Case 2: Mary Lee was only 22 years old and was involved in a serious car accident 1 year ago. She sustained multiple fractures in her spine and has become a quadriplegic (C5 level). She is now wheelchair bound and needs to live with her parents (both nearly 60 years old). She is fully dependent for all her ADL and is pondering what to do with the rest of her life. She has always been proud of her good looks before and wanted to be a movie star. Now her boyfriend has left her and she is feeling very lonely and depressed.
Leung Kar Ming, Kevin
Word Count: 800 words
Many victims of serious car accidents survived with impaired physical functions. Hong Kong record a high number of traffic accidents with more than 20,200 casualties per year1. Traffic accident (42.1%) is the most reported cause of spinal cord injury (SCI)2. In our case, Mary Lee is one of the unfortunate victims sustaining multiple fractures in her spine. Incomplete (30.1%) and complete (20.4%) quadriplegia are the most frequent categories of persons with SCI2. Less than 1% experienced complete neurologic recovery by hospital discharge2.
There are seven factors affecting patients coping with SCI: personal resources, health-related factors, social & physical context, cognitive appraisal, adaptive tasks, copping skills and health-related outcomes3.
I. Personal resources
These include self-efficacy (SE), self-esteem, sense of coherence (SOC), spirituality, optimism, intellect and other personality characteristics3,4. These factors are associated with positive coping, and are determinants of adjustment to long term outcomes4,5.
Mary was a pretty girl and dreamed of becoming a movie star. The traffic accident took away her health, good looks, relationship and became wheelchair bounded. It is essential to help Mary regain a high SE, self-esteem and SOC.
II. Health-related factors
More than 50% of SCI patients suffer from chronic pain which significantly affects quality of life (QOL)3,4,8,9. Patients who experience more pain tend to catastrophize more and have a decreased mental health well-being. Psychological factors helps contribute to the relationship between pain intensity and depression8,9,10. Substance abuse, especially abuse of drugs prescribed for spasticity and pain, may contribute to further health problems8.
In Mary’s case, it is very important that clinicians can provide effective pain control, and build a positive relationship with Mary to aid the effectiveness of the treatments.
III. Social & physical context
After the injury, Mary became fully dependent on her parents. Her parents, at their retirement age, have to learn to provide support and adapt to their daughter’s functional limitation. Her boyfriend has left her making her very depressed. It is important that these social and physical contexts are addressed.
Social context is the relationship, support and expectations of the significant others. Physical context focuses on accessibility, mobility, autonomy, as well as the personal space and privacy of the patient3,4. Finding of positive meaning in lives involves a continuous search for comfortable relationships between self, disability and society4,6,7,10. Encouraging engagement in social activities can work as a distraction technique to increase mood levels7,8. The burden of the caregiver should not be neglected. Care-giving burden is associated with locus of control, social support, and modes of coping. Caregivers also add to the discredit of self by making the injured person entirely dependent on them. Gaining independence from the caregiver is also a key to restoring competency in persons with SCI. Interventions should be tailored towards the needs of the care recipients as well as the caregivers.
IV. Cognitive appraisal
Cognitive appraisal is how an individual views a situation. Appraisals have a strong association with adjustment. It is important that focus on appraisal of the cause of injury is shifted to the appraisal of having an SCI. Such individuals were found to be well-adjusted psychologically.
Visible disabilities affected Mary significantly. Assistance to help her regain her self-image, develop coping skills, making the best use of her remaining bodily function and adjustments of dealing with disability is important.
V. Adaptive tasks
Mainly focuses on how the individual adapts to the new situation and how they prepare for an uncertain future. Individuals, like Mary, should be encouraged to be able to make decisions on choices of care, commitment to achieving individual goals and sustain independence. Such individuals with SCI are more likely to engage in positive coping strategies.
VI. Coping skills
Engaging strategies includes self-control, social support, accepting responsibility, problem solving and positive appraisal, resulting in an internal locus of control. Total locus of control, sense of coherence, self-worth, hope, purpose in life and positive affect were consistently associated with greater QOL. Disengaging strategies, however, should be discouraged. These include denial, wish-fulfilling fantasy, self and other blame to SCI and substance abuse.
Mary needs to overcome invisible barrier to social contacts. She learns to cope with environmental factors by enhancing functions of her arms and hands and learning wheelchair skills.
VII. Health-related outcomes
This is mainly the effects of the coping strategies. Also focus on the reduction of stress, emotion control, self-image, self-esteem and social relationship. The use of cognitive behavioral therapy (CBT) can improve the psychosocial outcomes in individuals with SCI.
The society is in high demand for clinicians to help patients to recover and resume their normal life activities. Interventions that promote coping and adjustment include: 1. physically, helping individuals on environmental adaptations, training on independent living skills and pain management; 2. psychologically, with the use of CBT and peer counseling; 3. socially, such as providing vocational rehabilitation, social engagement and family counseling.
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