Relationship between level of spinal cord injury and posttraumatic stress disorder symptoms

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

Low depressive symptoms in acute spinal cord injury compared to other neurological disorders

The aim of the study was to reveal the incidence and time course of depressive symptoms following acute spinal cord injury (SCI) in relation to clinical outcomes for comparison to other neurological disorders with severe impairment. In patients with acute traumatic SCI (n = 130), combined follow up assessments of neurological and functional outcomes, pain and patient-rated affective factors (e.g. mood, anxiety) were prospectively (1, 3, 6, 12 months after injury) collected during rehabilitation and follow up in out-patient clinics. We related these to the severity of depressive symptoms (no, mild, moderate and severe) based on the Beck Depression Inventory (BDI) scores. The mean 65% of patients showed no depressive symptoms and 30% mild depressive symptoms, while less than 5% presented moderate to severe depressive symptoms. The group findings and symptoms in individual patients remained stable over 1 year though patients revealed significant clinical recovery. Although two-thirds of the patients experienced pain, BDI scores were not related to pain intensity. BDI mean scores were only slightly higher than in control populations, but rather low compared to patients with other neurological disorders (e.g. stroke and multiple sclerosis) that are also associated with severe functional impairment. The prevalence of depressive symptoms following acute SCI is rather low and remains stable within the first year after injury despite the severe neurological impairment and loss of independency. In comparison to other neurological disorders that also involve brain function SCI patients seem to be less challenged by depressive symptoms that constitute additional burdens to respond to the severe functional impairments.

Post traumatic distress symptoms following spinal cord injury: a comparative review of European samples

OBJECTIVE

To highlight any cross-cultural differences in the prevalence of post traumatic distress (PTD), and the type of coping strategies implemented following spinal cord injury (SCI).

DESIGN

Cross-sectional questionnaire.

SETTING

A spinal cord rehabilitation unit in the UK, and six Swiss and German (CH/DE) spinal injury centres.

METHOD

A total of 85 SCI individuals in the UK, and 71 in CH/DE were evaluated on levels of PTD using the Impact of Event Scale (IES), and depressive symptomatology using the Beck Depression Inventory or the Berne Questionnaire of Well-Being at up to 6 months postinjury. In addition, the coping strategies utilised by the two samples were assessed using the COPE measure.

RESULTS

No significant difference between the two samples was noted with regard to levels of PTD determined by the total score on the IES, although there was a tendency for a higher rate in the UK. Approximately 20 and 10% of both samples scored above the clinical cutoff on the IES subscales of intrusion and avoidance, respectively. No significant difference was found to exist between the rate of PTD in the SCI CH/DE sample and the able-bodied sample in Switzerland. A lower prevalence of depression was noted in the CH/DE sample. The CH/DE sample scored higher on the use of positive reinterpretation and growth, suppression of competing activities, active and restraint coping, whereas the UK sample scored higher on the use of humour as a coping strategy. Overall, denial, focusing on and venting of emotions, mental disengagement and suppression of competing activities were associated with PTD.

CONCLUSION

No cross-cultural differences in the level of PTD seem apparent between the UK and CH/DE populations. Future research should focus on determining what protects individuals from developing PTD following SCI.

Post-traumatic stress disorder and emotional distress in persons with spinal cord lesion

STUDY DESIGN

Questionnaire.

OBJECTIVE

To evaluate the prevalence of post-traumatic stress disorder (PTSD) and emotional distress in persons with recent onset of spinal cord lesion.

SETTING

Denmark.

METHODS

A total of 69 patients with paraplegia or tetraplegia from two rehabilitation centres in Denmark filled in the questionnaire. PTSD and emotional distress were assessed using the Harvard Trauma Questionnaire and the Medical-Based Emotional Distress Scale, 83 days on average after the spinal cord lesion. The level of neurological lesion and completeness were recorded adhering to the International Standards for Neurological Classification of Spinal Cord Injury.

RESULTS

The prevalence of PTSD was 20%. Patients with PTSD experienced significantly more symptoms of depression and more emotional distress than patients without PTSD. Age and neurological level were related to PTSD in patients with traumatic injuries, but not in patients with nontraumatic lesions.

CONCLUSIONS

Persons with a recent onset of spinal cord lesions are at increased risk of having PTSD, and comorbidities such as depression and other symptoms of emotional distress.

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.