Research Findings from the Northwest Regional SCI System (NWRSCIS)
One of the missions of the NWRSCIS is to conduct studies designed to improve care for people with SCI. Findings from two studies that our investigators conducted during the previous 5-year cycle of National Institute on Disability and Rehabilitation Research (NIDRR) funding were presented at the American Spinal Injury Association (ASIA) meeting in May 2013.
By Charles Bombardier, PhD, Principal Investigator and Director of the NWRSCIS
Why we did the study
Depression and pain are two common conditions that make living with SCI that much harder. Though few like to admit they are “depressed,” the fact is that a group of symptoms that we call depression (including low mood, loss of interest in activities, sleep changes, appetite changes, poor energy, poor concentration, feeling worthless or guilty and thoughts of death or suicide) affect 20-30% of people with SCI (compared with about 7% in the general population). Pain affects even more people: 50-70% have chronic pain after SCI and for 20-30% that pain is severe. Treating depression and pain has been a major focus of our SCI Model System for years. Antidepressant medications have been used to treat depression and pain after SCI, but few if any high quality studies have been done to document what are the benefits and side-effects of this form of treatment.
How the study was done
With my colleague, Jesse Fann MD in the UW Department of Psychiatry and Behavioral Sciences, we led a team of six SCI centers in the first randomized, double-blind, placebo-controlled trial of the anti-depressant Venlafaxine XR (VFNXR) to see if it decreased depression and/or pain in people with SCI. Study participants were recruited from sites in Washington, Michigan, Texas, Alabama, Illinois and Florida. In the end 133 people between 18 and 64 years old, at least one month post-SCI, and with a diagnosis of major depression participated in the study. Of those who participated, 94% also had chronic pain. Participants were randomly assigned to receive either a placebo (fake pill) or VFNXR for 12 weeks. They completed questionnaires periodically that measure depression and pain to see if any changes or improvements had occurred. Preliminary results show that while not all symptoms of depression improved more with VFNXR than with placebo, a subset of symptoms— including depressed mood, feelings of guilt, lack of pleasure and anxiety—did improve more with VFNXR. In addition, people who had non-neuropathic (or non-nerve related) pain improved significantly with VFNXR.
What we learned
While the treatments we have are not yet as strong as we would like, they can be quite helpful. It is important to remember that both medical and behavioral approaches to treating depression and pain can help. For example, psychological counseling to learn relaxation skills, self-hypnosis, pacing, distraction and other coping strategies can help improve pain and reduce the amount pain interferes with life. The best results will probably come from using a combination of medical treatments and psychological counseling.
We want to continue to get across to people that after SCI, depression and pain are common but not ‘normal’ or expected. These are treatable conditions. People with depression and/or pain should work with their doctors on achieving as much improvement as possible through the use of medications. We think additional improvement in depression can come by helping people find enjoyable and meaningful activities to become involved in and by helping them become more confident in their ability to manage the effects of SCI.
By Jeanne M. Hoffman, PhD, Principal Investigator and Co-director of the NWRSCIS
Why we did the study
Rehabilitation hospital stays after SCI have gotten shorter and shorter in recent years. As a result, people are often discharged without learning everything they need to know to take care of themselves and stay healthy. This not only causes distress to patients and families, but often leads to more medical complications and higher rates of clinic visits and hospital stays in the first year after injury. Patients and families have also told us that their first year after injury is a time of difficult adjustment and anxiety. We wanted to find out if we could improve this situation by having trained counselors regularly call patients during the first year to check up on the patients’ adjustment, answer questions and identify potential problems before they got serious.
How the study was done
We designed a randomized controlled trial comparing scheduled telephone follow-up with usual care during the first year after discharge from acute rehab. All newly injured patients at UW and Harborview Medical Centers were invited to join the study. Of the 168 individuals who enrolled, 85 were randomly assigned to receive scheduled follow-up telephone calls (the study group) and 83 to usual care (the control group) after discharge from the acute rehab unit. We asked them about clinic visits and hospitalizations at three, six, nine and 12 months and had them complete a questionnaire at one year asking about quality of life and adjustment.
What we learned
Our findings showed that scheduled telephone follow-up did not have the expected beneficial effect on health care utilization or medical complications compared to usual care. There are many possible reasons for this. For one, we know that not everyone needs help during this time, so our phone calls were not likely to make a difference in their situations. For those who do need help, many of them stay in close contact with their doctors and nurses during the first year and already get the help they need. For others, phone calls may not be enough. We may need instead to target individuals who have specific concerns and find ways to address those problems more effectively within the existing health care system.
These findings and those of studies conducted by other SCI Model System centers have helped us design the SCI-CARE study we are now conducting for this current grant cycle. SCI-CARE enrolls individuals within the UW Medicine system who have requested help with specific problems that are typically difficult to manage in the current model of clinical care: depression, pain, and difficulty being active. It uses a collaborative care model in which a specially trained care manager works with the patient, his or her provider, and a team of experts to enhance health care delivery. This approach has been found to work well with patients who have chronic conditions such as diabetes and heart disease. If you currently receive your rehab care within the UW Medicine system and are interested in learning more about this study, go to the SCI-CARE page.