SCI Care: What Really Matters
SCI Care: What Really Matters
Dr. Michael Fehlings in discussion with Prof. Ashley Craig regarding Dr Craig's recent Spinal Cord publication.
Dr. Michael Fehlings - Professor of Neurosurgery, Robert Campeau Family Foundation-Dr. CH Tator Chair in Brain and Spinal Cord Research, Vice Chairman Research), Co-Director Spine Program, Department of Surgery, University of Toronto and Editor in Chief of Spinal Cord.
Prof. Ashley Craig - Professor at Kolling Institute, Faculty of Medicine and Health, The University of Sydney.
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The SCI Care: What Really Matters podcast aims to provide valuable insights and the most up-to-date information for those providing care to people with spinal cord injury (SCI) worldwide. The vision of the International Spinal Cord Society (ISCoS) is to "facilitate healthy and inclusive lives for people with spinal cord injury or dysfunction globally".
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Hello, I'm Michael Failings, a professor of neurosurgery at the University of Toronto. I'm the editor-in-chief of Spinal Cord, which is the flagship journal of ISCOS, and welcome to this ISCOS podcast, which features the monthly Editor's Choice journal article. And it's my distinct pleasure today to introduce the 2023 Sir Ludwig Goodman lecturer, professor Ashley Craig. Professor Craig is a professor of rehabilitation studies at the John Walsh Centre for Rehabilitation Research at the Colling Institute in the Faculty of Medicine and Health at the University of Sydney of Sydney, and Professor Craig's 2023 Sir Ludwig Goodman lecture was recently published as a special invited article in Spinal Cord, and the article deals with the psychosocial factors and adjustment dynamics after spinal cord injury a very important topic for sure. And, professor Craig, I wonder whether you might give us kind of a high-level summary of this article.
Speaker 2:Thank you for the opportunity. Thank you for the opportunity. Yes, look, there's no question that an injury like spinal cord injury could be called catastrophic. It comes with a lot of impairment on top of the motor and sensory issues that occur. Of the motor and sensory issues that occur Quite often we give priority to medical in the early stages, which is appropriate, but in our research we've looked long and hard at adjustment, because this is a disorder that is for a lifetime and we want people like Sir Ludwig Gutmann showed the way, really by introducing things after the Second World War into rehabilitation spinal cord injury rehabilitation which he thought would enhance the ability of the people to join their communities and contribute.
Speaker 2:For instance, we know that. You know, re-employment is a really important factor, but only about 20% or 30% ever get re-employed and I'm not sure if they're all full-time. So there are many barriers and so in the paper we've argued that and there are a number of barriers and in the paper I focus on five barriers that I've focused on over the years. The reason I focused on some of these barriers is that they have been neglected in the research. So those just very quickly. Certainly mental health hasn't been neglected, so psychological distress is a big factor, but we quite often think that everybody has psychological you know, serious psychological distress, but they don't. We think only about 30%, 40% do so what about the other 60%? We think only about 30-40% do so what about the other 60%? So, but they still, that 60% still suffers or experiences significant distress at times. So we've looked at that.
Speaker 2:Another one is pain, chronic pain, and there are many sources of pain, but pain catastrophizing especially we focused on because I believe strongly that if we, if we catastrophize chronically, it actually changes brain function and We've argued that that it will actually deteriorate our ability to to adjust. Then there's fatigue. No surprises there, but fatigue is a big barrier and quite often not looked at very much. There are no medications we know of that are specifically targeted for fatigue. Then there's sleep disorder, and so we've looked at these very important what I call psychosocial.
Speaker 2:And of course, the fifth one is cognitive impairment, which we're really focusing on now.
Speaker 2:And you know, cognitive impairment, probably with the type of injury we're dealing with, is most people will probably end up with some impairment given the number of barriers they face sleeplessness, age, increasing age of the disorder and so on and the inflammation that occurs with the injury itself causes some impairment.
Speaker 2:So, going on from there, we developed James Middleton and I and a few others have looked at ways of understanding adjustment better. So we've looked at in the paper and in the talk that I gave in Edinburgh in 23,. We looked at a multifactorial dynamic model that we borrow somewhat the background from the biopsychosocial theory and we look at this rather important model which gives a tool to people in the clinics, in the hospital, in the rehabilitation environments to actually understand adjustment better. So we also argue very strongly for you know, the person-centered care which is the way we all think about it now that it will enhance person-centered care and also that we think guidelines for psychosocial care should be standard in each unit. I finished the paper by talking about clinical guidelines, clinical implications, but I think you're going to ask me a question on that later so I'll leave it there.
Speaker 1:Thank you, that's a terrific summary. I really enjoyed reading the article and I like the way you had laid out these five psychosocial factors which I think individually make sense, but I hadn't really sort of conceptualized this in this kind of a framework, so I think that that is very, very helpful. I wonder whether you might amplify a concept that I had read in the article which you refer to in one of your case. Examples as and I'm quoting in one of your case examples is and I'm quoting engine room appraisal, reappraisal and coping process. So can you tell us a little bit what you mean by this and how a clinician might apply this?
Speaker 2:Sure, in the model we talk about moderators and we talk about mediators, and the moderators are multifactorial and many of those five factors that I've just talked about are moderators. But also age, sex, the level of injury, completion of injury and all these factors we call moderators and they can interact. And in the paper I showed that a lot of the research we've done and others show that there are quite strong moderators and relationships between those moderators. But to me, an interesting Michael, there's been a paper and I forget the author, but I saw that it was accepted in spinal cord which actually has independently verified this engine room process. That's exciting because we've done partial verification.
Speaker 2:But we thought of well, when a person is dealing with their life and dealing with difficulties in their life, they come to, they come well, they should, they come to conclusions about what they should do. This is standard psychology. Yeah, everybody experiences it. So we might decide to do something about it. We may not decide to do something about it. If my problem is difficulty with pain after spinal cord injury, I might decide to go to a medical consultant and get some medical help for it, like medication, sensible that helps or it doesn't help. So the reappraisal part is well, okay, it helped, that's good. It hasn't helped as much as I thought, so maybe there's something else. So the coping is really dealing with the solution, but the reappraisal is going back and saying, well, maybe I need to do something else.
Speaker 2:Now I call it the engine room because I feel that's where the strength lies in the whole process, just like an engine powers a system. I believe it's my bias, of course, but I believe that the decisions we make and things like self-efficacy, how much I feel in control of my life and how I can make decisions in my life, that's really important. But you can have a negative one too. You can have a catastrophizing effect where decisions I'm making are just making me think it's worse and harder and I just can't deal with this anymore, and so you come to decisions like drug abuse or even suicidal ideation. So that's what I mean by the. I hope that's clear. The engine room is the powerhouse, I think, of the whole model and we are starting to show statistically in research, in longitudinal research, that it actually does have a lot of power in the whole process of adjustment as it interacts moderators interact with the engine room.
Speaker 1:Yeah, yeah. So I think that helps to clarify the process and I like the idea of trying to break down the different, uh, you know, key psychosocial factors in terms of some buckets, if you will, to, to kind of to think about, and to, and to, and and to conceptualize. So I wonder, um, if in the next few minutes, ashley, if you could maybe just summarize maybe some key takeaways that a clinician might infer from your article.
Speaker 2:Thank you. I've worked on spinal cord injury units myself and I know that there are many priorities in spinal cord injury units, with discharge issues, goals set and so on. I think the model offers a terrific approach to perhaps map out the multiple effects, such as many of the moderators we've already mentioned and some of the barriers, but let's not forget facilitators because, as I've argued in the model, it can lead you to facilitators. Let's take an example. In the paper I do draw on two examples. In the paper I do draw on two examples one a successful engineering process and the other one a not so successful. Maybe I should look at the successful one as an example, Someone who has similar moderators affecting them. They've both got spinal cord injury, they've both got chronic pain and the difference between perhaps the two the one that I'm sort of putting in the paper is that the person who is going to be more successful is the person who is happy to communicate, happy to take advice, happy to listen and communicate, happy to take part in their own treatment, in a sense, with person-centered care issues. And I think the team with the model can map out what's going on in the engine. The person is appraising, they're doing what they would hope are the right things and as they take on solutions and they reach their own solutions with communication and agreement with the team, they have actually appropriate coping responses and that can lead to earlier discharge. It can lead to more appropriate adjustment.
Speaker 2:On the other hand, if we have someone with a barrier, this person for political reasons. I didn't choose for political reasons, but the guy was the one that didn't do well and the female was the one that did better. I don't know if there's any evidence that females did better, but in the paper I argued that for the guy who was married, had kids much the same as the one who did well or better. It's all becoming too much and they reject, they don't want to listen, they don't want to mix, they don't want to listen, they don't want to mix, they don't want to talk, they just want to isolate, they want to get home as soon as possible, even though they're nowhere near ready to do that. And so they start in the engine room, they start reaching conclusions which are leading them down, an inappropriate, poor coping response.
Speaker 2:And I think with the model the team can look at what factors, what model factors, moderators are affecting the person and they can start to map it out, just like I did in that paper, and I believe that would be my approach and it is my approach when I have a clinical case to look at, and it can lead me to perhaps be more confident as a clinician. That you know, when I was younger, much younger, and I saw these complex cases, not just spinal cord injury but complex injuries I thought what do I do here? You know, it was exasperation, it was frustration, it was overwhelming. But I think if you have a model and a pathway that you can map down and you can understand some of the relationships, it gives you greater confidence as a clinician, whether you're a physiotherapist or a rehab physician or psychologist or, you know, a social worker or whatever.
Speaker 1:Thank you.
Speaker 1:So again, I'm Dr Michael Failing, so Editor-in-Chief of Spinal Cord, and we've had the pleasure of having a conversation with Professor Ashley Craig from Sydney, who is a recipient of the 2023 Sir Ludwig Goodman Award, and delivered a keynote lecture at that meeting in Edinburgh and recently published a beautiful article in spinal cord, really highlighting psychosocial factors and adjustment dynamics after spinal cord injury.
Speaker 1:I would encourage all of you to read the article. The article is actually open access, which is my choice each month to select an article as an editor's choice. Personally, as a clinician, having dealt with my entire career with spinal cord injuries, I actually found this article to be very practical in helping to break down really a kind of a complex process, and I think that you know clinicians will find a number of very helpful concepts in this article. So I'm going to draw this podcast to a close, ashley, many thanks for joining in, and I would welcome all of you to have a look each month at the articles coming out in Spinal Cord, and we will be having a monthly a podcast to feature the editor's choice uh articles and, on that note, I wish you, um all um, a good day.