Associations between personality traits and depressive and anxiety symptoms among persons with spinal cord injury in first inpatient rehabilitation.

STUDY DESIGN: Retrospective analysis of medical records. OBJECTIVE: To assess personality traits in persons with spinal cord injury (SCI) and compare these with the general population group. Moreover, to explore associations between personality traits and depressive and anxiety symptoms among persons with SCI in first inpatient rehabilitation. SETTING: Specialized rehabilitation center in The Netherlands. METHODS: Data were used from a routine psychological screening, administered in the first weeks of admission (N = 67). Measures included the Hospital Anxiety and Depression Scale and the Dutch Personality Questionnaire, which includes subscales measuring neuroticism, social inadequacy, rigidity, hostility, egoism, dominance, and self-esteem. Correlational and regression analyses were conducted. RESULTS: Mean age of the participants was 58 (SD 17) years. The majority (63%) were male, and had a low lesion (57%). The participants scored significantly higher on dominance and lower on social inadequacy, hostility, and egoism in comparison with the general population. In the bivariate regression analyses, high neuroticism (ß = 0.42 and ß = 0.53) and low self-esteem (ß = -0.25 and ß = -0.29) were significantly associated with increased depressive and anxiety symptoms. In the hierarchical regression analyses, only high neuroticism was significantly associated with increased depressive (ß = 0.42, p < 0.05) and anxiety (ß = 0.55, p < 0.001) symptoms. CONCLUSIONS: Personality traits are not the same between the SCI population and the general population. Assessment of personality traits early in inpatient rehabilitation can help to identify individuals at risk of mood problems and, thereby, facilitate interventions. Future research with a larger, representative SCI sample, is required to confirm these findings.

The social dimension of quality of life following spinal cord injury or disease: an international ICF-linking study.

STUDY DESIGN: International Classification of Functioning, Disability and Health (ICF) linking study. OBJECTIVE: Analyze cognitive interview data using the ICF as an analytic framework, to examine aspects of social life relevant to quality of life (QoL) according to people with spinal cord injury or disease (SCI/D). This study builds upon results of an international study about the cross-cultural validity of the International SCI QoL Basic Data Set (QoL-BDS). SETTING: Four specialized outpatient clinics in SCI/D rehabilitation, from the US, Brazil and Australia. METHODS: Analysis of qualitative data from 39 cognitive interviews with SCI/D patients at least one year post onset. Participants were asked to define their concept of QoL, overall life satisfaction, physical health and psychological health, and other relevant matters. Four independent researchers coded text fragments related to the items, and fragments were linked to ICF chapters d6-d9, following established linking rules. RESULTS: The proportion of text referring to social life was 35.8% (definition QoL), 24.9% (QoL life as whole), 6.0% (physical health) and 34.9% (psychological health). The most frequent ICF categories were d760 Family relationships, d770 Intimate relationships and d920 Recreation and leisure. Most frequent responded social topics to the 'other issues' item were d770 Intimate relationships, d760 Formal relationships, and d870 Economic self-sufficiency. CONCLUSION: The importance of social life aspects to the QoL was highlighted based on responses of SCI/D patients, clearly demonstrated through the ICF linking process. Adding a satisfaction with social life item to the QoL-BDS has made this instrument a more comprehensive measure.

Reliability and validity of the Brief Illness Perception Questionnaire (B-IPQ) in individuals with a recently acquired spinal cord injury.

OBJECTIVE: To assess the reliability and validity of the Brief Illness Perception Questionnaire (B-IPQ) and possible subscales, and to interpret Brief Illness Perception Questionnaire (B-IPQ) total scores, in individuals with a spinal cord injury. DESIGN: Cross-sectional. SETTING: Seven Dutch rehabilitation centres. SUBJECTS: Individuals with a recently acquired traumatic or non-traumatic spinal cord injury at the start of inpatient spinal cord injury rehabilitation (N = 270). MAIN MEASURE: The Brief Illness Perception Questionnaire (B-IPQ) consists of eight items on an individual's cognitive and emotional representation of one's health conditions. Principal component analysis was performed to identify possible Brief Illness Perception Questionnaire (B-IPQ) subscales. Validity was assessed by testing hypotheses on correlations between the Brief Illness Perception Questionnaire (B-IPQ) and other measures. Cut-off points of the Brief Illness Perception Questionnaire (B-IPQ) total score were determined. RESULTS: Mean (SD) age of participants was 60.1 (16.5) years, 188 (71%) were male, and 119 (44%) had tetraplegia. Three potential subscales were revealed. Cronbach's alpha was acceptable for only one subscale. This subscale was named 'consequences' and included the items 'consequences', 'symptom burden', 'concern', and 'emotions'. The Brief Illness Perception Questionnaire (B-IPQ) total and the consequence subscale showed the expected strong correlations (>.50) with symptoms of anxiety and depression. Mean (SD) scores were 40.9 (12.3) on the 8-item Brief Illness Perception Questionnaire (B-IPQ) (range 0-80) and 25.1 (8.1) on the consequences subscale (range 0-40). Cut-off points for the Brief Illness Perception Questionnaire (B-IPQ) total score were determined as follows: <42 indicating low experienced threat, 42-49 indicating moderate experienced threat, and ≥50 indicating high experienced threat. CONCLUSION: The Brief Illness Perception Questionnaire (B-IPQ) total and consequences subscale seem applicable in individuals with a spinal cord injury in the rehabilitation practice and research.

Illness perception of individuals with spinal cord injury (SCI) during inpatient rehabilitation: a longitudinal study.

STUDY DESIGN: Multicentre longitudinal study. OBJECTIVES: To assess overall illness perception and specific illness representations at admission and discharge of inpatient spinal cord injury (SCI) rehabilitation, and to detect associations between demographic and injury-related variables, and illness perception. SETTING: Seven Dutch SCI-specialised rehabilitation centres. METHODS: Participants aged >18 years with a recent SCI were screened for cognitive and emotional illness representations at admission and discharge with the Brief Illness Perception Questionnaire (B-IPQ). Differences between B-IPQ item scores at admission and discharge were analysed with the Wilcoxon signed-rank test. Differences between B-IPQ total scores were analysed with the paired-samples t-test. Associations between B-IPQ total scores and other variables were tested with bivariable and multivariable regression analyses. RESULTS: B-IPQ results were available for 270 participants at admission (71% male, 59% paraplegia, 83% incomplete) and 119 at discharge (68% male, 50% paraplegia, 78% incomplete). The extent to which people experienced their SCI as a threat was highest for: 'consequences', 'symptom burden' and 'concern' both at admission and discharge. Participants generally experienced less threat at discharge. A more threatening illness perception was significantly associated with older age, complete SCI and a history of cognitive problems at admission. Age and completeness of injury, together, explained 12% of the variance of overall illness perception at admission. CONCLUSIONS: For most individuals, illness perception positively changed during SCI rehabilitation. Measuring illness perception in inpatient rehabilitation could support the identification of specific treatment goals in order to improve adjustment after SCI.

Post-traumatic stress disorder symptoms and pain intensity in persons with spinal cord injury.

STUDY DESIGN: Cross-sectional. OBJECTIVES: To examine the association between post-traumatic stress disorder (PTSD) symptoms and pain intensity, taking symptoms of anxiety and depression into account within persons with spinal cord injury (SCI). SETTING: Persons with SCI, who visited a Dutch rehabilitation centre between 2005 and 2010, were invited to complete a survey. METHODS: PTSD symptoms were measured with the Trauma Screening Questionnaire (TSQ), pain intensity with an 11-point Numerical Rating Scale (NRS), and symptoms of anxiety and depression with the Hospital Anxiety and Depression Scale (HADS). To determine associations between PTSD symptoms and pain intensity, linear regression analyses were performed. Confounding variables representing anxiety and depression were added to the final model. RESULTS: In total, 175 participants (55.8% traumatic, 29.1% complete) were included (response rate of 31.7%). Of them, 11.4% had clinically relevant symptoms of probable PTSD (TSQ score ≥ 6) 69.8% experienced moderate to severe pain levels (NRS ≥ 4), 14.9% had symptoms of anxiety and 20.8% symptoms of depression (HADS scores ≥ 11). Levels of PTSD symptoms were strongly associated with symptoms of anxiety (0.54) and depression (0.49). Bivariate analyses showed a moderate significant association (0.30) between PTSD symptoms and pain intensity. This association became small (0.10) when anxiety and depression comorbidity were factored into the final regression model. CONCLUSIONS: No independent association between PTSD symptoms and pain intensity was shown when adjusted for anxiety and depression. Results of this study suggest the usefulness of screening for PTSD in persons with SCI (regardless of injury cause or type/level) who score high on symptoms of anxiety/depression.

Changes in Quality of Life During Training for the HandbikeBattle and Associations With Cardiorespiratory Fitness.

OBJECTIVE: To investigate (1) changes in life satisfaction and mental health during 5 months of training for the HandbikeBattle and 4 months of follow-up; (2) associations between changes in handcycling cardiorespiratory fitness and changes in life satisfaction and mental health during the training period. DESIGN: This is a multicenter prospective cohort study with the following measurements: the start of the training (T1), after the 5-month training period, before the event (T2), and after 4 months of follow-up (T3). At T1, T2, and T3, questionnaires were filled out. At T1 and T2, a graded exercise test was performed to measure cardiorespiratory fitness (peak oxygen consumption [Vo2peak] and peak power output [POpeak]). SETTING: Ten Dutch rehabilitation centers training for the HandbikeBattle event. PARTICIPANTS: Patients with a rehabilitation history (N=136) and health conditions such as spinal cord injury, amputation, or multiple trauma history. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Life satisfaction as the sum score of 2 questions (range, 2-13) and the Mental Health subscale of the 36-item Short Form Health Survey (range, 0-100). RESULTS: Multilevel regression analyses showed that life satisfaction increased during the training period and did not significantly change during follow-up (mean ± SD, T1: 8.2±2.2; T2: 8.6±2.3; T3: 8.5±2.4). Mental health showed no change over time (T1: 77.7±14.5; T2: 77.8±14.5; T3: 75.7±16.5). An improvement in cardiorespiratory fitness was associated with an increase in life satisfaction (POpeak, ß=0.014, P=.046; Vo2peak, ß=1.068, P=.04). There were no associations between improvement in cardiorespiratory fitness and an increase in mental health (POpeak, P=.66; Vo2peak, P=.33). CONCLUSIONS: This study shows a positive course of life satisfaction during training for the HandbikeBattle. An improvement in cardiorespiratory fitness was longitudinally associated with an increase in life satisfaction. Mental health showed no changes over time.

Performance and Self-reported Functioning of People With Chronic Idiopathic Axonal Polyneuropathy: A 4-Year Follow-up Study.

OBJECTIVE: To describe the course of performance of activities (observed and self-reported) of people with chronic idiopathic axonal polyneuropathy (CIAP) over 4 years and to assess the associations with muscle strength, sensory function, and psychological personal factors (intention, perceived behavior control [PBC], and feelings of depression or anxiety). DESIGN: Prospective observational study with measurement at baseline, 6 months, 1 year, and 4 years. SETTING: Outpatient neurology clinic. PARTICIPANTS: People with CIAP (N=92). MAIN OUTCOME MEASURES: Walking was measured using the shuttle-walk test (SWT), a pedometer (mean step count/d), and the "physical functioning" subscale of the Short Form-36 questionnaire. Muscle strength and sensory function were measured using a MicroFET handheld dynamometer and the Sensory Modality Sum score. Personal factors were assessed with the Hospital Anxiety and Depression Scale, and intention and PBC were assessed with a protocolized questionnaire. RESULTS: Multilevel model analysis showed a significant decrease over time in mean scores in performance of activities (SWT, step count), which was associated with older age and loss of muscle strength (SWT: ß=73.392, step count: ß=676.279, P<.001). Limitations in self-reported functioning (physical functioning) significantly increased and were associated with older age (ß=-0.916, P=.001), increased comorbidity (ß=-6.978, P=.024), loss of muscle strength (ß=7.074, P<.001), low PBC (ß=0.744, P<.001), and increased feelings of depression (ß=1.481, P<.001). CONCLUSIONS: Performance of activities of people with CIAP decreased over time (SWT, step count, physical functioning). Older age, loss of muscle strength, comorbidity, feelings of depression, and low perceived behavior control were associated with this decrease. However, there were considerable individual differences.

Measuring resilience with the Connor-Davidson Resilience Scale (CD-RISC): which version to choose?

STUDY DESIGN: Cross-sectional psychometric study. OBJECTIVES: To compare psychometric properties of the Connor-Davidson Resilience Scale (CD-RISC) with 25, 10, and 2 items, and to assess the agreement between these versions in individuals with spinal cord injury (SCI). SETTING: Standard psychological screening at a Dutch rehabilitation centre during the first 2 weeks of inpatient rehabilitation. METHODS: Anonymous data from the psychological screening were analysed. CD-RISC outcomes were checked for floor and ceiling effects. Internal consistency was assessed by calculating Cronbach's α. Convergent validity was assessed by Spearman's correlation between resilience and anxiety, depression, passive coping, and life satisfaction. Agreement between CD-RISC versions was examined by calculating intraclass correlation coefficients (ICCs), corresponding 95% confidence intervals (CIs), and Bland-Altman plots. RESULTS: Total CD-RISC scores were only skewed on the CD-RISC 2 (-1.12). There were no floor and ceiling effects. Internal consistency of the 25-, 10-, and 2-item scales was good to moderate (0.90, 0.86, and 0.66, respectively). Good convergent validity was shown only for the CD-RISC 10. Agreement was highest between the CD-RISC 25 and CD-RISC 10 with an ICC of 0.90 with 95% CI from 0.85 to 0.94. CONCLUSIONS: Out of the three CD-RISC versions, the CD-RISC 10 showed the best combination of reliability, validity, and practicality. Therefore, this version is advised as measure of resilience in individuals with SCI in a rehabilitation setting. Measurement of resilience could be part of a psychological screening to identify individuals at risk to develop psychological problems after SCI.

Body Image in Patients With Spinal Cord Injury During Inpatient Rehabilitation.

OBJECTIVES: (1) To investigate the course of body image in patients with spinal cord injury (SCI) during their first inpatient rehabilitation stay; and (2) to explore the association between demographic and injury-related variables and body image and the association between body image and psychological distress. DESIGN: Longitudinal inception cohort study. SETTING: Rehabilitation center. PARTICIPANTS: Of the 210 people admitted for their first inpatient SCI rehabilitation program (between March 2011 and April 2015), 188 met the inclusion criteria. Of these, N=150 (80%) agreed to participate. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: The Body Experience Questionnaire was used to measure 2 dimensions of body image: alienation and harmony. RESULTS: Mean scores on the Body Experience Questionnaire alienation subscale decreased significantly during the rehabilitation program. Mean scores on the Body Experience Questionnaire harmony subscale did not increase significantly but showed a trend in the hypothesized direction. The 2 subscales showed weak correlations with demographic and injury-related variables. The 2 subscales together explained 16% and 14% of the variance of depression and anxiety, respectively, after correction for demographic and injury-related variables. CONCLUSIONS: During participants' first inpatient rehabilitation stay after SCI, body image progressed toward a healthier state. Body image explains part of the variance in depression and anxiety, and the entire rehabilitation team should be targeting interventions to improve body image.

Social skills: a resource for more social support, lower depression levels, higher quality of life, and participation in individuals with spinal cord injury?

OBJECTIVE: To examine the relevance of social skills and their different dimensions (ie, expressivity, sensitivity, control) in relation to social support, depression, participation, and quality of life (QOL) in individuals with spinal cord injury (SCI). DESIGN: Cross-sectional data collection within the Swiss Spinal Cord Injury Cohort. SETTING: Community-based. PARTICIPANTS: Individuals with SCI (N=503). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Depression, participation, and QOL were measured using the Hospital Anxiety and Depression Scale, the Utrecht Scale for Evaluation of Rehabilitation-Participation, and 5 selected items of the World Health Organization Quality of Life Scale. The Social Skills Inventory and the Social Support Questionnaire were used to assess social skills (expressivity, sensitivity, control) and social support, respectively. RESULTS: Structural equation modeling was conducted. In model 1 (χ(2)=27.81; df=19; P=.087; root mean square error of approximation=.033; 90% confidence interval=.000-.052), social skills as a latent variable was related to social support (ß=.31; R(2)=.10), depression (ß=-.31; total R(2)=.42), and QOL (ß=.46; R(2)=.25). Social support partially mediated the effect of social skills on QOL (indirect effect: ß=.04; P=.02) but not on depression or participation. In model 2 (χ(2)=27.96; df=19; P=.084; root mean square error of approximation=.031; 90% confidence interval=.000-.053), the social skills dimension expressivity showed a path coefficient of ß=.20 to social support and ß=.18 to QOL. Sensitivity showed a negative path coefficient to QOL (ß=-.15) and control a path coefficient of ß=-.15 to depression and ß=.24 to QOL. CONCLUSIONS: Social skills are a resource related to more social support, lower depression scores, and higher QOL.

Modeling life satisfaction in spinal cord injury: the role of psychological resources.

PURPOSE: The aims of the study were (1) to examine the associations between the psychological resources general self-efficacy (GSE) and purpose in life (PIL), appraisals, coping and life satisfaction, and (2) to examine whether the effects of the psychological resources on life satisfaction are mediated by appraisals and coping, as proposed by the spinal cord injury adjustment model (SCIAM). METHODS: Cross-sectional multicenter study conducted with persons with spinal cord injury (SCI) living in the community in Switzerland (N = 516). Pearson's correlations were calculated for aim 1, and structural equation modeling was conducted to address aim 2. RESULTS: GSE (r = .48) and PIL (r = .58) were positively related to life satisfaction. The initial model corresponding to the SCIAM yielded a poor model fit. The final model had a good model fit [χ (2) = 66.0, df = 21, p < .01, RMSEA = .065 (90 % confidence interval .048-.082), CFI = .97] explaining 57 % of variance of life satisfaction. PIL had a direct large effect on life satisfaction (ß = .54). The influence of GSE on life satisfaction was mediated by loss appraisals. Avoidance, active and humor coping had small effects on life satisfaction. CONCLUSIONS: Psychological resources have a substantial effect on life satisfaction in persons with SCI. Our results correspond with the SCIAM and its conceptualization of adjustment as a multifactorial process, but did not fully support the hypothesized mediation. PIL was strongly related to higher life satisfaction and may be a suitable intervention target to support persons with SCI.

Psychological resources, appraisals, and coping and their relationship to participation in spinal cord injury: a path analysis.

OBJECTIVE: To test the Spinal Cord Injury Adjustment Model and gain a better understanding about whether and how the psychological resources general self-efficacy (SE), purpose in life (PIL), appraisals, and coping influence participation in persons with spinal cord injury (SCI). DESIGN: Cross-sectional data collection within the Swiss Spinal Cord Injury Cohort. SETTING: Community setting. PARTICIPANTS: Persons with SCI (N=516) who are ≥ 16 years old and living in the community in Switzerland. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Participation was measured with the restrictions subscale of the Utrecht Scale for Evaluation of Rehabilitation-Participation, General SE with the General Self-Efficacy Scale, PIL with the Purpose in Life Test-Short Form, appraisals with the Appraisal of Life Events Scale, and coping with the Brief COPE. RESULTS: General SE (r=.32) and PIL (r=.23) were associated with less participation restrictions. The initial model yielded a poor model fit. The modified final model had an acceptable fit (χ(2)11=36.2; P<.01; root mean square error of approximation=.067 [90% confidence interval: .045-.09]; comparative fit index=.98). A total of 15% of the variance of participation was explained. In the final model, general SE had a moderate direct effect (ß=.24) and mediated effects via threat appraisal and challenge appraisal and humor on participation, indicating a partial mediation effect. The association between PIL and participation was indirect: challenge appraisal and humor acted as mediators. CONCLUSIONS: The results only partly support the double-mediating effect as suggested in the SCI adjustment model because both direct and indirect effects on participation were observed. Individuals with higher general SE and PIL perceive less participation restrictions. General SE seems an appropriate target to enhance participation. Longitudinal studies are needed to support our findings.

The Effect of Mindset and Breathing Exercises on Physical and Mental Health in Persons with Spinal Cord Injury-A Pilot Feasibility Study.

This study investigated the feasibility and efficacy of mindset and breathing exercises (Wim Hof Method (WHM)) on physical and mental health in persons with spinal cord injury (SCI). Ten individuals with SCI participated in this pilot study. These ten participants followed a 4-week WHM intervention, with one weekly group session in the rehabilitation center and daily practice at home using the WHM app. An in-person exit-interview was conducted post-intervention to collect qualitative information on participants' experiences, regarding the feasibility and effects of the intervention. Furthermore, tests and questionnaires were administered pre- and post-intervention to assess physical and mental health outcomes. Adherence to the weekly in-person meetings was excellent and no adverse events occurred. Physical and mental health outcomes in this small sample size showed some pre-post differences. This pilot feasibility study provides preliminary evidence supporting the feasibility and efficacy of the WHM, including mindset and breathing exercises, on physical and mental health of people with SCI. These results warrant a randomized-controlled trial, including cold exposure, of this novel intervention in people with SCI.

Changes in body satisfaction during and after a 5-month handcycle training period and associations with physical capacity and body composition in individuals with a physical impairment.

PURPOSE: To investigate: (1) changes in body satisfaction during five months of handcycle training and one year after the training period; (2) whether longitudinal changes are dependent on sex, waist circumference and severity of the physical impairment; (3) associations between changes in physical capacity or body composition, and body satisfaction. MATERIALS AND METHODS: Individuals (N = 143) with health conditions such as spinal cord injury filled out the Adult Body Satisfaction Questionnaire: at the start of the training (T1), directly after the training period (T2); and four months (T3) and one year after the training period (T4). At T1 and T2, physical capacity was determined with an upper-body graded exercise test, and waist circumference was measured. Handcycling classification was used as a proxy for the severity of impairment. RESULTS: Multilevel regression analyses showed that body satisfaction significantly increased during the training period and significantly decreased back to pre-training levels at follow-up. Individuals with more severe impairments showed a larger decrease at T4. Improvements in physical capacity and waist circumference were significantly associated with improvements in body satisfaction. CONCLUSIONS: Body satisfaction significantly increased during the training period, but significantly decreased during follow-up. Additional efforts might be necessary to keep individuals engaged in long-term exercise.

Body image disturbances are frequently described in individuals with a physical impairment.An increase in body image can be achieved by improvements in physical capacity and waist circumference as a consequence of training.It is important to keep individuals engaged in exercise, as body satisfaction decreases after termination of the training period.For individuals with severe physical impairments additional efforts are necessary to keep them engaged in exercise.

Effect of Training for an Athletic Challenge on Illness Cognition in Individuals with Chronic Disability: A Prospective Cohort Study.

Illness cognitions (IC) influence how a patient adapts to a chronic disease. The aim was (1) to determine if training for a handcycling mountain time trial (HandbikeBattle) improves IC and (2) to identify factors associated with IC change scores. Persons with a chronic disability (N = 220; including N = 151 with spinal cord disorder) trained 5 months and participated in the time trial. The IC Questionnaire measured helplessness, acceptance, perceived benefits and was assessed before training (T1), after training (T2), and four months after the event (T3). Age, sex, body mass index (BMI), time since injury (TSI), disability characteristics, self-efficacy, mental health (MH) and musculoskeletal pain were obtained at T1. Multilevel regression analyses showed that helplessness decreased (from 11.96 to 11.28, p < 0.01) and perceived benefits increased (from 16.91 to 17.58, p < 0.01) from T1 to T2. For helplessness this decrease persisted during follow-up (11.16 at T3). Changes in helplessness were associated with self-efficacy (p = 0.02), MH (p = 0.02) and lesion completeness (p = 0.02), and were independent of disability type (p = 0.66), lesion level (p = 0.30) and demographics such as sex (p = 0.29) and age (p = 0.67). Training with peers may improve helplessness and perceived benefits in individuals with a chronic disability. Especially individuals with MH problems might benefit from training for an athletic challenge with peers to improve illness cognitions, and ultimately, quality of life.

Changes in life satisfaction in persons with spinal cord injury during and after inpatient rehabilitation: adaptation or measurement bias?

PURPOSE: To analyze changes in life satisfaction (LS) scores over time in persons with spinal cord injury (SCI) and to interpret what these changes mean. METHODS: Multicenter, prospective cohort study of persons with SCI (n = 96) classified into 3 life satisfaction trajectories identified earlier. Assessment took place 6 times from the start of active rehabilitation up to 5 years after discharge. Three LS scores were compared: (1) LS 'now' score, (2) 'comparison' score between LS 'now' and LS 'before the SCI', and (3) retrospective score of LS 'before the SCI'. RESULTS: Persons in the low LS trajectory showed increase in the LS 'now' score, but not in the LS 'comparison' score and retrospective score. Persons in the recovery trajectory showed increase in the LS 'now' and LS 'comparison' scores, but not in the retrospective score. Persons in the high LS trajectory showed increase in the 'comparison' LS score and decrease in the retrospective score, but no change in the LS 'now' score. CONCLUSIONS: Diverging patterns of change were found and that were interpreted as adaptation or scale recalibration. Recalibration could also be considered healthy rebalancing after SCI. Being able to compare different LS ratings can facilitate the interpretation of change in and stability of LS.

Validity of the Life Satisfaction questions, the Life Satisfaction Questionnaire, and the Satisfaction With Life Scale in persons with spinal cord injury.

OBJECTIVE: To assess and compare the validity of 3 life satisfaction instruments in persons with spinal cord injury (SCI). DESIGN: Cross-sectional study 5 years after discharge from inpatient rehabilitation. SETTING: Eight rehabilitation centers with specialized SCI units. PARTICIPANTS: Persons (N=225) with recently acquired SCI between 18 and 65 years of age were included in a cohort study. Data were available for 145 persons 5 years after discharge. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The Life Satisfaction questions (LS Questions), the Life Satisfaction Questionnaire (LiSat-9), and the Satisfaction With Life Scale (SWLS). RESULTS: There were no floor or ceiling effects. Cronbach α was questionable for the LS Questions (.60), satisfactory for the LiSat-9 (.75), and good for the SWLS (.83). Concurrent validity was shown by strong and significant Spearman correlations (.59-.60) between all 3 life satisfaction instruments. Correlations with measures of mental health and participation were .52 to .56 for the LS Questions, .45 to .52 for the LiSat-9, and .41 to .48 for the SWLS. Divergent validity was shown by weak and in part nonsignificant correlations between the 3 life satisfaction measures and measures of functional independence and lesion characteristics. CONCLUSIONS: Overall, the validity of all 3 life satisfaction measures was supported. Despite questionable internal consistency, the concurrent and divergent validity of the LS Questions was at least as good as the validity of the LiSat-9 and the SWLS.

Trajectories and predictors of the course of mental health after spinal cord injury.

OBJECTIVE: To study the course and predictors of mental health in the period between the start of active spinal cord injury (SCI) rehabilitation and 5 years after discharge. The hypothesis was that different mental health trajectories would be identified. DESIGN: Multicenter prospective cohort study with measurements at the start of active rehabilitation, after 3 months, at discharge, 1, 2, and 5 years after discharge. SETTING: Eight Dutch rehabilitation centers with specialized SCI units. PARTICIPANTS: Persons (N=206) with recently acquired SCI aged between 18 and 65 years. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: The 5-item Mental Health Index with a total score between 0 (lowest mental health) and 100 (highest mental health). RESULTS: Levels of mental health increased between the start of active rehabilitation and 3 months later, remained stable thereafter, and increased again between 2 and 5 years after discharge. Latent class growth mixture modeling revealed 5 trajectories: (1) high scores (above 80) at all time-points (52%), (2) low scores (≤60) at all time-points (4%), (3) early recovery from 40 to scores above 70 (13%), (4) intermediate scores from 60 to scores above 70 (29%), and (5) severe deterioration of scores above 70 to scores below 30 (2%). Pain, sex, and education level were predictors to distinguish between the 5 trajectories. CONCLUSIONS: Five different mental health trajectories were identified between the start of active rehabilitation and 5 years after discharge. About one third of the persons with SCI still perceived moderate to severe mental health problems 5 years after discharge. Pain, sex, and education level only predicted a small part of the variance in mental health trajectories.

Relationships between activities, participation, personal factors, mental health, and life satisfaction in persons with spinal cord injury.

OBJECTIVE: To clarify relationships between activities, participation, mental health, and life satisfaction in persons with spinal cord injury (SCI) and specify how personal factors (self-efficacy, neuroticism, appraisals) interact with these components. We hypothesized that (1) activities are related directly to participation, participation is related directly to mental health and life satisfaction, and mental health and life satisfaction are 2 interrelated outcome variables; and (2) appraisals are mediators between participation and mental health and life satisfaction, and self-efficacy and neuroticism are related directly to mental health and life satisfaction and indirectly through appraisals. DESIGN: Follow-up measurement of a multicenter prospective cohort study 5 years after discharge from inpatient rehabilitation. SETTING: Eight Dutch rehabilitation centers with specialized SCI units. PARTICIPANTS: Persons (N=143) aged 18 to 65 years at the onset of SCI. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Mental health was measured by using the Mental Health subscale of the 36-Item Short Form Health Survey and life satisfaction with the sum score of "current life satisfaction" and "current life satisfaction compared with life satisfaction before SCI." RESULTS: Structural equation modeling showed that activities and neuroticism were related to participation and explained 49% of the variance in participation. Self-efficacy, neuroticism, and 2 appraisals were related to mental health and explained 35% of the variance in mental health. Participation, 3 appraisals, and mental health were related to life satisfaction and together explained 50% of the total variance in life satisfaction. CONCLUSIONS: Mental health and life satisfaction can be seen as 2 separate but interrelated outcome variables. Self-efficacy and neuroticism are related directly to mental health and indirectly to life satisfaction through the mediating role of appraisals.

Trajectories in the course of life satisfaction after spinal cord injury: identification and predictors.

OBJECTIVE: To identify different life satisfaction trajectories in the period between the start of active spinal cord injury (SCI) rehabilitation and 5 years after discharge, and to find predictors for distinguishing between trajectories. The hypotheses were that different life satisfaction trajectories would be identified and that demographic, lesion, physical, and social characteristics would be predictors of life satisfaction trajectory membership. DESIGN: Multicenter prospective cohort study with measurements at the start of active rehabilitation, after 3 months, at discharge, and 1, 2, and 5 years after discharge. SETTING: Eight Dutch rehabilitation centers with specialized SCI units. PARTICIPANTS: Persons (N=225) with recently acquired SCI between the ages of 18 and 65 years were included, and data from 206 persons were analyzed. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Life satisfaction was measured as the sum score of "current life satisfaction" and "current life satisfaction compared with life satisfaction before SCI" (range, 2-13). RESULTS: Five life satisfaction trajectories were identified by using latent class growth mixture modeling: (1) low median scores (3-5) at all time points (27%), (2) intermediate scores (6-7) at all time points (31%), (3) high scores (8-10.5) at all time points (17%), (4) improvements from 3 to 9 (23%), and (5) deterioration from 9 to 4 (2%). Logistic regression showed that predictors of the low versus high life satisfaction trajectory were functional independence and pain. Predictors of the low life satisfaction versus the recovery trajectory were sex and functional independence. These predictors explained only a small part of the total variance. CONCLUSIONS: Life satisfaction in people with SCI follows distinct trajectories. Monitoring life satisfaction at the start of active rehabilitation and 3 months later might allow identification of persons at risk for poor long-term adjustment.