REHABILITATION POTENTIAL OF PERSONALITY AND FUNCTIONAL INDEPENDENCE OF PERSONS WITH TRAUMATIC SPINAL CORD INJURY Khokhlova O.I.
Novokuznetsk Scientific and Practical Centre for Medical and Social Expertise and Rehabilitation of Disabled Persons, Novokuznetsk, Russia
Spinal cord injury, which is one of the components of polytrauma, is a complex (from medical point of view) and life-threatening condition [1]. The achievements in medicine and improvement in medical care resulted in increasing life span of persons with such injury, but most of them have disorders of motor, sensor and vegetative functions, with high rate of secondary complications. All these moments cause difficulties relating to realization of daily actions and lead to disability. According to Global Burden of Disease Study (2016), the main cause of disability through the whole world is neurological disorders. Spinal cord injuries present the fourth cause of disability in countries with high income [2]. Such high incidence of spinal cord injuries is observed in young, working-age people, mainly men, and it causes serious social and economic consequences [3]. However, according to the report from the World Medical Organization − International Review of Spine Injuries (2013), the spinal cord injury can be prevented; one can survive it; it should not present obstacles for good quality of life and positive benefit to society [1]. Moreover, the important role is taken by the program of continuous rehabilitation, one of the main tasks of which is achievement of maximally possible level of functional independence.
Rehabilitation can be determined as active and dynamic process, which helps to acquire knowledge and skills for maximal activation of functional capabilities (physical, mental, social) and disability minimization [4].
The modern understanding of rehabilitation supposes its addressing to the patient's personality. It has been generally accepted that consideration of its features and resource capabilities can give success during realization of the complex of rehabilitation procedures promoting return of the patient to high-quality life.
The system of personal resources, which are necessary for coping with a critical situation, determines the rehabilitation potential of the personality. It includes motivation, self-estimate and communication components, as well as internal picture of the disease [5]. According to O.N. Gudilina (2012), the personal rehabilitation potential presents the system of personal features of the rehabilitant which allow him or her to actively and efficiently participate in the process of complex rehabilitation, as well as to adapt to alternating conditions of environment [6].
Consideration of personal resources is especially actual for individuals with consequences of the spine and spinal cord injury since this injury is a catastrophic event, which suddenly changes the usual life style and often worsens the mental and social state, with negative influence on rehabilitation results [7]. However, there were no studies of the personal rehabilitation potential and its relationship with functional independence values in persons with traumatic spinal cord injury (TSCI). It has determined the objective of this study.
Objective – investigate the interrelation of the degree of functional independence and the level of rehabilitation potential of personality among persons with traumatic spinal cord injury (TSCI).
MATERIALS AND METHODS
The study was approved by the ethical committee of Novokuznetsk Scientific and Practical Centre for Medical and Social Expertise and Rehabilitation of Disabled Persons, and corresponded to the international ethical standards.
32 patients with traumatic spinal cord injury were examined. The patients were admitted to the neurosurgery unit at Novokuznetsk Scientific and Practical Centre for Medical and Social Expertise and Rehabilitation in the period from June 2019, to December, 2019, in the beginning of the course of medico-social rehabilitation. There were 27 (84.4 %) men and 5 (15.6 %) women. The mean age was 37.2 ± 9.95.
The inclusion criteria were prescription of injury not more than 3 years, available written consent.
The exclusion criteria: evident cognitive disorders, objective communication difficulties relating to language barrier; a tracheostomy tube; unwillingness to participate in the study.
The study included patients with duration of the posttraumatic period from 2 months to 3 years: before 1.5 year − 25 (78.1 %), more than 1.5 year − 7 (21.9 %) patients. A half of the patients (50 %) received injuries in road traffic accidents, 34.4 % − after falling from height, 6.3 % − when diving, 9.3 % − other causes (a blow with a heavy object, falling from height of own stature, air disaster).
16 (50 %) patients had paraplegia determined by the spinal cord injury at thoracic and/or lumbar level, 16 (50 %) − tetraplegia after cervical spine injury. According to American Spinal Injury Association Impairment Scale, the type A was found in 21.4 % of patients, type B − in 32.1 %, type C − in 25.1 %, type D − in 21.4 %.
Most patients had secondary professional education (62.6 %), 18.7 % − higher education, 18.7 % − high school education or incomplete high school education.
Before hospital admission, 87.5 % of disabled persons lived in their families which cared for them (50 % − with marriage partners, 31.3 % − with parents, 6.2 % − with adult children). 4 persons lived independently; 3 of them − with periodical outside help (from relatives and social workers). SCIM-III (Spinal Cord Independence Measure version III) [8] and FIM (Functional Independence Measure) were used for estimation of level of functional independence of patients.
SCIM-III was developed specially for estimation of disorders of vital activity in patients with spinal cord injuries. It is used for estimation of ability to perform basic daily actions: self-care (nutrition, washing of upper or lower body parts, dressing, personal hygiene activities), breathing, sphincter control, mobility (movements in the bed, walking inside and outside the house). The results are presented by summing of points of all items of each section and summarily. The maximal possible sum is 100 points (full independence). The minimal point is 0 (absolute dependence).
FIM was developed for patients with stroke. However, it is widely used for persons with spinal cord injuries. FIM presents the score consisting of 18 items, including estimation of disability in self-care, sphincter control, mobility, movement, communication, psychosocial adaptation and cognitive function, with seven levels of responses to each one (from full dependence from other persons − 1, to full independence − 7). The possible summary range of 18-26 points: the lower sum of points, the higher dependence on other persons in daily life.
The rehabilitation potential of personality was estimated with the corresponding method − "Rehabilitation Potential of Personality" by I.Yu. Kulagina and L.V. Senkevich (2011) [5]. The method presents a questionnaire including five scores, which estimate the components of the rehabilitation potential − motivation, emotional, self-estimate, communication and internal picture of a disease. Totally, the questionnaire includes 28 questions with three variants of answers, which are estimated from 0 to 2. The "null" point supposes insufficient personal resources for disease control in some fields; 2 points mean presence of personal resources for efficient rehabilitation in the corresponding field. The sum of points and percentages of maximal possible sum of each score are calculated. The general level of the personal rehabilitation potential is presented by the percentage of the sum of points from maximal value (56) for all 28 items. The levels were considered as average after receive of values within the range from 41 to 60 %, the high − more than 60 %, low − less than 41 %.
IBM SPSS Statistics 23 was used for statistical analysis of results.
The quantitative data were presented as the mean arithmetic ± standard deviation (age, prescription of injury) or as the median with interquartile range (25%-75%) (other values). For parameters, which characterize the qualitative signs, the absolute number and relative values (%) are indicated. The comparative analysis of the groups with various levels of movement disorders (patients with paraplegia and tetraplegia) was performed. Mann-Whitney's test was used for this purpose. Spearman's correlation rank test was used for identification of relationships between the signs. Intergroup differences and correlation relationships were significant with p < 0.05.
RESULTS
It was found that persons with TSCI had serious problems with realization of daily actions: values of functional independence with SCIM-III and FIM were significantly lower than the maximally possible values (100 points for SCIM-III and 126 points for FIM) (the table 1). The maximal sum of points for SCIM-III was 93, for FIM − 116 (1 patient).
Table 1
Values of functional independence in patients with traumatic disease of spinal cord (median (25 %-75 %))
|
|
SCIM-III, points |
FIM, total points |
|||
|
Total points |
Self-care |
Breathing/sphincter control |
Mobility |
||
|
All patients (n = 32) |
43.5 (27.5–67.0) |
15.0 (5.25–20.0) |
25.0 (18.0–30.75) |
10.0 (0.0–18.75) |
70.5 (51–100) |
|
Patients with paraplegia (n = 16) |
63.0 (47.0–81.0) |
20.0 (16.0–20.0) |
28.0 (26.0–35.0) |
16.0 (9.0–30.0) |
86.0 (71–103) |
|
Patients with tetraplegia (n = 16) |
27* (19.5–39.5) |
5.0* (1.0–10.0) |
19.0* (10.0–24.5) |
3.0* (0.0–5.0) |
50* (42–66) |
|
ð |
< 0.001 |
< 0.001 |
0.002 |
0.001 |
0.002 |
* – statistically significant differences between patients with para- and tetraplegi;a
ð – probability of no differences between groups with para- and tetraplegia .
The daily activity of 80 points and higher according to SCIM-III was in 17.9 % of cases, 60-79 points − 21.4 %, 40-59 points − 17.9 %, < 40 points − 42.8 %. The most intense disorders were in the section "mobility": none of patients had 40 points, which are maximal for this section. Only 17.9 % of patients had the summary point within 30-33. These persons could independently move in the bed, sit, move from the bed to the wheel-chair and back and walk with special technical measures (walking frame, crutches, canes). Almost a quarter of patients (21.4 %) could not perform any actions of movement activity without outside help (0 points; mainly patients with tetraplegia).
Most patients (64.3 %) required for aid or special secondary tools for realization of actions in section "self-care"; a third of them depended on other people.
For bowel and bladder functions, various disorders were observed in 89.3 % of patients with TSCI. Most of them needed for outside help during periodical catheterization, introduction of suppositories, use of individual measures for draining (condom catheter, urologic pads), or urination was realized with permanent catheter or epicystostoma.
68 % of patients could not toilet with all necessary manipulations (dressing and undressing, use of toilet paper, personal hygiene) independently (even with use of secondary methods).
The minimal values of all values of daily activity were observed in patients with cervical spine injury that was determined by disorder of movement function of both upper and lower extremities (tetraplegia − full disappearance of movement function of four extremities, tetraparesis − decrease in movement function), resulting in significantly reduced abilities for self-care and movement.
A study of the personal rehabilitation potential showed that most patients with TSCI had average (53.1 % of cases) or slightly higher than average (40.6 %) general level of the rehabilitation potential. Moreover, its level is determined by intense communication component: this value was higher than 60 % in 93.7 % of patients (the table 2). At the same time, the high incidence of low levels of self-estimate component (26.2 %) and internal picture of a disease (31 %) was observed. It supposed the predominance of pessimistic relation to the disease in this category of patients, as well as to own possibilities of recovery, and insufficiency of personal resources.
Table 2
Values of rehabilitation potential of personality in patients with traumatic spinal cord injury (the median (25 % - 75 %))
|
|
IPD |
MC |
EC |
SEC |
CC |
TLRPP |
|
All patients (n = 32) |
47.5 (35.0–55.0) |
58.3 (50.0–75) |
62.5 (41.0–75.0) |
62.5 (37.5–75.0) |
81.2 (75.0–87.5) |
58.0 (52.4–65.6) |
|
Patients with paraplegia (n = 16) |
52.5 (35.0–58.75) |
58.3 (52.0–89.6) |
69.0 (50.0–87.5) |
62.5 (41.0–87.9) |
81.2 (75.0–87.5) |
63.2 (52.4–74.1) |
|
Patients with tetraplegia (n = 16) |
45.0 (30.0–53.75) |
50.0 (35.4–75) |
56.2 (37.5–62.9) |
62.5 (27.75–72.0) |
81.2 (75.0–87.5) |
57.1 (49.5–59.7) |
The motional component, which presents the general emotional background of the patient's life and its change in relation to a disease in most patients with TSCI was high (56.2 %) or average (18.7 %). In 25 %, the level of this component was lower than 40 % that testified the inconsistence of mental status, impossibility to control own emotions and behavior than can negatively influence on results of rehabilitation.
The level of the motivation component in 50 % of patients was within 41-60 %, in 37.5 % − > 60 %, in 12.5 % − low. This component reflects the range of interests and a degree of activity of the patient in solving of home, professional (educational) problems and tasks relating to preservation (restoration) of health [5]. The low level of the motivation component of the rehabilitation component shows the absence of patient's interest to improvement of own condition and requires for individual approach to formation of the plan of the rehabilitation procedures.
The comparison of the values of the rehabilitation potential of personality did not find any statistically significant differences in comparison of patients with paraplegia and tetraplegia. Probably, it was associated with low number of groups, and further adjustment is needed.
The realization of the correlation analysis showed that the general level of the rehabilitation potential in persons with TSCI directly depended on levels of motivational, self-estimate and emotional components, and internal picture of a disease (the table 3).
Table 3
Coefficients of Spearman rank correlation between values of functional independence and components of rehabilitation component of person
|
|
SCIM-III |
FIM |
TLRPP |
|
Age |
-0.217 (ð = 0.267) |
-0.285 (ð = 0.142) |
-0.186 (ð = 0.308) |
|
Time after spinal cord injury |
0.128 (ð = 0.518) |
0.273 (ð = 0.16) |
-0.015 (ð = 0.937) |
|
TLRPP |
0.586 (ð = 0.001) |
0.437 (ð = 0.02) |
- |
|
IPD |
0.454 (ð = 0.015) |
0.275 (ð = 0.157) |
0,656 (ð=0,000) |
|
MC |
0.574 (ð = 0.001) |
0.452 (ð = 0.016) |
0.849 (ð < 0.0001) |
|
EC |
0.418 (ð = 0.027) |
0.381 (ð = 0.046) |
0.63 (ð < 0.0001) |
|
SEC |
0.353 (ð = 0.066) |
0.321 (ð = 0.091) |
0.769 (ð < 0.0001) |
|
CC |
-0.243 (ð = 0.213) |
-0.35 (ð = 0.067) |
-0.015 (ð = 0.937) |
Further analysis showed significant direct correlation relationships between the values of functional independence and total level of the personal rehabilitation potential, motivation and emotional components (the table 3). The patients with paraplegia showed negative correlation between values of the communication component and FIM functional independence: Spearman's correlation test ρ = -0.604, ð = 0.017, supposing the negative influence of high communication component on results of rehabilitation relating to excessive care and formation of dependence on people.
The methods of optimization of functional capabilities after spinal cord injury depend on a level and severity of an injury and on medical complications relating to an injury. One of the important elements of rehabilitation is mental aspect [10]. It has been shown that the condition of individual mental health can change the results of medical rehabilitation [11]. As known, rehabilitation is the interactive process, in which behavior of the patients can influence on results. A review by F. Al Huthaifi et al. (2017) presents the data showing that persons, which are more responsible to rehabilitation, likely have some personal characteristics, which promote increasing activity and participation, and, as result, level of functional independence on FIM [4]. Therefore, successful rehabilitation of such patients require for the complex approach with participation of medical psychologist. However, there is uncertainty in relation to selection of methods for estimation of personal resources in patients with TSCI. Therefore, there are not any actual findings which describe a relationship between a degree of daily activity and a level of rehabilitation potential. It resulted in carrying out of this study.
In conditions of the clinic of the rehabilitation center, 32 patients who received SSCI not more than 3 years ago were examined. It was shown that most patients had significant limitations of daily activity, mainly relating to evident movement disorders: only 17.9 % of examined persons could walk with use of various technical tools (walking frame, crutches, canes); other 82.1 % moved in the wheel-chair; more than 60 % of patients had full or partial dependence on other people. The average or high values of general level of the rehabilitation potential in 93.7 % suppose the presence of personal resources for increasing efficiency of rehabilitation in this category of patients. The identified significant direct correlations between values of functional dependence and general level of the rehabilitation potential confirm this assumption and present the perspective for increasing level of the personal rehabilitation potential in disabled persons with traumatic spinal cord injury for increasing their independence.
At the same time, it was found that the total level of the personal rehabilitation potential was mainly determined by the high communication component in 93.7 % of examined persons. This component shows the specifics of significant social relationships and the time course of interpersonal relationships during a disease [5]. Social support and favorable atmosphere in the family are necessary for a person with limited abilities in both mental and rehabilitation perspective, influencing on efficiency of treatment and rehabilitation. There are some publications, which show that caregivers are the important resource for treatment of patients with spinal cord injuries, especially, if the quality of care corresponds to quality of professional aid [12]. However, from other perspective, excessive care from other people can lead to negative results [13]. It is associated with the fact that excessive care presents an obstacle for manifestation and development of own activity of person. It is especially actual for relationship between child and parent. According to the literature data, such behavior creates the asymmetrical dependence in relationships, but also decreases self-efficiency and independence of aid receiver [14]. Therefore, the issue of necessity of training for caregivers dealing with persons with spinal cord injury is being discussed currently. In its turn, the increasing independence of aid receiver will allow reducing the requirement for care [15].
The formation of depended position in part of patients with TSCI is confirmed by high incidence of low self-care component (in 26.2 % of examined persons), internal picture of a disease (31 %), and absence of correlations between general level of the person's rehabilitation potential and the communication component. It is also confirmed by the data from persons with paraplegia: negative correlations were found between values of the communication component and FIM (Spearman's correlation test ρ = -0.604, ð = 0.017).
CONCLUSION
The results of our study and the literature data showed that increasing level of the rehabilitation potential (including motivation stimulation, correction of incorrect opinions about person, condition and role in the process of recovery, formation of positive self-care and partner relationships with relatives, improvement in emotional background) can efficiently increase the efficiency of rehabilitation and, as result, the level of functional independence in persons with TSCI. It requires for the interdisciplinary approach to rehabilitation with obligatory participation of medical psychologist and training of caregivers.
The present study is limited by low amount of examined persons with TSCI that did not allow identifying the features of the person's rehabilitation potential in individuals of various age, gender, social status, and realization of estimation of a relationship with values of daily activity in dependence on a level and a degree of spinal cord injury and duration of the posttraumatic period. It presents the perspective for further studies. At the same time, the received data can be helpful for practical activity of specialists of the multidisciplinary team.
CONCLUSION
1. More than 60 % of persons with spinal cord traumatic disease with prescription of injury up to 3 years partially or completely depend on other people in terms of various spheres of daily activity that is related to evident movement disorders.
2. In 93.7 % of patients with spinal cord traumatic disease, average and high levels of general level of the personal rehabilitation potential are observed. It testifies the presence of personal resources for increasing efficiency of rehabilitation in such patients.
3. The identified significant correlations between general level of the personal rehabilitation potential and sums of points of SCIM-III and FIM supposes the possibility for increasing degree of independence of disabled persons with spinal cord traumatic disease by means of increasing level of the personal rehabilitation potential. Direct correlations between level of the general personal rehabilitation potential and values of the motivation, self-estimate and emotional components and internal picture of a disease indicate some directions of impaction: for increasing motivation, self-estimate and for formation of adequate relation to a disease, and positive emotional feeling.
4. High level of the communication component in 93.7 % of patients does not correlate with general level of the personal rehabilitation potential, but with inverse relationships with FIM in persons with paraplegia (Spearman's rank test ρ = -0.604, ð = 0.017). It shows its negative role in the process of rehabilitation due to excessive care which promotes formation of dependence on other people.
Gratitude
The author thanks Pavlenko Lyudmila Viktorovna and Bushueva Ksenia Andreevna, the senior research assistants of the department of medical and social-professional rehabilitation of Novokuznetsk Scientific and Practical Centre for Medical and Social Expertise and Rehabilitation of Disabled Persons, for their participation in examination of the patients.
Information on financing and conflict of interests
The study was conducted without sponsorship. The author declares the absence of any clear or potential conflicts of interests relating to publication of this article.