Psychosocial Considerations in Spinal Cord Injury

Introduction

Psychosocial considerations in spinal cord injury

Spinal cord injury (SCI) has the potential of resulting in devastating consequences after the occurrence.[1] Often, the management of SCI is centered on the motor, sensory, and autonomic dysfunctions, yet SCI can have tremendous psychosocial consequences on affected individuals.[2][3][4] Research has shown that many with sudden onset of SCI will exhibit extreme negative emotions which can impair psychological as well as social integration after an injury.[1] Also, mental health problems such as anxiety, depression, post-traumatic stress disorder among others may be at an elevated level for people with SCI,[3][4] with psychological and social factors having a role to play in both the incidence and progression of these mental health problems.[5] Thus, it is necessary to pay attention to these psychosocial factors which may have extreme consequences on achieving remarkable rehabilitation goals and improving the quality of life (QoL) of people with SCIs,[1]

Incidence of Psychosocial Issues in Patients with Spinal Cord Injury

The advances in the medical management following spinal cord injury have increased the life expectancy of patients in recent years.[6] Yet SCI leads to considerable physical disability and also secondary medical complications[2]. Furthermore, there have been reports of abnormal incidence of substance abuse,[7] psychological morbidity,[8] and risk of suicide in patients with spinal cord injury.[7]

A research showed that psychological and social support factors are related to subjective wellbeing in patients with SCI.[3] A systematic review on psychological morbidity revealed that up to 30% of people with SCI are at the risk of having a depressive disorder, with a higher relative risk of anxiety disorder, increased level of anxiety, poor quality of life (QoL), and feelings of helplessness.[8]

In a study[9] in Iran on psychosocial outcomes following SCI, there were findings of psychosocial problems that were associated with financial hardship, basically due to unemployment, high cost of living, with other factors such as difficulty in transportation, inadequate home modifications, marriage, social communication, education, sports and entertainment. These issues were also found to vary with the gender of persons with SCI.[9]

Psychosocial Factors in Spinal Cord Injury

The occurrence of SCI is statistically determined to be around the second to the third decade of life.[10] This period corresponds to an important period of emotional and psychological development for many people.[1] Therefore, the psychology of the patient with SCI is affected, and this is influenced by culture, conditions, and settings in a community.[9]

These psychosocial factors may feature early after a SCI, and continue into an individual's life, requiring adjustments and adaptions in order to improve the quality of life of the patient, and overall outcome of care.[1] There is a link described between psychological dimensions such as personalities, perceptions, and adjustments to SCI, with younger individuals more accepting of SCI than older individuals.[1] A prospective longitudinal study[11] shows that there is a combined effect of self-efficacy of the person (belief about one’s ability to cope with a variety of difficult situations in life) with SCI or person with Acute Brain Injury and that of their significant others (often family members or a close friend) on personal and family adjustment. The study suggests that low self-efficacy appearing to be a risk factor for adjustment problems, emphasizing the importance of screening for low self-efficacy of the patients and their care-givers that may help healthcare professionals to identify and support families that are more at risk at an early stage, which may help to prevent later adjustment problems and related costs[11].

Psychosocial Reactions to SCI

The psychological and social reaction following spinal cord injury in an individual may include the following:[1][3][4][5]

  • Depression
  • Post-traumatic stress disorder
  • Suicidal thinking or lack of desire to live
  • Apathy and not caring about life
  • Inability to provide self-care and follow medical advice
  • Marital and relationship conflict
  • Lack of motivation for vocational or educational pursuits
  • Feeling trapped in the family surroundings
  • Unnecessary dependency on others
  • Social Isolation
  • Negative body image or shame
  • Feelings of worthlessness
  • Low self-esteem
  • Anger and aggression
  • Shame and embarrassment
  • Feelings of helplessness and hopelessness
  • High levels of stress
  • Self-Blame

Psychosocial Considerations in Spinal Cord Injury

With increasing evidence depicting elevated levels of depression in people with SCI,[8] as well as negative psychosocial states such as anxiety and a reduction in the quality of life of people with spinal cord injuries[1], it is important that appropriate considerations should be applied to psychosocial issues in SCI. According to Dezarnaulds and Ilchef,[1] about 40% of patients recently diagnosed with SCI can have an accompanying psychiatric diagnosis, with common ones including substance abuse disorders, delirium, depressive disorders, and adjustment disorders.

Thus, individuals with SCI must receive psychosocial treatment in a bid to decrease psychosocial morbidity and improve general quality of life.[8][6] The aim of these treatments would primarily be to improve perceptions of control, improve mood, elevate the level of social engagement, increase level of self-management, improve employability, increase understanding and influence of injury on important aspects of life such as physical and mental health, and sexuality.[12][13][14]

Psychosocial Providers in Spinal Cord Injury

Psychosocial providers are concerned with the emotional well-being of the person with spinal cord injury, as well as their families.[15]

The psychosocial provision comprises of a multidisciplinary team that plays highly dynamic roles.[15]

Psychiatrists

They evaluate the need of individuals with SCI for psychotropic medications, after an assessment of the symptoms and range of psychiatric symptoms. [15]

Clinical Psychologists

They create individual or group psychotherapy and evaluation for patients with spinal cord injuries, especially those with cognitive challenges following SCI. They also carry out psychosocial assessments after the admission of patient with spinal cord injury to recognize the risk factors. The psychologist helps to improve the perception of the individual to keep in place their feelings, goals and aspirations, and not to see themselves as a patient alone, helping to help patient make physical and psychological gains during rehabilitation. [15]

Social Workers

They help patients and family arrange for funding to pay rehabilitation services, and also prepare patient for discharge. They also carry out counselling to the family of the individual with SCI, and prepare services that would be available in the community post discharge.[15]

Occupational Therapists

Occupational therapists assess and target the development of skills to enable the individual perform needed daily roles. They are trained to have a robust conceptualization of the integration of the person, environment and task.[15]

Peer Counsellors

They help the patient with their psychological adjustment after SCI. Usually, they are role models for patients with SCI through their participation in activities such as sports, social engagements, suggestions, education and counselling. Peer counsellors are usually previous patients with SCI that have been able to successfully re-enter the community.

Impact of Psychosocial factors in Spinal Cord Injury on Physical Therapy

A study demonstrated that functional recovery is associated with psychosocial factors such as motivation during acute hospitalizations.[16] Also, there were associations found between functional recovery and depression during this same period.[16] This suggests that psychosocial factors can affect physical therapy outcomes. It has been seen that psychosocial factors are involved in the management of patients with spinal cord injury, thus the physical therapist should be aware of these factors and act accordingly when they are encountered in the management of persons with spinal cord injury.[15]

Though there is a dearth of information on guidelines for the physical therapist on how to address psychosocial factors in SCI, yet, patients with signs of psychosocial reactions need to be assessed using psychosocial screening tools.[15] Furthermore, the results of the psychosocial screening can be reviewed and communicated with members of the rehabilitation team through appropriate media to address these factors that may affect the outcomes of treatment. Through the screening, a true distinction between psychosocial factors that may affect the outcomes of treatment and pathological factors that may actually limit activity can be identified. Finally, appropriate plans or modification to plans of treatment have to follow the findings of the psychosocial screening. This may mean referral to another member of the health care team, especially the psychosocial providers earlier mentioned. 

Conclusion

Psychosocial concerns are common following spinal cord injuries. These concerns are usually influenced by a number of factors which are usually around the psychology and the social interaction of the patient. It is important for these psychosocial problems to be recognized and managed by the multidisciplinary team of psychosocial providers, especially from the acute phase of the injury where assessments and identification of risk factors can be made. Efficient management of these psychosocial problems can lead to a better quality of life for patients with SCI and improve rehabilitation outcomes.

Resources

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References

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