Rehabilitation Studies Unit, Faculty of Medicine, University of Sydney,
Sydney, NSW Australia
Yvonne Tran, PhD
Department of Medical and Molecular Biosciences, University of
Judy Lovas, MSc
Department of Medical and Molecular Biosciences, University of
James Middleton, PhD
Rehabilitation Studies Unit, Faculty of Medicine, University of Sydney
& Royal Rehabilitation Centre, Sydney, NSW Australia
Craig A, Tran Y, Lovas J, Middleton J (2008). Spinal Cord Injury
and its Association with
Negative Psychological States. International
Journal of Psychosocial Rehabilitation. 12 (2), 115-121
and reprints: Professor Ashley Craig, Rehabilitation Studies
Unit, Faculty of Medicine, University of Sydney, Sydney, NSW, Australia
Spinal cord injury (SCI) is
believed to place the individual at a high risk of psychological
objective of this paper was to examine the relationship between SCI and
psychological states by comparing levels of negative psychological
SCI and able-bodied controls. Participants included 33 people with SCI
completed their inpatient rehabilitation (that is, when living in the
community) and 33 able-bodied controls matched for age and sex. In
determine levels of negative psychological states, the Profile of Mood
the Spielberger Trait Anxiety Inventory were completed by all
SCI group was found to have raised levels of psychopathology, with 20%
negative psychological states typical of people with a psychiatric
with SCI have an increased risk of suffering debilitating levels of
Future research needs to investigate psychosocial rehabilitation
lowering negative psychological states such as depressive mood in
people with SCI
after they have completed their rehabilitation program.
Words: spinal cord injury, depression, anxiety, post-traumatic
Spinal cord injury (SCI) results from
trauma when the cord is lacerated, bruised, severed or damaged as a
disease. While SCI is a relatively uncommon disorder, its effects can
devastating (Middleton, Tran & Craig, 2007). The
level of impairment resulting from the injury depends upon
factors such as the level and completeness of the lesion. The
SCI is usually permanent paralysis of voluntary muscles below the
reduced mobility, impairment of social and vocational activities, with
negative impact on body systems such as respiratory, cardiovascular,
gastrointestinal, reproductive and sensory (Sommer, 2001). Due to
survival rates, the prevalence of SCI is increasing and the risk (world
standardized incidence) is low, at around 15 per million persons per
though risk is higher for males aged 15 to 24 years at around 40 per
(O’Connor, 2006; Wyndaele & Wyndaele, 2006). The
majority of people who sustain a SCI
commonly do so as a result of motor vehicle accidents, fall
related injuries (especially in the elderly), and
sports injuries (O’Connor, 2006).
impact of SCI on mental health and psychological function has been
debated (Elliott & Kennedy, 2004; Middleton et al., 2007). Stage
that risk of psychopathology was minimal, suggesting that any
or despondency was a necessary component of a stage process of
their injury (Buckelew, Frank, Elliott, Chaney & Hewett, 1991;
& Kennedy, 2004). Other more recent research has suggested that SCI
associated with raised risks of negative psychological outcomes that
be considered a “normal” response to the injury (Craig, Hancock &
1994a; Craig, Hancock & Dickson, 1999; Elliott & Kennedy, 2004;
1999). Rates of depression have been estimated to range from 20% to 43%
the person with SCI is attending rehabilitation as an inpatient (Frank, Kashani, Wonderlich,
Visot, 1985; Judd, Stone, Webber, Brown, & Burrows, 1989). Risk of
depressive symptoms such as depressive mood and anxiety after discharge
rehabilitation has been estimated to be around 15% (Bombardier,
Krause, Tulsky, & Tate, 2004) up to 50-60% (Craig et al., 1994a;
Neilson, & Cameron, 1987; Kennedy & Rogers, 2000). Research
suggests that risks of negative psychological states remain high unless
individuals receive effective treatment such as cognitive behaviour
during rehabilitation (Hancock, Chang, & Dickson, 1998).
The risk of negative
psychological states has been found to be associated with factors such
poor sleep and feelings of helplessness (Craig, Hancock & Dickson,
Norrbrink Budh, Hultling, & Lundeberg, 2005; Rintala,
Loubser, Castro, Hart, & Fuhrer, 1998) as well as frequent
medical complications, poor self-care, and difficulties with
Forchheimer, Maynard, & Dijkers, 1994). In preliminary research,
researchers are finding risks of post-traumatic stress disorder (PTSD)
people with SCI (Kennedy & Evans, 2001; Radnitz,
Schlein, & Hsu, 2000). This is not surprising given that SCI is generally a
traumatic and life-threatening event.
majority of people with SCI have been found to be not at risk of
psychological states, around 30-40% have been found to have more
and externally focussed in their thinking (Craig, Hancock & Chang,
While factors such as level of lesion, age, age at the time of injury, sex, time since injury and
completeness of the lesion
have not been consistently found to be associated with lower quality of
negative psychological states and pain intensity have been found to
lower QOL in
people with SCI (Middleton et al., 2007). Coupled with the potential
raised risks of psychological disturbance, research has also shown that
substance abuse and
risk of suicide are more
prevalent in the SCI population relative to the able-bodied population
and after the injury (Craig et al., 1999; Heinemann, Doll, Armstrong, Schnoll, & Yarkony, 1991; Stanford, Soden, Bartrop, Mikk,
& Taylor, 2007).
rarely has research compared the risk of negative psychological states
matched able-bodied controls during rehabilitation or after
the SCI person is living in the community. Therefore, the aim of the
study was to investigate the level of negative psychological states in
with SCI living in the community relative to able-bodied persons
age and sex.
included 33 adult persons (26 males; 7 females) who had a SCI (mean
SD=11.6; range 22 to 60 years). Exclusion criteria included a history
psychopathology before the SCI, traumatic brain injury, and non-English
speaking. The mean time since their injury was 11.7 years (SD=11) and
complete lesions (that is, American Spinal Injury Association or ASIA impairment grade A). The
consisted of 33 adult persons with a similar sex ratio (7 females) and
age (mean age= 39.5, SD=12.3; range 22 to 57 years). All SCI and
subjects were approached to take part in the present study while they
participating in an ongoing larger study into the relationship between
activity and neurological damage. They were admitted into the study
gave written consent. Institutional ethics approval was obtained prior
participation in the study.
of negative psychological states
The Profile of
Mood States (POMS; McNair, Lorr,
2005) was used to estimate the level of negative psychological states
two groups. The six
POMS sub-constructs (Tension, Depression, Anger, Vigor,
Fatigue, Confusion) and the Total POMS mood state score were used. The POMS has been shown to be a
and valid instrument in measuring psychological states and
(McNair et al., 2005). Inspection of the items of the POMS suggests it
provide an estimate of psychopathology free of medical conditions
a disease like SCI that are likely to inflate the depressive mood score
such as problems sleeping, or reduced physical activity). Even though
has been used widely in non SCI fields, it has rarely been used to
extent of psychopathology in SCI people. Therefore, we believed the use
POMS for this task would make a valuable contribution to the
The Spielberger Trait
Anxiety Inventory (
Spielberger, Gorsuch, Luschene, Vagg, &
1983) was used to assess trait anxiety. This has also
been shown to be a reliable and valid questionnaire (Spielberger et
t-tests were used to detect significant differences between the two
Based upon prior studies, a moderate to large effect size (0.6) was
occur for the difference between the SCI and able-bodied groups (Craig
1994a), with 33 subjects in each group providing sufficient power to
true differences (power= 70%). The Sign Test (Siegal, 1956) was used to
determine the probability that the SCI group would always be higher in
psychological state scores than the able-bodied group. A value of 0.5
therefore given to each prediction of difference for all 8 measures
two groups, since there is theoretically a 1 in 2 probability of the
being greater or lower than the able-bodied group. A value of 1 was
each incorrect prediction (that is, SCI value was actually lower than
score for the able-bodied group). Using this technique, the probability
estimating the direction of difference by chance can be determined.
Table 1: Descriptive statistics for the POMS
sub-contructs and POMS Total Score for SCI Group 1 and Able-bodied
Control Group 2
Table 2: 2x2
contingency table with the number of participants with SCI who reported
abnormally high levels of psychopathology versus those with low levels
to the able bodied controls
Low POMS Total
High POMS Total (≥70)
Χ2=4.0, df=1, p<.05, Odds
Table 1 shows the
results for the independent t-tests for the POMS sub-constructs, the
score and Spielberger trait anxiety measure. Inspection of the data
demonstrates that the people with SCI had consistently higher levels of
psychopathology in all the 8 measures relative to the able-bodied
some cases only marginally, such as for Fatigue). The Sign Test
suggests that the chance probability of all 8 measures being higher in
sample relative to the control is remote (p<.05). The SCI group was
have significantly higher levels of depressive mood (p<.05, df=64).
failure to find significant differences for Anger and POMS Total was
part to the large variation in scores in the SCI sample (in all POMS
the SCI standard deviations were as large or larger than the mean
is noteworthy that the POMS Total psychopathology score for the SCI
twice the level of the able-bodied controls (23.8 versus 12.7). This
variation in psychopathology scores in the SCI sample is further
Table 2, which shows 2x2 contingency data in which participants who
abnormally high levels of psychopathology were compared to those with
levels in both groups. A score of 70 in the POMS Total score was used
as the cut
off score given that scores of 70 or over typically occur in
populations (McNair et al., 2005). Persons with SCI had a significantly
chance of having a psychopathology score of 70 or above (Χ2=4.0,
df=1, p<.05), with a high odds ratio score of 7.1
(that is, the odds of persons with SCI
having high levels of psychopathology is seven times that of
persons). There were no significant correlations between time since
injury and ASIA level with self-reported psychological states.
data presented in this paper confirmed the findings of the literature
suggest a significant proportion of people with SCI are at risk of
psychological states (Elliott & Kennedy, 2004; Middleton et al.,
North, 1999). The SCI group had significantly raised levels of
depressive mood relative to the able-bodied controls. While differences
the SCI group and the controls did not reach significance for the other
measures, the SCI group had consistently higher levels of negative
psychological states for all measures, compared to the able-bodied
Furthermore, people with SCI had seven times the risk of having
levels of negative psychological states typical of people with a
disorder compared to the able-bodied controls (20% of the SCI people
elevated levels of negative psychological states). It is possible that
questionnaires (such as the Beck Depression Inventory) inflate negative
scores because they contain items biased towards medical complications
associated with SCI (eg. items that focus on sleep, weight and physical
performance). However, inspection of the items in the POMS suggests
this is not
a problem, as items require subjects to respond to 60 adjectives about
feel. Therefore, the elevated POMS scores associated with SCI more than
reflect valid increases in self-reported negative psychological states.
finding is somewhat concerning given that the participants had been
the community on average 11 years after their injury, and were people
getting on with their lives. They were not psychologically upset people
recruited from hospital wards due to complications or mental health
Clearly, the findings have implications for current psychosocial
being used during and after rehabilitation.
One limitation in this study was the use
of only a
self-report questionnaire to assess psychological states. Future
needs to utlize a comprehensive range of assessment including
interviews designed to detect psychopathology. However,
as stated above, the findings of this
paper have revealed possible challenges for current rehabilitation
designed to counter negative psychological states. Further research
assess and gather best evidence regarding treatments that can reduce
psychological states in SCI people during rehabilitation, as this may
reduce the prevalence of negative states in the long-term by assisting
person with SCI to maintain a healthy mental health and adjustment
al., 1998). Potential treatments include pharmacological therapies to
psychopathology such as depression, as well as non-pharmacotherapies
such as cognitive
behavioral therapy or other psychosocial therapies known to be
improving psychological status. It is crucial however, that
mental health be seen as important outcomes for rehabilitation
(Middleton et al., 2007).
It is also becoming clear that our
knowledge about the
association between negative psychological states and SCI needs
years ago rehabilitation researchers and clinicians were calling for
research that could clarify the nature of the psychological reaction of
to SCI (Elliott & Frank, 1996; Jacobs, Zachariah & Bhattacharji, 1995). Unfortunately, little has
changed today. We need to determine the prevalence of people with SCI
despondency or mild depressive disorder (eg. elevated negative
states) as distinct to a major depressive disorder (MDD), dysthymia or
adjustment disorder. We also need to determine how many people with SCI
depressive symptoms due to a primary anxiety disorder such as PTSD. The influence of
factors on psychopathology both during and after rehabilitation also
clarification. Clearly, prospective
research needs to be conducted to resolve the gaps in our
knowledge about the association between SCI and negative psychological
comprehensive data could well lead to an improvement
in rehabilitation strategies that address the
psychosocial needs of people with SCI.
Bombardier, C.H., Richards,
J.S., Krause, J.S., Tulsky, D., & Tate, D.G. (2004). Symptoms of
major depression in people with spinal cord injury: Implications for
screening. Archives Physical Medicine Rehabilitation, 85, 1749-1756.
Buckelew, S.P., Frank, R.G., Elliott, T.R., Chaney, J., &
Hewett, J. (1991). Adjustment to spinal cord injury: stage theory
revisited. Paraplegia, 29, 125-130.
Craig, A.R., Hancock, K., & Chang, E. (1994). The influence
of spinal cord injury on coping styles and self-perceptions two years
after the event. Australian and New Zealand Journal of Psychiatry, 28,
Craig, A.R., Hancock, K.M., Chang, E., & Dickson, H.G.
(1998). Immunizing against depression and anxiety following spinal cord
injury. Archives Physical Medicine Rehabilitation, 79, 375-377.
Craig, A.R., Hancock, K.M., & Dickson, H.G. (1994a). A
longitudinal investigation into anxiety and depression in the first 2
years following a spinal cord injury. Paraplegia, 32, 675-679.
Craig, A.R., Hancock, K.M., & Dickson, H.G. (1994b). Spinal
cord injury: A search for determinants of depression two years after
the event. British Journal of Clinical Psychology, 33, 221-230.
Craig, A., Hancock, K., & Dickson, H. (1999). Improving the
long-term adjustment of spinal cord injured persons. Spinal Cord, 37,
Elliott, T.R., & Frank, R.G. (1996). Depression following
spinal cord injury. Archives of Physical Medicine and Rehabilitation,
Elliott, T.R., & Kennedy, P. (2004). Treatment of depression
following spinal cord injury: An evidence-based review. Rehabilitation
Psychology, 49, 134-139.
Frank, R.G., Kashani, J.H., Wonderlich, S.A., Lising, A., &
Visot, L.R. (1985). Depression and adrenal function in spinal cord
injury. American Journal of Psychiatry, 142, 252-253.
Fuhrer, M.J., Rintala, D.H., Hart, K.A., Clearman, R., &
Young, M.E. (1993). Depressive symptomatology in persons with spinal
cord injury who reside in the community. Archives of
Physical Medicine and Rehabilitation, 74, 255-260.
Hancock, K., Craig, A., Martin, J., Chang, E., & Dickson,
H.G. (1993). Anxiety and depression over the first year of spinal cord
injury: A longitudinal study. Paraplegia, 31, 349-357.
Heinemann, A.W., Doll, M.D., Armstrong, K.J., Schnoll, S., &
Yarkony, G.M. (1991). Substance use and receipt of treatment by persons
with long-term spinal cord injuries. Archives of Physical Medicine and
Rehabilitation, 72, 482-487.
Jacobs, K.S., Zachariah, K., & Bhattacharji, S. (1995).
Depression in individuals with spinal cord injury: methodological
issues. Paraplegia, 33, 377-380.
Judd, F.K., Stone, J., Webber, J., Brown, D., & Burrows,
J.D. (1989). Depression following spinal cord injury: A prospective
in-patient study. British Journal of Psychiatry, 154, 668-671.
Kennedy, P., & Evans, M.J. (2001). Evaluation of post
traumatic distress in the first 6 months following SCI. Spinal Cord,
Kennedy, P., & Rogers, B. (2000). Anxiety and depression
after spinal cord injury: A longitudinal analysis. Archives of Physical
Medicine and Rehabilitation, 81, 932-937.
MacDonald, M.R., Neilson, W.R., & Cameron, M.G. (1987).
Depression and activity patterns of spinal cord injured persons living
in the community. Archives of Physical Medicine and Rehabilitation, 68,
McNair, D.M., Lorr, M., & Droppleman, L.F. (2005). POMS.
Profile of mood states manual. New York: MHS.
Middleton, J., Tran, Y., & Craig, A. (2007). Relationship
between quality of life and self-efficacy in persons with spinal cord
injuries. Archives of Physical Medicine and Rehabilitation, 88,
Norrbrink Budh, C., Hultling, C., & Lundeberg, T. (2005).
Quality of sleep in individuals with spinal cord injury: a comparison
between patients with and without pain. Spinal Cord, 43, 85-95.
North, N.T. (1999). The psychological effects of spinal cord
injury: a review. Spinal Cord, 37, 671-679.
O’Connor, P.J. (2006). Trends in spinal cord injury. Accident
Analysis and Prevention, 38, 71-77.
Radnitz, C.L., Schlein, I.S., & Hsu, L. (2000). The effect
of prior trauma exposure on the development of PTSD following spinal
cord injury. Journal of Anxiety Disorders, 14, 313-324.
Rintala, D.H., Loubser, P.G., Castro, J., Hart, K.A., &
Fuhrer, M.J. (1998). Chronic pain in a community-based sample of men
with spinal cord injury: Prevalence, severity, and relationship with
impairment, disability, handicap, and subjective well-being. Archives
of Physical Medicine and Rehabilitation, 79, 604-614.
Siegal, S. (1956). Non parametric statistics for the Behavioral
Sciences. New York: McGraw-Hill.
Sommer, M.F. (2001). Spinal cord injury. Functional
rehabilitation. New Jersey: Prentice Hall.
Spielberger, C.D., Gorsuch, R.L., Luschene, R.E., Vagg, P.R.,
& Jacobs, G.A. (1983). Stai Manual for the State-Trait Anxiety
Inventory. New York: Consulting Psychologists Press.
Stanford, R.E., Soden, R., Bartrop, R., Mikk, M., & Taylor,
T.K.F. (2007). Spinal cord and related injuries after attempted
suicide: psychiatric diagnosis and long-term follow-up. Spinal Cord,
Tate, D., Forchheimerm M., Maynard F., & Dijkers, M. (1994).
Predicting depression and psychological distress in persons with spinal
cord injury based on indicators of handicap. Archives of Physical
Medicine and Rehabilitation, 73, 175-183.
Wyndaele, M., & Wyndaele, J.J. (2006). Incidence, prevalence
and epidemiology of spinal cord injury: what learns a worldwide
literature survey? Spinal Cord, 44, 523-508.