Selected Abstracts from the 2006 SCI Conference
Support Group and Individual Psychotherapy Equally Effective in Reducing Depression During Rehabilition
Jennifer Duchnick, PhD; Sarah Asmussen, MS; and Nancy Cuevas-Soto, MSN, RN
Objectives:
Introduction: Depression is often observed in spinal cord injury (SCI) patients and depressive disorders may complicate the individual with SCI’s health, activities of daily living, and interpersonal relationships. Providing psychotherapy is believed to be clinically indicated, but research supporting the effectiveness of individual or group therapeutic interventions for SCI patients is limited. Group interventions have resulted in reductions in depression, higher levels of adjustment, fewer hospital re-admissions, and reduced use of drugs when compared to SCI control groups without psychological treatment. Supportive therapy groups have been associated with positive changes in depression, quality of life, and self esteem in other medical populations and individual therapy is also a widely supported treatment for depressive symptoms. No known studies, however, have compared the effectiveness of individual and group therapy to identify a preferred method of treatment for depressive symptoms in SCI patients.
Objective: This study evaluated the effectiveness of support group versus individual psychotherapy in reducing the level of depressive symptoms reported by individuals with SCI during inpatient rehabilitation.
Method:Participants (N = 20) were veterans or military personnel who underwent Acute Injury Rehabilitation. Support group participants (n = 10) were compared to a sample (n = 10) selected from all individual psychotherapy participants (n = 26), who were matched for level of depression upon admission and injury level. The Center for Epidemiologic Studies Depression Scale was completed at pre- and post-treatment. A two-way split plot ANOVA was calculated with treatment condition (Support Group vs. Individual) as a between-groups factor, with individual participants nested within treatment condition, and evaluation time (Pre- vs. Post-treatment) as a within-subjects factor.
Results & Conclusions: The main effect for Treatment condition and Treatment X Time interaction were not significant, suggesting that the treatment conditions were equally effective in reducing depressive symptoms. A main effect was found for time ( (F = 17.37[1,18] p < .001) indicating that in both conditions, participants depressive symptoms decreased significantly from pre-to post-treatment. Psychotherapeutic intervention, whether in a group or individual therapy environment appears to decrease depressive symptoms over time.
Quantification of Qualitative Data Concerning Stress and Coping Among Women With Spinal Cord Injury
Anthony H. Lequerica, PhD
Objectives:
Introduction and Problem Statement: Because quantitative and qualitative analyses are often viewed as polar opposites, researchers fail to realize the benefits of a combined approach. In a study of women with spinal cord injury (SCI) that utilized both qualitative and quantitative methodologies, a combined approach to data analysis was explored.
Goals/Objectives: 1) Show that the relative number of references to problem-focused and emotion-focused coping will vary according to how stress is appraised; and 2) show that greater time since injury (TSI) is associated with lower levels of perceived stress and that stress appraisal mediates this relationship.
Methods: Fifty women with SCI were interviewed about their experiences with stress and coping. Interviews were transcribed and coded to nodes by two trained coders using a computer software package. References to stress were coded as Challenge, Threat, or Loss. References to coping were coded as Problem-Focused or Emotion-Focused. Data Supporting Hypothesis: Values for each participant were generated representing the number of references coded to various nodes, as well as the intersections between nodes indicating certain stress appraisal and coping strategies discussed in combination. These values were imported into a quantitative dataset containing demographic information, such as TSI, and scores on various quantitative measures, including the Perceived Stress Scale.
Results: Problem-focused coping was referred to most in relation to stress appraised as a challenge and leas in association with loss. After examining descriptive statistics and a correlation matrix, a series of hierarchical multiple regressions showed that the relative references to challenge vs. loss appraisals mediated the relationship between years post injury and perceived stress.
Conclusions: Consistent with the concept of adjustment as a developing capacity, results suggest that women with a longer time since injury showed lower levels of perceived stress mainly because of a greater tendency to see stressors as challenges as opposed to losses making them more amenable to problem-focused coping strategies. Quantitative analysis of qualitative data can supplement other findings and yield results that can provide a basis for future studies.
Bridging the Digital Divide: Harnessing Internet Resources for Successful Patient Outcomes
Bethlyn V. Houlihan, MSW, MPH; Jane Wierbicky, BSN; Mari-Lynn Drainoni, PhD; and Steve Williams, MD
Objectives:
For the full participation of people with disabilities, Internet access has become a necessity rather than a mere novelty. Studies show that patients with disabilities, including spinal cord injury (SCI), use the Internet at ever increasing rates for information and resources. The Internet’s significant impact on psychosocial outcomes cannot be trivialized. For instance, studies report that well-informed patients have better health outcomes. Additionally, qualitative findings with people with SCI suggest the Internet to be more stimulating and educational than other home-based leisure activities, such as television, that improves quality of life. With short hospital stays, the Internet can provide urgently needed tools to support successful community transition. Clinicians are in a unique position to empower marginalized groups by guiding patients to online resources otherwise unavailable due to their marginalized status. A clinician must become familiar with high quality sites that address: reliable medical information, assistive technology, home accessibility, psychosocial issues and behavioral change, active online support systems, employment, and life management tools. Website assessment tools, such as a checklist developed by the New England Regional SCI Center (NERSCIC), assist clinicians to critique a multitude of SCI-specific Web sites for important components often lacking, including a system to assess resource quality and possible misinformation, involvement of consumers, readily available information in a simple, accessible format (such as fact sheets), advanced search engines, or a truly user-friendly layout. Exemplary sites include: The University of Alabama’s SCI Information Network(www.spinalcord.uab.edu, The Christopher Reeve Foundation (www.chrisopherreeve.org), and the National SCI Association (www.spinalcord.org). Clinicians can guide patients to online social and psychological support resources, shown to mediate social isolation and depression among cancer patients, older adults, and youth with disabilities.
Communication Skill Building for Family Caregivers of Individuals with Multiple Sclerosis
Christine Martin, PhD; and Crystal D. Moore, PhD
Objectives:
One of the foremost responsibilities of multiple sclerosis (MS) family caregivers is the necessity of becoming the conduit for communication between patient and provider. Many family caregivers express a myriad of feelings regarding their interaction with health care professionals ranging from helplessness to intimidation. The National
Family Caregivers Association (NFCA) recognized the need for increased communication skills and empowerment training for all family caregivers and developed an extensive training program in that regard called the Communicating Effectively with Healthcare Professionals. The project 1) emphasizes family caregiver self-empowerment, utilizing a diversified network of professionals and family caregivers to convey the philosophy and needed skills, and 2) focuses specifically on improving understanding of medical terminology and communicating effectively with professionals in the health and social service system. Our pilot adapted this workshop to meet the needs of MS Caregivers in two ways: 1) we introduced vocabulary and common role-play scenarios regarding symptoms and treatments specific to MS and, 2) we developed a pre-post questionnaire to analyze the effectiveness of the training with regard to variables of self-efficacy, comfort/confidence levels, and knowledge/skill improvement. Since the physical manifestations of spinal cord injury (SCI) often mirror those of MS, the results of our pilot study may be easily adapted to caregivers of individuals with SCI. Significance was found in all 28 variables. Of notable interest was improvement in managing power in a caregiving relationship (p < 0.000) and confidence in using key principles of effective communication (p< 0.000). Self efficacy change in skills regarding empowerment and communication pre and post was significant (p < 0.000). Caregivers felt significant improvement in selfefficacy regarding their place in the health care team following completion of the training (p = 0.001). There was also significant improvement (p = .021) in self-efficacy beliefs regarding the ability to communicate well with health care professionals and organizational skills needed to provide information and records regarding their care recipients (p = 0.012). This curriculum is easily adaptable to other care models such as spinal cord injury, oncology, chronic disease, etc. Since the literature indicates the need for additional caregiver skill and knowledge building in areas such as problem solving, coping, and health promoting behaviors, the investigators are now entering the continuation phase of this project with the collaboration and development of additional instructional modules that will be generalizable across care disciplines.
Pediatric-Onset Spinal Cord Injuries: Relationship of Adult Outcomes to Environmental Factors
Caroline J. Anderson, PhD; Lawrence C. Vogel, MD; Kathleen M. Chlan, BA; Randal R. Betz, MD; and Craig M. McDonald, MD
Objectives:
The International Classification of Function (ICF) includes environmental factors as potentially important to consider for their impact on outcomes. The objectives of this study were to describe the environmental barriers reported by adults with pediatric-onset spinal cord injuries (SCI), identify demographic and injury-related factors associated with those barriers, and determine the impact of environmental barriers on the adult outcomes of those patients. Participants were individuals with SCI sustained at age 18 years or younger, now 24 years of age or older. A structured interview was administered which included several standardized measures. To assess environmental factors, the Craig Hospital Inventory of Environmental Factors-Short Form (CHIEF-SF) was administered. This measure asked subjects to rate 12 possible environmental barriers in terms of frequency and magnitude of the problem. From this, 5 subscale scores are derived. Other measures included the Functional Independence Measure (FIM), the Craig Handicap Assessment and Reporting Technique (CHART) to assess participation, and the Satisfaction with Life Scale (SWLS) to assess global life satisfaction. Results are reported on 141 subjects, mean age of injury of 14(0-18) years and at interview of 30 (24-41) years. Environmental barriers were rated in the following order, starting with the most significant barriers: Policies, physical/structural, services/assistance, attitudes/support, work/school. The policy subscale, which was deemed most problematic, includes both government and business policies. The next most problematic category, physical/structural, includes the natural environment such as terrain and temperature, as well as other aspects of the environment such as crowds and noise. The impact of environmental barriers did not vary by gender, race, age at injury, or age at interview. Those with tetraplegia were more bothered by barriers than those with paraplegia and those with less functional independence were also bothered more. Barriers were not associated with the outcomes of education, employment, marital status, or independent living. They were associated with perceived health, CHART scores, and SWLS scores. CHIEF-SF was a significant predictor in regression analyses for both the outcomes of CHART and SWLS. In conclusion, environmental barriers are associated with significantly decreased participation and life satisfaction. Since policies and physical/structural barriers are the most problematic, strong efforts should be made to reduce these barriers.
ET Phones Home: Networking From Your Desktop
Tony Spillie, MSW, LCSW; and E. Jason Mask, MSW
Objectives:
Technology can help in the provision of clinical services and help facilitate the availability of clinician networking and training. This is especially important in this era of tight budgets, staffing restrictions, and doing more with less. The outreach capabilities of this technology can also be a critical factor in bridging the geographical distances between clinicians and clients and other clinicians as well as overcoming the obstacles of SCI clients which prevent them from accessing support groups and patient education services. The specific technology that can be used is NetMeeting™. NetMeeting is a Microsoft application whose primary purpose is to promote communication and file sharing between two or more individuals simultaneously using an Internet connection. There are multiple features contained within NetMeeting that pertain to the clinical and training needs of SCI staff. NetMeeting allows you to place calls using directory servers, conferencing servers, and Web pages. In addition, programs can be shared with participants, allowing for multiple participants to work on one document simultaneously, as well as allowing for files to be sent and received between participants. With the chat feature, one can talk with multiple people simultaneously and chat calls can be encrypted, to ensure confidentiality. In summary, the three primary features that were found to be particularly useful for networking as well as training were: the ability to conduct on line training meetings; the option of sharing programs; and the ability to conduct support groups and/or similar clinical activities using the chat feature. Initially, the online training feature was used to facilitate the implementation of a multi-state home telehealth program. Program implementation required the development of a data management system, a clinical documentation program, and an overarching set of policy protocols. The sharing program feature was used to create Word documents for policy and other administrative purposes, in which staff were able to co-create and edit these documents simultaneously. The chat feature was used as a forum to discuss mutual clinical issues and administrative problems. Additionally, the chat feature was tested as a virtual support group for persons with SCI.
Abuse and Health in Men and Women with Spinal Cord Injury/Disorder
Dena S. Hassouneh-Phillips, PhD, RN, ANP; Elizabeth McNeff, MPA-HA; and Roxie Choroser, MS
Objectives:
This presentation will review findings from an ongoing study of abuse and health in individuals with SCI/D. The aims of the study were to: 1) estimate the percentage of men and women with SCI/D who experience abuse; 2) explore predictors of abuse in men and women with SCI/D; and 3) explore the impact of abuse on health in men and women with SCI/D. The learning goals of this presentation correspond to these 3 aims. No significant differences between men and women in the reporting of any type of abuse with the exception of physical abuse was found, with men being significantly more likely to report current physical abuse than women. To address aim 2, separate logistic regressions for each predictor including gender and the gender-predictor interactions were run to determine if the effect of the predictor on current abuse (e.g. abuse occurring within the past year) was different depending on gender. The only significant interaction was physical dependency-gender (p = .009). In the final model physical dependency was more strongly associated with current abuse for women than for men. Past adult abuse was also a significant predictor of current abuse (OR 69.85). To address aim 3, one-way ANCOVA using planned contrasts were conducted to investigate whether participants reporting no abuse had better health outcomes than participants who reported current or past adult abuse controlling for age, gender, and physical dependency. Neither gender nor the interaction gender-abuse were significant predictors. In the final model individuals reporting past or current adult abuse were significantly more likely to experience depressive and post-traumatic symptoms (PTSD) than individuals who reported no past adult abuse (p = 007 and p < .001 for depressive symptoms; p < .001 for PTSD in both groups). Individuals reporting current abuse were also significantly less likely to engage in health promoting behaviors such as healthy eating, exercise, and accessing preventative health care than individuals who reported no past abuse history (p = .046). To our knowledge, these findings are the first to quantitatively identify factors that place individuals with SCI/D at risk for abuse and demonstrate the significant negative health outcomes associated with abuse in this population.
Relationship Between Family Functioning and Posttraumatic Stress in Pediatric-Onset Spinal Cord Injury Roseanne Cantor, MS; and Bret A. Boyer, PhD
Objectives:
A growing body of research has investigated post-traumatic stress (PTS) following pediatric-onset SCI. Previous studies have indicated that PTS is related to family functioning. This study investigates relationships between specific domains of family functioning and PTS symptom clusters (e.g., Re-experiencing, Avoidance, Hyperarousal). Participants included 109 patients pediatric-onset SCI (aged 11-24, M = 17.8, SD = 3.66; 49 with tetraplegic injuries, 60 with paraplegic injuries; 92% Caucasian, 4% African-American, 3% Hispanic), as well as 92 mothers and 91 fathers. PTS was measured with the Post-traumatic Diagnostic Scale (for those age 18 and over, and their parents) and the Child Posttraumatic Stress Symptom Scale (PTSS) (for children under age 18); and Family Functioning was measured using the Family Assessment Device (FAD). When FAD subscales (i.e., Communication, Problem solving, Roles, Affective responsiveness, Affective Involvement, Behavior Control) were entered into a hierarchical multiple regression, the only subscale that contributed significantly to the prediction of any PTS symptom cluster was the Roles subscale. Roles showed partial correlations of R = .33 with patient total PTS severity score (p < .001), and between R = .23 and R = .37 (all significant at p < .02) for patient PTS symptom clusters. For mother’s PTS, the Roles subscale showed partial correlations of R = .37 for mothers total PTS severity scores (p < .001), and between R = .25 and R = .41 for mothers PTS symptom cluster scores (all significant at p < .02). For fathers , the Roles subscale showed partial correlations of R = .42 with fathers total PTS severity score (p < .001), and between R = .31 and R = .39 for fathers PTS symptom cluster scores (all significant at p < .02). No other domain of family functioning contributed significantly to the prediction of PTS, except for the Communication subscale, which contributed significantly to the prediction of the Mothers avoidance symptom cluster score (R = .21, p< .05). Results indicate that specific domains of family functioning are highly correlated with one another, and that the Roles subscale appears to encompass measurement of broader domain of family factors than the other FAD subscales. Measurement difficulties will be discussed, as well as the implications of these findings for screening and intervention for both family functioning problems and PTS.
Individuals Using Assistive Technology Perceive Fewer Environmental Barriers
Kathy L. Miller, BA; Jerry Wright, BA; and Tamara Bushnik, PhD
Objectives:
Objective: To examine the relationship between use of assistive technology and perceived environmental barriers. Design: Longitudinal National Database.
Setting: Sixteen SCI Model Systems of Care (SCIMS).
Participants: 3,460 individuals who met the inclusion criteria for the SCIMS and were admitted to a SCIMS from 1995 to 2005 and were interviewed between 1 and 10 years post injury.
Main Outcome Measures: The Craig Hospital Inventory of Environmental Factors Short Form (CHIEF-SF).
Results: The CHIEF measures the frequency and magnitude of perceived environmental barriers by individuals using 5 subscales (policies, physical and structural, work and school, attitudes and support and services and assistance) and a total score. Significant differences in CHIEF scores were found for those reporting computer use, Internet use, owning a modified vehicle and owning a cell phone. Individuals who use a computer perceive fewer and less serious environmental barriers than individuals who do not use a computer (total CHIEF, p = .0003). Individuals accessing the Internet for disability/health information (total CHIEF, p < .0001), email (policies, p = .01), chat rooms (total CHIEF, p = .01) and games (work and school, p = .008) also perceive fewer and less serious environmental barriers. Individuals who own a modified vehicle perceive less environmental barriers than those who do not own a motor vehicle (total CHIEF, p = .05) and individuals who own a cell phone also perceive fewer environmental barriers (total CHIEF, p = .01).
Conclusions: Individuals with SCI who use assistive technology, such as cell phones, modified vehicles and computers, perceive fewer and less severe environmental barriers. This may allow individuals with SCI greater access to employment opportunities or more independent living.
Employment and Caregivers of Persons with Spinal Cord Injury
Phyllis S. Ellenbogen, MSW, MBA; Nicole Abdul, BA; Michelle Meade, PhD; Njeri Jackson, PhD; and Kirsten Barrett, PhD
Objectives:
Caregivers play key roles in assisting with the continued health and community integration of persons with SCI. Many of these individuals are employed full or part time, for one of any number of reasons including economic necessity, professional interests, or social need. Employment may add complexity to a potentially difficult and stressful situation or may be a way of maintaining balance and connections. While research is available on caregivers of individuals with SCI and plentiful on employment of caregivers of the frail elderly and those with Alzheimer’s, we could find no research focused on employment factors/issues of caregivers of persons with SCI. This project examines the issue of employment in caregivers, how individuals balance multiple roles, and what they describe as their needs and concerns. Multiple data types are used to examine this issue, including: (a) qualitative data from 9 caregivers interviewed either individually or as part of a focus group; and (b) quantitative data from a multimethod survey completed by over 500 persons with SCI and over 300 persons identifying themselves as caregivers. Quantitative data revealed that about half (53%) of the caregivers (N = 156) were employed at least 30 hours a week. 138 respondents answered yes to whether they provided any personal assistance. Of this group, 44% (N = 60) reported that their employment was limited because of the time spent providing personal care. Caregivers who were unemployed or partially employed expressed interest in several services at a higher rate then those fully employed, including assistance with transportation, financial assistance, assistance with lawyers, family support or counseling and help with bathing and dressing. Furthermore, fully employed caregivers reported statistically significant higher levels of health than those partially or unemployed (p = 001). Qualitative data provided information about the issues, concerns and challenges caregivers faced related to employment. Common themes included the need for flexible work schedules, problems with hired help in the home, and the lack of opportunity for social connections, leisure time and career advancement. Further research is needed to better understand the needs of employers caregivers of persons with SCI–– who they are, what level of services they are providing, what can be done to provide support for them.
Relationships Between Pain, Pain Interference, and Depression in People with Spinal Injury
Heather J. Clark, PhD; Eva Widerstrom-Noga, DDS, PhD; Salome Perez, PhD; and Yenisel Cruz-Almeida, MSPH
Objectives:
The relationship between pain and depression is well known in the general population. Likewise, depression is reportedly elevated among people who have spinal cord injuries (SCI) and chronic pain. Many people with SCI also suffer from chronic heterogeneous pains in numerous locations that interfere with common daily activities. Lower activity levels are commonly associated with depression. This study examined the relationships between extent of pain (number of pain locations), pain interference, and depression among a sample of people who had concurrent chronic pain and SCI. SCI individuals (152 males, 27 females) were administered the Beck Depression Inventory (BDI) and a Pain History Form within the context of a larger study. Hierarchical regression revealed that extent of pain and pain interference each independently account for a significant portion of the variance in BDI. Furthermore, pain interference (R2 = .134) remained significant even after extent of pain (R2 = .035) was controlled for. The model was highly significant (p < .001). A 2 x 2 two-way ANOVA was used to examine to what degree extent of pain was a moderator of the relationship between pain interference and depression in a SCI population. There was asignificant main effect for pain interference, but no main effect for extent of pain or the interaction between interference and pain extent. Therefore, the extent of pain does not appear to significantly influence or moderate the relationship between pain interference and depression. Regarding pain interference, individuals with minimal interference had significantly lower BDI scores than people with moderate or severe interference from pain. There was no noticeable difference in BDI scores between the moderate and severe pain interference groups. In conclusion, number of pain locations and pain interference are individually related to depression. The degree to which pain interference is associated with depressive symptoms, however, does not seem to be influenced by how widespread pain is throughout the body. This finding may indicate that people with chronic pain and SCI who are able to remain active, despite their pain, are less prone to depression.
HOME