INTRODUCTION
A spinal cord injury (SCI) can cause damage to the central nervous system because of spinal cord pressure and can be described as a state in which motor, sensory, and autonomic nerve functions are impaired. Moreover, SCI can cause severe sequelae in both the mind and body [1]. According to statistics on SCI patients in Korea, as of 2018, the incidence rate was approximately 23 cases per million population. The leading causes of SCI are traffic accidents and falls. Additionally, about 75% of SCI patients are men, predominantly aged between 40 and 60. Data from 2009 to 2018 reveal that the main causes of SCI are traffic accidents (50.3%), falls (27.2%), and sports activities (12.6%) [2].
SCI is a permanent disability that can lead to physical health problems, namely, bladder and bowel control disorders, pain, and bedsores, among others [3]. Despite the varying levels of injury, all spinal cord injury (SCI) patients experience limited physical activity and decreased movement, leading to reduced energy consumption [4]. This reduction in daily activities among SCI patients can result in chronic diseases such as hypertension, hyper-cholesterolemia, diabetes mellitus, and metabolic syndrome. These can lead to cardiovascular diseases and potentially increase patient mortality [5]. Therefore improving the activities of daily living (ADL) among people with SCI is essential.
Additionally, people with SCI can develop psychosocial problems such as loneliness, depression, and anxiety. This is brought about by their decreased social activity and interaction with people as well as breaks from their community [6]. Depression is prevalent among 22∼43% of patients with SCI, with a higher prevalence among patients with comorbid medical conditions [7]. Moreover, depression can reduce independent activities [8] which can increase levels of depression, creating a vicious cycle. Reduced physical activity can also negatively impact the QoL of people living with SCI. Therefore, the physical and psychosocial health problems associated with SCI may affect patients’ quality of life (QoL) [9]. People with spinal cord injuries have to live with disabilities for a long period of their lives, They experience physical, mental, economic, and social difficulties because the damage is caused by sudden accidents [6,9].
Furthermore, it has been found that falling is another problem affecting the QoL of people living with SCI. SCI affects balance and walking ability, which can increase the risk of falling among patients [10]. Hence, falls can reduce the QoL of patients with SCI [10]. These patients experience at least one fall between 6 and 12 months after their injuries [11]. Falls can be caused by various medical conditions, such as arthritis, dizziness, and fear of falling (FoF) [5,11]. Unfortunately, they can result in secondary complications such as head trauma, soft tissue injuries, fractures, and dislocations [11], further perpetuating FoF among people living with SCI. FoF is a predictor of falling [12] and can be regarded as a variable related to QoL. Despite this, studies on the relationship between FoF, depression, ADL, and QoL of people living with SCI are limited. Many studies provide cross-sectional data on depression and quality of life in SCI patients, but there is a lack of long-term follow-up research. Longitudinal data can offer critical insights into how the psychological and physical health of SCI patients evolves over time. Additionally, there is a shortage of comprehensive research on how FoF is directly related to physical activity and how this, in turn, affects psychological states such as depression. Understanding these interactions is essential for developing more effective intervention programs [13].
SCI patients face physical, psychological, and social challenges after their injury. Understanding how these factors impact their quality of life is essential for developing more effective rehabilitation and support programs. For example, fear of falling can limit a patient's physical activity, which in turn can exacerbate psychological issues such as depression. Additionally, the ability to perform ADL is directly linked to the independence of SCI patients, and a decline in this ability can increase psychological stress and depression. SCI is a complex neurological condition that affects patients physically, psychologically, and socially. After injury, patients experience long-term loss of physical function, psychological stress, and economic burdens. Therefore, research on evaluating and improving the quality of life for these patients is necessary to enhance their overall health and well-being. Therefore, the purpose of this study is to investigate the relationships between FoF, ADL, psychological difficulties (such as depression), and QoL in SCI patients. Understanding these factors is crucial for the development of targeted interventions that can improve the overall quality of life for SCI patients.
This study aims to identify factors affecting the QoL of patients with SCI. The specific research objectives are as follows: (1) identify the general characteristics of patients with SCI, depression, FoF, ADL, and QoL; (2) analyze the relationship between the general characteristics of patients with SCI, depression, FoF, ADL, and QoL; and (3) identify the factors affecting the QoL of patients with SCI.
METHODS
1. Design and Participants
This study used a prospective cross-sectional design. The study participants were patients with SCI from Rehabilitation Medicine's outpatient department at a general hospital in D City, Korea. The selection criteria for participants were as follows: (a) aged 19 years or older; (b) without brain damage and able to communicate with a clear mental state; (c) have a lapse of more than six months after SCI; (d) be able to move because of restored functioning of their lower extremities (Excluding AIS grade A); and (e) have an understanding of the study's purpose and consent to participate in the study. The AIS (American Spinal Injury Association Impairment Scale) is a standardized neurological examination used to assess the sensory and motor levels affected by SCI. Grade A refers to a total impairment with no motor and sensory functions. Grades B, C, and D refer to an incomplete impairment. Grade B has some sensory function but no motor function. The motor function in Grade C is preserved below the neurologic level. However, more than half of the key muscles below the neurologic level have a muscle grade of less than three. Grade D has a motor grade of at least three scores below the neurologic level of injuries. Patients with Grade E injuries have regular motor and sensory functions but may still experience abnormal reflexes or other neurologic phe-nomena [14].
The number of samples was calculated based on the studies by Zheng et al.[13]. The number of participants for multiple regression analysis was calculated using G* Power 3.1. The calculation was based on the median effect size of .15 [13], significance level (⍺) .05, power (1-β) .80. and the four predictors (i.e., depressive symptoms, FoF, ADL, and the other) influencing QoL. The minimum sample size was 80. However, 70 data points were collected and used for the analysis.
2. Procedures
Data were collected between October 16, 2017, and February 2, 2018. The study's purpose and content were explained to the participants, and written consent was ob-tained from those who agreed to participate in the data collection. Participants were informed that they could dis-continue their participation in the study at any time without any adverse consequences. A self-reported question-naire was utilized. Participants who were able to complete the questionnaire independently did so, while the researcher read the questionnaire to those with poor eye-sight or difficulty moving their arms. The survey lasted approximately 20 minutes. The responses were immediately recovered upon the survey's completion.
The participants’ ADL were assessed by residents or rehabilitation therapists using the spinal cord independence measure II (SCIM II) tool, and this study utilized this data. SCIM II is a tool that measures three domains: self-care, respiration and sphincter management, and mobility. The outpatient visiting period spanned an average of three to four months. Thereafter, there was an overlap with the patients, and the researchers stopped administering the survey. As an incentive, pain relief patches were given to the participants who responded to the questionnaire.
3. Ethical Considerations
This study was approved by the Institutional Bioethics Committee of the affiliated hospital (201704-HR-010).
4. Measures
1) Depression
The researchers used the Patient Health Questionnaire (PHQ-9) depression module to measure depression. It is a self-reporting test designed to screen for depression and assess its severity. It operationalizes most of the Diagnos-tic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) and International Classification of Diseases, Ninth Revision (ICD-9) diagnostic criteria for major depression. The PHQ-9 is a test used to determine the frequency of experiencing these problems over a period of two weeks. Responses are rated on a 0∼3 point scale, with 10 being the cutoff for depressive symptoms [15]. The internal reliability of the PHQ-9 in Kroenke et al.'s [15] research had a Cronbach's ⍺ of .89, whereas it was .90 in this study.
2) ADL
The Spinal Cord Independence Measure II (SCIM II) is a tool developed by Catz et al. [16]. The SCIM includes three areas of function: self-care (sub-score 0∼20), respiration and sphincter management (0∼40), and mobility (0∼40). Self-care is classified into feeding, bathing, dressing, and grooming, with bathing and dressing further evaluated separately for the upper body and lower body. The total score for the four parts of self-care is a maximum of 20. Respiration and sphincter management are divided into assessments of the need for respiratory devices, bladder sphincter management, bowel sphincter management, and use of the toilet (perineal hygiene, clothes adjustment be-fore/after, use of napkins or diapers), with a maximum total score of 40. Mobility is categorized into room and toilet mobility and indoor and outdoor mobility, evaluated based on the level of mobility. The total score for mobility is a maximum of 40. The total SCIM score ranges from 0 to 100, with higher scores indicating greater independence in activities [16].
3) Fear of falling
FoF is measured in two ways in this study. The Falls Efficacy Scale-International (FES-I) was used to measure patients’ FoF [17]. In the Korean version, the scale is divided into physical activities within and outside the home, with seven and five items, respectively. Each item is rated on a 4-point (1∼4) Likert scale. Higher scores indicated lower fall efficacy or higher FoF. The Cronbach's ⍺ for FES-I was .96 and .95 in Yardley's [17] and present research, respectively.
4) Quality of Life
QoL was assessed using the Euro QoL Questionnaire 5-Dimensional Classification (EQ-5D-5L). The EQ-5D-5L index is divided into five domains: mobility, self-care, daily activity, pain and discomfort, and anxiety and depression [18]. Each of the five dimensions is divided into five levels of perceived problems. Level 1 indicates no problem, level 2 indicates slight problems, level 3 indicates moderate problems, level 4 indicates severe problems, and level 5 indicates unable to/extreme problems. If all five dimensions are ‘no problem’, it is represented as ‘11111’, while if all are ‘severe problems’, it is represented as ‘44444’. The EQ-5D-5L is calculated with weights applied. The score calculated is as follows: ⅰ) constant (0.096), ⅱ) the weighted score corresponding to the 5-dimensions (mobility (M), self-care (S), usual activity (U), pain and discomfort (P), and anxiety and depression (A), ⅲ) weighted score if any of the 5- dimensions is 4 or above (N4). After summing these three scores, the result is subtracted from 1. The following is the calculation formula [19].
Quality weight=1 - (0.096 + 0.046 × M2 + 0.058 × M3 + 0.133 × M4 + 0.251 × M5 + 0.032 × S2 + 0.050 × S3 + 0.078 × S4 + 0.122 × S5 + 0.021 × U2 + 0.051 × U3 + 0.100 × U4 + 0.175 × U5 + 0.042 × P2 + 0.053 × P3 + 0.166 × P4 + 0.207 × P5 + 0.033 × A2 + 0.046 × A3 + 0.102 × A4 + 0.137 × A5 + 0.078 × N4)
5. Statistics Analysis
The statistical analyses were performed using IBM SPSS Statistics 24.0. The values of general characteristics were analyzed using descriptive statistics. The correlations were analyzed by performing Spearman's rank-order tests. Multiple linear regressions were performed as the variables were related to the correlation analysis. The Durbin-Watson, tolerance, and Variance Inflation Factor tests were performed to confirm the severity of multicollinearity among the independent variables in the regression model. A p-value of < .05 was considered statistically significant in this study.
RESULTS
A total of 70 participants (men: 39; women: 31) were eligible to participate in this study.
The AIS grades of participants are C (12.9%) and D (87.1%). There were no participants with Grades A, B, or E. Disease comorbidity was analyzed among the participants with multiple responses, and it was found that 38 people had comorbid diseases. Diabetes and high blood pressure constituted 34.5% and 32.7% of these diseases, respectively. Additionally, 44.3% of the participants experienced falling within the past year. Furthermore, 77.1% did not receive fall prevention education. The SCI duration had a mean of 4.98±5.06. The means for depressive symptoms, ADL, FoF, and QoL were 10.19±6.79, 73.36±11.07, 33.33 ±7.81, and 0.505±0.202, respectively (Table 1).
Table 1.
Characteristics of Participants (N=70)
| Variables | Categories | Range | n (%) or M± SD |
|---|---|---|---|
| Gender | Men | 39 (55.7) | |
| Women | 31 (44.3) | ||
| Age (year) | 22∼80 | 57.94±12.89 | |
| ＜60 | 36 (51.5) | ||
| ≥60 | 34 (48.5) | ||
| Religion | No | 37 (52.9) | |
| Yes | 33 (47.1) | ||
| Education | ≤ Middle | 22 (31.4) | |
| High school | 28 (40.0) | ||
| ≥ College | 20 (28.6) | ||
| Income | 200,000∼5,000,000 | 1,538,142.86±1,119,619.88 | |
| 1st quartile | 17 (24.3) | ||
| 2nd quartile | 12 (17.1) | ||
| 3rd quartile | 23 (32.9) | ||
| 4th quartile | 18 (25.7) | ||
| Self-rated health | Bad | 38 (54.3) | |
| Moderate | 26 (37.1) | ||
| Good | 6 (8.6) | ||
| SCI duration (year) | 0.53∼23.40 | 4.98±5.06 | |
| AIS grade | C | 9 (12.9) | |
| D | 61 (87.1) | ||
| Comorbidities | No | 32 (45.7) | |
| Yes | 38 (54.3) | ||
| DM† | 19 (34.5) | ||
| HTN† | 18 (32.7) | ||
| Musculoskeletal disease† | 9 (16.4) | ||
| Others† | 9 (16.4) | ||
| Cohabitation | Lives alone | 21 (30.0) | |
| Lives with a cohabitant | 49 (70.0) | ||
| Experience of falling (within one year) | No | 39 (55.7) | |
| Yes | 31 (44.3) | ||
| Place of falling | Home | 17 (24.3) | |
| Out of house | 14 (20.0) | ||
| Education on fall prevention | No | 54 (77.1) | |
| Yes | 16 (22.9) | ||
| Depressive symptoms | 0∼25 | 10.19±6.79 | |
| No | 29 (41.1) | ||
| Yes | 41 (58.6) | ||
| Activities of daily living | 43∼100 | 76.36±11.07 | |
| Fear of falling | 12∼48 | 33.33±7.81 | |
| Quality of life | 0.088∼0.904 | 0.50±0.20 |
FoF was statistically significantly correlated with self-rated health (Spearman rho=−.32, p=.007), ADL (Spearman rho=−.24, p=.049), and depressive symptoms (Spearman rho=.51, p<.001). The depressive symptoms had a statistically significant negative correlation with self-rated health (Spearman rho=−.48, p<.001) and AIS grade (Spearman rho=−.33, p<.001). QoL had a statistically significant positive correlation with self-rated health (Spearman rho= .41, p<.001) and correlated negatively with the duration of SCI (Spearman rho=−.26, p=.030), depressive symptoms (Spearman rho=−.43, p<.001), and FoF (Spearman rho= −.75, p<.001)(Table 2).
Table 2.
Correlations among Variables (N=70)
Table 3 presents the results of the multiple linear regression analysis. There was no multicollinearity problem among the explanatory variables (all variance inflation factors had a score between 1 and 2, whereas all tolerance factors had a score between 1 and 13). Durbin-Watson was 1.643, which is close to 2. Therefore, the model is independent. The included variables had significant relationships. QoL has a statistically significant negative association with SCI duration (β=−.18, p=.025) and FoF (β=−.68, p<.001). This model accounted for 59.5% of the variance in QoL.
Table 3.
Factors Associated with QoL in Patients with Spinal Cord Injuries
DISCUSSION
QoL is important for patients with SCI. Studies have tried to elucidate factors related to the QoL of patients with SCI [9,10]. Patients with AIS Grade C or D retain some motor function, and their ability to perform activities of daily living (ADL) is crucial for their QoL. A decline in this ability can lead to increased psychological stress and depression [20]. Particularly for patients with AIS Grade C or D, rehabilitation exercises that maintain or improve partial motor functions can significantly contribute to better QoL [21]. The average QoL score for AIS grade C patients is generally moderate and can vary based on physical and psychological factors. For example, one study reported that the average QoL score for AIS grade C patients was 0.5±0.2 [22]. AIS grade D patients tend to have relatively higher QoL scores, which are associated with partial recovery of motor functions. For instance, some studies have found that the average QoL score for AIS grade D patients is close to 0.7. For AIS grade C and D SCI patients, the QoL scores vary significantly based on their condition and recovery [23].
It was found that the QoL of patients with SCI was lower than that of other diseases, except for diseases requiring pain control. The reason is believed to be that patients with SCI experience complex difficulties in addition to physical discomfort due to disability compared to other chronic diseases. In addition to the loss of physical function, there are socioeconomic limitations, and they experience more than other chronic diseases due to difficulties in inter-personal relationships. In addition, since sudden accidents cause most spinal cord injuries, it is difficult to accept the situation and adapt to the changed life on their own.
The mean duration of SCI among the participants was 4.98±5.06 years. QoL was negatively correlated with SCI duration, and the regression analysis showed that SCI duration was a predictor of QoL. Studies have indicated a significant relationship between QoL and SCI duration [9]. Furthermore, previous studies have found that the duration of SCI significantly impacts the QoL [24]. It has been reported that the longer the injury duration, the more likely it is that chronic health problems and psychological stress will reduce the QoL, confirming results similar to those of this study [25]. Therefore, the duration of SCI and QoL are closely related, and it is essential to consider the duration when evaluating QoL.
The regression analysis identified FoF as the strongest predictor of QoL in SCI patients. Approximately 44.3% of participants experienced falls in the past year, significantly restricting activity and reducing QoL [11]. A strong correlation between FoF and QoL was found, particularly among older adults [26-29]. Results show that FoF among SCI patients is a critical factor impacting their QoL [30]. The study indicates that reducing FoF is essential to improve the QoL of SCI patients, similar to its impact on older adults. Therefore, efforts to mitigate FoF in SCI patients are necessary.
Patients with SCI require physical, vocational, and psychological rehabilitation to enhance the effectiveness of rehabilitation treatments [30]. When an integrated rehabilitation program is applied and multiple aspects are considered, the QoL of the patient can be improved [30] Additionally, a program to reduce the FoF during psychological rehabilitation is needed for patients with SCI [9].
Although this study has significant implications, it also has limitations, including a small sample size and the recruitment of participants from a single university hospital. Regarding the sample size, when the effect size was 0.15, the alpha error was 0.05, the sample size was 70 in this study, and a number of predictors of 4 were input into G*power, the power was confirmed to be 0.7. Therefore, despite the small sample size, the level of power does not appear to be concerning. However, the characteristics of participants recruited from a single university hospital may affect the generalizability of the study results, so comparison with the results of future studies is necessary.
As confirmed in this study, the QoL was reduced when patients with SCI had physical discomfort and psychological fear of falling. Patients with SCI need nursing intervention for appropriate physical activity because there is a possibility of other disabilities or body damage during falls. In particular, nursing intervention for the sense of balance is actively taking place, and it would be effective to implement psychological intervention along with this. Based on the results of this study, I would like to make the following suggestions. First, this study has limitations in the external validity and generalization of the study because data were collected and expressed randomly in one hospital. Therefore, research using the expansion of the sample area and randomization method is necessary. Second, this study may have limitations in the validity and significance of the study due to its small sample size. Therefore, a study is needed to secure sufficient samples of patients with SCI.
CONCLUSION
This study found that QoL in SCI patients is associated with self-rated health, SCI duration, depressive syndrome, and FoF. Results show that FoF and SCI duration have the most significant impact on patients’ QoL. Additionally, FoF reduces physical activity, leading to secondary problems such as cardiovascular disease (CVD), which further decreases QoL. Continuous intervention to reduce FoF can improve QoL. Therefore, interventions to enhance QoL in SCI patients should consider the duration of injury and include FoF as a critical factor. Incorporating these findings into clinical nursing practice can significantly enhance the QoL of SCI patients. By focusing on reducing FoF, promoting physical activity, and providing continuous, individualized support, nurses can help SCI patients lead healthier, more fulfilling lives.
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