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

Effectiveness of Behavioral and Pharmacologic Interventions for Depressive Symptoms After Spinal Cord Injury: Findings From a Systematic Review

OBJECTIVE

To summarize and evaluate evidence regarding the efficacy of interventions for depressive symptoms in adults living with spinal cord injury (SCI) and comorbid major depressive disorder or significant depressive symptoms to inform the development of clinical practice guidelines.

DATA SOURCES

Articles published since 2013 and available in Medline, The Cochrane Library, Embase, Scopus, CINAHL, or PsycINFO. Databases were searched in June 2022 and updated November 2023.

STUDY SELECTION

Inclusion criteria: age 18 years or older, traumatic SCI, and clinically significant depression (Population), mental health interventions including behavioral, pharmacologic, and complementary and alternative medicine (Intervention), inclusion of a control group (Comparator), with a primary outcome of depression symptom reduction (Outcome). Criteria were applied by multiple reviewers and disagreements were reconciled via unanimous decision among the entire research team. Eight articles of 2780 screened met the selection criteria.

DATA EXTRACTION

Data were extracted independently by multiple reviewers. Two reviewers independently assigned a quality score using the guidelines described by Hawker and associates and independently evaluated the risk of bias of each article using version 2 of the Cochrane risk-of-bias tool.

DATA SYNTHESIS

All studies assessed depressive symptoms during participant recruitment, screening, and/or at a baseline assessment stage. Pharmacotherapy with venlafaxine XR and several behavioral interventions appear promising, including an online mindfulness course and eye movement desensitization and reprocessing therapy. Remote interventions may be effective in reaching individuals who are unable to travel to in-person therapy sessions.

CONCLUSIONS

This systematic review provides valuable information for clinicians who treat individuals with SCI and comorbid major depressive disorder or significant depressive symptoms. It highlights the importance of considering a variety of interventions and individualizing treatment to meet individuals' needs and preferences. Future research should aim to identify effective interventions for treating depressive symptoms in individuals with SCI and optimal delivery methods for these interventions.

Impact of Robotic-Assisted Gait Therapy on Depression and Anxiety Symptoms in Patients with Subacute Spinal Cord Injuries (SCIs)-A Prospective Clinical Study

BACKGROUND

Mood disorders, especially depression, and emotional difficulties such as anxiety are very common problems among patients with spinal cord injuries (SCIs). The lack of physical training may deteriorate their mental state, which, in turn, has a significant impact on their improvement in functioning. The aim of the present study was to examine the influence of innovative rehabilitation approaches involving robotic-assisted gait therapy (RAGT) on the depression and anxiety symptoms in patients with SCI.

METHODS

A total of 110 participants with subacute SCIs were enrolled in this single-center, single-blinded, single-arm, prospective study; patients were divided into experimental (robotic-assisted gait therapy (RAGT)) and control (conventional gait therapy with dynamic parapodium (DPT)) groups. They received five training sessions per week over 7 weeks. At the beginning and end of therapy, the severity of depression was assessed via the Depression Assessment Questionnaire (KPD), and that of anxiety symptoms was assessed via the State-Trait Anxiety Inventory (STAI X-1).

RESULTS

SCI patients in both groups experienced significantly lower levels of anxiety- and depression-related symptoms after completing the seven-week rehabilitation program (KPD: Z = 6.35, p < 0.001, r = 0.43; STAI X-1: Z = -6.20, p < 0.001, r = 0.42). In the RAGT group, post-rehabilitation measurements also indicated an improvement in psychological functioning (i.e., decreases in depression and anxiety and an increase in self-regulation (SR)). Significant results were noted for each variable (STAI X-1: Z = -4.93; KPD: Z = -5.26; SR: Z = -3.21). In the control group, there were also decreases in the effects on depression and state anxiety and an increase in self-regulation ability (STAI X-1: Z = -4.01; KPD: Z = -3.65; SR: Z = -2.83). The rehabilitation modality did not appear to have a statistically significant relationship with the magnitude of improvement in the Depression Assessment Questionnaire (KPD) (including self-regulation) and State-Trait Anxiety Inventory (STAI) scores. However, there were some significant differences when comparing the groups by the extent and depth of the injury and type of paralysis. Moreover, the study did not find any significant relationships between improvements in physical aspects and changes in psychological factors.

CONCLUSIONS

Subjects in the robotic-assisted gait therapy (RAGD) and dynamic parapodium training (DPT) groups experienced decreases in anxiety and depression after a 7-week rehabilitation program. However, the rehabilitation modality (DPT vs. RAGT) did not differentiate between the patients with spinal cord injuries in terms of the magnitude of this change. Our results suggest that individuals with severe neurological conditions and complete spinal cord injuries (AIS A, according to the Abbreviated Injury Scale classification) may experience greater benefits in terms of changes in the psychological parameters after rehabilitation with RAGT.

Risk Factors Associated With Suicidal Ideation in Individuals With Spinal Cord Injury

Objective

To assess the frequency of suicidal ideation (SI) among individuals with chronic spinal cord injury (SCI) and to identify risk factors associated with SI.

Design

Cross-sectional.

Setting

Community setting.

Participants

Two hundred and forty-six individuals with chronic SCI participating in the Spinal Cord Injury Model Systems at a Level 1 Trauma center.

Interventions

Not applicable.

Main Outcome Measure

SI, as assessed by question 9 of the Patient Health Questionnaire-9.

Results

Twenty-seven (11.0%) participants endorsed SI; 6 (22.2%) of whom endorsed active SI with a plan of self-harm. Participants who endorsed SI had significantly higher depressive symptoms, lower resilience, and lower satisfaction with life (all Ps<.001). They also had lower perceived health (P<.001), Craig Handicap Assessment & Reporting Technique Short Form (CHART-SF) physical independence (P=.013), and Spinal Cord Injury - Functional Index with Assistive Technology domains of basic mobility (P=.003), self-care (P=.042), and fine motor skills (P=.035). However, participants who endorsed SI were not significantly different in re-hospitalization rates and in other domains of CHART-SF and SCI-AT. Logistic regression, with a forward selection procedure, was used to identify significant predictors of endorsing SI in the context of multiple associated variables. Depressive symptoms (odds ratio [OR]=1.18, P=.020), resilience (OR=0.85, P=.003), and physical independence (OR=0.98, P=.019) remained significant predictors of SI.

Conclusion

Study findings suggest higher levels of SI among people with SCI, a substantial proportion of whom have active SI. Individuals with SCI who endorse SI have greater burden of poor physical and mental health, as well as poorer functional status and adaptation. Interventions targeting multiple dimensions of quality of life may help reduce risk of SI and suicide among individuals with SCI.

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.

Telepsychology for Individuals With Spinal Cord Injury: Protocol for a Randomized Control Study of Video-Based Cognitive Behavioral Therapy

Background

A substantial proportion of individuals with spinal cord injury (SCI) experience depression, which has been negatively associated with recovery and community participation after injury. Despite significant barriers to seeking and receiving in-person mental health care, little research has focused on the efficacy of telepsychology among individuals with SCI.

Objectives

To describe the design and implementation of an ongoing single-center, randomized controlled, video-based cognitive behavioral therapy (CBT) intervention among individuals with SCI.

Methods

Participants within 1 year of SCI will be randomized 1:1 to intervention or usual care in a 24-week study. Intervention participants will engage in 10 sessions of CBT over 12 weeks with a licensed clinical psychologist, using iPads via Apple FaceTime. Primary outcomes are depressive symptomatology, anxiety, and life satisfaction (as measured by the Patient Health Questionnaire-9, Generalized Anxiety Disorder-7 and Satisfaction with Life Scale, respectively) measured at three time points (baseline, 12 weeks, and 24 weeks). These and other measures are also assessed during monthly telephone surveys conducted between primary timepoints.

Results

Recruitment is ongoing. Forty-six participants have been enrolled thus far.

Conclusion

Telepsychology is a convenient, flexible, and effective alternative to traditional in-person services. We anticipate that intervention participants will experience improvements in depressive and anxiety symptoms and will have greater life satisfaction. Telepsychology interventions among individuals with SCI are tasked to maintain participant privacy, provide assistive technology and/or engage caregivers to minimize mobility limitations, and manage risk remotely. Challenges encountered include recruitment during the COVID-19 pandemic. Early intervention on symptoms of psychological morbidity using telepsychology may facilitate greater adaptation following SCI.

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.

Mental Health and Spinal Cord Injury: Clinical Considerations for Rehabilitation Providers

Purpose of Review

Assessing and addressing the mental and behavioral health concerns of individuals with SCI during rehabilitation is crucial, as untreated mental health distress can lead to reduced gains in rehabilitation and poor overall health. This review provides an overview of the latest research on prevalence rates of common mental and behavioral health concerns in the SCI population, highlighting disability-specific factors that may impact traditional assessment and treatment of mental health concerns.

Recent Findings

While those with SCI are at a heightened risk for experiencing mental health distress, overall, the majority of those with SCI adapt well, and live a full and meaningful life.

Summary

Rehabilitation psychologists are a vital aspect of rehabilitation teams, as they can address behavioral health and mental health concerns that may impede patients achieving their rehabilitation goals.

Coping Strategies of Women With Long-Term Spinal Cord Injury: The Role of Beliefs About the World, Self-Efficacy, and Disability

The present study aimed to investigate the indirect effect of appraisal of disability on the relationship between basic hope and coping strategies in women with long-term spinal cord injury (SCI), taking into account the moderating role of general self-efficacy. A cross-sectional study with 187 women with paraplegia was conducted. Main outcome measures, the Coping Orientations to Problems Experienced (COPE), the Basic Hope Inventory (BHI), Appraisals of Disability Primary and Secondary Scale (ADAPSS), and General Self-Efficacy Scale (GSES), were used. Our study showed that the strategies most commonly used by participants are seeking emotional support, religion, and acceptance. More than 45% of the respondents reveal average levels of basic hope, 58.82% reveal high levels of general self-efficacy, and most of them assessed their disability as determined resilience while noticing its negative aspects. The indirect effect of disability appraisal on the relationship between basic hope and coping strategies (denial, focus on emotions, seeking emotional support, religion, and acceptance) was confirmed. The moderating role of general self-efficacy in this analysis of mediating was also confirmed. General self-efficacy plays a significant role in explaining the relationship between basic hope and coping strategies mediated by appraisals of disability in women with long-term SCI.

Online psychosocial intervention for persons with spinal cord injury: A meta-analysis

BACKGROUND

Delivery of psychosocial interventions via the Internet has the potential to overcome barriers and increase access; however, effectiveness is yet to be established among those with spinal cord injury (SCI).

METHODS

The objective of this meta-analysis is to evaluate the efficacy of Internet-based psychosocial interventions on the symptoms of anxiety, depression, and pain amongst those with SCI. The databases Medline, PsycInfo, and EMBASE were used to locate studies published between 1990 and December 2020. A study was included if (1) the study involved the application of an online psychosocial intervention; (2) adults with SCI; and (3) reported outcomes on depression and/or anxiety. From each study, participant characteristics and study details were extracted. A standardized mean difference (SMD) ± standard error and 95% confidence interval (CI) was calculated for each outcome of interest and the results were pooled using a fixed-effects model.

RESULTS

The search yielded 920 studies, of which five were included in the final meta-analysis; It was revealed that Internet-based psychosocial interventions had a small effect on reducing overall anxiety (SMD: 0.42 ± 0.09, p < 0.001) and depression (SMD: 0.41 ± 0.09, p < 0.001) symptoms at the end of the study period. Online psychosocial interventions also had a moderate effect in maintaining reduction of anxiety (SMD: 0.50 ± 0.1, p < 0.001) and depressive (SMD: 0.64 ± 0.10, p < 0.001) symptoms at 3-month follow-up.

CONCLUSION

The results of this meta-analysis provide evidence for the use of internet-based psychosocial interventions to manage anxiety and depression symptoms among those with spinal cord injuries.

Appraisals of disability and psychological adjustment in veterans with spinal cord injuries

Context/Objective: Following a spinal cord injury or disability (SCI/D), cognitive appraisals are a marker of psychological adjustment. The present study evaluated the clinical utility and discriminant validity of the Appraisals of DisAbility Primary and Secondary Scale - Short Form (ADAPSS-sf). The ADAPSS-sf was evaluated on 1. identification of individuals experiencing poor psychological adjustment and 2. prediction of life satisfaction beyond measures of emotional distress.Design: A retrospective study was completed using ROC analyses and odds ratios to identify the clinical utility of the ADAPSS-sf. In addition, blocked hierarchical regression explored the ADAPSS-sf predictive characteristics for satisfaction with life beyond measures of emotional distress.Setting: Veteran's Health Administration SCI Center.Participants: Ninety outpatient veterans with SCI/Ds.Outcome Measures: Measures of psychological adjustment post-SCI/D included the PHQ-9, GAD-7, PC-PTSD, and the Diener Satisfaction with Life Scale (SWLS). The ADAPSS-sf was used as a measure of cognitive appraisals.Results: Results indicated the ADAPSS-sf is effective in identification of poor psychological adjustment, P < .001. Diagnostic odds ratios and ADAPSS-sf cut scores were selected to prioritize sensitivity (7.17, ≤ 11), specificity (68.25, ≥ 22), or a balance of the two (16.32, ≤ 19). Hierarchical regression indicated the ADAPSS-sf accounted for unique variance in life satisfaction beyond measures of emotional distress, (ΔR² = .20, β = -.66, t(89) = 6.54, P < .001).Conclusion: Results indicated SCI/D specific appraisals are predictive of concurrent poor psychological adjustment and provide insight into satisfaction with life beyond measures of emotional distress.

Psychological interventions with older adults during inpatient postacute rehabilitation: A systematic review

Objective: Older adults in inpatient postacute care settings report high rates of depression and anxiety. Psychological interventions address these symptoms through educational, cognitive, behavioral, relaxation, and/or psychosocial approaches. The purpose of this study was to systematically evaluate the quality of existing literature on psychological interventions for depression and/or anxiety among older adults during an inpatient postacute care stay. Method: Medline, Embase, Cochrane Library, CINAHL, PsycINFO, and Google Scholar were searched for key concepts. Studies were included that (a) sampled skilled nursing facility or inpatient rehabilitation facility patients, (b) evaluated a psychological intervention, (c) measured depression and/or anxiety symptoms before and after interventions, and (d) had a mean or median age of 65+. Two raters assessed articles for inclusion and risk of bias. Results: Search strategies identified 7,506 articles for screening; nine met inclusion criteria. Included studies varied by study design, intervention type, and methodological quality. Only one study had low overall risk of bias. Four studies demonstrated preliminary treatment benefits for depression symptoms; none reported benefits for anxiety symptoms. Conclusions: Most of the included studies were limited by small sample size and high risk of bias. Thus, currently, there is insufficient evidence to support the effectiveness of psychological interventions for depression or anxiety among older adults during an inpatient postacute care stay. The authors offer a detailed discussion of methodological limitations, empirical gaps, and future directions to develop this body of literature. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

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.

Minimal Clinically Important Differences for Measures of Pain, Lung Function, Fatigue, and Functionality in Spinal Cord Injury

OBJECTIVE

The objective of this study was to determine the minimal clinically important differences (MCIDs) for the numerical pain rating scale (NPRS), peak cough flow (PCF), peak expiratory flow (PEF), fatigue severity scale (FSS), and London chest activities of daily living scale (LCADL) in patients with spinal cord injuries (SCIs) after rehabilitation.

METHODS

Inpatients with SCI from 2 rehabilitation centers participating in a daily rehabilitation program were recruited. The NPRS, PCF, PEF, FSS, and LCADL were collected at baseline and discharge. The global rating of change scale was performed at discharge. MCIDs were calculated using anchor (linear regression, mean change, and receiver operating characteristic curves) and distribution-based methods (0.5 times the baseline SD, standard error of measurement, 1.96 times standard error of measurement, and minimal detectable change) and pooled using arithmetic weighted mean.

RESULTS

Sixty inpatients with SCI (36 males; 54.5 [15.9] years) participated. On average their rehabilitation program lasted 7.3 (1.7) weeks. Pooled MCID estimates were 1.6 points for the NPRS, 69.8 L/min for the PCF, 77.4 L/min for the PEF, 1.1 points for the FSS, and 1.4 points for the LCADL.

CONCLUSION

Established MCIDs for NPRS, PCF, PEF, FSS, and LCADL will help health professionals to interpret results and guide rehabilitation interventions in patients with SCI.

IMPACT

Health professionals and researchers may now use -1.6 points for the NPRS, 69.8 L/min for the PCF, 77.4 L/min for the PEF, 1.1 points for the FSS, and 1.4 points for the LCADL to interpret if changes in pain, cough intensity, expiratory flow, fatigue and activities of daily living after rehabilitation of patients with SCI have been clinically relevant.

Mindfulness for pain, depression, anxiety, and quality of life in people with spinal cord injury: a systematic review

BACKGROUND

Populations with reduced sensory and motor function, such as spinal cord injury (SCI) are at increased risk of depression, anxiety, pain, and poorer quality of life (QoL). Mindfulness-Based Interventions (MBIs) have been developed with the aim of improving outcomes for people with SCI. To understand the value of MBIs, a systematic review was conducted pertaining to the use of MBIs, and interventions including elements of mindfulness, with people with SCI.

METHODS

Databases were reviewed from 1996 to October 2018 (updated January 2020). Eligibility criteria included the assessment of at least one of the common secondary consequences of SCI (i.e. risk of depression, anxiety, pain, and QoL), describe the use of mindfulness training as a component part of an intervention, or as the whole intervention. The Cochrane Collaboration Risk of Bias and The Effective Public Health Practice Project Quality Assessment Tools were utilised for quality appraisals. Two assessors appraised the studies and demonstrated good agreement (Cohen's k = .848, p < .001).

RESULTS

Five papers met the inclusion criteria, and demonstrated a range of results of interventions delivered individually, in a group format, in person, and online. Only one study reported significant reductions in pain-related outcomes (with moderate effect sizes), with the remaining studies (n = 4) demonstrating no change. Four studies described reductions in depressive symptoms and three reported reductions in anxiety. Despite the importance of good QoL as a goal for people with SCI, few studies (n = 2) assessed this as an outcome with no improvements reported. Study quality ranged from high to low/weak.

CONCLUSIONS

The findings in this review provide mixed support for the use of mindfulness to improve outcomes after SCI. In particular, findings indicate that mindfulness may be particularly effective for improving symptoms of depression and anxiety. This review highlights the requirement for more rigorous, high-quality research, particularly larger randomised-controlled trials with long-term follow-up, in this area. The small number of studies included in the present review mean that conclusions drawn are preliminary and thus reflects the paucity of the research in the area to date.

Development of Emotional Well-Being indicators to advance the quality of spinal cord injury rehabilitation: SCI-High Project

Context: Emotional Well-Being (EWB) post-spinal cord injury or disease (SCI/D) is a critical aspect of adjustment to disability. Advancing care and assuring equity in care delivery within this rehabilitation care domain is essential. Herein, we describe the selection of EWB structure, process and outcome indicators for adults with SCI/D in the first 18 months after rehabilitation admission. Methods: A pan-Canadian Working Group completed the following tasks: (1) defined the EWB construct; (2) conducted a systematic review of available outcomes and their psychometric properties; (3) constructed a Driver diagram summarizing available evidence associated with EWB; and, (4) prepared a process map. Facilitated meetings allowed selection and review of feedback 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 EWB and access to experts and resources. The process indicator is the proportion of SCI/D patients who were screened for depression and anxiety symptoms at rehabilitation admission and rehabilitation discharge. The intermediary outcome is the proportion of SCI/D patients at risk for depression or anxiety at rehabilitation discharge based on screening symptom scores. The final outcomes are: (a) proportion of individuals at risk for depression or anxiety based on screening symptom scores; and (b) proportion of individuals who received referral for EWB services or intervention. Conclusion: The proposed indicators have a low administrative burden and will ensure feasibility of screening for depression and anxiety at important transition points for individuals with SCI/D. We anticipate that the current structures have inadequate resources for at-risk individuals identified during the screening process.

SCI and depression: Does inflammation commandeer the brain?

The incidence of depression is almost twice as high in the spinally injured population compared to the general population. While this incidence has long been attributed to the psychological, economic, and social burdens that accompany spinal cord injury (SCI), data from animal studies indicate that the biology of SCI may play an important role in the development of depression. Inflammation has been shown to impact stress response in rodents and humans, and inflammatory cytokines have been associated with depression for decades. The inflammation inherent to SCI may disrupt necessary mechanisms of mental homeostasis, such as serotonin production, dopamine production, and the hypothalamic pituitary adrenal axis. Additionally, gut dysbiosis that occurs after SCI can exacerbate inflammation and may cause further mood and behavior changes. These mediators combined may significantly contribute to the rise in depression seen after SCI. Currently, there are no therapies specific to depression after SCI. Elucidation of the molecular pathways that contribute to SCI-specific depression is crucial for the understanding of this disease and its potential treatments.

Heterogeneity and Its Impact on Rehabilitation Outcomes and Interventions for Community Reintegration in People With Spinal Cord Injuries: An Integrative Review

Background: Various injury characteristics such as cause, level, severity, and time since injury divide individuals with spinal cord injury (SCI) into many subgroups. The heterogeneity among individuals' injuries and personal characteristics has significant implications for SCI rehabilitation practice, specifically directed toward community reintegration, which is a key goal of rehabilitation interventions for people with disabilities. Purpose: This study aims to summarize the evidence on attributes that make the SCI population heterogeneous, the impact of these attributes on community reintegration, and the implications of heterogeneity for rehabilitation interventions directed toward optimizing community reintegration. Methods: We used an integrative review approach to conduct this study. MEDLINE, PubMed, CINAHL, EMBASE, Google Scholar, and PsycINFO were searched from inception until May 2017. Out of 670 articles retrieved, 49 provided evidence on the impact of various attributes that make SCI heterogeneous on rehabilitation outcomes related to community reintegration. Results: An array of injury-related, personal, social, and environmental factors are associated with various rehabilitation outcomes that affect community reintegration of people with SCI. There is level 1 evidence that social support, self-efficacy, and self-esteem facilitate community reintegration among people with SCI while there is level 5 evidence that presence of psychological or medical complications decreases it. There is lack of clarity on the impact of injury-related factors on community reintegration. Conclusion: This integrative review found that social support and individuals' self-efficacy can improve community reintegration of people with SCI. However, evidence regarding the impact of injury characteristics on community reintegration is still underdeveloped. Approaches directed at community reintegration should involve components of psychosocial, physical, and vocational rehabilitation while considering personal and societal aspects of an individual's life.

Impact Of Spinal Cord Injury On Sleep: Current Perspectives

Sleep disorders are commonly encountered in people living with spinal cord injury (SCI). Primary sleep disorders such as sleep-disordered breathing (SDB), sleep-related movement disorders, circadian rhythm sleep-wake disorders, and insomnia disorder are common conditions after SCI but remain under-recognized, underdiagnosed and therefore remain untreated for a majority of patients. Sleep disturbances in people living with SCI are associated with significant impairments of daytime function and quality of life. Previous reviews have described findings related mainly to SDB but have not examined the relationship between other sleep disorders and SCI. This narrative review examines various sleep abnormalities and related functional and physical impairments in people living with SCI. It discusses new evidence pertaining to management, highlights existing limitations in the literature and recommends future directions for research.

Re-inventing yourself after spinal cord injury: a site-specific randomized clinical trial

Study Design:

Parallel-arm randomized controlled trial comparing an interactive group format versus a no-intervention control.

Objective:

To evaluate the efficacy of a replicable group treatment program for improving self-efficacy after spinal cord injury (SCI) in a single center cohort of adults.

Setting:

Regional SCI center.

Methods:

Participants included 81 individuals with SCI who were at least 4 weeks post-discharge from initial rehabilitation. Those randomized to treatment participated in six interactive learning sessions (2 hours each, one session per week) with structured and facilitated group interactions to improve self-efficacy. A wait-list control group was followed at matching time points for all outcome measures. The primary outcome measure was the Moorong Self-Efficacy Scale (MSES); secondary outcomes were the Generalized Self-Efficacy Scale (GSES); Diener Satisfaction with Life Scale (SWLS); Participation Assessment with Recombined Tools – Objective (PART-O); Patient Health Questionnaire – 9 (PHQ-9); and General Anxiety Disorder 7-item (GAD-7).

Results:

Individuals in the Treatment group had greater increases in MSES scores from baseline to immediately post-intervention (6 weeks) than the Control group, but that difference did not remain significant after controlling for multiple comparisons. However the improvement in the treatment group relative to the control group was not maintained through follow-up at 30 weeks. There was no evidence of an immediate or sustained treatment effect on any of the secondary outcomes.

Conclusions:

Self-efficacy improved for participants with SCI in the Treatment group, however, this improvement was not significant or maintained on follow-up.

Basic hope and posttraumatic growth in people with traumatic paraplegia- the mediating effect of acceptance of disability

STUDY DESIGN

Cross-sectional study.

OBJECTIVES

Investigating the correlations between basic hope, acceptance of disability, and posttraumatic growth (PTG) in people with traumatic paraplegia, exploring the mediating effect of acceptance of disability.

SETTING

Community-dwelling people with traumatic paraplegia in Poland.

METHODS

Data were obtained from 281 individuals with paraplegia. The set of questionnaires included: The Posttraumatic Growth Inventory (PTGI); Basic Hope Inventory (BHI); and The Multidimensional Acceptance of Loss Scale. Four dimensions of disability acceptance were measured: subordinating physique relative to other values, enlarging the scope of values, transforming comparative-status values into asset values, and containing the effects of disability. Mediation was tested with the Baron and Kenny's approach.

RESULTS

A positive and statistically significant correlation between basic hope, acceptance of disability, and posttraumatic growth was found. Using a hierarchical regression analysis, a mediating effect of acceptance of disability was found for explaining the relationship between basic hope and posttraumatic growth in people with paraplegia. Only two dimensions of disability acceptance, subordinating physique relative to other values and transforming comparative-status values into asset values, were found to play a mediating role.

CONCLUSION

Beliefs about the world and the transformation of values ​​that constitute acceptance of disability are important for explaining PTG in people with paraplegia. Correlations between these variables are complex. The correlation between basic hope and posttraumatic growth in individuals with paraplegia may be understood better by taking into account the mediating role of acceptance of disability.

Efficacy of Internet-Delivered Mindfulness for Improving Depression in Caregivers of People With Spinal Cord Injuries and Chronic Neuropathic Pain: A Randomized Controlled Feasibility Trial

OBJECTIVES

To explore the feasibility and efficacy of web-based mindfulness training for carers of people with spinal cord injury (SCI).

DESIGN

Randomized controlled feasibility study with 3-month follow-up.

SETTING

Community setting.

PARTICIPANTS

Spouses or family caregivers (N=55) of people with SCI and chronic neuropathic pain were recruited via the direct care team and advertisements. Participants were older than 18 years (no upper age limit), with Internet access for the duration of the study. Participants were randomly allocated to an 8-week online mindfulness training intervention (n=28), or to receive 8 weeks of psychoeducational materials on SCI and chronic pain (n=27).

INTERVENTIONS

An established web-based, mindfulness training course was delivered over 8 weeks. Participants completed 10 minutes of mindfulness practices, twice per day, 6 days per week, totaling 960 minutes. The control group received a weekly e-mail with psychoeducational materials (based on the established elements) on SCI and pain for 8 weeks.

MAIN OUTCOME MEASURE

Depression severity.

RESULTS

Mindfulness reduced depression severity more than psychoeducation at T2 (mean difference= -.891; 95% confidence interval,-1.48 to -.30) and T3 (mean difference=-1.96; 95% confidence interval, -2.94 to -.97). Mindfulness training also reduced anxiety at T2 (mean difference=-.888; 95% confidence interval, -1.40 to -.38) and T3 (mean difference=-2.44; 95% confidence interval, -3.20 to -1.69).

CONCLUSIONS

Results indicate that Internet-delivered mindfulness training offers unique benefits and is viable for caregivers of people with SCI and chronic neuropathic pain. Further work should explore the feasibility of combined education and mindfulness training incorporating both patient and caregiver, for optimum benefit.

Evidence-based position paper on Physical and Rehabilitation Medicine (PRM) professional practice for persons with spinal cord injury. The European PRM position (UEMS PRM Section)

INTRODUCTION

Spinal cord injury (SCI) is a devastating condition and a challenge for every health system and every society. This EBPP represents the official position of the European Union through the UEMS PRM Section and designates the professional role of PRM physicians for people with SCI. The aim of the paper was to improve Physical and Rehabilitation Medicine (PRM) physicians' professional practice for persons with SCI in order to improve their functionality, social and community reintegration, and to overcome activity limitations and/or participation restrictions.

EVIDENCE ACQUISITION

A systematic review of the literature and a consensus procedure by means of a Delphi process have been performed involving the delegates of all European countries represented in the UEMS PRM Section.

EVIDENCE SYNTHESIS

The systematic literature review is reported together with thirty-eight recommendations resulting from the Delphi procedure.

CONCLUSIONS

The professional role of PRM physicians who have expertise in the rehabilitation of SCI is to run rehabilitation programmes in multi-professional teams, working in an interdisciplinary way in a variety of settings to improve the functioning of people with SCI.

[Pain in patients with paraplegia]

Chronic pain is one of the most reported health problems in patients suffering from spinal cord injuries and is described by the patients as one of the most burdensome sequelae of paraplegia. Various types of pain, such as nociceptive, neuropathic and other types of pain can occur. In addition, multiple pathophysiological mechanisms based on the biopsychosocial pain model play a role in the origins of the pain. These aspects necessitate a multimodal pain management approach in this patient group. This article presents an overview of the occurrence, importance and pathophysiology of chronic pain following spinal cord injury as well as diagnostic and therapeutic approaches.

Are Comorbid Pain and Depressive Symptoms Associated with Rehabilitation of Individuals with Spinal Cord Injury?

Objective: To examine the difference in functional outcomes and therapy intensity among individuals with spinal cord injury (SCI) with comorbid depression and pain symptoms compared to those without these symptoms. Methods: A retrospective chart review was conducted of 100 patients admitted to a specialized SCI inpatient rehabilitation unit. Standard demographic factors were collected. Patients were divided into 2 groups: those with comorbid depression and pain symptoms and those without. Outcomes were compared between the 2 groups using analysis of covariance (ANCOVA). Age, gender, level of injury, severity of injury, and FIM^® admission were included in the model as covariates. Main outcomes included FIM^® discharge, length of stay (LOS), intensity of therapy (total physical therapy time [PTt] and total occupational therapy time [OTt]), living arrangement, and vocational status. Results: No significant difference was seen between the 2 groups in FIM^® discharge or OTt; however, those in the comorbidity group required significantly greater PTt than those without (p = .002). Those in the comorbid group also spent longer in inpatient rehabilitation (p = .005). The groups did not differ in postdischarge living arrangements or vocational status. Conclusion: Inpatient rehabilitation physical therapy and LOS differ substantially among individuals with comorbid depression and pain symptoms. This comorbidity may have a negative impact on functional recovery such that individuals may require more physical therapy time and longer LOS. This may also point to the increased resources required to manage individuals with SCI and comorbid depression and pain symptoms.

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.

Depressive mood in adults with spinal cord injury as they transition from an inpatient to a community setting: secondary analyses from a clinical trial

STUDY DESIGN

Prospective cohort controlled trial design.

OBJECTIVES

(i) To investigate mood benefits of adding group cognitive behaviour therapy (group-CBT) to standard spinal cord injury (SCI) inpatient rehabilitation (SR) that included access to antidepressant medication and individually delivered CBT on demand. (ii) To determine whether those with elevated depressive mood during inpatient rehabilitation significantly improve.

SETTING

SCI rehabilitation and community settings in New South Wales, Australia.

METHODS

Participants included 50 adults with SCI who completed SCI rehabilitation that included group-CBT compared with 38 participants who also completed SCI rehabilitation that did not contain group-CBT. Comprehensive assessment occurred after admission, within 2 weeks of discharge and 12 months post-injury. Multivariate repeated measures analyses were conducted to examine differences between groups and over time.

RESULTS

The addition of group-CBT to SR did not result in significant improvement in mood. However, participants with clinically elevated depressive mood assessed during inpatient rehabilitation experienced significant reductions in depressive mood when assessed in the community regardless of CBT dosage. Anxiety correlated with mood while no sociodemographic/injury factors correlated with mood at any time period except education level.

CONCLUSION

There were no mood advantages over time of adding group-CBT to inpatient SCI rehabilitation that contains individually delivered CBT on demand and access to antidepressant medication. However, findings showed those with elevated depressive mood during inpatient rehabilitation significantly improved when assessed in the community; however, their levels of depressive mood remain high. Future research should investigate the efficacy of providing individual preferences for managing depression in people with SCI.

Multiple mediation path model of pain's cascading influence on physical disability in individuals with SCI from Colombia, South America

BACKGROUND

Research has begun to document the bivariate connections between pain in individuals with spinal cord injury (SCI) and various aspects of health related quality of life (HRQOL), such as fatigue, social functioning, mental health, and physical functioning.

OBJECTIVE

The purpose of this study was to construct and test a theoretical path model illuminating the stage-wise and sequential (cascading) HRQOL pathways through which pain increases physical disability in individuals with SCI in a sample from Colombia, South America. It was hypothesized that increased pain would lead to decreased energy, which would lead to decreased mental health and social functioning, which both would lead to emotional role limitations, which finally would lead to physical role limitations.

METHODS

A cross-sectional study assessed individuals with SCI (n = 40) in Neiva, Colombia. Participants completed a measure indexing various aspects of HRQOL.

RESULTS

The path model overall showed excellent fit indices, and each individual path within the model was statistically significant. Pain exerted significant indirect effects through all possible mediators in the model, ultimately suggesting that energy, mental health, social functioning, and role limitations-emotional were likely pathways through which pain exerted its effects on physical disability in individuals with SCI.

CONCLUSIONS

These findings uncover several potential nodes for clinical intervention which if targeted in the context of rehabilitation or outpatient services, could result in salubrious direct and indirect effects reverberating down the theoretical causal chain and ultimately reducing physical disability in individuals with SCI.

The relationship between perfectionistic self-presentation and reactions to impairment and disability following spinal cord injury

Univariate and multivariate relationships between perfectionistic self-presentation and reactions to impairment and disability following spinal cord injury were examined. A total of 144 adults with spinal cord injury ( M = 48.18 years old, SD = 15.96) completed self-report measures. Analyses revealed that, after controlling for time since injury and gender, perfectionistic self-presentation predicted six of eight reactions, shock, depression and internalised anger particularly strongly. In addition, at multivariate level, perfectionistic self-presentation was positively related to non-adaptive reactions and negatively related to adaptive reactions. The findings suggest that perfectionistic self-presentation may contribute to poorer psychosocial adaptation to spinal cord injury.

Effects of a Tailored Positive Psychology Intervention on Well-Being and Pain in Individuals With Chronic Pain and a Physical Disability: A Feasibility Trial

OBJECTIVES

To determine the feasibility, acceptability, and efficacy of a computer-based positive psychology intervention in individuals with a physical disability and chronic pain.

METHODS

Individuals with spinal cord injury, multiple sclerosis, neuromuscular disease, or postpolio syndrome and chronic pain were randomly assigned to a positive psychology or a control condition. Participants in the intervention group were instructed to practice 4 personalized positive psychology exercises. Participants in the control group were instructed to write about life details for 8 weeks. Participants completed online well-being and pain-related questionnaires at baseline, posttreatment, and at the 2.5-month follow-up, and rated treatment satisfaction at posttreatment.

RESULTS

Ninety-six participants were randomized and 68 (70%) completed follow-up assessments. Participants in the positive psychology intervention group reported significant pretreatment to posttreatment improvements in pain intensity, pain control, pain catastrophizing, pain interference, life satisfaction, positive affect, and depression. Improvements in life satisfaction, depression, pain intensity, pain interference, and pain control were maintained to the 2.5-month follow-up. Participants in the control group reported significant pretreatment to posttreatment improvements in life satisfaction, and pretreatment to follow-up improvements in pain intensity and pain control. Significant between-group differences, favoring the treatment group, emerged for pretreatment to posttreatment improvements in pain intensity and pain control. Participants were similarly satisfied with both treatments.

DISCUSSION/CONCLUSIONS

The results support the feasibility, acceptability, and potential efficacy of a computer-based positive psychology intervention for improving well-being and pain-related outcomes in individuals with physical disabilities and chronic pain, and indicate that a full trial of the intervention is warranted.

Development of an intervention to improve mental health for obstetric fistula patients in Tanzania

Obstetric fistula is a debilitating childbirth injury that has been associated with high rates of psychological distress. Global efforts have helped to link women to surgical repair, but thus far no evidence-based interventions exist to address the psychological needs of these women during the hospital stay. In this paper, we describe the development of a psychological intervention for women in Tanzania who are receiving surgical care for an obstetric fistula. The intervention was developed based on theories of cognitive behavioral therapy and coping models. Content and delivery were informed by qualitative data collection with a range of stakeholders including women with fistula, and input from a study advisory board. The resulting intervention was six individual sessions, delivered by a trained community health nurse. The session topics were (1) recounting the fistula story; (2) creating a new story about the fistula; (3) loss, grief and shame; (4) specific strategies for coping; (5) social relationships; and (6) planning for the future. A trial run of the intervention revealed that the intervention could be delivered with fidelity and was acceptable to patients. A future randomized control trial will evaluate the efficacy of this intervention to address the mental health symptoms of this population.

Reducing cardiometabolic disease in spinal cord injury

Accelerated cardiometabolic disease is a serious health hazard after spinal cord injuries (SCI). Lifestyle intervention with diet and exercise remains the cornerstone of effective cardiometabolic syndrome treatment. Behavioral approaches enhance compliance and benefits derived from both diet and exercise interventions and are necessary to assure that persons with SCI profit from intervention. Multitherapy strategies will likely be needed to control challenging component risks, such as gain in body mass, which has far reaching implications for maintenance of daily function as well as health.

Comparison of mental health between individuals with spinal cord injury and able-bodied controls in Neiva, Colombia

Although research has investigated the mental health of individuals with spinal cord injury (SCI), an overwhelming majority of this research has been conducted in the United States, Western Europe, and other developed countries. The purpose of this study was to compare the mental health of individuals with SCI with able-bodied controls in Neiva, Colombia, South America. Subjects included 40 Colombians with SCI and 42 age- and sex-matched controls (N = 82). The groups did not differ based on age, sex, years of education, or socioeconomic status. However, controls were twice as likely to be married. Four measures assessed mental health, including satisfaction with life (Satisfaction with Life Scale), depressive symptoms (Patient Health Questionnaire-9), self-esteem (Rosenberg Self-Esteem Scale), and anxiety (State-Trait Anxiety Inventory). In comparison with able-bodied controls, individuals with SCI reported significantly lower mental health on both depressive symptoms and satisfaction with life. These effect sizes were medium and large, respectively. The groups did not differ significantly on measures of self-esteem or anxiety. Mental health of individuals with SCI should be considered a central part of SCI rehabilitation interventions, particularly in Latin America.

Evaluation of a community reintegration outpatient program service for community-dwelling persons with spinal cord injury

Objective. To evaluate the effectiveness of a community reintegration outpatient (CROP) service for promoting well-being and community participation following spinal cord injury (SCI). Participants. Community-dwelling adults (N = 14) with traumatic and nontraumatic SCI. Interventions. The CROP service is a 12-week (1 × week; 120 minutes) interprofessional closed therapeutic education service. Main Outcome Measure(s). Moorong Self-Efficacy Scale (MSES); Impact on Participation and Autonomy (IPA); Positive Affect and Negative Affect Scale (PANAS); Coping Inventory of Stressful Situations (CISS); World Health Organization Quality of Life (WHOQOL-BREF); semistructured qualitative interviews. Methods. Twenty-one participants were recruited from two subsequent CROP services, with only 14 persons completing all data assessments. Data were collected at baseline (week 0), at exit (week 12), and at a three-month follow-up. Semistructured interviews were conducted at exit. Results. Self-efficacy (MSES) and positive affect (PANAS) improved from baseline to exit (P < .05), but the changes were not maintained at follow-up. Qualitative analysis identified four major themes related to therapeutic benefits: (1) role of self; (2) knowledge acquisition; (3) skill application; and (4) group processes. Conclusions. Participation in a therapeutic education service has the potential to improve well-being in persons with SCI, but there is a need to identify strategies to maintain long-term gains.

The relationship between physical and mental health variables in individuals with spinal cord injury from Latin America

BACKGROUND

Previous research has examined the health-related quality of life (HRQOL) and mental health of persons with spinal cord injury (SCI), but the majority of the research has taken place in the United States, Western Europe, and other developed countries. Limited research has been conducted with persons with SCI in Latin America.

OBJECTIVE

To examine the relationship between HRQOL and mental health in persons with SCI from Neiva, Colombia.

DESIGN

Cross-sectional.

SETTING

Participants were recruited from the Foundation for the Integral Development of People with Disabilities, a nonprofit community organization for persons with disabilities.

PARTICIPANTS

Forty persons with SCI from Neiva, Colombia.

METHODS

Caregivers completed the Spanish versions of questionnaires.

MAIN OUTCOME MEASURES

Participants completed self-report measures of HRQOL (SF-36 Health Questionnaire) and mental health (Satisfaction with Life Scale, Patient Health Questionnaire-9, and State Trait Anxiety Inventory).

RESULTS

The hypothesis that higher HRQOL would be related to better mental health found robust support, as the canonical correlation between these 2 sets of variables uncovered that 50.4% of the variance was shared, such that persons with lower HRQOL had reduced mental health. Within this canonical correlation, anxiety, fatigue, and general health loaded most highly, suggesting that persons with SCI who experienced lower energy and reduced general health tended to have high anxiety. Additionally, 9 out of the 18 bivariate correlations between these 2 variable sets were statistically significant.

CONCLUSIONS

In Latin America, SCI rehabilitation services are extremely sparse and rarely include interventions that target postinjury mental health. The current study suggests that mental health issues in patients with reduced HRQOL warrant attention in SCI rehabilitation services, especially in this region.

Pain intensity and its association with negative mood States in patients with spinal cord injury

Introduction

Chronic and persistent pain is a prevalent and debilitating secondary condition in patients with a neurological injury such as spinal cord injury (SCI). Patients with SCI have an increased risk of developing other co-morbid conditions such as elevated negative mood states. Arguably, the presence of chronic pain would act to intensify the chances of developing negative mood states as opposed to resilient mental states. The objective of this research was to investigate the association between pain intensity and levels of negative mood states in adult patients with SCI.

Methods

Participants included 107 adults with SCI living in the community who completed an assessment regimen in a relaxed environment. Mean pain intensity over a period of 1 week and the Profile of Mood States, a validated psychometric measure of mood states (anxiety, depressed mood, anger, vigor, fatigue, confusion and total negative mood score) were used to determine associations between pain intensity and mood states. The sample was divided into a low pain intensity sub-group (<4 where 0 = no pain; 10 = worst pain imaginable) and a clinically significant or high pain intensity sub-group (≥4), allowing negative mood to be compared between the sub-groups.

Results

Mean age was 47.1 years, and 87% of the sample was male. Clinically significant pain intensity over the week prior to assessment was found in 52% of the 107 participants. The high pain intensity sub-group was found to have significantly elevated anxiety, depressed mood, anger, fatigue, confusion and significantly reduced vigor.

Conclusion

These results provide further evidence that patients with SCI experience clinically elevated negative mood states if they have intense levels of pain over extended periods of time. In contrast, patients without intense pain have mood states similar to those in the able-bodied community. Implications for the treatment of SCI are discussed.

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.