IN RECENT YEARS, scientific research to enhance functional

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1 597 ORIGINAL ARTICLE Psychological Contributions to Functional Independence: A Longitudinal Investigation of Spinal Cord Injury Rehabilitation Paul Kennedy, DPhil, Peter Lude, PhD, Magnus L. Elfström, PhD, Emilie F. Smithson, BA ABSTRACT. Kennedy P, Lude P, Elfström ML, Smithson EF. Psychological contributions to functional independence: a longitudinal investigation of spinal cord injury rehabilitation. Arch Phys Med Rehabil 2011;92: Objectives: To investigate the contribution of prerehabilitation appraisals of spinal cord injury (SCI) and patient s coping strategies to the variance in functional independence postdischarge. Design: Longitudinal, cohort study. Patients aged 16 and older and sustaining an SCI were recruited from English- and German-speaking specialist spinal injuries centers. Measures of appraisals, coping strategies, mood, and functional independence were administered on commencing active rehabilitation (12-weeks postinjury) and following hospital discharge (1-y postinjury). Setting: Specialist SCI rehabilitation centers in England, Germany, Switzerland, and Ireland. Participants: Patients (N 127) completed questionnaires at both time points. Sample age ranged between 17.5 and 64.5 years with a mean age of 39.3 years. Demographic and injury characteristics were similar to those reported in international statistics databases. Interventions: Not applicable. Main Outcome Measure: FIM (motor subscale). Results: Injury characteristics, age, sex, current depression, and the utilization of the coping strategy, social reliance, at 12-weeks postinjury explained 33.5% of the variance in motor FIM at 1-year postinjury. Strong relationships were found between appraisals, coping styles, mood, and functional outcomes. Conclusions: The coping strategy, social reliance, was found to contribute significantly when explaining the variance in functional outcomes. Suggestions were made to assess appraisals and coping strategies early in rehabilitation in order to provide effective interventions and additional support to those scoring highly on negative coping styles. Further research is recommended to provide support for the relationship between dependent coping strategies and functional outcomes. Key Words: Coping skills; Psychological; Rehabilitation; Spinal cord injuries. From the Oxford Doctoral Course in Clinical Psychology, University of Oxford, Oxford (Kennedy); the Department of Clinical Psychology, The National Spinal Injuries Centre, Stoke Mandeville Hospital, Aylesbury (Kennedy, Smithson), UK; the Swiss Paraplegic Research and Swiss Paraplegic Centre, Nottwil, Switzerland (Lude); the School of Sustainable Development of Society and Technology, Psychology Division, Mälardalen University, Västerås, Sweden (Elfström). No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated. Reprint requests to Paul Kennedy, DPhil, Oxford Doctoral Course in Clinical Psychology, Isis Education Centre, Warneford Hospital, Oxford, OX3 7JX, paul.kennedy@hmc.ox.ac.uk /11/ $36.00/0 doi: /j.apmr by the American Congress of Rehabilitation Medicine IN RECENT YEARS, scientific research to enhance functional outcomes in SCI has generated much excitement. However, while there has been discussion of clinical trials using laboratory-based neuroregenerative models and stem cell transplants as a possible strategy for curative therapy, no efficient curative therapy for human SCI currently exists. 1 Meanwhile, clinicians and professionals working in rehabilitation settings continue to assist patients in regaining their independence in everyday tasks: in returning to work, in participating in social activities, and in improving their quality of life. A standardized method of assessing rehabilitation effectiveness in a clinical care setting is through the use of the FIM. 2 The FIM assesses the person s independence across a number of functional areas: self care, sphincter control, mobility, locomotion, communication, and social cognition. In patients with SCI, demographic factors and clinical variables relating to injury have to be taken into consideration when planning rehabilitation and functional recovery (which the patient will be aiming towards). However, even when these factors are taken into consideration, a large amount of variability remains in the functional outcomes achieved by patients with similar injury characteristics. Research studies conducted in other population groups have reported psychological variables (eg, mood, cognition, and coping strategies) as contributing factors when explaining such variance in functional independence. It has been suggested that psychological factors can have an impact on rehabilitation outcomes over and above demographic and medical factors. Nanna et al 3 investigated ambulatory recovery in 423 geriatric patients who were admitted to rehabilitation hospitals. They looked at the relationship between depression and cognition at admission to functional abilities at discharge and found these variables to explain 7% of the unique variance in the model. Self-esteem was found to be related to functional outcomes in patients admitted to the hospital following a stroke, 4 whereas preoperative self-efficacy was a significant predictor of postoperative walking speed and long-term outcomes after total hip replacement. 5 A further study 6 found a relationship between mood, coping style, and functional outcomes, while positive coping and getting on with life were significantly related to functional outcomes in 228 patients participating in joint-replacement rehabilitation. 7 A review of psychosocial factors and COPE HADS SCI SCL CSQ List of Abbreviations Coping Strategies questionnaire Hospital Anxiety and Depression Scale spinal cord injury Spinal Cord Lesion-Related Coping Strategies Questionnaire

2 598 PSYCHOLOGICAL FACTORS IN THE FIM, Kennedy surgical outcomes 8 found that attitudinal factors (eg, positive expectations, self-efficacy, and perceived control) were effective in predicting speed of return to functional activities. Clearly, personal coping styles and psychological factors have a significant role to play in the recovery of functional and physical skills. Given that such factors are potentially modifiable, the relationship between psychological factors and functional independence is one which warrants further exploration, and one which may provide clinicians with effective intervention strategies. The model of stress, appraisal, and coping by Lazarus and Folkman 9 proposes that a person will assess or appraise a given stressor in terms of it being a threat, a loss, or benign. Following this primary appraisal, a person forms a secondary appraisal with regard to his/her own capabilities and available resources for dealing with the stressor. The appraisals will then inform the coping strategies, which the person engages to manage the given stressor. According to Lazarus and Folkman, 9 coping involves both cognitive and behavioral efforts to manage the perceived discrepancy between the demands of the stressful situation and the person s own resources. In the SCI population, a large amount of literature based on the Lazarus and Folkman study 9 suggests there is a strong relationship between coping strategies and behavioral efforts to manage the consequences of injury. It is also suggested that this model plays a role in the long-term psychological adjustment to life after SCI (see Galvin and Godfrey 10 for a review). However, in contrast to other rehabilitation settings, there remains relatively little information on how psychological factors may influence functional outcomes in this population. A recent study by Kennedy et al 11 investigated this relationship in a cross-sectional sample of 81 persons with SCI who were living in the community. The authors used a scale developed specifically to measure appraisals of disability in people with SCI 12 and the FIM. Regression analyses found the model to explain 48% variance in the FIM. The appraisal Negative Perceptions of Disability explained 33% of the variance in functional independence. In support of Lazarus and Folkman s 9 model of stress, appraisal, and coping, researchers have also found evidence of a relationship between the types of coping strategies people with SCI utilize and their functional independence scores. 13 In particular, the use of an SCI-specific measure of coping strategies highlighted a relationship between FIM scores and the coping strategies of acceptance and social reliance. (The authors define acceptance as: The lesion and its ramifications are seen as integrated parts of the individual s life. The individual tries to find new values and interests to replace those made unattainable by the lesion. 13(p 5) The authors define social reliance as: The individual adopts the view that he/she is dependent on other people and their ability to help. Support from others is viewed as the only protection against helplessness 13(p 6) ). These findings suggest that, in addition to contributing to psychological adjustment to injury, appraisals, and coping strategies, they may also have an impact on the person s approach to rehabilitation and ultimately, their level of functional independence. If further research in this population group can provide support for such a hypothesis, the potential for clinical benefit is promising. Through early assessment prior to active rehabilitation and the provision of additional support to those patients identified as at risk, engagement and participation in rehabilitation may be enhanced, and subsequently, functional independence optimized. Aim The purpose of the study was to investigate the relationship between appraisals, coping, and functional independence in a spinal cord injured population. Specifically, the study aimed to examine the contribution of prerehabilitation appraisals of injury and coping strategies when explaining the variance in functional independence postdischarge. METHODS Participants All newly acquired injuries in selected British, Swiss, German, and Irish spinal centers with injuries representative of the SCI population. Participants were fluent in the language of the country from which they were recruited. Patients with a known head injury or communication disorder were excluded from the study, as such difficulties would prevent the comprehension and completion of the questionnaires. Demographics The sample (N 127) had a mean age SD of years (range, y) and contained more men (n 101) than women (n 26). Most of the sample were people with paraplegia with complete lesions (n 48), followed by incomplete tetraplegia (n 33), incomplete paraplegia (n 24), and complete tetraplegia (n 22). Sixty participants were recruited from English-speaking centers and 67 from German-speaking centers. The majority of the sample (92.1%) incurred a traumatic injury; most injuries occurred following a road traffic accident (n 43) or fall (n 39), followed by sports (n 29), and 1 person incurred their injury as a result of an assault. At the time of injury, most people were married or living with a partner (n 65), followed by single (n 52), divorced or separated (n 8), and widowed (n 2). Design The study was a prospective, cohort design. Questionnaires were administered on commencement of active rehabilitation (12-weeks postinjury) and repeated following hospital discharge (1-y postinjury). Each country collected the data for 1 or more specific centers; data were entered into a standardized template. Data were entered using coded strings and stored in accordance to ethical guidelines. Ethical approval for this study was obtained from each center s local research ethics committee. Materials A double translation method was used for all questionnaires. For all scales other than the FIM, scales are not intended to provide an overall total score, but subscales used to indicate a particular mood, appraisal construct, or coping strategy. Hospital Anxiety and Depression Scale. The HADS enables detection of clinical cases and assessment of severity without contamination of scores through physical symptomology. 14 Scores on Anxiety and Depression subscales can be obtained separately with higher scores indicating more psychopathology. Participants can score a total of 0 to 21 on 20 items measured on a 3-point Likert-type scale. The scale has previously been used in people with SCI. 15 A review of articles assessing the validity and reliability of the HADS indicated that it has good psychometric properties, with internal consistency varying from.68 to.93 (mean,.83) for the HADS-Anxiety, and between.67 to.90 (mean,.82) for the HADS-Depression. 16 FIM. 2 The FIM assesses the degree of independence in activities of daily living in 6 areas of function. Higher scores indicate a higher level of independence. Participants rate their

3 PSYCHOLOGICAL FACTORS IN THE FIM, Kennedy 599 independence on a 7-point scale (1 complete assistance, 7 completely independent) on 18 items, scoring a maximum of 126 points. The measure has been widely used in the SCI population, 17 and has been favorably evaluated for use as a self-report measure in this population group. 18 The scale has a good psychometric profile, with an internal consistency coefficient of.91 to.92 for the total scale, and an item total correlation range from.33 to.81. The FIM can be separated into motor and cognitive independence scores. The motor score was utilized for the purpose of this study. Appraisal of Life Events. 19 The Appraisal of Life Events is a checklist of 16 adjectives designed to elicit respondents cognitive appraisals of stressful life events in terms of a threat (6 adjectives, maximum score 30), a challenge (6 adjectives, maximum score 30), or a loss (4 adjectives, maximum score 20). It has previously been used in SCI populations and has shown good factor structure, good test-retest reliability (range,.48.90), internal reliabilities (range,.75.91), and construct validity. 20,21 Spinal Cord Lesion-Related Coping Strategies Questionnaire. 22 This questionnaire was developed specifically to explore coping processes in people with SCI. It contains 12 items measuring 3 coping strategies: acceptance (eg, I think I have accepted my lesion ), fighting spirit (eg, It is important for me to set goals that I can fight to achieve ), and social reliance (eg, Without support from others I would feel completely helpless ). Higher scores (maximum subscale score of 4) indicate that the person tends to use one of the aforementioned coping strategies in response to a given stressful situation. The scale has good psychometric properties, with acceptable internal validity correlations (range,.44.64) and internal reliability coefficients (range,.72.79) for the 3 strategies. Based on the findings of previous research, 23 our study used a questionnaire containing amended wording of some questionnaire items. Selected subscales from the COPE. The COPE is a generic coping measure, which measures coping strategies as opposed to situation-specific coping strategies. 24 This measure has previously been used with an SCI population. 25,26 Three subscales that were found to be associated with adjustment in previous research were used: positive reinterpretation, behavioral disengagement, and planning. Scores ranged from 4 to 16, with higher scores indicating greater use of a particular strategy. Procedure Participants were approached shortly after admission to the rehabilitation centers. Once they were medically stabilized, they were provided with an information leaflet about the study. At 12 weeks (average commencement of active rehabilitation), questionnaires were administered. At 1-year postinjury (postdischarge), questionnaire booklets were sent out to participants via postal service. Data included in the current study are part of a longitudinal study, looking at adjustment and coping during the first 2 years of injury. Data Analysis Data were analyzed using the SPSS, Version a Data quality checks were performed to examine the distribution of measures and internal consistencies within scales. Analyses of variance and t test comparisons were conducted to establish whether any differences were present between the scores on measures of functional independence, appraisals, mood, and coping according to demographic and injury variables. The relationships between scores on measures of appraisals, coping, mood, and depression were investigated through correlational methodology. Regression analyses were structured on the theoretical model of mood and coping as described by Lazarus and Folkman. 9 The analyses explored how much variation in scores on the motor subscale of the FIM at 1-year postinjury can be explained by appraisals and coping at 12-weeks postinjury. Due to the potential confound of current depression affecting scores on the motor FIM, coexisting depression scores were entered into the regression model. RESULTS Appraisals and Coping Strategies Descriptive statistics are displayed in table 1. To investigate differences in appraisals according to demographic and injury variables, t test and analyses of variance were conducted where appropriate. Differences were found in scores on threat appraisals according to sex, with women (mean SD, ) scoring significantly higher than men (mean SD, ) (t , P.014). Differences were found in scores on challenge appraisals according to age, with those people in the 16 to 34 years age range (mean SD, ) scoring significantly higher than those in the 35 to 60 years age range (mean SD, ) and the over 61 years age range (mean SD, ) (F 2, , P.001). There were no significant differences in subscale scores on the Appraisal of Life Events scale measure according to injury characteristics. There was a significant difference in scores on the social reliance subscale of the Spinal Cord Lesion Coping Strategies Questionnaire according to injury characteristics. Those with complete tetraplegia (mean SD, ) scored higher than those with complete paraplegia (mean SD, ), incomplete tetraplegia (mean SD, ), and incomplete paraplegia (mean SD, ). No differences were found in scores on Spinal Cord Lesion Coping Strategies Questionnaire subscales according to sex and age. There were no significant differences in COPE subscales according to age, sex, or injury characteristics. Mood At 1-year postinjury, mean HADS-Depression scores SD were Scores were categorized according to nonclinical (0 7), possible case (8 10), and clinical case (11 21). Most of the sample (n 74) were categorized as nonclinical, with 21 possible cases, and 32 participants categorized as Table 1: Statistical Data for Appraisals and Coping Strategies 12 Weeks After Injury Variable Name ALE threat ALE challenge ALE loss SCL CSQ acceptance SCL CSQ fighting spirit SCL CSQ social reliance COPE positive reinterpretation COPE behavioral disengagement COPE planning Abbreviation: ALE, Appraisal of Life Events scale. Mean SD

4 600 PSYCHOLOGICAL FACTORS IN THE FIM, Kennedy Table 2: Correlations Between Appraisals and Coping Variables Variable ALE Loss ALE Challenge ALE Threat SCL CSQ acceptance.535*.525*.538* SCL CSQ fighting spirit.357*.346*.412* SCL CSQ social reliance.474*.290*.405* COPE positive reinterpretation.330*.495*.364* COPE behavioral disengagement * COPE planning NS NS NS Abbreviations: ALE, Appraisal of Life Events scale; NS, not significant. *P.001; P.01. clinical cases. There were no significant differences in mood according to age, sex, or injury characteristics. Functional Independence At 1-year postinjury, mean FIM motor score SD was Analyses of variance revealed a significant difference in FIM motor scores according to injury characteristics (F 3, , P.001). Those persons with incomplete paraplegia scored highest (mean SD, ), followed by complete paraplegia (mean SD, ), incomplete tetraplegia (mean SD, ), and complete tetraplegia (mean SD, ). No differences were found according to sex or age. Variable Relationships Pearson correlations were performed to examine the relationship of appraisals and coping at 12 weeks after injury with scores on HADS and FIM 1 year after injury. Significant relationships were revealed between appraisals, coping, and functional outcomes and are displayed in tables 2 and 3. Regression Analysis To investigate the contribution of appraisals and coping strategies to the variance on measures of motor functional independence, hierarchical stepwise regression analyses were performed, controlling for age, sex, injury characteristics (paraplegia, tetraplegia, complete, incomplete), and depression. Results are displayed in table 4. From the regression analyses, injury level, age, sex, current depression, and social reliance at 12-weeks postinjury accounted for 33.5% of the variance in the motor subscale of the FIM at 1-year postinjury. Between Country Differences In order to ascertain whether country had an effect on the salient variables in the model, independent sample t tests were performed. Results found that German- and English-speaking samples were not significantly different in terms of sex, age, and injury characteristics. They also did not differ significantly on the coping strategy (social reliance), depression, or functional independence. DISCUSSION The results from this study revealed significant relationships between appraisals, coping, and functional outcomes. The relationships observed between appraisals and coping provided further support for the applicability of the Stress-Appraisal coping model 9 when understanding adjustment to SCI. A strong negative correlation between motor FIM and social reliance suggests that those who scored highly on measures of social reliance, scored lower on measures of functional independence. The type of statements that would be endorsed by people using this method of coping would be phrases such as I feel helpless without support and my injury has taught me that I am dependent on others. The appraisals of threat and loss were also found to be related to the motor subscale of the FIM. The Stress-Appraisal coping model suggests that those who appraise problems as a threat or loss may be more likely to endorse passive coping strategies, which would be consistent with the strong relationships observed between these appraisals and social reliance in the current study. In the current sample, the coping strategy (social reliance) was found to account for a unique proportion of the variance in motor FIM. The results of the current investigation support the findings in previous studies. 12 According to Lazarus and Folkman, 9 if the person perceives a stressful situation as threatening and unmanageable, and underestimates the degree to which they have the skills and resources to cope with their situation, this may increase the likelihood that they will engage in avoidant and passive coping strategies. This leads to contributing minimal effort to the rehabilitation process or displaying an increased social reliance on other people. Negative appraisals of disability and dysfunctional coping strategies (eg, social reliance and behavioral disengagement) have been linked to depressive symptomology in SCI patients, which in turn has been found to have a negative impact on functional achievements. Therefore, depressive symptomology may also impact on a person s motivation to engage with therapy and rehabilitation. Empirical research has shown that depression may also lead to increased awareness of physiologic symptoms of pain and fatigue, and thus could result in additional negative impact on rehabilitation progress. The regression analyses, performed in the current study, found that the injury characteristics of the person (complete/ incomplete, paraplegia/tetraplegia) did contribute to explaining the variance in FIM scores. However, the purpose of this study was not to disregard the impact of SCI on functional independence but to highlight the unique contribution that psychological and potentially modifiable aspects of the person s situation can make towards improving independence and autonomy. Clinical Implications From previous research on coping and adjustment to SCI, 10,30 a clear relationship is evident between the coping strategies that people with SCI endorse and subsequent psychological well being. This recent research would appear to suggest that people who adopt a dependent framework to describe themselves socially may not participate fully in reha- Table 3: Correlations Between Appraisals and Coping Variables With HADS and FIM Scores Variable HADS-Depression FIM Motor SCL CSQ acceptance.464* NS SCL CSQ fighting spirit.427*.197 SCL CSQ social reliance.385*.456* COPE positive reinterpretation.390* NS COPE behavioral disengagement.286 NS COPE planning.201 NS ALE threat ALE challenge.415*.181 ALE loss.546*.214 Abbreviations: ALE, Appraisal of Life Events scale; NS, not significant. *P.001; P.01; P.05.

5 PSYCHOLOGICAL FACTORS IN THE FIM, Kennedy 601 Table 4: Regression of FIM Motor Scores at 1 Year Postinjury Using Appraisal and Coping Variables at 12 Weeks Postinjury Variable Adjusted R 2 R 2 Change F Change Sig F Change P Block 1 Injury characteristics Block 2 Injury characteristics Age Block 3 Injury characteristics Age Sex Block 4 Injury characteristics Age Sex Current depression Block 5 Injury characteristics Age Sex Current depression Social reliance at 12 weeks bilitation. Consequently, it would make sense for people more likely to use passive and avoidant coping strategies to be identified early in their rehabilitation and provided with additional psychological support such as coping effectiveness training. Coping effectiveness training has been used specifically with patients in a spinal cord injured population. The training is delivered in a peer-group setting and aims to equip patients with the knowledge and the confidence to apply adaptive coping strategies to manage the changes arising from a spinal injury. A study by Kennedy et al 31 compared patients completing the coping effectiveness training program against those receiving standard care and found significantly reduced anxiety and depression scores in the intervention group when compared to controls. Future research investigating this method of intervention should study functional abilities in order to evaluate the potential benefits it may have on rehabilitation outcomes in specialist SCI centers. Study Limitations The sample used in this study was followed from admission to the specialist SCI rehabilitation center until discharge, after which participants completed postal questionnaires. This methodology meant that initial questionnaires were completed in the presence of a researcher, while the follow-up questionnaires were completed in the home environment. However, despite the physical presence of a researcher at 12 weeks, both questionnaires were completed as self-report and previous research would support the use of the FIM in this way in this population. Grey and Kennedy 18 evaluated the FIM as a self-report measure and found clinician and self-reported ratings to be highly correlated. What the current study did not control was whether the patient s perceived level of independence changed when leaving the supportive hospital environment and returning to the community. CONCLUSIONS Our study investigated the contribution of prerehabilitation appraisals and coping strategies when explaining the variance in postrehabilitation functional independence. The findings suggest that those who relinquish autonomy and independence after SCI, relying on others to do things for them, and feeling helpless without assistance, may show poorer rehabilitation outcomes than those who try to manage on their own and set themselves challenging goals. We suggest a need for further research in this area using a broader range of psychological measures and functional assessment tools. This research has reiterated the importance of psychological appraisals and coping strategies in explaining functional outcomes. Our research suggests that early assessment of patient need and provision of appropriate psychological support may improve long-term quality of life and independence of people with SCIs. Acknowledgements: We thank those who gave their time to help with the recruitment and questionnaire process and the staff at the spinal units in Nottwil, Zurich, Basel, Bad Haring, Tobelbad, Berlin, Kreisha, Bad Wildungen, Halle, Hamburg, Heidleburg, Herdecke, Murnau, Lund, Stoke Mandeville, and Dublin. References 1. Privat A. Stem cell transplants after SCI: what is the preclinical evidence for benefit and what are the sources of transplant materials? In: Symposium conducted at the 48th Annual Scientific Meeting of the International Spinal Cord Society, October 21-24, 2009; Florence, Italy. 2. Hamilton BB, Granger CV. Guide for the use of the uniform data set for medical rehabilitation. Buffalo: Research Foundation of State, University of New York; Nanna MJ, Lichtenberg PA, Buda-Abela JT, Barth JT. The role of cognition and depression in predicting functional outcome in geriatric medical rehabilitation patients. J Appl Gerontol 1997;16: Vickery CD, Sherer M, Evans CC, Gontkovsky ST, Lee JE. The relationship between self-esteem and functional outcome in the acute stroke-rehabilitation setting. Rehab Psychol 2008;53: van den Akker-Scheek I, Stevens M, Groothoff JW, Bulstra SK, Zijlstra W. Preoperative or postoperative self-efficacy: which is a better predictor of outcome after total hip or knee arthroplasty? Patient Educ Couns 2007;66:92-9.

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