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1.  Depression, Pain Intensity, and Interference in Acute Spinal Cord Injury 
Background:
The high prevalence of pain and depression in persons with spinal cord injury (SCI) is well known. However the link between pain intensity, interference, and depression, particularly in the acute period of injury, has not received sufficient attention in the literature.
Objective:
To investigate the relationship of depression, pain intensity, and pain interference in individuals undergoing acute inpatient rehabilitation for traumatic SCI.
Methods:
Participants completed a survey that included measures of depression (PHQ-9), pain intensity (“right now”), and pain interference (Brief Pain Inventory: general activity, mood, mobility, relations with others, sleep, and enjoyment of life). Demographic and injury characteristics and information about current use of antidepressants and pre-injury binge drinking also were collected. Hierarchical multiple regression was used to test depression models in 3 steps: (1) age, gender, days since injury, injury level, antidepressant use, and pre-injury binge drinking (controlling variables); (2) pain intensity; and (3) pain interference (each tested separately).
Results:
With one exception, pain interference was the only statistically significant independent variable in each of the final models. Although pain intensity accounted for only 0.2% to 1.2% of the depression variance, pain interference accounted for 13% to 26% of the variance in depression.
Conclusion:
Our results suggest that pain intensity alone is insufficient for understanding the relationship of pain and depression in acute SCI. Instead, the ways in which pain interferes with daily life appear to have a much greater bearing on depression than pain intensity alone in the acute setting.
doi:10.1310/sci2001-32
PMCID: PMC3919692  PMID: 24574820
depression; pain; spinal cord injuries
2.  Measuring Depression in Persons With Spinal Cord Injury: A Systematic Review 
Background/Objective:
Depression has been studied extensively among people with spinal cord injury (SCI). However, basic questions persist regarding the reliability and validity of depression measurement in the context of SCI. The objective of this study was to evaluate the state of knowledge of depression measurement in persons with SCI.
Methods:
English-language peer-reviewed citations from MEDLINE, CINAHL, PsycINFO, ProQuest, Google Scholar, and Web of Science from 1980 to present. Two reviewers screened 377 abstracts on SCI and depression topics to identify 144 containing classifiable psychometric data. All 144 were reviewed by 6 reviewers. Twenty-four studies reporting psychometric data on 7 depression measures in SCI samples were identified, including 7 validity studies.
Results:
Reliability data were limited to internal consistency and were consistently good to excellent across 19 studies. Validity data were limited to concurrent validity, construct validity, and/or clinical utility in 10 studies. Measures were comparable with respect to internal consistency, factor structure, and clinical utility. Results are limited to peer-reviewed, English literature, and studies were not judged for quality.
Conclusions:
Greater attention should be paid to the psychometric evaluation of established measures. Although existing evidence may not justify universal screening, we recommend depression screening in clinical practice when patients may be seen by nonpsychology personnel. There is insufficient evidence to recommend one screening measure over another. Therefore, selection of measures will depend on clinician preferences. Psychometric studies are needed to show test–retest reliability, criterion validity, and sensitivity to change to improve depression recognition and treatment.
PMCID: PMC2647502  PMID: 19264045
Depression; Screening; Psychometrics; Spinal cord injuries
3.  Preliminary Reliability and Validity of a Spinal Cord Injury Secondary Conditions Scale 
Background/Objective:
Although the impact of secondary conditions after spinal cord injury (SCI) on health, well being, and financial burden have been studied, there are psychometrically sound scales of secondary conditions in the extant literature. The use of such scales allows for cross-sample comparison of secondary condition prevalence rates and associations with functional, medical, and psychosocial factors. Thus, the purpose of this study was to evaluate the preliminary reliability of a SCI secondary conditions scale.
Methods:
The Spinal Cord Injury Secondary Conditions Scale (SCI-SCS) is a 16-item scale based on the Seekins Secondary Conditions Scale. Sixty-five individuals with SCI completed written surveys at 5 time-points over 2 years.
Results:
Internal consistency across each of the time-points exceeded 0.76; test–retest reliability ranged from 0.569 to 0.805. Convergent validity was assessed with 6 physical functioning items from the SF-12. Spearman ( coefficients were all statistically significant and ranged from 0.317 (accomplished less because of health problems) to 0.644 (pain). The most prevalent secondary conditions were chronic pain, joint and muscle pain, and sexual dysfunction.
Conclusions:
Preliminary testing of the SCI-SCS suggests that it is a reliable and valid scale, and further development (ie, factor analysis, item revision) and examination of validity are recommended with larger and more diverse SCI samples.
PMCID: PMC2031942  PMID: 17591225
Spinal cord injuries; Secondary conditions; Respiratory disease; Pain; Spasticity; Urinary tract infections; Pressure ulcers; Autonomic dysreflexia; Psychometrics; Validity; Reliability; Scales
4.  Marital Status, Marital Transitions, Well-Being and Spinal Cord Injury: An Examination of the Effects of Sex and Time 
Objective
To examine the applicability of marital resource (marriage has substantial benefits for well being over not being married) or marital crisis models (marital dissolution leads to poorer well being) to the spinal cord injury (SCI) population by studying the effects of gender, marital status and marital transitions on well-being.
Design
Prospective cohort from the SCI Model Systems National Database.
Setting
Community.
Participants
4,864 men and 1,277 women who sustained traumatic SCI and completed a minimum of one follow-up interview beginning at one year through 15 years post-injury.
Interventions
None.
Main outcomes measures
Life satisfaction, depressive symptomatology, and self-perceived health status using linear mixed models for longitudinal data.
Results
In general, well being improved over time since injury. Hypothesis testing supported the marital crisis model as marital loss through being or becoming separated or divorced and being or becoming widowed had the most consistent and negative impact across well-being outcomes, while being or becoming married only had an advantage for lower depression symptomatology over time. However, marital dissolution or loss did not have a uniformly adverse impact on well-being outcomes and this effect was often moderated by gender such that widows had higher depressive symptomatology and poorer self-perceived health than widowers, but separated or divorced women had higher life satisfaction and self-perceived health than men. Irrespective of gender, being separated or divorced vs. being single was associated with higher depression over time.
Conclusions
The results support the marital crisis model and that women and men can experience marital dissolution differently. Nor does all marital loss result in compromised well-being or marriage enhance well-being, highlighting complex dynamics worthy of further investigation in this population.
doi:10.1016/j.apmr.2010.07.239
PMCID: PMC3594832  PMID: 21276959
Quality of life; Rehabilitation; Spinal cord injuries
5.  Menopause Characteristics and Subjective Symptoms in Women with and without Spinal Cord Injury 
Objective
Examine menopause transition characteristics and symptom bother in women with spinal cord injury (SCI).
Design
Prospective cohort (four data collection periods across four years).
Setting
Community.
Participants
Sixty-two women with SCI (injury levels C6 through T12, non-ambulatory and > 36 months post-injury; 86.1% retention) and 66 women without SCI (92.9% retention) with intact ovaries, not using hormone therapy and between the ages of 45 and 60 years volunteered. 505 observations were collected and analyzed.
Interventions
None.
Main outcome measures
Age at final menstrual period (FMP); transitions through menopause status classifications; and menopause symptom bother (vasomotor, somatic, psychological symptoms).
Results
The number of women transitioning through a menopause status classification over the course of the study did not significantly vary by group (p = 0.263) nor did age at FMP (p = 0.643). Women with SCI experienced greater bother of somatic symptoms (a sub-scale, p ≤ 0.001), bladder infections (p ≤ 0.001), and diminished sexual arousal (p = 0.012). Women without SCI had significantly greater bother of vasomotor symptoms (p = 0.020). There were no significant group by menopause status interactions; main effects for menopause status were only significant for vasomotor symptoms and vaginal dryness.
Conclusions
Results suggested that women with SCI experience greater symptom bother in certain areas, but that patterns of symptom bother across menopause and transition through menopause and age at FMP is similar to their peers. Larger studies are needed to examine menopause outcomes with respect to level of injury and completeness of injury. These findings provide a framework that women with SCI and their health care providers can use to address the menopause transition and highlights the importance of multidisciplinary involvement to maximize health and well being during this transition.
doi:10.1016/j.apmr.2009.12.012
PMCID: PMC2978078  PMID: 20382288
menopause; spinal cord injuries; paraplegia; quadriplegia; women
6.  Association of Daily Stressors and Salivary Cortisol in Spinal Cord Injury 
Rehabilitation psychology  2009;54(3):288-298.
Objective
Examine the diurnal variation of salivary cortisol in adults with spinal cord injury (SCI) and the effect of stressors on cortisol and mood.
Method
Ecological momentary assessment (EMA) to capture cortisol, stress and mood from 25 persons with SCI and 26 without SCI. Data were analyzed using linear mixed models.
Results
There were no systematic differences between groups on missing data. Diurnal variation of cortisol of participants with SCI reflected an expected pattern. No significant group differences for cortisol diurnal pattern, stress or mood; when group interactions were significant, results indicated lower cortisol reactivity to stress in participants with SCI. Stress had a significant impact on positive, negative and agitated moods.
Conclusions
Stress in daily life and its association with cortisol and mood were largely similar between persons with and without SCI. A key methodological contribution is the demonstration of using EMA to collect biological and behavioral data in the field from participants with SCI. The use of EMA in rehabilitation psychology research has great potential to advance our understanding of the dynamics of daily life with disability.
doi:10.1037/a0016614
PMCID: PMC2924200  PMID: 19702427
spinal cord injuries; stress, psychological; hydrocortisone; ecological momentary assessment
7.  Outcome Measures in Spinal Cord Injury 
Spinal cord  2009;47(8):582-591.
Study Design
review by the Spinal Cord Outcomes Partnership Endeavor (SCOPE), which is a broad-based international consortium of scientists and clinical researchers representing academic institutions, industry, government agencies, not-for-profit organizations and foundations.
Objectives
assessment of current and evolving tools for evaluating human spinal cord injury (SCI) outcomes for both clinical diagnosis and clinical research studies.
Methods
a framework for the appraisal of evidence of metric properties was used to examine outcome tools or tests for accuracy, sensitivity, reliability and validity for human SCI.
Results
imaging, neurological, functional, autonomic, sexual health, bladder/bowel, pain, and psycho-social tools were evaluated. Several specific tools for human SCI studies have or are being developed to allow the more accurate determination for a clinically meaningful benefit (improvement in functional outcome or quality of life) being achieved as a result of a therapeutic intervention.
Conclusion
significant progress has been made, but further validation studies are required to identify the most appropriate tools for specific targets in a human SCI study or clinical trial.
doi:10.1038/sc.2009.18
PMCID: PMC2722687  PMID: 19381157
outcome tools; upper and lower limb; diagnostic tools; spinal cord clinical trial targets; functional assessment; quality of life; community participation
8.  Patient Health Questionnaire-9 in Spinal Cord Injury: An Examination of Factor Structure as Related to Gender 
Background/Objective:
Despite the attention depression after spinal cord injury (SCI) has received, research and clinical practice have been hampered by inadequate emphasis on reliable and valid measurement. Assessment of symptoms in persons with SCI is challenged by the presence of “transdiagnostic” symptoms and unexamined effects of gender. The objective of this study was to examine the factor structure of the Patient Health Questionnaire-9 (PHQ-9; the 9-item depression scale of the Patient Health Questionnaire) and determine whether the structure replicates across gender.
Methods:
A total of 1,168 women and men were matched on level/completeness of SCI, follow-up year, and age to create 584 pairs. Exploratory factor analysis examined 1- and 2-factor models and congruence in 2 randomly split half samples to establish congruence of the factor solution and replication across gender.
Results:
The 1- and 2-factor solutions fit the structure of the items accounting for 41% to 51% of original item variance. Congruence between random samples was uniformly high for the 1-factor solution (r = 0.791–0.948) but variable for the 2-factor solution. Although congruence was high for the combined sample and men (r = 0.90–0.97 and 0.71–0.94, respectively), it was variable for women (r = 0.29–0.85).
Conclusions:
Although there was support for the 1-factor structure of the PHQ within and between sexes, the low congruence between sexes and within women for the 2-factor structure indicates potentially important differences about how certain symptoms may be experienced or interpreted differently by men and women with SCI. Future research should focus on where sexes diverge in cognitive, affective, and somatic dimensions of depressive symptoms and whether sex-specific or sex-neutral measures are warranted.
PMCID: PMC2678286  PMID: 19569462
Spinal cord injuries; Affective disorders; Depression; Gender issues; Psychometrics; Factor analysis

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