Biopsychosocial factors associated with community reintegration of patients with traumatic spinal cord injury: A retrospective study

INTRODUCTION

Spinal cord injury (SCI) rehabilitation is a lengthy process that requires several remedial measures and sympathetic behavior from rehabilitation professionals and family members. In general, rehabilitative goals are decided mainly for improving functions and transforming the inclusion and reintegration of people with SCI into the mainstream of society.

The results of SCI not only damage independence and physical function but also cause many secondary conditions/complications (neurogenic bladder and bowel, urinary tract infections, pressure ulcers, orthostatic hypotension, fractures, deep vein thrombosis, spasticity, autonomic dysreflexia, pulmonary and cardiovascular problems, and depressive disorders) from the injury.^[1] Several studies have reported that individuals with SCI are treated for around 8–14 secondary conditions per year,^[2-4] which can complicate their health status and impact productivity/employment, dignity, mobility, independence, and quality of life.^[5,6] Post et al. point out that the prevalence of secondary complications and their impact on the health status of SCI individuals are often related to their level of social and psychological functioning, and even those were more important predictors of life satisfaction than the seriousness of the injury.^[7]

Increased social participation improves community reintegration and feelings of self-worth and confidence among individuals with SCI.^[8] However, several factors, such as support from caregivers, and social and psychological support, have been shown to affect community reintegration in people with SCI potentially.^[9-13]

Integration into the community is a multifaceted issue that refers to participation in societal functions, including occupation, recreation, social activities, and relationships with others. Inclusion (concept of community integration) is creating environments and situations where all people have equal access to opportunities, resources, and knowledge regardless of their abilities.^[14]

From a practical standpoint, it is important to acknowledge SCI individuals’ experience of medical issues by considering the dynamic interactions of physiological factors (bio) with psychological personal (psycho), and societal components (social).^[15] An extensive review of literature shows that there is a paucity of published literature on the biopsychosocial factors that affect the community reintegration of subjects with SCI in the Indian context. Hence, this retrospective study was designed to identify the possible factors influencing the community reintegration of subjects with SCI in Karnataka State of India.

The purpose of this study was to (1) investigate the bio-psychosocial processes of SCI individuals and (2) to find out which bio-psychosocial factor influences societal inclusion and integration of SCI individuals.

MATERIALS AND METHODS

A retrospective exploratory study was conducted, extracting relevant data from anonymized medical records of subjects with SCI who had registered for and evaluated in a state-level rehabilitation fair for paraplegics organized by the Department of Health and Family Welfare Government of India, in association with a tertiary care hospital of Dakshina Kannada District, Karnataka, India, and various NonGovernmental Organizations.

Medical records of patients over 18 years of age of either gender with traumatic SCI who were hospitalized for screening of secondary conditions from September 24 to 26, 2023, were included in the study. Individuals with SCI who had incomplete clinical assessment data on their medical records were excluded.

The Ethics Committee of Kasturba Medical College, Mangalore (Manipal Academy of Higher Education) approved the study (IEC KMC MLR 01/2024/40). The Institutional Review Board of the hospitals approved the review process and waived off the requirement to obtain patients’ written informed consent.

RESULTS

Data were collected from the records of a total of 94 subjects with SCI, whose mean age was 39.2 ± 10.1 years. Data regarding the age at the time of injury were available for 88 subjects, and it was 28.4 ± 10.9 years. Less than half of the subject population were married (45.7%), and 48.9% of the subjects attended university education. Demographic details of the subject population are given in Table 1.

Generalized anxiety disorder (GAD-2), patient health questionnaire (PHQ-2), and SCI secondary condition scale were other key independent variables collected, whereas reintegration to normal living index (RNLI) was the primary dependent variable. The range (Minimum–Maximum), median, and interquartile range values of these variables are listed in Supplementary File 2.

A correlation analysis revealed that age at the time of injury (rho = −0.256, P < 0.05), SCI secondary conditions scale (rho = −0.323, P < 0.05), and PHQ-2 (rho = −0.332, P < 0.05) showed statistically significant correlation with RNLI. All three variables showed a weak negative correlation [Table 2].

Multiple linear regression analysis showed that, when adjusted for other variables, only PHQ-2 scores and age at the time of injury were significant predictors for RNLI scores. Table 2 depicts the correlation and regression analysis findings.

DISCUSSION

The out-turn of SCI, SCI demands changes in every domain of life among the sufferers and endures itself as the root cause of many social and psychological problems. After discharge from acute rehabilitation, people with SCI and their families face more obstacles in learning to navigate the “real world” environment and society.^[15] Relatively, it is more beneficial for them to live within the community to gain a sense of self-worth and confidence^[8] in the interests of their early re-engagement and integration into the communities to achieve a promising quality of life. With this, our retrospective study focuses on investigating which bio-psychosocial characteristics influence the societal inclusion and reintegration of SCI individuals.

With the outset of demographic factors, the majority of the studied participants (n = 94) were young persons at their time of sustaining SCI, as mean age (28.4 ± 10.9) indicated and more males than females took part in the State-level Rehab Mela for paraplegics, Karnataka, India, from where we collected secondary data for retrospective analysis. All the recruited participants had traumatic SCI with a fall from height (63.8%) and motor vehicle accident (19.1%) as the leading causes, and the majority of them were managed by surgical treatment (80.9%). Ning et al., in 2012, in a systematic review, studied the epidemiology of traumatic SCI in Asia and observed that incidence rates ranged from 12.06 to 61.6 per million, with an average age of injured 26.8– 56.6 years and noted that motor vehicle accidents and falls were the main causes of traumatic SCI.^[20] In our study, the majority of them, that is, 69.1% had an injury at the thoracic level, and based on the ASIA impairment scale, 61.7% were complete (Grade A), 6.4%, and 31.9% with American Spinal Injury Association Grades B and C, respectively. Only 5.3% of individuals with SCI studied were not adapted, and 39.4% were completely adapted to their living/home arrangement. However, from the SCI-injured perspective home adaptability requires a multi-dimensional change of context from balancing loss and acceptance, facing external structural barriers to the strength of social relationships, and that will determine their transition to a meaningful life.^[21] Fundamentally, home environment adaptability will certainly assist people with SCI to perceive their rehabilitation-related acquisition skills as a meaningful footstep for future functioning and to reintegrate into the mainstream of society.

The majority of the participants in the present study suffered from one or more secondary conditions/complications following SCI, many of them having negative psychological consequences such as anxiety and depression, and their community reintegration score was low. This can be attributed to multifactorial causation, which may have arisen during the rehabilitation phase or after returning home to integrate into the community. Literature has established that people with SCI have higher comparative risks of anxiety disorder, elevated levels of anxiety, and feelings of helplessness, and approximately 30% of them are at risk of having depressive disorder, although in rehabilitation, and approximately 27% are at risk of having raised depressive symptoms when living in the community.^[22]

Achieving maximum functional independence and returning to pre-injury activity level was always the primary goal of rehabilitation programs for almost all non-traumatic and traumatic conditions. However, from a clinical perspective, understanding biological, psychological, and social factors and their influence on disease processes is extremely important to plan an effective treatment strategy to ensure the long-term goal of early community integration. In our study, correlational analysis showed that mobility, self-care, daily activity, recreational activity, and family roles which were evaluated with RNLI have a strong significant monotonic relationship with psychological variables such as mood disorder-depression and secondary conditions/complications associated with SCI. This may be suggestive of the certainty that the individuals with SCI who experienced secondary conditions had more difficulty in reintegration into the community. These results of our study are in line with studies of other developing countries, where they concluded that the presence of secondary health conditions limits the SCI individual’s ability to perform activities of daily living, education, and employment activities, participating in life situations resulting in poor community reintegration.^[23-26]

In the present study, the mean age at the time of sustaining SCI injury was 28.4 ± 10.9 and a moderate statistical significant association was observed in correlational analysis in our study. However, a few studies reported that having sustained an SCI at a younger age is associated with improved employment and education outcomes among individuals with SCI which often results in enhanced community reintegration.^[23,27,28] Meanwhile, the current age (39.2 ± 10.1) of the studied population showed no statistically significant association with the reintegration score, indicating that growing age is not a factor that decisively affects nature or outcomes related to societal inclusion. Similarly, no statistical association was noted between GAD-2 and community reintegration, which indicates that anxiousness concerning life situations alone may not act as a substantial barrier to social participation among these morbid individuals with SCI.

With reintegration into normal living as the dependent variable, our study results of multiple linear regression analysis showed that the research participant’s age at the time of sustaining SCI and psychological traits such as depression were the only explanatory variables that can affect the community integration among people with SCI. These findings of depression as an important psychological variable for explaining the reason behind limited community participation are analogous to the previous research.^[29,30] Considering the bio-psycho-social model of interacting factors for the person with SCI,^[15] we came to know that in our studied participants, mood disorder and their age at the time of injury may have cascaded into further impairment in their physical functioning and participation in family and societal roles. Considering that many studied participants experienced one or more secondary conditions following SCI, the results imply that psychological behavior may have been attributed to the seriousness of their secondary health conditions and this complication indirectly ruins their overall participation in the mainstream of society.

Community reintegration is one of the most important aspects of SCI rehabilitation, and likely the most challenging in terms of reorganizing the varied physical, emotional, and social characteristics of the injured. Almost all of the clinical rehabilitation-based goals were mainly focused on maximizing functional independence at one end, with tailored specific therapeutic measures, and at the other end to gain societal function adaptableness following their age and gender. However, the recovery phenomena of SCI injury may vary depending on many factors/barriers – from the individual’s level and severity of lesions to the environmental situations. Therefore, our study focused more on addressing the bio-psychosocial model to see which barrier from the SCI individual’s perspective affects community participation. With our study findings, it can be stated that psychological rehabilitation along with physical should be initiated from the acute care to the final phase of rehabilitation and requires adequate follow-up assessment related to home and social integration, productive activities based on the clinical expectation of maximum neurological recovery.

In this retrospective study, we consider the outcome measures for analyzing the bio-psychosocial characteristics with all the subjective screening tools, in which there may be few analytical biases due to recall errors and misreporting. However, our study findings reflected a general picture of the level of reintegration into the community of SCI victims. Future and further prospective research is required to be carried out in a diversified sample of individuals with SCI to address the bio-psychosocial variables’ affliction from the acute rehabilitation phase to the permanent community inclusion.

CONCLUSION

The findings of the study suggest that among a plethora of variables, age at the time of injury, psychological factors, and the prevalence of secondary conditions influence the community reintegration of subjects with SCI. Hence, from a clinical perspective, it’s imperative that any rehabilitation program aimed at social reintegration of subjects with SCI must be multidisciplinary with a mandatory focus on psychosocial variables.