Picture this: one moment, you’re cruising through life; the next, you’re face-to-face with a spinal cord injury (SCI). It’s sudden. It’s unexpected. It’s like life threw you a curveball without warning. But fear not, because there is a secret to SCI recovery: cognitive appraisals. In our journey to uncover the uncertainties of SCI recovery, we have discovered that it’s not just about physical therapy; it’s about adjusting your thinking to overcome challenges.
Background
The spinal cord, stretching from our brain to the pelvis, is vital for everyday functions like walking, breathing, and bladder control — tasks we often take for granted. However, when this intricate system is injured by a fall or a neurological disorder, it can drastically impact our lives. Patients with spinal cord injury (SCI) often endure chronic pain, limited mobility and skin complications like pressure sores and ulcers.
The severity of SCIs varies depending on the injury site. Upper spinal injuries can affect arm and leg functions, while lower spinal injuries can potentially impede lower body movements and bowel control. Causes of SCI range from falls to car accidents, sports-related injuries, and violence, with mortality rates ranging from 3.1% to 22.2% in developed countries.
Now, imagine being a patient facing a recent SCI — it’s undoubtedly a frightening experience. But here’s the thing: These physical characteristics do not determine your SCI recovery. The key lies within you. Your cognitive appraisals, i.e., the personal meaning and significance you give to your injury, play an integral role in psychological recovery. In stressful situations, we typically go through two appraisal stages: primary appraisals evaluate the situation for potential harm or gain, while secondary appraisals consider our resources for dealing with it. With healthy and adaptive appraisals, individuals with SCI can benefit hugely from reduced psychological risks, such as heightened susceptibility to depressive moods and associated complications like prolonged hospitalisation periods and medical issues.
In essence, your mindset and outlook can significantly influence your recovery.
Research insights
We aimed to assess whether cognitive appraisals, measured as early as admission, could distinguish between patients demonstrating a significant appraisal change throughout rehabilitation. This understanding could guide early intervention for those predicted to have poorer outcomes. We measured the patients’ cognitive appraisals at admission and discharge using the Appraisals of Disability Primary and Secondary Scale short form (ADAPSS-sf). ADAPSS-sf is a SCI-specific standardised measuring tool that scores from 0-36. An individual who scores high on ADPASS-sf demonstrates poorly adjusted appraisals, and marks above 22 indicate a problematic appraisal that requires clinical attention. We refer to this boundary as the clinical cut-off.
We gathered 42 patients in the Royal National Orthopaedic Hospital, all under the London Spinal Cord Injury Centre (LSCIC) Department of inpatient rehabilitation, between January 2021 and February 2024. While all patients showed good physical recovery at discharge, our analysis of their psychological recovery revealed some intriguing findings:
76% of SCI patients were discharged with a healthy appraisal! 32 out of 42 patients were discharged, with an average of 16.0 on ADAPSS-sf discharge. However, concerns arose for the remaining 10 patients (24%), with ADAPSS-sf averaging 26.1.
55% of SCI patients have decreased ADAPSS-sf scores between admission and discharge. 23 patients are discharged with decreased ADAPSS-sf, signifying an improvement in appraisal adjustment (i.e., negative score change). On the contrary, 17 patients (40%) had deteriorated appraisals (i.e., positive score change), and the remaining two (5%) had remained at the same score.
Patients admitted with the least adjusted appraisals were discharged with the most appraisal improvement. ADAPSS-sf above the clinical cut-off (>22) are considered poorly adjusted appraisals. Look at the graph below. We saw a significant difference in admission ADAPSS-sf score between patients who improved in appraisals (red), deteriorated (blue), and remained the same (green). Patients who showed improvement in appraisals had an average admission ADAPSS-sf of 23, while those with worsened appraisals over time scored an average of 16 at admission, showcasing a notable 7-point difference.
This supported our prediction, with numbers suggesting the possibility of distinguishing, at admission, between individuals who progress with a positive appraisal development and those who do not.
Implications and Future Directions
These findings have implications for healthcare settings, particularly at admission, where appraisals are freshly formed. Early intervention in SCI is crucial, as our results indicate that patients with well-adjusted appraisals upon admission may require closer monitoring. On the other hand, healthcare providers should not be deterred by the lack of significant appraisal difference across admission and discharge, as most patients, 76% to be exact, were discharged with healthy appraisals well below the clinical cut-off, signalling a positive outlook towards their SCI.
Our trajectory model mirrors findings from other studies, raising an intriguing question: Why do patients who initially struggled with the psychological adaptation to their SCI end up being discharged with the most well-adjusted appraisals? One potential explanation lies in the way these patients perceive significant stressors. Research suggests that those who adapt the best view challenges as opportunities to overcome rather than insurmountable obstacles. Conversely, patients who experience worsened appraisal at discharge may have entered rehabilitation with initially well-adjusted appraisal and have realised their injury is more than they can handle.
This delayed worsening of appraisal echoes findings from Bonanno and Colleagues (2012), where a minority of patients (12.8% and 9.3%) experienced delayed depression and anxiety onset, respectively, after three months of rehabilitation. Future research could delve into the qualitative aspect to understand the triggers behind the worsening of appraisals longitudinally after SCI. Identifying common characteristics among this group could offer valuable insight into the long-term maintenance of psychological well-being in SCI.
References
Bonanno, G. A., Kennedy, P., Galatzer-Levy, I. R., Lude, P., & Elfström, M. L. (2012). Trajectories of resilience, depression, and anxiety following spinal cord injury. Rehabilitation Psychology, 57(3), 236–247. https://doi.org/10.1037/a0029256
Chevalier, Z., Kennedy, P., & Sherlock, O. (2009). Spinal cord injury, coping and psychological adjustment: a literature review. Spinal Cord, 47, 778-782. https://doi.org/10.1038/sc.2009.60
Dean, R. E., & Kennedy, P. (2009). Measuring appraisals following acquired spinal cord injury: A preliminary psychometric analysis of the appraisals of disability. Rehabilitation Psychology, 54(2), 222–231. https://doi.org/10.1037/a0015581
Hoffman, J., Bombardier, C., Graves, D., Kalpakjian, C., Krause, J. (2011). A Longitudinal Study of Depression From 1 to 5 years After Spinal Cord Injury. Archives of Physical Medicine and Rehabilitation, 92(3), 411-418. https://doi.org/10.1016/j.apmr.2010.10.036
Kang, Y., Ding, H., Zhou, H., Wei, A., Liu, L., Pan, D., Feng, S. (2018). Epidemiology of worldwide spinal cord injury: a literature review. Journal of Neurorestoralogy, 6(1), 1-9. https://www.dovepress.com/getfile.php?fileID=39925
Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping. Spinger Publishing Company.
Ricciardi, L. Lofrese. G., Perna, A., & Trungu, S. (2023). Spinal Cord Injury — Current Trends in Acute Management, Funtion Preservation and Rehabilitation Protocols.
van Leeuwen, C. M., Hoekstra, T., Koppenhagen C. F., de Groot, S., & Post M. W. (2012). Trajectories and Predictors of the Course of Mental Health After Spinal Cord Injury. Archives of Physical Medicine and Rehabilitation, 93(12), 2170-2176. https//doi.org/10.1016/j.apmr.2012.07.006.
Credits
Cover picture from Northeast Spine and Sports Medicine: https://www.northeastspineandsports.com/blog/can-acupuncture-help-treat-back-pain/
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