Christel M. C. van Leeuwen

Life satisfaction in people with spinal cord injury during the first five years after discharge from inpatient rehabilitation

Purpose: To describe the course of life satisfaction in persons with spinal cord injury (SCI) during the first 5 years after discharge from inpatient rehabilitation and to examine its determinants. Methods: Multi-centre prospective cohort study with four measurements, the first at discharge from inpatient rehabilitation, the last 5 years after discharge. Data of 162 persons with SCI were analyzed. Life satisfaction was measured as the sum score of ‘current life satisfaction’ and ‘current life satisfaction compared to life satisfaction before SCI’. Lesion characteristics, functional independence, secondary impairments, pain, social support and self-efficacy were analyzed as possible determinants of life satisfaction. Random coefficient analysis was used for the analyses. Results: No significant changes in life satisfaction were found between discharge and 2 years later, however there were significant increases from two to 5 years post discharge. High functional independence, low pain, high everyday social support and high self-efficacy were significant determinants of a positive course of life satisfaction after discharge. Conclusions: Increases in life satisfaction were found in persons with SCI in the long run. High functional status, low pain, good social skills and high self-efficacy were related to high life satisfaction. Implications for Rehabilitation A spinal cord injury (SCI) is a major life event leading to serious physical disability and secondary medical problems, which has important consequences for the life satisfaction of the persons involved. No changes in mean life satisfaction ratings were found between discharge and two years later, but slight increases in life satisfaction were reported from two to five years post-discharge in persons with SCI. High functional independence, low pain, high everyday social support, and high self-efficacy were significant determinants of a positive course of life satisfaction after discharge. A combined model of physical (functional independence and pain) and psychosocial factors (social support and self-efficacy) explained 66% of the variance in life satisfaction.

Validity of the Life Satisfaction Questions, the Life Satisfaction Questionnaire, and the Satisfaction With Life Scale in Persons With Spinal Cord Injury

OBJECTIVE To assess and compare the validity of 3 life satisfaction instruments in persons with spinal cord injury (SCI). DESIGN Cross-sectional study 5 years after discharge from inpatient rehabilitation. SETTING Eight rehabilitation centers with specialized SCI units. PARTICIPANTS Persons (N=225) with recently acquired SCI between 18 and 65 years of age were included in a cohort study. Data were available for 145 persons 5 years after discharge. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES The Life Satisfaction questions (LS Questions), the Life Satisfaction Questionnaire (LiSat-9), and the Satisfaction With Life Scale (SWLS). RESULTS There were no floor or ceiling effects. Cronbach α was questionable for the LS Questions (.60), satisfactory for the LiSat-9 (.75), and good for the SWLS (.83). Concurrent validity was shown by strong and significant Spearman correlations (.59-.60) between all 3 life satisfaction instruments. Correlations with measures of mental health and participation were .52 to .56 for the LS Questions, .45 to .52 for the LiSat-9, and .41 to .48 for the SWLS. Divergent validity was shown by weak and in part nonsignificant correlations between the 3 life satisfaction measures and measures of functional independence and lesion characteristics. CONCLUSIONS Overall, the validity of all 3 life satisfaction measures was supported. Despite questionable internal consistency, the concurrent and divergent validity of the LS Questions was at least as good as the validity of the LiSat-9 and the SWLS.

Social support and life satisfaction in spinal cord injury during and up to one year after inpatient rehabilitation.

OBJECTIVE To describe the course of social support in persons with recently acquired spinal cord injury, and to examine direct and indirect relationships between social support and life satisfaction over time. DESIGN A multi-centre prospective cohort study with measurements at the start of active rehabilitation, at discharge from inpatient rehabilitation and one year after discharge. SUBJECTS One hundred and ninety individuals with spinal cord injury from 8 Dutch rehabilitation centres. METHODS Social support was measured with the Social Support List-12. Life satisfaction was measured as the sum score of current life satisfaction and current life satisfaction compared with life satisfaction before spinal cord injury. Distress was operationalized as functional dependence and measured with the Functional Independence Measure. Random coefficient analysis was used for the analyses. RESULTS Everyday social support and support in problem situations decreased, and esteem support remained stable over time. Everyday support and support in problem situations were directly associated with life satisfaction over time. Significant interaction effects between social support and distress on life satisfaction were found. CONCLUSION Different types of social support showed different courses over time. Social support was associated with life satisfaction after spinal cord injury, in particular in persons with relatively high levels of distress.

Longitudinal relationship between wheelchair exercise capacity and life satisfaction in patients with spinal cord injury : A cohort study in the Netherlands

Abstract Objective To examine the relationship between wheelchair exercise capacity and life satisfaction in persons with spinal cord injury from the start of active inpatient rehabilitation up to 5 years after discharge. Design Prospective cohort study. Subjects Persons with spinal cord injury, aged 18–65 years, and wheelchair dependent at least for long distances. Method Measurements at the start of active rehabilitation, after 3 months, at discharge from inpatient rehabilitation, and 1 and 5 years after discharge. A peak wheelchair exercise test was performed to record peak oxygen uptake (VO2peak) and peak power output (POpeak). Life satisfaction was measured as current life satisfaction and change of life satisfaction in comparison with life after spinal cord injury. Relationships between (changes in) exercise capacity and (changes in) life satisfaction were analyzed random coefficient analysis, corrected for possible confounders (age, gender, level of lesion, functional status, secondary impairments, pain, and sports activity) if necessary. Results Of 225 persons included, 130 attended two or more peak exercise tests, who were include in the analyses. Mean age at start was 39 years, 75% were male, 73% had paraplegia, and 76% had a traumatic lesion. Mean POpeak increased during the study from 32.9 to 55.9 Watts, mean VO2peak from 1.02 to 1.38 l/minute, and mean life satisfaction from 5.7 to 7.8. An increase of POpeak with 10 W was associated with a 0.3-point increase of life satisfaction (P = 0.01). An increase of VO2peak with 0.1 l/minute was associated with a 0.1-point increase of life satisfaction (P = 0.049). Conclusion High(er) wheelchair exercise capacity is related to high(er) life satisfaction in spinal cord injury patients.

Psychological Resources, Appraisals, and Coping and Their Relationship to Participation in Spinal Cord Injury: A Path Analysis

OBJECTIVE To test the Spinal Cord Injury Adjustment Model and gain a better understanding about whether and how the psychological resources general self-efficacy (SE), purpose in life (PIL), appraisals, and coping influence participation in persons with spinal cord injury (SCI). DESIGN Cross-sectional data collection within the Swiss Spinal Cord Injury Cohort. SETTING Community setting. PARTICIPANTS Persons with SCI (N=516) who are ≥ 16 years old and living in the community in Switzerland. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Participation was measured with the restrictions subscale of the Utrecht Scale for Evaluation of Rehabilitation-Participation, General SE with the General Self-Efficacy Scale, PIL with the Purpose in Life Test-Short Form, appraisals with the Appraisal of Life Events Scale, and coping with the Brief COPE. RESULTS General SE (r=.32) and PIL (r=.23) were associated with less participation restrictions. The initial model yielded a poor model fit. The modified final model had an acceptable fit (χ(2)11=36.2; P<.01; root mean square error of approximation=.067 [90% confidence interval: .045-.09]; comparative fit index=.98). A total of 15% of the variance of participation was explained. In the final model, general SE had a moderate direct effect (β=.24) and mediated effects via threat appraisal and challenge appraisal and humor on participation, indicating a partial mediation effect. The association between PIL and participation was indirect: challenge appraisal and humor acted as mediators. CONCLUSIONS The results only partly support the double-mediating effect as suggested in the SCI adjustment model because both direct and indirect effects on participation were observed. Individuals with higher general SE and PIL perceive less participation restrictions. General SE seems an appropriate target to enhance participation. Longitudinal studies are needed to support our findings.

Course of social support and relationships between social support and life satisfaction in spouses of patients with stroke in the chronic phase

OBJECTIVE To describe the course of social support in spouses of patients with stroke, and to examine direct and indirect relationships between social support and life satisfaction over time. METHODS Prospective cohort study (N=180) with measurements at 2 months after discharge from inpatient rehabilitation, 1 year, and 3 years after stroke. Social support was assessed using the Social Support List-12, Life satisfaction with the Life Satisfaction Questionnaire (LiSat-9) and Caregiver strain with the Caregiver Strain Index. Random coefficient analyses was used. RESULTS Total social support and the 3 subtypes of social support decreased significantly over time. In all models, caregiver strain was associated with lower life satisfaction and social support was associated with higher life satisfaction, but there were no interaction effects between caregiver strain and social support on life satisfaction. CONCLUSION Spouses of patients with stroke experienced a decline of social support over time. Social support was positively associated with life satisfaction, regardless of the amount of caregiver strain experienced by the spouses. PRACTICE IMPLICATIONS It is important to discuss with caregivers of stroke patients the importance of maintaining their own social contacts and to facilitate this by arranging support if appropriate.

Return to work five years after spinal cord injury inpatient rehabilitation: is it related to wheelchair capacity at discharge?

OBJECTIVE To describe the proportion of people with spinal cord injury who returned to work 5 years after discharge from inpatient rehabilitation, and to investigate whether return to work is related to wheelchair capacity at discharge from inpatient rehabilitation. DESIGN Multi-centre prospective cohort study. SUBJECTS A total of 103 participants with acute spinal cord injury at 8 Dutch rehabilitation centres, specialized in the rehabilitation of spinal cord injury. All participants were in paid employment before injury. METHODS Main outcome measure was return to work for at least 1 h per week. The independent variables of wheelchair capacity were peak oxygen uptake (VO2peak), peak aerobic power output (POpeak), and wheelchair skill scores (ability, performance time, and physical strain). Possible confounders were age, gender, lesion level and lesion completeness, and educational level. RESULTS The proportion of participants who returned to work was 44.7%. After correction for the confounders, POpeak (p=0.028), ability score (p=0.022), performance time (p=0.019) and physical strain score (p=0.038) were significantly associated with return to work. VO2peak was not significantly associated with return to work. CONCLUSION More than 40% of the participants were able to return to paid work within 5 years after discharge from inpatient rehabilitation. Return to work was related to wheelchair capacity at discharge. It is recommended to train wheelchair capacity during rehabilitation in the context of return to work, since the association with return to work is another benefit of the training of wheelchair capacity in addition to the improvement of mobility and functional independency.

Trajectories and Predictors of the Course of Mental Health After Spinal Cord Injury

OBJECTIVE To study the course and predictors of mental health in the period between the start of active spinal cord injury (SCI) rehabilitation and 5 years after discharge. The hypothesis was that different mental health trajectories would be identified. DESIGN Multicenter prospective cohort study with measurements at the start of active rehabilitation, after 3 months, at discharge, 1, 2, and 5 years after discharge. SETTING Eight Dutch rehabilitation centers with specialized SCI units. PARTICIPANTS Persons (N=206) with recently acquired SCI aged between 18 and 65 years. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE The 5-item Mental Health Index with a total score between 0 (lowest mental health) and 100 (highest mental health). RESULTS Levels of mental health increased between the start of active rehabilitation and 3 months later, remained stable thereafter, and increased again between 2 and 5 years after discharge. Latent class growth mixture modeling revealed 5 trajectories: (1) high scores (above 80) at all time-points (52%), (2) low scores (≤60) at all time-points (4%), (3) early recovery from 40 to scores above 70 (13%), (4) intermediate scores from 60 to scores above 70 (29%), and (5) severe deterioration of scores above 70 to scores below 30 (2%). Pain, sex, and education level were predictors to distinguish between the 5 trajectories. CONCLUSIONS Five different mental health trajectories were identified between the start of active rehabilitation and 5 years after discharge. About one third of the persons with SCI still perceived moderate to severe mental health problems 5 years after discharge. Pain, sex, and education level only predicted a small part of the variance in mental health trajectories.

Depression in spinal cord injury: assessing the role of psychological resources.

PURPOSE To test the spinal cord injury adjustment model (SCIAM) and to examine how psychological resources may influence depressive symptoms in persons with spinal cord injury (SCI). We expect that (a) higher general self-efficacy (GSE) and higher purpose in life (PIL) are associated with lower levels of depressive symptoms, and that (b) the effect of GSE and PIL on depressive symptoms is mediated by appraisals and coping strategies, as proposed by the SCIAM. METHOD A nationwide cross-sectional survey (the Swiss Spinal Cord Injury Cohort Study) was conducted with individuals with SCI living in the Swiss community (N = 516). Structural equation modeling was used to test relationships between variables as specified in the SCIAM. RESULTS Higher GSE (r = -.54) and PIL (r = -.62) were significantly associated with lower depressive symptoms. The initial model yielded poor model fit. However, the final modified model fitted well, with χ2(21) = 54.00, p < .01, RMSEA = .055 (90% CI [.038, .073]), CFI = .98, explaining 62.9% of the variance of depressive symptoms. PIL had a direct large effect and an indirect effect on depressive symptoms via appraisals and coping strategies. The influence of GSE on depressive symptoms was fully mediated by appraisals and coping strategies. CONCLUSIONS Psychological resources of individuals with SCI can have a direct effect on depressive symptoms. The mediated pathways are present, but not exclusive in our data, yielding only partial support for the mechanism proposed by the SCIAM.

Psychological factors and mental health in persons with spinal cord injury: : An exploration of change or stability

OBJECTIVES To examine the course of mental health and psychological factors over time in persons with a recent spinal cord injury and to determine whether change in psychological factors is associated with change in mental health. DESIGN Prospective cohort study in the Netherlands with 3 measurement time-points. SUBJECTS A total of 60 persons with recently acquired spinal cord injury. METHODS Standardized validated measurement instruments were used to assess mental health, self-efficacy, mastery, optimism, illness cognitions, purpose in life, and social comparison. Descriptive statistics and multilevel analysis were used. RESULTS Multilevel regression analyses showed that neither mental health nor psychological factors, except for social comparison-upward identification, showed statistically significant change over time. However, increasing scores for self-efficacy, mastery, acceptance cognitions, and purpose in life were significantly associated with increasing mental health. In contrast, increasing scores for optimism, social comparison, helplessness cognitions, and disease benefits cognitions were not significantly associated with increasing mental health in persons with spinal cord injury. CONCLUSION Most psychological factors showed stability up to 6 months post-discharge. Purpose in life, acceptance cognitions, self-efficacy, and mastery showed more variability and seem to be most promising as targets for interventions, which may lead to an improvement in mental health in persons with spinal cord injury.