Are patient educational resources effective at deterring stroke survivors from considering experimental stem cell treatments? A randomized controlled trial.

OBJECTIVE: To evaluate whether online resources developed to educate people about the risks associated with experimental stem cell (SC) treatments influence stroke survivors' attitudes about the safety and effectiveness of these treatments. METHODS: Adult stroke survivors who had not previously received SC treatments (N = 112) were recruited from international stroke advocacy/support groups for a prospective, parallel-group randomized controlled trial. Participants indicated whether they were considering SC treatments (yes/no) prior to, immediately following, and 30-days after reading/viewing the International Society for Stem Cell Research booklet or Stem Cell Network video. Participant attitudes regarding the safety, effectiveness, accessibility and affordability of SC treatments were examined on each occasion, and compared to those of a waitlist control group. RESULTS: Significantly fewer participants were considering SC treatments immediately after reading the SC research booklet (p =.031), although neither intervention had any impact after 30-days (p >.05). Waitlist and intervention groups reported positive attitudes toward SC treatments at each assessment. CONCLUSIONS: Stroke survivor attitudes toward SC treatments were initially influenced by the patient booklet, however these changes were not maintained. PRACTICAL IMPLICATIONS: Clinicians are encouraged to initiate discussions about experimental SC treatments during inpatient rehabilitation and to reinforce the risks throughout subsequent care.

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 (rw=0.64, (95% CI, 0.54-0.72)), negative appraisals (rw=0.63 (95% CI, 0.52-0.72)), distress (rw=0.57 (95% CI, 0.50-0.62)), anxiety (rw=0.56 (95% CI, 0.49-0.61)) and pain severity (rw=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 (QB (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.

Psychosocial aspects of spinal cord injury pain: a meta-analysis.

STUDY DESIGN: Meta-analysis. OBJECTIVES: Although the association between modifiable psychosocial factors and spinal cord injury (SCI) pain has been identified, the full range of psychological and social difficulties for those who experience acute and/or persistent pain remains unclear. This meta-analysis consolidates the available evidence, using the International Classification of Functioning, Disability and Health (ICF) as a reference framework. METHODS: Nineteen studies that examined persistent neuropathic, nociceptive or mixed pain subtypes in adults with a SCI (newly acquired and chronic; Nparticipants=2934) were identified from electronic database searches. Standardised mean differences between SCI pain and no-pain groups on self-reported psychosocial outcomes were calculated, along with 95% confidence intervals, fail-safe Ns and heterogeneity statistics. RESULTS: Twenty individual outcomes were grouped into nine ICF-related categories. Emotional functions were the most frequent (100%) psychosocial outcomes assessed, with pain contributing to heightened stress (d=-0.85), depression (d=-2.49) anxiety (d range=-0.85 to -1.45), poor self-efficacy (d=-0.77), lowered wellbeing (d range=-0.67 to -1.02) and decreased use of adaptive coping, such as illness acceptance (d=-0.85). Activity limitations and participation restriction were examined by seven studies (43%), although these findings were largely characterised by single studies. CONCLUSIONS: Multicomponent treatments that target mood disturbance and foster community connections are important in SCI pain management. However, to improve the comparability of future studies, SCI pain research must adopt definitions of pain consistent with the International Spinal Cord Injury Pain Classification along with validated outcomes that map onto the ICF framework.

Anxiety prevalence following spinal cord injury: a meta-analysis.

STUDY DESIGN: Meta-analysis. OBJECTIVES: Prevalence estimates indicate that anxiety following spinal cord injury (SCI) is a common problem. However, methodological differences between studies may impact the clinical interpretation of these data. METHODS: Data from 18 independent studies (Nparticipants=3158), which reported the prevalence of an anxiety disorder or associated symptoms, were identified from the Embase, PubMed and PsycInfo databases. Proportions were the primary effect size estimate. Confidence intervals, fail-safe Ns and the I(2) statistic were additionally calculated to identify the extent to which findings were robust and consistent across studies. RESULTS: Five per cent of participants met the criteria for either GAD or panic disorder, with Agoraphobia identified in 2.5%. These diagnostic data were, however, limited to two studies. Higher rates were noted for self-reported 'caseness' of anxiety, with 27% reporting clinically significant symptoms. Anxiety prevalence estimates varied across the individual self-report measures (range: 15-32%). Method of administration (range: 26-32%) did not impact significantly on these estimates nor did recruitment source, with similarly high anxiety levels reported by hospital (27%) and community (29%) samples. CONCLUSIONS: Early identification and treatment of anxiety are important in SCI rehabilitation, with a subgroup of individuals experiencing chronic symptoms. Further research is needed to establish guidelines for the interpretation of self-report data, including the use of clinical cutoffs.

Telepsychology for Posttraumatic Stress Disorder: A systematic review.

The effectiveness of psychological services provided remotely, telepsychology, for the management of Posttraumatic Stress Disorder (PTSD) was evaluated. Eleven studies (n = 472 participants) were identified from electronic database searches. Study quality was assessed, with studies characterised by small and underpowered samples. Effect sizes and associated confidence intervals (CIs) were calculated to determine the direction and magnitude of treatment change. Short-term treatment gains were reported for internet and video-based interventions. This included significant medium to large improvements (d range = 0.66-3.22) in cognitive and behavioural symptoms of depression, generalised anxiety and posttraumatic stress. However, the equivalence of telepsychology and face-to-face psychotherapy could not be determined, with few comparative studies available. Both treatment gains and deterioration were noted 1 to 6 months following treatment cessation, although this was based on limited follow-up data. Further larger scale and longitudinal research will help to ascertain the minimum requirements for the management and treatment of PTSD in a technology-supported environment.

Psychological variables associated with employment following spinal cord injury: a meta-analysis.

OBJECTIVES: Spinal cord injury (SCI) research has highlighted links between psychological variables and employment outcome; however, there remains a need to consolidate the available heterogenous data. METHODS: Meta-analytic techniques were used to examine and quantify differences in psychological functioning and employment status among adults with an acquired SCI. Fourteen observational studies (N = 9, 868 participants) were identified from an electronic database search. Standardised mean difference scores between employed and unemployed groups were calculated using Cohen's d effect sizes. Additionally, 95% confidence intervals, fail-safe Ns, percentage overlap scores and heterogeneity statistics were used to determine the significance of d . RESULTS: Moderate to large and positive weighted effects were noted across three broad psychological constructs: affective experience or feelings (dw = 3.16), quality of life (dw = 1.06) and life satisfaction (dw = 0.70). However, the most compelling non-heterogeneous finding was associated with life satisfaction, a finding that was also not subject to publication bias. Inconsistent and weak associations between employment and individual measures of vocational attitude, self-efficacy, locus of control, adjustment and personality were also noted. CONCLUSION: Psychological factors and attributes are linked to employment post-SCI; however, the available data are limited in quantity. Longitudinal research is also needed to determine whether these variables can help to preserve employment over time.

Systematic review of leisure therapy and its effectiveness in managing functional outcomes in stroke rehabilitation.

BACKGROUND: Evidence suggests that the incorporation of leisure activities in adult stroke rehabilitation can contribute to improved physical, cognitive, and psychological outcomes. However, differences in study design and treatment delivery may affect these findings. Furthermore, the magnitude of therapeutic change associated with leisure therapy is unclear, with few quantitative reviews available. OBJECTIVE: To synthesize and evaluate the empirical evidence examining leisure therapy in stroke rehabilitation. METHODS: Eight independent studies (N = 615 participants) were identified from a comprehensive database search. Study quality was evaluated using the Oxford Levels of Evidence. Pre- and posttreatment data for participants who received leisure therapy, in comparison with peers who received standard care or no treatment, were evaluated by calculating Cohen's d effect sizes and 95% confidence intervals. RESULTS: No studies met the criteria for the highest level of methodological rigor, although all used randomization procedures. Leisure therapy contributed to significant short-term improvements in psychological outcomes, namely quality of life and mood (d range, 2.10 to 0.54), in addition to leisure-specific outcomes, including increased participation in and satisfaction with leisure activities (d range, 0.81 to 1.23). Longer term effects of treatment could not be determined, with one study providing data and reporting nonsignificant effects (d range, -0.07 to 0.17). CONCLUSIONS: There is some evidence that leisure therapy offers an opportunity to enhance short-term treatment gains in community-based stroke rehabilitation. Further controlled research is needed to establish its longer term effects and assist the development of evidence-based guidelines for this treatment.

Resilience, self-esteem and self-compassion in adults with spina bifida.

STUDY DESIGN: Cross-sectional survey. OBJECTIVES: To examine factors that may enhance and promote resilience in adults with spina bifida. SETTING: Community-based disability organisations within Australia. METHODS: Ninety-seven adults with a diagnosis of spina bifida (SB) completed a survey comprising of demographic questions in addition to standardised self-report measures of physical functioning (Craig Handicap Assessment and Reporting Technique), resilience (Connor-Davidson Resilience Scale, 10 item), self-esteem (Rosenberg Self-esteem Scale), self-compassion (Self-compassion Scale) and psychological distress (Depression Anxiety Stress Scales, 21 item). RESULTS: The majority (66%) of respondents reported moderate to high resilience. Physical disability impacted on coping, with greater CD-RISC 10 scores reported by individuals who were functionally independent in addition to those who experienced less medical co-morbidities. Significant correlations between resilience and psychological traits (self-esteem r=0.36, P<0.01; self-compassion r=0.40, P<0.01) were also noted. However, the combined contribution of these variables only accounted for 23% of the total variance in resilience scores (R(2)=0.227, F(5,94)=5.23, P<0.01). CONCLUSION: These findings extend current understanding of the concept of resilience in adults with a congenital physical disability. The suggestion is that resilience involves a complex interplay between physical determinants of health and psychological characteristics, such as self-esteem and self-compassion. It follows that cognitive behavioural strategies with a focus on self-management may, in part, contribute to the process of resilience in this group. Further large-scale and longitudinal research will help to confirm these findings.

Examining factors that contribute to the process of resilience following spinal cord injury.

STUDY DESIGN: Cross-sectional survey. OBJECTIVE: To examine factors that contribute to the process of positive adjustment, or resilience, in an adult community sample with spinal cord injury (SCI). SETTING: South Australian Spinal Cord Injury Service, Hampstead Rehabilitation Centre, South Australia, Australia METHODS: A postal survey comprising standardised measures of resilience (Connor-Davidson Resilience Scale-10 item), self-efficacy (Moorong Self-Efficacy Scale), locus of control (Locus of Control of Behaviour Scale) and psychological distress (Depression Anxiety Stress Scale--21 item). RESULTS: Of 60 respondents, 58% reported moderate to high levels of resilience. Resilience correlated significantly with high self-efficacy (r=0.68, P<0.01), internal locus of control (r=-0.52, P<0.01) and low psychological distress (depression r=-0.68, P<0.01; anxiety r=-0.55, P<0.01; stress r=-0.67, P<0.01). In comparison, resilience was not significantly influenced by degree of neuropathic pain (r=-0.23, P>0.05), time since injury (r=-0.14, P>0.05), gender (t(58)=-0.92, P>0.05), lesion completeness (t(57)=-0.86, P>0.05), or SCI diagnosis (t(58)=-1.21, P>0.05). A multiple regression indicated that psychological distress and self-efficacy were the only two variables that uniquely contributed to resilient behaviour. CONCLUSION: Resilience is an important psychological process in the longer-term management of SCI which can be promoted by targeting rehabilitation interventions towards mood management in addition to self efficacy beliefs. Larger-scale research will help to validate these results.

Psychosocial outcomes of telephone-based counseling for adults with an acquired physical disability: A meta-analysis.

BACKGROUND: The delivery of mental health services by telephone, referred to as telecounseling, has the potential to improve the health outcomes of adults with an acquired physical disability in a cost-effective way. However, the efficacy of this form of treatment requires further evaluation before it is used on a larger scale. AIM: This meta-analysis provides a critical and quantitative evaluation of the impact of telephone-administered psychological interventions on the psychosocial functioning of adults with an acquired physical disability caused by spinal cord injury, limb amputation, severe burn injury, stroke, or multiple sclerosis. METHOD: A comprehensive search of eight electronic databases identified eight studies (N = 658 participants) that compared treatment efficacy to that of matched control groups. Differences in the psychosocial outcomes of treatment and control participants were examined using Cohen's d effect sizes. Fail-safe Ns and 95% confidence intervals were used to evaluate the significance of these results. RESULTS: Significant improvements in coping skills and strategies (overall d = 0.57), community integration (overall d = 0.45), and depression (overall d = 0.44) were observed immediately after telecounseling, with modest improvements in quality of life maintained at 12 months post-intervention (overall d = 0.37). CONCLUSIONS: The results suggest that telecounseling is an effective treatment modality for adults adjusting to a physical disability; however, further trials are needed to establish the long term psychosocial benefits.

Psychological intervention during spinal rehabilitation: a preliminary study.

STUDY DESIGN: A repeated measures, non-randomised controlled trial. OBJECTIVE: To examine the effectiveness of individualised cognitive behaviour therapy (CBT) on the psychological adjustment of patients undergoing rehabilitation for newly acquired spinal cord injury. SETTING: South Australian Spinal Cord Injury Service, Hampstead Rehabilitation Centre, South Australia, Australia. METHODS: Eleven participants received individual CBT as part of their spinal rehabilitation. Self-reported levels of depression, anxiety and stress were assessed before the intervention, at week 12 of rehabilitation and at 3 months post-discharge, using the depression, anxiety and stress scales (DASS-21). Functional independence was also assessed, using the Functional Independence Measure (FIM). Responses were compared with 13 participants, closely matched on demographic and injury variables, who received standard psychological care (that is, assessment and monitoring only). RESULTS: Depression scores for treatment participants showed a significant time effect, with worsening symptoms reported at three-month follow-up, after CBT was discontinued. In contrast, the DASS-21 scores of standard care participants remained at subclinical levels throughout the study. Clinical improvements in symptoms of anxiety and stress were also reported by the treatment group as inpatient therapy progressed. CONCLUSION: Targeted, individualised psychological treatment contributed to short-term, meaningful improvements in emotional outcomes for individuals reporting psychological morbidity after recent spinal injury. The results also highlight the need for ongoing access to specialised, psychological services post-discharge. Replication of these results with a larger sample is required before definitive conclusions can be drawn.

Screening for depression and anxiety in spinal cord injury with DASS-21.

STUDY DESIGN: Comparison of two self-report instruments with a structured diagnostic interview. OBJECTIVE: To investigate the properties of the Depression Anxiety Stress Scales-21 (DASS-21) in patients with spinal cord injuries. SETTING: South Australian Spinal Cord Injuries Service, Hampstead Rehabilitation Centre, Northfield, South Australia. METHODS: Forty paraplegic or tetraplegic patients participated. Two self-report measures, DASS-21 and Brief Symptom Inventory (BSI), assessed Depression, Anxiety and Stress. These measures were compared with each other and with diagnoses based on the Mini International Neuropsychiatric Interview. RESULTS: Mean scores on both self-report measures were below clinical threshold levels. Prevalence rates of anxiety and depression were higher on DASS-21 than on BSI. DASS-21 was as sensitive as BSI, but had lower specificity to detect anxiety and depression. CONCLUSION: DASS-21 is a promising screening measure for patients with spinal cord injury in a rehabilitation setting. It has greater sensitivity for identifying those with possible anxiety disorders than it does for those with depressive disorders.