparison with similar persons in the control group.

CONCLUSIONS

Group cognitive behavior therapy for spinal cord injured persons who are abnormally depressed and anxious appears to reduce depressive mood and anxiety in the short and long term.

The effectiveness of group psychological intervention in enhancing perceptions of control following spinal cord injury

OBJECTIVE

This research investigated the effects of a structured psychological intervention, delivered during hospital rehabilitation, on the perceptions of control in people with spinal cord injury (SCI).

METHOD

A longitudinal study was designed to assess perceptions of control (using an objective measure of locus of control) in SCI persons who participated in specialised group cognitive-behavioural therapy (CBT) during hospital rehabilitation. The treatment SCI group's responses on locus of control were compared with a control group of SCI persons who only received traditional rehabilitation services during their hospitalisation.

RESULTS AND CONCLUSIONS

Mean locus of control scores were not high (i.e. external) for both groups and there were no overall group differences on locus of control responses across time in comparison to the control group. However, subjects in both groups who initially perceived life as externally controlled were extracted to form subgroups. The members of the subgroup who received CBT were significantly more likely to feel in control of themselves 2 years post injury compared to similar persons in the control group. Furthermore, an external locus of control was significantly but mildly associated with depressive mood 2 years after the injury. This research suggests that the provision of a structured psychological program in the rehabilitation stage will be beneficial for many SCI persons who feel that they have little control over their lives.