Self-Management and Self-Efficacy in Patients With Acute Spinal Cord Injuries: Protocol for a Longitudinal Cohort Study

Patient activation during the first 6 months after the start of spinal cord injury rehabilitation: a cohort study

BACKGROUND

Spinal cord injury (SCI) is a serious injury that leads to motor and sensory disorders and ultimately affects people's physiological, psychological, and social well-being.

AIM

To test patient activation from discharge from the department of spinal surgery until 6-month follow-up.

DESIGN

Longitudinal inception cohort study.

SETTING

This study was conducted at the Spinal Surgery Department of the Third Affiliated Hospital of Soochow University in China.

POPULATION

A total of 367 participants with traumatic SCI received community-based or hospital-based rehabilitation between October 2020 and November 2023 and were recruited using convenience sampling.

METHODS

Patient activation was evaluated using the short version of the Patient Activation Measure (PAM). Assessments were conducted at baseline, 3-month, and 6-month follow-up.

RESULTS

At baseline, the mean PAM score was 53.2, with the number of participants in PAM levels 1, 2, 3, and 4 being 92, 142, 114, and 19, respectively. Between baseline and 6-month, 164 participants remained at the same PAM level, 85 participants increased, 86 participants decreased. The multivariate mixed-effects model analysis showed that the PAM score decreased significantly over time (P=0.007). Older age had a positive effect on improvement over time (P=0.023). Higher self-efficacy, resilience, health literacy, and Modified Barthel Index (MBI) remained significantly related with higher PAM scores over time (P<0.001, P<0.001, P<0.001, and P=0.010, respectively). Fewer symptoms of depression remained significantly related with higher PAM scores over time (P<0.001).

CONCLUSIONS

PAM scores decreased slightly over time from the start of rehabilitation up to the 6-month follow-up. Furthermore, about two-third of participants remained at low levels of patient activation, which suggests that patient-centered care interventions during rehabilitation to improve patient activation might be of value.

CLINICAL REHABILITATION IMPACT

This study examined the course of patient activation from the start of SCI rehabilitation to the 6-month follow-up period. These findings provide the necessary basis for the development and evaluation of effective interventions to promote patient activation levels and enhance self-management in people with SCI.

Learning to direct one's care: barriers and facilitators reported by people with tetraplegia

STUDY DESIGN

Qualitative analysis of focus group data.

OBJECTIVE

Identifying barriers to and facilitators of learning to direct one's own care as a person with tetraplegia due to spinal cord injury (SCI).

SETTING

Community, in New Jersey and Georgia, USA.

METHODS

Three focus groups of veterans and civilians with SCI, involving 26 people with chronic (≥1 year) tetraplegia due to SCI who provided direction to caregivers on a daily basis. Content analysis was used to identify barriers and facilitators.

RESULTS

Challenges to learning to direct one's care included: (1) lack of acceptance of lasting effects of SCI; (2) not yet understanding one's body post-SCI; (3) embarrassment; (4) being overwhelmed with information; (5) differences between the inpatient rehabilitation setting and the "real world"; (6) lack of capable and willing assistants; and (7) hesitance to criticize caregivers. Factors that helped participants become successful directors of care included: (1) experience living with SCI; (2) being observant; (3) communicating effectively; (4) developing confidence to advocate for one's own needs; (5) learning when to "let go" and when to speak up; and (6) learning from peers.

CONCLUSIONS

Direction of care is a complex skill that is developed over time, and requires awareness of one's needs and preferences, self-confidence, and strong communication skills. Rehabilitation clinicians' efforts to prepare people with SCI to direct their own care effectively should cultivate awareness of one's body, identify strategies for communicating successfully with caregivers, and provide opportunities for practice of care direction skills and discussion with experienced peers.

Effects of a self-efficacy-centered self-management program on neurogenic bladder after spinal cord injury: A randomized controlled trial

PURPOSE

The present research aimed to investigate the effects of a self-efficacy-centered self-management program on persons with neurogenic bladder (NGB) after spinal cord injury (SCI).

DESIGN

A randomized controlled trial.

MATERIALS AND METHODS

Eighty-two individuals with NGB after spinal cord injury (SCI) were randomized into either the control or intervention group. The control group received standard admission and discharge education and follow-up. The intervention group received the self-efficacy-centered self-management program. Self-efficacy was assessed at preintervention, 4, 8, and 12 weeks post-intervention. Self-management ability, the incidence of urinary tract infection (UTI), residual urine volume, bladder safety capacity, and quality of life were assessed at 12 weeks post-intervention.

RESULTS

Of the 82 recruited participants, only 79 participants (control group: n = 39, 67% males, intervention group: n = 40, 58% males) received the full intervention. A significant difference was observed in self-efficacy score between the control and intervention groups (2.54 ± .247 versus 2.71 ± .218, mean difference = .174, 95% confidential interval: .070-.278, p = .001) at 12 weeks post-intervention. The intervention group demonstrated significantly better outcomes than the control group at 12 weeks post-intervention in self-management ability, urinary tract infection (UTI) incidence, residual urine volume and bladder safety capacity. There were significant differences in quality of life (vitality [VT] and mental health [MH] subscales) between the two groups.

CONCLUSIONS

The self-efficacy-centered self-management program developed in this study can significantly increase participants' self-efficacy and bladder self-management ability, thereby improving their bladder functional status and quality of life.

Correlates of physical activity in ambulatory people with spinal cord injury during the first year after inpatient rehabilitation

STUDY DESIGN

Longitudinal cohort study.

OBJECTIVES

Examine the longitudinal association between mobility and level of physical activity (PA) and explore which other factors are also associated with level of PA in ambulatory people with Spinal Cord Injury (SCI) during the first-year post-inpatient rehabilitation.

SETTING

Three SCI-specialized rehabilitation centers and the Dutch community.

METHODS

Forty-seven adults with recent SCI and ambulatory function were included. All had motor incomplete lesions, 49% had tetraplegia, and the mean age was 55 ± 13 years. Duration of accelerometry-based all-day PA and self-reported level of mobility, exertion of walking, pain, fatigue, depressive mood symptoms, fear of falling, exercise self-efficacy, and attitude toward PA were measured just before discharge from inpatient rehabilitation and 6 and 12 months after discharge. All data were longitudinally analyzed using generalized estimating equations analyses. Models were corrected for age, lesion level, and time since injury.

RESULTS

Mobility was longitudinally associated with level of PA (beta: 4.5, P < 0.001, R2: 41%). In addition, lower levels of exertion of walking (beta: -5.6, P < 0.001), fear of falling (beta: -34.1, P < 0.001), and higher levels of exercise self-efficacy (beta: 2.3, P = 0.038) were associated with higher levels of PA. Exertion of walking and fear of falling were associated with level of PA independent of mobility.

CONCLUSIONS

Mobility, exertion of walking, fear of falling, and exercise self-efficacy seem to be correlates of level of PA in ambulatory people with SCI during the first year after inpatient rehabilitation. Targeting these factors using an interdisciplinary approach may enhance levels of PA in this population.

Predictors of activation among persons with spinal cord injury during hospitalization: A cross-sectional study

AIM

To test the contributions of self-efficacy, resilience, social support, and negative moods (i.e., anxiety, depression) to patient activation among persons with spinal cord injury (SCI).

METHODS

One hundred and twenty-two participants with SCI were recruited from the spinal surgery department at a large general hospital. During the period before discharge after surgery, standardized self-assessment questionnaires were used to collect data on patient activation, self-efficacy, resilience, social support, anxiety, depression, demographics (age, gender, education, marital status), and disease-related information (etiologies, level of injury, American Spinal Injury Association Impairment Scale score). Hierarchical regression analysis, mediation analysis, and moderation analysis were performed in SPSS, Amos, and Jamovi to determine the influencing factors of patient activation.

RESULTS

Self-efficacy, resilience, social support, anxiety, and depression uniquely explained 38.2% (p < .001) of the variance in patient activation after controlling for demographic and disease-related covariates. The full model explained 53.7% (p < .001) of the variance in patient activation. In the mediation analysis, self-efficacy, resilience, and social support had partial mediating effects (p < .05). In the moderation analysis, marital status moderated the relationship between self-efficacy and patient activation (p < .05).

CONCLUSIONS

Activation of persons with SCI is a positive psychosocial resource related to higher self-efficacy, resilience, and social support. Marital status may affect activation in persons with SCI. The causal relationship between these psychosocial variables needs to be proved by further intervention studies.

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.

Evaluation of secondary complication awareness among individuals with spinal cord injury

Secondary complications (SCs) are common and cause high morbidity and mortality in individuals with spinal cord injury (SCI). There is no information or a satisfactory scale of measurement for evaluating the opinions of individuals with SCI on whether they have sufficient knowledge about these complications. This study aimed to evaluate the opinions of individuals with SCI about whether they have sufficient information on SCI-related SCs. Demographic and clinical characteristics of 64 SCI individuals were recorded. A questionnaire was applied to evaluate the opinions of the participants and whether they have sufficient information about SCs before and after a multidisciplinary rehabilitation for SCI. A test was performed to measure the knowledge level at admission to the hospital and discharge. The mean value of the total questionnaire score, which was 6.2 at admission, increased to 7.91 at discharge ( P  < 0.001). All subgroup scores of the questionnaire were higher at discharge than at admission (all P  < 0.05). Total, neurogenic bladder, neurogenic bowel and spasticity test scores increased at discharge compared to admission (all P  < 0.05). There is a relationship between the change in questionnaire scores and some demographic and injury characteristics. The opinions of the individuals with SCI on having sufficient information about SCs and their knowledge levels increased after a multidisciplinary rehabilitation program. Applying such a questionnaire and test at admission may have increased the awareness of the participants about SCs and contributed to a higher level of knowledge and opinion.

The contribution of bio-psycho-social dimensions on sexual satisfaction in people with spinal cord injury and their partners: an explorative study

STUDY DESIGN

Cross-sectional explorative observational study.

TITLE

Sexual satisfaction in people with spinal cord injury and their partners: an explorative study.

OBJECTIVE

To investigate the determinants of sexual satisfaction among individuals with spinal cord injury and relative partners by assuming a bio-psycho-social perspective.

SETTING

Online survey.

METHODS

Thirty-eight individuals (22 individuals with SCI and their partners) were provided with an anonymous self-report questionnaire. Bio-psycho-social dimensions were investigated by using the Barthel Modified Index, Beck Depression Inventory-II, Short Form Health Survey (SF-36). Sexual attitudes of participants were assessed via the Multidimensional Sexual Self-Concept Questionnaire (Snell, 1993).

RESULTS

While no differences were observed between individuals with SCI and their partners, women with SCI were overall more satisfied about their sexual life when compared to men with SCI. Coping strategies promoting self-efficacy and an active role in the sexual issues were predictive of Sexual Satisfaction in the couples of persons with SCI and their partners. No significant contribution was played by physical variables.

CONCLUSION

A tailored-made approach assessing the needs of both individuals with SCI and partners is a key aspect for effective sexual rehabilitation protocols. According to the needs and features of each couple, health professionals should drive individuals with SCI and partners to cope with their sexuality within a bio-psycho-social framework underlying it.

Learning self-care skills after spinal cord injury: a qualitative study

BACKGROUND

People with a recent spinal cord injury (SCI) often follow intensive rehabilitation. Learning appropriate self-care, deal with their impairments and prevent secondary health conditions (SHCs), is highly important during rehabilitation. To date it is not clear how self-care skills are taught to people with SCI. The objective of this study was to understand how people with SCI experienced the learning of appropriate self-care skills during inpatient rehabilitation, including the role of the rehabilitation team.

METHODS

Individual semi-structured interviews were conducted with 15 people with SCI, recently discharged from initial inpatient rehabilitation. Interviews were audio-taped, transcribed and analyzed thematically.

RESULTS

Two main themes and seven sub-themes were identified. Participants stated that the contribution of the rehabilitation team to learning self-care, including prevention of SHCs, was mostly made by optimizing opportunities to learn through experience. For preventing SHCs, education and lessons learned from the professionals during therapy and the formal educational program, was experienced as especially important. Further, the motivational attitude of the professionals which participants found stimulating and was based on respect, combined with their positive contribution as one team, were seen as essentials elements for learning appropriate self-care. However participants did not recognize the contribution of the nursing staff as part of their rehabilitation, although it was seen as very important. An important aspect of the participants' own contribution was challenging oneself to learn self-care. This was done in different ways by the participants. Further, their own mental adjustment was considered important in the learning process. The gaining of confidence was by most participants seen as personal characteristic, although they also recognized the importance of the team effort and the experiences they underwent.

CONCLUSIONS

Learning appropriate self-care was mostly done through experience, by challenging themselves, and making use of the opportunities given by the members of the rehabilitation team. The same strategies used by the rehabilitation team to teach people with SCI to perform appropriate self-care, were also helpful for the participants to gain confidence. Explicit attention for self-care training as an important goal in SCI rehabilitation may strengthen the nursing staff's role and stimulate interdisciplinary working.

The value of the whole picture: rehabilitation outcome measurement using patient self-report and clinician-based assessments after spinal cord injury

STUDY DESIGN

This is a retrospective longitudinal study.

OBJECTIVES

To explore the relative impact and contribution of using both the Spinal Cord Independence Measure III (SCIM) and Stoke Mandeville Spinal Needs Assessment Checklist (SMS-NAC) to assess rehabilitation outcome following an acute spinal cord injury (SCI).

SETTING

The study was performed at National Spinal Injuries Centre (NSIC), Stoke Mandeville Hospital, Buckinghamshire Healthcare NHS Trust, Aylesbury, UK.

METHODS

A patient self-report SMS-NAC and clinician-rated SCIM were administered on admission and discharge from the NSIC as part of standardised care. This paper presents a retrospective analysis of the rehabilitation outcomes of 195 people with spinal cord injury (PwSCI) following their first admission.

RESULTS

In both measures, PwSCI improved from admission to discharge. Individuals with higher SCI obtained lower scores in both measures, at both admission and discharge. The SMS-NAC demonstrated the greatest increase in knowledge and skill for PwSCI who had higher and more complete injuries. On the SCIM, PwSCI who had lower and less complete injuries demonstrated the greatest increase in outcome.

CONCLUSIONS

Overall, both measures demonstrated responsiveness to change during SCI rehabilitation and enable clinicians to systematically determine areas to focus rehabilitation effort. The relative strengths and contribution to delivering person-centred care for each are identified. The SMS-NAC enables clinicians to record, for people with higher injuries, their subjective self-report of skill and knowledge gains from rehabilitation that may be missed with other measures. Consequently, using both is encouraged in appreciation of the value of recording verbal (instructional) independence as well as functional (physical) independence.

Trajectories of Self-Efficacy, Depressed Mood, and Anxiety From Admission to Spinal Cord Injury Rehabilitation to 1 Year After Discharge

OBJECTIVE

Self-efficacy (SE) is an important determinant for the psychological adjustment of people with spinal cord injury (SCI). However, little is known about the course of SE during inpatient rehabilitation up to 1 year after discharge. The aim of this study was to determine latent trajectory classes of SE, depressive mood, and anxiety in people with SCI, as well as the interrelationships between these trajectories.

DESIGN

Longitudinal inception cohort study.

SETTING

Eight specialized SCI rehabilitation centers.

PARTICIPANTS

The participants (N=268) were mainly men 183 of 268 (68.3%) with a mean age of 55.6 years. Almost half had a traumatic SCI 135 of 268 (50.4%) and tetraplegia (53.7%), and the minority had a motor complete SCI (32.2%).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

SE was measured using the University of Washington Self-Efficacy Scale. In addition, the Hospital Anxiety and Depression Scale was used to asses distress and perform dual trajectory modeling analyses.

RESULTS

Three trajectories of SE, indicating low, middle, and high SE, could be distinguished. Furthermore, a 2-class trajectory solution for depressive mood and a 4-class solution for anxiety were found to be most suitable. All trajectories were stable over time. Developmental connections between SE and depressive mood and between SE and anxiety were revealed. In particular, participants who adjusted well, reporting low scores on depressive mood and anxiety, could be identified by their high SE scores. However, the group of participants with high depressive mood scores and anxiety scores could not always be identified based on their SE trajectory.

CONCLUSIONS

In accordance with our hypotheses, distinct trajectories of SE, depressive mood, and anxiety were identified and high probabilities that SE trajectories were interrelated to the trajectories from depressive mood and anxiety were confirmed. Concurrent screening for SE and distress might best detect people at risk for adjustment problems.

Development of community participation indicators to advance the quality of spinal cord injury rehabilitation: SCI-High Project

Community participation following spinal cord injury/disease (SCI/D) can be challenging due to associated primary impairments and secondary health conditions as well as difficulties navigating both the built and social-emotional environment. To improve the quality of SCI/D rehabilitation care to optimize community participation, the SCI-High Project developed a set of structure, process and outcome indicators for adults with SCI/D in the first 18 months after rehabilitation admission.

A pan-Canadian Working Group of diverse stakeholders: (1) defined the community participation construct; (2) conducted a systematic review of available outcomes and their psychometric properties; (3) constructed a Driver diagram summarizing available evidence associated with community participation; and (4) prepared a process map. Facilitated meetings allowed selection and review of a set of structure, process and outcome indicators.

The structure indicator is the proportion of SCI/D rehabilitation programs with availability of transition living setting/independent living unit. The process indicators are the proportion of SCI/D rehabilitation inpatients who experienced: (a) a therapeutic community outing prior to rehabilitation discharge; and, (b) those who received a pass to go home for the weekend. The intermediary and final outcome measures are the Moorong Self-Efficacy Scale and the Reintegration to Normal Living Index.

The proposed indicators have the potential to inform whether inpatient rehabilitation for persons with SCI/D can improve self-efficacy and lead to high levels of community participation post-rehabilitation discharge.

Enhancing our conceptual understanding of state and trait self-efficacy by correlational analysis of four self-efficacy scales in people with spinal cord injury

Background

Self-efficacy is an important determinant of adjustment following spinal cord injury. Self-efficacy is defined as the belief that one can successfully execute behavior required to produce the desired outcomes. In its original conceptualization, self-efficacy refers to the confidence that people have in their ability to accomplish specific tasks and behaviors within a specific context. Over the years these situation specific aspects have been unconfined and multiple constructs of self-efficacy have been proposed. The most common is a division in trait and state self-efficacy. Another used division that is utilized is between general, domain-specific and task-specific self-efficacy. The scientific support for these constructs is to date still unclear. The objective of this study was to enhance the understanding of the self-efficacy construct by comparing four self-efficacy scales designed to measure three aspects of self-efficacy (general versus domain-specific versus task-specific) in people with spinal cord injury.

Methods

Dutch and Australian adults with spinal cord injury (N = 140) completed four frequently used self-efficacy scales; the Moorong Self-efficacy Scale, General Self-efficacy Scale, University of Washington Self-efficacy Scale and a Self-care Self-efficacy Scale approximately 6 months after their inpatient rehabilitation. Pearson correlations examined inter-relationships between the scales.

Results

Hypothesized strong correlations between scales measuring similar aspects of self-efficacy were found (correlations 0.50–0.65). However, the hypothesized weak to moderate correlations between scales measuring diverging aspects of self-efficacy were only partly found (correlations 0.31–0.74), with 7 out of 12 correlations being strong instead of moderate.

Conclusions

The expected distinctions between the three aspects of self-efficacy was not demonstrated. All four scales measure a common latent construct, most likely general self-efficacy aspects. Further research is necessary to find ways to improve the measurement of domain-specific and task-specific aspects of SE, so that they are sensitive enough to capture change over time, and thus enhance clinical outcomes of people with SCI as they adjust to their disability.

Physical Activity and Sedentary Behavior From Discharge to 1 Year After Inpatient Rehabilitation in Ambulatory People With Spinal Cord Injury: A Longitudinal Cohort Study

OBJECTIVE

To evaluate changes in duration of physical activity (PA) and sedentary behavior (SB) from discharge to 1 year after inpatient rehabilitation in ambulatory people with spinal cord injury (SCI).

DESIGN

Longitudinal cohort study with objective measurements of physical behavior at discharge and at 6 and 12 months post discharge.

SETTING

Three rehabilitation centers and the participant's home environment.

PARTICIPANTS

Participants (N=47) with ambulatory function were consecutively recruited from the self-management and self-efficacy in patients with SCI cohort (age 18 years or older, recent SCI, expected inpatient stay ≥4wk). Mean age was 54.5±12.9 years, all had incomplete lesions, 53% were men, 49% had tetraplegia, and 51% were community ambulators at discharge.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Duration (min) of PA (summed duration of walking, cycling, running, and wheeling) and SB (sitting/lying).

RESULTS

Mean duration of PA increased by 21 min/d (95% confidence interval, 7-35) and SB decreased by 64 min/d (95% confidence interval, -94 to -35) from discharge to 6 months after inpatient rehabilitation. No changes were found in the second half-year. One year after discharge mean PA was 116±59 min/d and mean SB was 665±121 min/d. The increase in PA was the result of an almost doubling of time spent walking. Variability in physical behavior and its change was large. Older age and lower ambulation level were associated with lower PA, lower ambulation level with higher SB, and tetraplegia was associated with a reduced increase in PA.

CONCLUSIONS

At group level, duration of PA and SB improved following inpatient rehabilitation in ambulatory people with SCI. However, there were large differences between individuals. Levels 1 year after discharge were still unfavorable, particularly regarding SB.

Measuring resilience with the Connor-Davidson Resilience Scale (CD-RISC): which version to choose?

STUDY DESIGN

Cross-sectional psychometric study.

OBJECTIVES

To compare psychometric properties of the Connor-Davidson Resilience Scale (CD-RISC) with 25, 10, and 2 items, and to assess the agreement between these versions in individuals with spinal cord injury (SCI).

SETTING

Standard psychological screening at a Dutch rehabilitation centre during the first 2 weeks of inpatient rehabilitation.

METHODS

Anonymous data from the psychological screening were analysed. CD-RISC outcomes were checked for floor and ceiling effects. Internal consistency was assessed by calculating Cronbach's α. Convergent validity was assessed by Spearman's correlation between resilience and anxiety, depression, passive coping, and life satisfaction. Agreement between CD-RISC versions was examined by calculating intraclass correlation coefficients (ICCs), corresponding 95% confidence intervals (CIs), and Bland-Altman plots.

RESULTS

Total CD-RISC scores were only skewed on the CD-RISC 2 (-1.12). There were no floor and ceiling effects. Internal consistency of the 25-, 10-, and 2-item scales was good to moderate (0.90, 0.86, and 0.66, respectively). Good convergent validity was shown only for the CD-RISC 10. Agreement was highest between the CD-RISC 25 and CD-RISC 10 with an ICC of 0.90 with 95% CI from 0.85 to 0.94.

CONCLUSIONS

Out of the three CD-RISC versions, the CD-RISC 10 showed the best combination of reliability, validity, and practicality. Therefore, this version is advised as measure of resilience in individuals with SCI in a rehabilitation setting. Measurement of resilience could be part of a psychological screening to identify individuals at risk to develop psychological problems after SCI.